Morbidity & MortalityMorbidity & MortalityOther Indications: Th Pr i it C tr rThe Proximity...

Morbidity & MortalityMorbidity & Mortality

Anita Chiu, MDlKings County Hospital Center

December 3, 2009

www.downstatesurgery.org

Case PresentationCase PresentationTrauma Code: 29 yo male s/p GSW x 2 to LLE

GSW#1 l ft i j t di l t f l• GSW#1 – left groin just medial to femoral pulse

• GSW#2 – left medial thigh approximately 4GSW#2 left medial thigh approximately 4 fingerbreadths below first GSW

• Active hemorrhage at scene per EMSGCS 4/ /6 i l• GCS 4/5/6 on arrival

• No PMH/PSH


Case PresentationCase Presentation•Vitals:

• BP 106/48 HR 83 RR 16 O2sat 100%•Physical Exam:

• Gen: A&Ox3, in acute distress due to pain from LLE• HEENT: NCAT• Neck: FROM• Chest: CTA B/L• CV: S1 S2• Abd: soft, NT/NDAbd: soft, NT/ND• Ext: GSWx2 to left groin and left medial thigh, no active bleeding,

2+ femoral and DP/PT pulses, moderate stable hematoma left thigh, externally rotated, sensation intact; left hand with laceration of left ring finger, through and through wound proximal to PIP of left g g , g g pmiddle finger, ABIs: 1.1 b/l


Case PresentationCase Presentation

7 0211.6

316141 102 13 1727.02

36.0316

3.6 26 1.4172

6.5

4.1

25

17

39

0.3

VBG 7.371/45.1/29.1/24.1/55%/+0.9Lactate 5.3


Case PresentationCase Presentation

• Negative CXR.•Bullet Bullet casings in region of left proximal pfemur.• Proximal comminuted femoral fracture.


Comminuted spiral oblique displaced fracture of proximal left femoral shaft. Bullet fragment in soft tissues laterally.


Comminuted midshaft fracture of proximal phalanx of third digit, left hand.


C Pr t tiCase Presentationwww.downstatesurgery.org

Angiogramg gwww.downstatesurgery.org

Case PresentationCase Presentation• Negative angiogram by IR.g g g y• Upon transfer from IR table to stretcher, patient experienced significant hemorrhagefrom proximal wound, likely high flow venous bleeding.Taken immediately to operating room with • Taken immediately to operating room with

digital pressure in wound for emergent surgical exploration.g p


Operative CourseOperative Course• Left groin exploration via longitudinal g p gincision• Macerated left femoral vein just proximal to saphenofemoral junction including anterior saphenofemoral junction including anterior and posterior walls• Left saphenous vein anterior wall injury• Left femoral and saphenous veins ligated at SFJArterial tree intact• Arterial tree intact


Postoperative CoursePostoperative CoursePOD#0: Left femur traction pin placed by p p yOrthopedics. Leg elevated and wrapped.POD#3: Taken to OR for left thigh fasciotomy for compartment syndrome.POD#6: Taken to OR for IM nailing of left subtrochanteric femur fracture and VAC subtrochanteric femur fracture and VAC placement.POD#9: Transferred to floorPOD#9: Transferred to floor.Currently awaiting rehab and placement.


Indications for Angiogram in

L E i TLower Extremity Trauma


H rd & S ft Si f V l r I j rHard & Soft Signs of Vascular InjuryHard Signs Soft SignsgActive arterial bleeding

gNeurologic injury in proximity to vesselSmall to moderate Pulselessness/

evidence of ischemiaExpanding pulsatile

Small to moderate sized hematomaUnexplained h t iExpanding pulsatile

hematomaBruit or thrill

hypotensionLarge blood loss at scene

Arterial pressure index <0.90 pulse deficit

Injury in proximity to major vessel

Rich et al. Chapter 5: Diagnosis of Vascular Trauma, Vascular Trauma, 2nd edition.


Art ri l Pr r I dArterial Pressure IndexJohansen et al (1991) – API<0.9 for Johansen et al (1991) API<0.9 for identification of occult arterial injury

95% sensitivity97% specificity

API>0.9 – 99% negative predictive value for arterial injurySafe, accurate, cost-effective

Johansen K, Lynch K, Paun M Copass M: Noninvasive vascular tests reliably exclude occult arterial trauma in injured extremities. J Trauma 1991;31(4):515-522.


