Challenges with vascular injuries in resource poor setting
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Transcript of Challenges with vascular injuries in resource poor setting
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Joel ArudchelvamConsultant Vascular and Transplant Surgeon
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TEACHING HOSPITAL ANURADHAPURA
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TEACHING HOSPITAL ANURADHAPURA
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VASCULAR INJURY
Head And Neck
Thorax
Abdomen and Pelvis
Limbs (Extremity )
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VASCULAR INJURY
Head And Neck
Thorax
Abdomen and Pelvis
Limbs (Extremity )
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VASCULAR INJURY
Head And Neck
Thorax
Abdomen and Pelvis
Limbs (Extremity )
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VASCULAR INJURY
Head And Neck
Thorax
Abdomen and Pelvis
Limbs (Extremity )
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EXTREMITY VASCULAR INJURIES
Common
Results in limb loss at times loss of life
Loss of earning capacity
Economic burden
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CAUSES
Road Traffic Accidents – 38.5%
Trap gun – 7.5%
Fractures and dislocations
Cuts and stabs
Iatrogenic
Teaching Hospital Anuradhapura 2015
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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
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CAUSES
Road Traffic Accidents – 38.5%
Trap gun – 7.5%
Fractures and dislocations
Cuts and stabs
Iatrogenic – 5 cases
Teaching Hospital Anuradhapura 2015
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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
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CAUSES
Road Traffic accidents – 38.5%
Trap gun – 7.5%
Fractures and dislocations
Cuts and stabs
Iatrogenic
Mechanism of injury
Sharp / penetrating
Blunt
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MECHANISM OF DISRUPTION ARTERIAL LEVEL
Transection
Laceration
Contusion
Kink
Intimal flap
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VASCULAR TRAUMA
Signs of a vessel injury
Hard signs
Soft sign
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VASCULAR TRAUMAHard signs
Active bleeding Signs of distal ischaemia – ‘ Ps ’
Absent pulse
Pain
Pale
Perishing Cold
Paresthesia / Anaesthesia
Paresis / Paralysis
Thrills, Bruits Expanding hematoma
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VASCULAR TRAUMA
Soft signs
Hematoma
Injury close to a known neurovascular bundle
Reduced pulse
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VASCULAR TRAUMA
Soft signs Hematoma
Injury close to a known neurovascular bundle
Reduced pulse
Hard signs – explore
Soft signs – observe
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VASCULAR TRAUMA
Paresis / Paralysis & Paresthesia / Anaesthesia
Late Signs
Paresis & Paresthesia
Viability Of The Limb Is In Immediate Threat
Anaethesia & Paralysis
Not Viable
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PROBLEM WITH VASCULAR INJURY
Delay α Dead Limb
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SUCCESSFUL MANAGEMENT OF EXTREMITY VASCULAR INJURY
Early Detection
Early intervention
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CHALLENGES
Failure to detect early
Transport and Communication
Trained Staff, ability to handle Case load and
Infrastructure
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SUCCESSFUL MANAGEMENT OF EXTREMITY VASCULAR INJURY
Delay in Detection
Delayed intervention
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FAILURE TO DETECT EARLY
Lack of knowledge
Busy emergency units
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TRANSPORT
Ambulance service
Traffic
All takes time
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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
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TRANSPORT
Staff transport
Most live away from Anuradhapura
Average distance to travel – 85km
Mode – own vehicle and self driving
No official transport
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TRANSPORTATION
Average time from injury to reperfusion
- 12.6 hours (0.5 to 48)
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CASE LOAD, TRAINED STAFF AND INFRASTRUCTURE
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CASE LOAD
Anuradhapura district Population –860,575 (4.2%)
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CASE LOAD
Other areas covered Total population covered -5,546,355 (27%)
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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
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Insert ministry charts
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Insert ministry charts
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STAFF
Medical officers - 05
Nurses - 15
• Ward• Theatre• HDU
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“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
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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
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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
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Thank You