Irina Kovatch, PGY 4 Kings County Medical Center Morbidity and Mortality December 9, 2010

Size: px

Start display at page:

Download "Irina Kovatch, PGY 4 Kings County Medical Center Morbidity and Mortality December 9, 2010"

Felicity Bradley
5 years ago
Views:

1 Irina Kovatch, PGY 4 Kings County Medical Center Morbidity and Mortality December 9, 2010

2 29 yo M BIBEMS as a trauma code on 10/14/2010 Multiple GSW: right chest, RUE, RLE VS: 98, 165/90, 110, 22, 100% A&O, agitated, c/o severe pain in RLE, oozing from wounds in RUE and chest with nonexpanding hematomas PMH: denied Case Presentation PSH: s/p ex-lap, left nephrectomy for GSW 11 years ago at Brookdale Hospital Intubated for airway protection IVFs/PRBCs transfusion initiated

3 Head: NC/AT, intubated Abd: soft, NT/ND, BS+, midline laparotomy scar Wounds - 10 Physical Exam Right chest: anterior and posterior axillary folds, axilla RUE: medial and lateral proximal arm, lateral distal arm, lateral and medial forearm - no radial pulse, fingers warm, pink with good cap refill RLE: anterior proximal thigh, posterior distal thigh - gross deformity, thigh swelling, good distal foot pulses

4 CBC /14.4/42.4/216 BMP - 136/3.8/100/22/19/1.47/144 LFTs - 7.7/4.4/52/21/47/0.4 Amylase/Lipase - 65/52 Lactic Acid VBG /69/24/20.8/-0.2 EtOH <10 UA neg Labs Utox positive for cocaine, not confirmed

5 Imaging CXR - 2 bullets projecting over the right acromion process and mid clavicle with associated comminuted fxs, no PTX Right humerus XRay - metallic shrapnel adjacent to humeral head and comminuted fracture of the greater tubercle R forearm XRay - no fxs Pelvis XRay - neg Femur XRay - severely comminuted fracture of the mid femoral shaft with associated metallic shrapnel Transfer to IR for angiogram of RUE and RLE Vascular surgery and orthopedic surgery consults

8 Angiogram RUE vasospasm and injury to the distal brachial artery, no bleeding, no other injuries the area of injury bridged and a 6 mm x 5 cm Viabahn stent graft deployed distal runoff with vasospasm - 4 boluses of 200 mcg of nitroglycerine achieved temporary relief, however spasm returned observe, if limb threat becomes apparent - exploration right hand viable, good cap refill RLE no major vascular injury

13 Serial doppler and compartment checks Flexor compartment 10 mm Hg Ortho - RLE traction Total transfusion: 10 Units PRBC and 5U FFP Stable overnight HD 1 - ICU

14 Forearm SBP: left 120, right 70 - possibly occluded stent graft, no compartment, good cap refill Repeat angiogram - thrombosis of the stent with distal filling of the radial and ulnar arteries via collaterals OR for vascular repair Ortho: External fixation of right femur awaiting ICU clearance for definitive fixation IVC filter placement by IR HD 2

16 Vascular Surgery Exploration of right brachial artery via lazy S incision Arterial injury identified: blast effect and ~ 1.5 cm destruction of the intima (vein completely transected) Stent-graft removed, artery transected to attain healthy intima at proximal and distal ends Proximal Fogarty thrombectomy 3 cm basilic vein harvested, reversed Proximal anastomosis Distal thrombectomy and anastomosis, SubQ and skin closed, JP left Excellent radial pulse, no compartment

17 Hospital Course HD 3 - extubated, sling for RUE HD 5 Ortho: removal of ex-fix, IM nailing of right femur POD 1 - RLE WBAT HD 6 Transfer to floor, neuro and rehab consults Neuro: exam limited due to pain, decreased motion of the RUE, decreased grip - pain control, rehab, EMG in 2-3 weeks as outpatient Dispo: acute rehab placement

19 Questions

20 Peripheral Vascular Trauma Initial assessment and care control of external hemorrhage diagnosis of limb ischemia neurologic status of the injured extremity compartment syndrome Identifying the arterial segment involved Window of opportunity for salvage varies site and nature of injury the presence of efficient collaterals patient's age and hemodynamic status

21 Hard Signs of Vascular Injury Presence of hard signs mandates immediate intervention Pulsatile bleeding Expanding hematoma Absent distal pulses Cold, pale limb Palpable thrill Audible bruit If the site of injury is obvious angiography is unnecessary Otherwise, angiography can be performed emergently in the OR, unnecessary interventions and investigations should be avoided to minimize the delay of definitive care