A tAnatomywww.downstatesurgery.org

N ti r i pl r tiNegative groin explorationsSnyder et al (1978)Snyder et al (1978)177 patients with 183 penetrating injuries evaluated using arteriographye a uated us g a te og ap y1 false negative and 14 false positiveArteriography invaluable in patients in Arteriography invaluable in patients in whom the diagnosis is less clear 2-4% complication rate2 4% complication rate

Snyder WH, Thal ER, Bridges RA, et al: The validity of normal arteriography in penetrating trauma. Arch Surg 1978;113(4):424-428.


Indications for arteriography: E iExtremity trauma

Unclear location or extent of vascular Unclear location or extent of vascular injuryExtensive soft tissue injuryte s e so t t ssue ju yFracture or dislocationTrajectory parallel to an arteryTrajectory parallel to an arteryMultiple woundsShotgun injuriesShotgun injuriesPeripheral vascular disease



Other Indications: Th Pr i it C tr rThe Proximity Controversy

Dennis & Frykberg et al (1998)Group 1 – 43 patients with 44 clinically occult injuries subsequently demonstrated on angiographyangiography

4 (9%) deteriorated within a month and required operative repairF ll ith 9 1 f 58% f ll Follow up with mean 9.1 years for 58% of group – all asymptomatic

Group 2 – 287 patients with 309 asymptomatic proximity injuries evaluated by PE alone

4 (1.3%) deteriorated and required surgeryFollow up with mean 5 4 years for 29% of group – all Follow up with mean 5.4 years for 29% of group all asymptomatic

Dennis JW, Frykberg ER, Veldenz HC, et al: Validation of nonoperative management of occult vascular injuries and accuracy of physical examination alone in penetrating extremity trauma: 5- to 10-year follow up. J Trauma 1998; 44(2):242-252.


Th Pr i it C tr rThe Proximity ControversyRoutine proximity angiograms will identify p y g g yabnormalities in up to 10% of casesAuthors champion PE alonePatients who require surgery will develop hard signs“Minimal” vascular injuries – most heal by Minimal vascular injuries most heal by themselves

Intimal flapsSegmental narrowingsSmall false aneurysmsSmall AVFs

Rich et al. Chapter 5: Diagnosis of Vascular Trauma, Vascular Trauma, 2nd edition.Ascher et al. Chapter 35: Vascular Trauma, Haimocivi’s Vascular Surgery, 5th edition (2004)


Th Pr i it C tr rThe Proximity ControversyWeaver et al (1990) – use of angiogram to screen for an arterial injury when proximity alone is the indication rarely identifies a significant injury and should be abandonedN=373 with penetrating extremity injuryI l i it i Inclusion criteria:

Bruit, history of hemorrhage or hypotension, fracture, hematoma, decreased capillary refill, major soft-tissue injury, nerve or pulse deficitAbsent above findings but “proximity” to a major neurovascular bundle

216 patients underwent angiogram65 injuries identified, 19 required intervention

Indication was “proximity” in 157 patients17 injuries identified 1 required repair17 injuries identified, 1 required repair

Weaver et al: Is Arterial Proximity a Valid Indication for Arteriography in Penetrating Extremity Trauma? A Prospective Analysis. Arch Surg 1990; 125:1256-1260.


Th C tThe CountyTrooskin and Sclafani et al (1993)Prospective study using penetrating extremity trauma registry over 10 monthsN=228 patient with 320 injuriesp j

51 patients had 50 arterial and 17 venous injuriesLimb salvage 100%22 patients taken to OR immediately

41 admitted patients underwent angiography with 46.4% of patients with positive findings

Nine required surgeryAngiogram for proximity done in 153 injuries

7 arterial injuries revealed (4.6%)3 required surgery

Trooskin SZ, Sclafani S, Winfield J, Duncan AO, Scalea T, Vieux E, Atweh N, GertlerJ: The management of vascular injuries of the extremity associated with civilian firearms. Surg Gynecol Obstet. 1993 Apr;176(4):350-4.


