challenges with vascular injuries in resource poor setting

Joel ArudchelvamConsultant Vascular and Transplant Surgeon

TEACHING HOSPITAL ANURADHAPURA

TEACHING HOSPITAL ANURADHAPURA

VASCULAR INJURY

Head And Neck

Thorax

Abdomen and Pelvis

Limbs (Extremity )

VASCULAR INJURY

Head And Neck

Thorax

Abdomen and Pelvis

Limbs (Extremity )

VASCULAR INJURY

Head And Neck

Thorax

Abdomen and Pelvis

Limbs (Extremity )

VASCULAR INJURY

Head And Neck

Thorax

Abdomen and Pelvis

Limbs (Extremity )

EXTREMITY VASCULAR INJURIES

Common

Results in limb loss at times loss of life

Loss of earning capacity

Economic burden

CAUSES

Road Traffic Accidents – 38.5%

Trap gun – 7.5%

Fractures and dislocations

Cuts and stabs

Iatrogenic

Teaching Hospital Anuradhapura 2015

TRAP GUN

Made of a metal pipe, metal pallets and explosives (from fire cracker)

About 75 trap gun injury / year

About 10 – 15 % with arterial injuries

Multilevel injury

Teaching Hospital Anuradhapura 2015

CAUSES

Road Traffic Accidents – 38.5%

Trap gun – 7.5%

Fractures and dislocations

Cuts and stabs

Iatrogenic – 5 cases

Teaching Hospital Anuradhapura 2015

CAUSES

Road Traffic Accidents – 38.5%

Trap gun – 7.5%

Fractures and dislocations

Cuts and stabs

Iatrogenic – 5 cases Accidental cannulation of femoral artery in

infants and iliac vessel injury following discectomy

Teaching Hospital Anuradhapura 2015

CAUSES

Road Traffic accidents – 38.5%

Trap gun – 7.5%

Fractures and dislocations

Cuts and stabs

Iatrogenic

Mechanism of injury

Sharp / penetrating

Blunt

MECHANISM OF DISRUPTION ARTERIAL LEVEL

Transection

Laceration

Contusion

Kink

Intimal flap

VASCULAR TRAUMA

Signs of a vessel injury

Hard signs

Soft sign

VASCULAR TRAUMAHard signs

Active bleeding Signs of distal ischaemia – ‘ Ps ’

Absent pulse

Pain

Pale

Perishing Cold

Paresthesia / Anaesthesia

Paresis / Paralysis

Thrills, Bruits Expanding hematoma

VASCULAR TRAUMA

Soft signs

Hematoma

Injury close to a known neurovascular bundle

Reduced pulse

VASCULAR TRAUMA

Soft signs Hematoma

Injury close to a known neurovascular bundle

Reduced pulse

Hard signs – explore

Soft signs – observe

VASCULAR TRAUMA

Paresis / Paralysis & Paresthesia / Anaesthesia

Late Signs

Paresis & Paresthesia

Viability Of The Limb Is In Immediate Threat

Anaethesia & Paralysis

Not Viable

PROBLEM WITH VASCULAR INJURY

Delay α Dead Limb

SUCCESSFUL MANAGEMENT OF EXTREMITY VASCULAR INJURY

Early Detection

Early intervention

CHALLENGES

Failure to detect early

Transport and Communication

Trained Staff, ability to handle Case load and

Infrastructure

SUCCESSFUL MANAGEMENT OF EXTREMITY VASCULAR INJURY

Delay in Detection

Delayed intervention

FAILURE TO DETECT EARLY

Lack of knowledge

Busy emergency units

TRANSPORT

Ambulance service

Traffic

All takes time

TRANSPORT

When patient reaches

Not fit for intervention

Limb is not viable

Mean ischaemic time - 12.6 hours (0.5 to 48)

Clinically marginally viable / nonviable limbs -15.75 (7.5 to 25.5) hours

TRANSPORT

Staff transport

Most live away from Anuradhapura

Average distance to travel – 85km

Mode – own vehicle and self driving

No official transport

TRANSPORTATION

Average time from injury to reperfusion

- 12.6 hours (0.5 to 48)

CASE LOAD, TRAINED STAFF AND INFRASTRUCTURE

CASE LOAD

Anuradhapura district Population –860,575 (4.2%)

CASE LOAD

Other areas covered Total population covered -5,546,355 (27%)

CASE LOAD, TRAINED STAFF AND INFRASTRUCTURE

No dedicated trauma centers and theatres

9 vascular surgeons

Only 1 – in north and north central region – 27%

of population

Number of other doctors

Number of nurses and associated staff

Insert ministry charts

Insert ministry charts

STAFF

Medical officers - 05

Nurses - 15

• Ward• Theatre• HDU

“DEAD LIMBS”

Dead or marginally viable limb - anesthetic and paralytic or after fasciotomy if two or more compartments are non-viable

Revascularization done if:

Young

Systemically well

No severe soft tissue injury

Local infection

Arudchelvam, J., (2017). Outcome after revascularisation of marginally viable limbs and dead limbs following lower limb arterial injuries. Ceylon Medical Journal. 62(3), pp.203–204. DOI: http://doi.org/10.4038/cmj.v62i3.8526

RESULTS

Dead or marginally viable limb revascularized -

4/13

Mean ischaemic time was 15.75 (7.5 to 25.5)

All underwent fasciotomy to confirm viability

reduced sensation before revascularisation

improved following revascularization in all

Only 25% improvement in motor function

Arudchelvam, J., (2017). Outcome after revascularisation of marginally viable limbs and dead limbs following lower limb arterial injuries. Ceylon Medical Journal. 62(3), pp.203–204. DOI: http://doi.org/10.4038/cmj.v62i3.8526

HOW CAN WE IMPROVE…..

Needs to have; Dedicated Trauma centers

Adequate Trained staff

Prompt transport facilities

We need to increase the threshold for revascularizing dead limbs

Arudchelvam, J., (2017). Outcome after revascularisation of marginally viable limbs and dead limbs following lower limb arterial injuries. Ceylon Medical Journal. 62(3), pp.203–204. DOI: http://doi.org/10.4038/cmj.v62i3.8526

Thank You