22 Investigation or exploration of patients with soft signs alone is not warranted peripheral nerve deficit Soft Signs of Vascular Injury history of moderate hemorrhage at scene reduced but palpable pulse injury in proximity to a major artery Patients should be admitted and observed for 24 hours

23 Noninvasive Diagnostic Adjuncts Pulse oximetry reduction in readings in one limb is suggestive of, but neither confirms nor excludes a significant vascular injury Doppler Ultrasound presence of a doppler signal in a pulseless limb does not imply a less severe or less urgent injury reduction in the ABI in the presence of a palpable pulse does not indicate the presence of a vascular injury requiring intervention Duplex Ultrasound can detect intimal tears, thrombosis, false aneurysms and arteriovenous fistulae and has a high sensitivity

24 Angiography Remains the gold-standard for investigation and delineation of vascular injury Best performed in the operating room, with the surgeon exposing the vessel proximal to the injury for control Transfer to the radiology suite should be restricted to hemodynamically stable patients with proximal injuries Angiography may be used to treat certain selected injuries, where expertise and technical facilities are available

25 Angiography Pros & Cons Pros can evaluate multiple levels of injury in the same blood vessel can be used to image vascular structures within the thorax, abdomen, retroperitoneum, or extremities at the same time allows for control of vascular injury at the time of diagnostic angiography Cons may not necessarily grade the severity of vascular injury accurately does not image all vascular structures, therefore does not evaluate venous injury very well

26 Surgical Clinics of North America - Volume 81, Issue 6 (December 2001) Interventional Techniques in Vascular Trauma Scalea T, Sclafani S. Definitive hemostasis - embolization Torso pelvic, lumbar, peripancreatic, perinephric, hepatic Extremity injuries limited use due to distal ischemia, may be used for profunda femoris, axillary and popliteal artery branches Vascular control - balloon occlusion Mediastinal vascular injuries left subclavian, axillary Neck Zone 1 and Zone 3 Lower extremity for injury at the level of inguinal ligament Vascular repair - limited experience with transcatheter stenting for trauma, theoretical therapeutic options include use for Zone 3 carotid injury from blunt trauma traumatic aortic and popliteal vascular injury

27 The Journal of Trauma: Injury, Infection, and Critical Care downstatesurgery.org Issue: Volume 60(6), June 2006, pp Results of a Multicenter Trial for the Treatment of Traumatic Vascular Injury with a Covered Stent White R, Krajcer Z, Johnson M, et al. Prospective, multicenter, nonrandomized registry trial with a historical control to surgical management 62 patients treated with Wallgraft Endoprosthesis for arterial trauma ( ) Endpoints exclusion success at procedure and at 12-months primary patency and freedom-from-bypass at 12-months major adverse events Locations of arterial injuries iliac (33), subclavian (18), femoral (11) Indication for treatment perforation/rupture (33) acute pseudoaneurysm (10) AV fistula (16) and dissection (3)

28 The Journal of Trauma: Injury, Infection, and Critical Care Issue: Volume 60(6), June 2006, pp Results of a Multicenter Trial for the Treatment of Traumatic Vascular Injury with a Covered Stent White R, Krajcer Z, Johnson M, et al. Results post-procedure exclusion in 58 of 62 cases (93.5%) 1-year exclusion rates % iliac, 90.0% subclavian, and 62.3% femoral 1-year primary patency rates % iliac, 85.7% subclavian, and 85.7% femoral freedom-from-bypass - in 74.3% iliac and 100% femoral and subclavian injuries most common adverse events - stenosis 4.8%, occlusion 7.9% no device- or procedure-related deaths rates and severity of complications - less than those associated with surgical repair

29 29 yo M s/p fall from a bucket truck (height - 7 m) Multiple injuries to the left arm, right leg, and pelvis Evaluation VS: 90/60, 98, 24 downstatesurgery.org The Journal of Trauma: Injury, Infection, and Critical Care Issue: Volume 56(6), June 2004, pp Endovascular Repair of Brachial Artery Transection Associated with Trauma - Case 1 Maynar M, Baro M, Qian Z, et al extensive soft tissue laceration on the left arm and axilla no distal pulses in the LUE left forearm and hand were cold, pale, and edematous multiple fractures in the pelvis and right tibia and fibula