P i h l V l TPeripheral Vascular TraumaBleeding Ischemiag

Likely needs exploration

Likely needs exploration

Nonmassive bleeding in a hemodynamically

May consider angio to define ischemic segmenthemodynamically

stable patient: indication for angiogram

segment

angiogramBelow knee injuries: consider jangiography to avoid exploration


K Di l tiKnee DislocationPopliteal artery injury is frequently associated with knee dislocation following blunt traumaIncidence of vascular injuries more common with posteriorthan anterior dislocations because of higher force needed to produce this injuryposterior dislocations: more likely to result in direct injury & even rupture of popliteal artery (isolated transection)anterior dislocations: stretching of popliteal artery may lead to intimal disruption & thrombosis (damage is over a longer segment of the artery)


K Di l tiKnee Dislocation

Nicandri.GT et al. Practical management of knee dislocations: a selective angiography protocol to detect limb-threatening vascular injuries. Clin J Sport Med. 2009 Mar;19(2):125-9.


V I j iVenous InjuriesTimberlake showed no difference in outcome between ligation and repair making ligation an acceptable alternativeK t l t l i ti t d ff t f Kurtoglu et al investigated effects of venous ligation on major veins when primary repair was impossible due to extensive laceration Early leg swelling after ligation most common morbidityN l f h i i ffi iNo sequelae of chronic venous insufficiencyDVT treated with oral anticoagulation and compression stockingscompression stockings

Kurtoglu M et al. Serious lower extremity venous injury management with ligation: prospective overview of 63 patients. Am Surg. 2007 Oct;73(10):1039-43.Timberlake GA and Kerstein MD. Venous injury: to repair or ligate, the dilemma revisited. Am Surg. 1995 Feb;61(2):139-45.


Alt r ti i Di iAlternatives in DiagnosisCatheter-based angiography is gold Catheter based angiography is gold standard for diagnosis of vascular injuries

VERSUS

Color flow duplex imagingComputed Tomographic Angiographyp g p g g p yMagnetic Resonance Angiography


E l ti f V l r I j rEvaluation of Vascular Injury



ReferencesReferencesAscher, Enrico MD, Haimovici, Henry, MD. Haimovici’s Vascular Surgery, 5th edition (2004).Dennis JW Frykberg ER Veldenz HC et al: Validation of nonoperative management Dennis JW, Frykberg ER, Veldenz HC, et al: Validation of nonoperative management of occult vascular injuries and accuracy of physical examination alone in penetrating extremity trauma: 5- to 10-year follow up. J Trauma 1998; 44(2):242-252.Johansen K, Lynch K, Paun M Copass M: Noninvasive vascular tests reliably exclude occult arterial trauma in injured extremities. J Trauma 1991;31(4):515-522.Knudson M, Lewis F, et al: The Role of Duplex Ultrasound Arterial Imaging in Patients Knudson M, Lewis F, et al: The Role of Duplex Ultrasound Arterial Imaging in Patients with Penetrating Extremity Trauma. Arch Surg 1993;128(9):1033-1038.Kurtoglu M et al. Serious lower extremity venous injury management with ligation: prospective overview of 63 patients. Am Surg. 2007 Oct;73(10):1039-43.Nicandri.GT et al. Practical management of knee dislocations: a selective angiography protocol to detect limb-threatening vascular injuries. Clin J Sport Med. 2009 p g j pMar;19(2):125-9.Rich, Norman MD, Mattox, Kenneth, MD, Hirshberg, Asher, MD. Vascular Trauma, 2nd

edition.Snyder WH, Thal ER, Bridges RA, et al: The validity of normal arteriography in penetrating trauma. Arch Surg 1978;113(4):424-428.Stannard J, Sheils T, Lopez-Ben R, et al: Vascular Injuries in Knee Dislocations: The Role of Physical Examination in Determining the Need for Arteriography. JBJS 2004; 86:910-915.Timberlake GA and Kerstein MD. Venous injury: to repair or ligate, the dilemma revisited. Am Surg. 1995 Feb;61(2):139-45.T ki SZ S l f i S Wi fi ld J D AO S l T Vi E At h N G tl J Trooskin SZ, Sclafani S, Winfield J, Duncan AO, Scalea T, Vieux E, Atweh N, GertlerJ: The management of vascular injuries of the extremity associated with civilian firearms. Surg Gynecol Obstet. 1993 Apr;176(4):350-4.Weaver et al: Is Arterial Proximity a Valid Indication for Arteriography in Penetrating Extremity Trauma? A Prospective Analysis. Arch Surg 1990; 125:1256-1260.


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