Limb vascular injury
Introduction
Introduction to limb vascular injury Vascular injury to the extremities is one of the most common severe injuries, with approximately 90% occurring in one limb. In the war, the lower extremity vascular injury is more common. Usually, the upper extremity is more common. The degree of arterial injury of the extremities is as follows: femoral artery, radial artery and radial artery. basic knowledge Sickness ratio: 0.5%-0.9% Susceptible people: no specific population Mode of infection: non-infectious Complications: shock
Cause
Causes of vascular injuries in extremities
Causes:
Vascular injury of the extremities may be caused by sharp injury factors such as bullets, knife stab wounds, etc.; it may also be caused by blunt injury factors such as crush injury, blunt sexual violence, etc. during production operations, traffic accidents, etc. Fractures and joint dislocations caused by sexual external forces are often accompanied by peripheral vascular injuries, which can be either open or closed.
Pathogenesis:
When the arterial vessel is completely broken due to injury, the vascular end is retracted to the surrounding tissue, and the ruptured intima is curled inward to form a thrombus. The distal pulsation of the artery disappears, and the amount of bleeding is often small, but the distal end of the limb has a high rate of necrosis. Partially fractured, the partially fractured artery cannot be completely retracted to the surrounding tissue, and the retraction of the artery enlarges the breach, and the bleeding is more serious. Sometimes the curled inner membrane can cause local thrombosis, cover the gap, and other arterial walls. Maintaining integrity, so the distal pulse can still exist, the arterial blood vessels are partially broken, and if the surrounding tissue wraps the hemorrhage and hematoma, it is limited, and the traumatic pseudoaneurysm will be formed in the long-term, such as accompanied by nearby vein damage. Arteriovenous fistula will be formed. Arterial contusion is caused by blunt violence. The endocardium and medial membrane are poorly stretched, pulled, and distorted. The first rupture causes extensive hematoma of the arterial wall, and the intima of the artery is broken. Detach into the lumen to form a thrombus.
Prevention
Limb vascular injury prevention
Timely and thorough treatment of trauma.
(1) Closely observe the changes in vital signs of the patient. The pulse and blood pressure are measured every 15 minutes. The patient is found to have pale face, rapid pulse and blood pressure. The rescue measures should be taken quickly, and the intravenous blood transfusion channel should be established quickly when the doctor is notified.
(2) Close observation of the affected limb for proper care.
1) Observe the brakes and knees of the affected limb. If the patient's distal limb is found to have insufficient blood supply or the dorsal artery of the foot is not touched, the patient should immediately give the patient a lower occipital pillow, bend the knee 90°, bend the hip, and brake the affected limb to reduce the tension of the radial artery. Before the fracture is reset, the Brown frame or the plate frame is disabled to raise the affected limb or tow.
2) Observe the local hematoma. The bedside is equipped with a rubber tube tourniquet. If the swelling around the affected limb continues to increase, you should prepare for the bleeding.
Complication
Complications of extremity vascular injury Complications
1. Bleeding: open vascular injury can cause external bleeding, jetted bright red blood is arterial hemorrhage, large amount of bleeding can cause shock; spilled dark red blood is venous hemorrhage; extensive oozing is capillary bleeding.
2. Shock: Large blood vessel injury can be shocked by a large amount of blood loss. Closed vascular injury causes a large amount of blood to flow into the interstitial space, causing swelling and blood stasis or into the chest cavity, causing internal bleeding in the abdominal cavity or pelvic cavity.
3. Limb pain: Arterial injury caused acute ischemia of the limbs, tissue hypoxia, severe pain, 1-2 hours after ischemia, limbs felt numb or disappeared, muscle paralysis after 4 hours of ischemia, loss of contractile function.
4. Arterial injury The distal pulsation of the limb disappeared, the skin was pale, the skin temperature decreased, and the limb collapsed; the venous injury was distal to the sputum or purple spot, the skin temperature decreased, and the swelling was severe.
Symptom
Symptoms of vascular injury in extremities Common symptoms Traumatic traumatic bleeding Calf or forearm gap syndrome Hypotension Hematoma formation severe pain Vascular injury Open injury shock
Firearm injuries, cut wounds, fractures, dislocations and contusions on the main vascular paths of the extremities should be alert to the possibility of vascular injuries. High-speed bullets or shrapnel wounds such as the main blood vessels adjacent to the injured road should be explored during debridement. Sometimes the bullets are not Passing through the blood vessels, but the shock wave can cause severe contusion of the blood vessels, leading to embolism or rupture.