30 The Journal of Trauma: Injury, Infection, and Critical Care Issue: Volume 56(6), June 2004, pp Endovascular Repair of Brachial Artery Transection Associated with Trauma - Case 1 Maynar M, Baro M, Qian Z, et al Angiography - brachial artery transection above elbow with extravasation and non-visualization of distal arteries 6 58-mm Teflon-covered Jostent deployed over a wire Repeat angiogram - no extravasation, distal runoff intact Patient started on LMW heparin for 3 months Immediate return of pulses, increased temperature, shorter capillary refill time, and improved skin color Segmental blood pressure, Doppler ultrasound, tissue oximetry - significant improvement of distal circulation Penetrating wound surgically repaired, ortho repairs, patient continued on antibiotics throughout hospital stay

32 The Journal of Trauma: Injury, Infection, and Critical Care Issue: Volume 56(6), June 2004, pp Endovascular Repair of Brachial Artery Transection Associated with Trauma - Case 1 Maynar M, Baro M, Qian Z, et al Patient required repeated LUE wound debridements in OR HD 16 paresthesia/intense pain in left forearm and hand PE - diminished pulse in the left forearm Angiography - complete occlusion at the level of the proximal end of the stent-graft Occluded segment was dilated with angioplasty balloon and a second Jostent was placed over the original one Repeat angiogram showed a fully patent graft with excellent runoff in the radial and ulnar arteries

35 The Journal of Trauma: Injury, Infection, and Critical Care Issue: Volume 56(6), June 2004, pp Endovascular Repair of Brachial Artery Transection Associated with Trauma - Case 1 Maynar M, Baro M, Qian Z, et al Fibrinolytic therapy was initiated (urokinase) for partially occluded interosseous artery Next day, a patent interosseous artery was demonstrated Discharged from the hospital 8 weeks after the event Last follow-up (7 months) the stent-graft is patent, with good distal runoff Patient remains free of vascular symptoms and continues to receive PT for his injured hand

36 67 yo F s/p fall downstatesurgery.org The Journal of Trauma: Injury, Infection, and Critical Care Issue: Volume 56(6), June 2004, pp Endovascular Repair of Brachial Artery Transection Associated with Trauma - Case 2 Maynar M, Baro M, Qian Z, et al PMH: Parkinson s disease, s/p multiple bilateral shoulder dislocations VS: BP 182/84, HR 95 Conscious but anxious, agitated, pale, and sweating Right axillary hematoma cm Right arm and hand pale, swollen, and pulseless Xray - right shoulder dislocation, no fracture

37 The Journal of Trauma: Injury, Infection, and Critical Care Issue: Volume 56(6), June 2004, pp Endovascular Repair of Brachial Artery Transection Associated with Trauma - Case 2 Maynar M, Baro M, Qian Z, et al Angiography - abrupt discontinuation of the right proximal end of the brachial artery with opacification of the distal artery via collaterals (45 mm segment) Attempts to cross the injured segment via femoral approach were unsuccessful A guidewire was advanced to subclavian artery via a retrograde approach from the ipsilateral brachial artery Repeat angiogram - contrast extravasation suggestive of a partial transection

39 The Journal of Trauma: Injury, Infection, and Critical Care Issue: Volume 56(6), June 2004, pp Endovascular Repair of Brachial Artery Transection Associated with Trauma - Case 2 Maynar M, Baro M, Qian Z, et al Two covered stents (Jostent) used to repair the injury (6 58 mm and 7 58 mm with 20 mm overlap) Post-procedural angiography - complete bridging of the partially transected brachial artery, no leak Urokinase bolus given for slow distal runoff with improved blood flow after injection Distal pulses, limb temperature, and skin color improved Significant improvement in segmental blood pressure, Doppler ultrasound, and tissue oximetry Patient transferred for orthopedic treatment the next day 1 month post-procedure - excellent flow across the stented segment by Doppler ultrasound

41 Conclusion Catheter-based therapy has an increasing role in the management of vascular trauma to the extremity Described areas of treatment of arterial injury with application of covered stents include subclavian, brachial, iliofemoral, and infrageniculate arteries Application of these techniques is fairly new, long-term results remain to be seen Endovascular treatment of arterial lesions should be considered in centers with sufficient experience and available personnel to perform the procedure expediently

Combat Extremity Vascular Trauma

Combat Extremity Vascular Trauma Training teams to be a TEAM Chatt A. Johnson LTC, MC, USA 08 March 2010 US Army Trauma Training Center Core Discussion Series Outline: Combat Vascular Injury Physiologic