Abdominal vascular injuries Prof TV Mulaudzi Abdominal vascular

Abdominal vascular injuries Prof TV Mulaudzi

Abdominal vascular injuries The most common cause of death following penetrating abdominal trauma

Incidence and Epidemiology n In patients undergoing laparotomy n n n Gunshot wounds (Civilian) = 14% Stabwounds = 10% Blunt trauma = 3%

Incidence and Epidemiology n n n n Incidence similar for arterial and venous IVC = 25% of injuries Aorta = 21% Iliac artery = 20% Iliac veins = 17% SMV = 11% SMA = 10%

Prehospital management n n Rapid transportation to hospital for immediate surgical control of bleeding Controlled hypotension is beneficial n Prevents massive exsanguination

Clinical presentation n n Major abdominal vascular injuries many die at the scene Depends on injured vessel, size & type of injury, associated injuries and prehospital time

Investigations n n n Mostly Immediate laparotomy Diagnosis mostly intraoperatively Stable pt’s CXR & AXR CT scan

Emergency department management n Large bore IV catheters in n Upper extremities or Central veins of thoracic inlet Controlled hypotension

Operative management n General principles n Diminish hypothermia n n Warm operating room Pre-warm infused fluids to 40 -42° Cover extremities with warm blankets Rapid infusion devices

Operative management n Penetrating trauma n n Explore all hematomas irrespective of size Blunt trauma n Retroperitoneal hematoma rarely require exploration low incidence of vascular or hollow viscus injuries requiring repair n Exceptions: *Expanding, pulsatile or leaking hematomas *Absent ipsilateral femoral pulse in Zone 3 *Para-duodenal hematomas

Damage control procedures n Early damage control and definitive reconstruction at a later stage n n n Massive blood transfusions Hypotensive Severely hypothermic Acidotic Coagulopathic intraoperative n n Complex venous injuries are ligated Arterial injuries may be shunted Diffuse retroperitonal or parenchymal bleeding tight gauze packing ICU for resuscitation stabilize return to OR

Specific vascular injuries n Abdominal aorta: n Penetrating injuries by far most common n n Many die at the scene Temporarily contained in the retroperitoneum Blunt injury is extremely rare, usually due to MVA’s, direct blows, falls, exposions Rarely injury missed and presents later as pseudoaneurysm or AV-fistula

Abdominal aorta n Management n Operative n n Primary or prosthetic graft repair Endovascular selected cases n Infrarenal dissection, false aneurysms, or aortocaval fistulae

Abdominal aorta n Mortality n n n Blunt trauma: Overall mortality 27% Penetrating trauma: 67% Suprarenal worse than infrarenal

Abdominal vascular trauma Early intervention saves life

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