Open injury is mainly characterized by local pulsatile hemorrhage, hematoma formation or hemorrhagic shock caused by it, and closed injury is characterized by local tension hematoma, progressive swelling of the limb or with varying degrees of hemorrhagic shock, and the injured artery is far away. The pulse of the end can be weakened or disappeared, and it can exist continuously. The degree of ischemia of the distal limb of the injured artery depends on the degree of vascular injury, the compensatory ability of the collateral circulation, the degree of damage of the surrounding tissue, and the like, and the arterial blood supply is interrupted. Distal arterial thrombosis and increased pressure in the compartmental compartment are common causes of distal circulatory disorders. Injury limbs can cause severe pain due to trauma and ischemia. Long-term ischemia can cause limb paresthesia to sensory loss, and limbs appear. Hey, severe pain turns into pain disappearing. Arterial contusion caused by blunt injury may have no limb ischemia symptoms in the early stage, but the fracture of the endothelium will undoubtedly lead to arterial embolism. This usually occurs several hours to several days after injury.
X-ray films should be considered for the possibility of vascular injury if the fracture and displacement of the limb are found, and the angiographic examination can determine the diagnosis of vascular injury. Ultrasound Doppler examination can find that the distal artery pulsation disappears.
According to the medical history, clinical manifestations and angiography and other auxiliary examinations can usually make a diagnosis, early diagnosis of arterial injury is more difficult, combined with non-invasive vascular examination is a common means of diagnosis of limb injury, short-term observation (12 ~ 24h) is also a diagnosis When the ankle index (ABI) <1.00, the arterial pulsation still weakens or disappears after the shock is corrected, and the angiography and limb vascular injury diagnosis steps should be performed.
It is worth noting that 20% to 30% of injuries, despite arterial vascular injury, can still affect the pulsation of the distal arteries. Therefore, the presence or absence of pulsation can not be determined solely by the presence or absence of arterial pulsations.
Examine
Examination of limb vascular injury
First, arterial angiography
A large number of clinical data indicate that patients with sharp and blunt trauma, if their limbs are beating normally and the ankle index (ABI) 1.00, no arterial angiography is required; for distal pulsation weakened or disappeared or ABI < 1.00 Patients, diagnostic angiography is of great value. In a study of 373 patients with sharp injuries, there were 104 high-risk patients with one or more of the pulse, nerve damage and gunshot wounds. Arteriography confirmed that there were 40 patients (38%) with vascular injury, 15 of whom required arterial repair; 165 of the moderate risk group, including ABI <1.00 or showed fracture, hematoma, bruise, capillary filling Delayed, patients with a history of hemorrhage, hypotension, and soft tissue injury, 20% of the angiograms confirmed vascular injury, 5 required repair; the remaining 104 were low-risk groups, 9% of which were confirmed to have vascular injury, and none required surgery The remaining clinical studies have also confirmed that this selective angiographic examination can detect more than 95% of patients with vascular injury, and the remaining missed patients include obstruction of small branch vessels or small non-obstructive injury of large vessels. It is usually clinically insignificant and does not require surgical treatment.
2. Color Doppler Ultrasound (CFD) CFD is increasingly used in the diagnosis of vascular injuries in extremities. Bynoe et al. reported a sensitivity of 95%, a specificity of 99%, and an accuracy of 98%. Can be used as an alternative or auxiliary examination of angiography. Gayne reported in 43 cases of angiography to diagnose 3 cases of superficial femoral artery, deep femoral artery and posterior tibial artery injury and CFD failed to diagnose, CFD diagnosis One case of superficial femoral artery intimal pulsation and angiography missed diagnosis, although CFD could not detect all cases, it can find all the major injuries that require surgical treatment, and save the patient's cost.
Second, surgical exploration
Clinical symptoms showing a large possibility of major arterial injury can not be diagnosed, should be immediately angiographic or surgical exploration, although there may be negative exploration, but if missed diagnosis or delay treatment, can cause limb or loss of life, in acute limb ischemia In the case, negative observations and conservative treatment should not be taken.
Diagnosis
Diagnosis and diagnosis of vascular injuries in extremities
diagnosis
According to the clinical manifestations, the vascular injury can be correctly diagnosed.
Differential diagnosis
Arterial injury and abscess should be identified, and this misdiagnosis has occurred since ancient times. Because the penetrating wound is accompanied by a hematoma, the bleeding can stop spontaneously and the peripheral arteries beat normally. The vessel is tangentially damaged, and hematoma and pseudoaneurysm occur after a few days to weeks after the wound is closed. As the hematoma compresses the peripheral nerves, it can cause pain, and edema infiltration can be misdiagnosed as abscess.
