Vascular debridement

In the following cases, debridement should be performed in time to explore blood vessels, control bleeding, treat combined injuries, and prepare for early recovery of vascular access: 1 persistent bleeding or repeated bleeding. 2 subcutaneous pulsatile hematoma, or the limb circumference is increasing, there may be deep hematoma. 3 The injured limb has a temperature drop, the pulse disappears, the skin is pale, numb, and the motor function is weakened. 4 deep stab wounds or through the injury suspected of important organ or tissue damage. Treatment of diseases: vascular injury, hand vascular injury, limb vascular injury, preoperative preparation 1. Temporary hemostasis: Generally, hemostasis is temporarily stopped by pressure bandaging, stuffing, etc., and the tourniquet is used as little as possible. There are fractured limbs that need to be temporarily fixed. 2. Prevention and treatment of shock: rapid blood transfusion, plasma or other expansion agents (such as dextran) to control shock. In case of emergency, first lose glucose or normal saline. 3. Improve blood supply: If the blood pressure is relatively stable, it can be used for sympathetic ganglion closure and improve the blood supply of the injured limb. For occlusive injury, sympathetic ganglion closure can identify vascular injury and vasospasm. After the sympathetic ganglia is closed, if the serious lack of blood supply to the injured limb fails to improve immediately, it needs to be surgically explored. 4. Anticoagulant: Anticoagulant is generally not used before surgery. If surgery must be delayed for a few hours, heparin may be considered intravenously or subcutaneously in the absence of acute bleeding in the wounded to reduce the chance of distal thrombosis. Heparin has a short-acting effect and has little effect on subsequent surgery. If influential, it can be neutralized with protamine sulfate. If there is extensive damage to the soft tissue, it is best not to use anticoagulant to avoid large area exudation. 5. Injury preparation: The skin of the entire injured limb should be disinfected in order to expose the distal blood vessels if necessary for retrograde thrombectomy. Surgical procedure The success or failure of vascular repair is largely determined by the thoroughness of debridement, and this operation should be done carefully. 1. Control bleeding: In debridement, you should first control bleeding, and be prepared to stop large amounts of bleeding at any time. The wound is first pressured and bandaged to temporarily stop bleeding, and the pressure can not be removed before the measures to control bleeding are not done. In order to reduce intraoperative bleeding, a tourniquet can be used as a last resort. In areas where the tourniquet cannot be used, a small incision should be made above the wound to reveal the proximal segment of the injured artery. After separation, a gauze band is used (use a soft rubber tube if necessary) to block the blood if necessary. Flow, stop bleeding. There are many ways to control blood flow, and it is most convenient to use a non-invasive blood vessel clamp. If there is no suitable blood vessel clamp, the following methods are available: (1) Pull the gauze over the blood vessel or lift it around one turn, then pinch it with your fingers or hold the gauze band with a normal hemostat. (2) A piece of rubber tube is placed on the artery to tie the gauze band. (3) After the two ends of the gauze tape are brought together, put a short thick rubber tube, and after tightening the gauze band, clamp it with a hemostat. 2. Wash the wound: Clean the wound and surrounding skin according to debridement. Usually the wound is initially cleaned, the foreign body is removed, the blood is stopped and rinsed, and the main blood vessel is repaired and further debrided. 3. Exploring the blood vessels: along the direction of the blood vessels, the incision is extended up and down to fully expose the blood vessels. Before the two ends of the blood vessel are completely exposed and controlled, if there is bleeding, the bleeding can be stopped by hand on the outside of the wound, or the blood can be stopped by the finger in the wound. Then, the proximal and distal segments of the arteries and veins are separated in the healthy tissue of the injured area, respectively, in order to accommodate the non-invasive blood vessel clamp to control bleeding. After controlling bleeding in the wound, the tourniquet or other proximal blood flow control should be relaxed. If the artery is blocked for a longer period of time, a small amount of heparin solution (10 mg of heparin in 100 ml of normal saline) should be injected into the distal part of the artery to prevent thrombosis. Finally, further identify the type, extent and extent of vascular injury and the condition of adjacent tissue damage to determine the method of repair. 4. Whole blood vessels: Repair and suture of blood vessels must be performed on healthy walls. Therefore, the damaged tissue of the tube wall should be fully removed to remove the contaminated and damaged parts; the intima of the blood vessel should be carefully examined, and if the endometrium is incomplete, it should be removed. If it is a firearm injury, it should be removed about 5mm beyond the visible part of the naked eye to prevent thrombosis. However, it is also necessary to prevent unnecessary excessive resection so as not to affect the end-to-end anastomosis of the blood vessel. The ends of the vessel after the repair of the broken end or the end of the damaged end should be slightly inclined to make an anastomosis. When the blood vessel is divided and lacerated, if the edge of the crack is still neat, the slit can be cut with a small scissors for repair. However, if the gap is not neat and the pollution is serious, it should be removed and end-to-end anastomosis or vascular grafting. The segment of the blood vessel that has been clamped with a conventional hemostatic forceps should also be removed. When the blood vessel is completely broken, the broken end of the blood vessel needs to be trimmed. In the case of vascular contusion, the intima often becomes thick or ruptured, and there may be a dissection of the hematoma or thrombosis, which must be completely removed and then anastomosed.