CHAPTER 24

Vascular Trauma

Michelle Tinkham

First Edition Author: Isobel Green

OBJECTIVES

Overview/Introduction

Trauma is the leading cause of death in persons under the age of 44. Trauma accounts for approximately 164,112 deaths yearly (Emergency Nurses Association, 2007). Recent increases in violent crimes, together with an increase in high-speed motor-vehicle accidents, have not only resulted in an increase in vascular trauma, but also a change in the types of injuries sustained. In marked contrast to the predominance of extremity vascular trauma documented during wartime, many neck and trunk vascular injuries are currently being observed (Gupta, Rao, & Sieunarine, 2001). In addition, there has been an increase in the number of vascular injuries due to self-injection of a variety of substances by intravenous drug users, and complications from endovascular procedures leading to dire consequences for the vascular system.

I. Mechanism of Injury
The mechanism and severity of vascular injuries are the determining factors in management.

A. Penetrating Trauma

1. Most common cause of injury to arterial and venous structures

a. Gunshot wounds account for 55% of vascular injuries

b. Knife wounds account for 35% of vascular injuries

c. Iatrogenic injuries have increased in number because of more frequent interventional radiological procedures (Hallet, Brewster, & Clement Darling, 1995)

2. Causes localized damage to vessels in the case of knife wounds and low velocity missiles. High-velocity missiles (e.g., from a hunting rifle) can create a wide area of explosive cavitation damage around the missile path extending for an area 30 to 40 times the size of the missile (Hallet et al., 1995)

B. Blunt Trauma

1. Refers to an injury in which there is no communication with the outside environment

2. Most commonly caused by motor-vehicle accidents, falls, assaults, and contact sports

3. May cause damage by fracture fragments or fracture dislocations causing excessive and sudden stretch contusions of arteries (Hallet et al., 1995)

4. Prognosis usually more serious than for penetrating injuries because the mechanism of injury is more difficult to diagnose and treat

5. Can often be the cause of accidental death (Payne, 1994)

C. Blast Injuries

1. Refers to injuries from explosions

2. Often associated with military and terrorism but may also be industrial accidents

3. Most common blast injury in US is from fireworks

II. Risk Factors

A. Age

B. Gender

C. Race

D. Alcohol

E. Violence and Self-Inflicted Injury

F. Tobacco and Drug Use

III. Iatrogenic Vascular Damage

A. Frequently Involves Femoral and Brachial Vessels Serving as Access Sites for Arteriography and Endovascular Procedures (Caps, 1998)

B. Injuries

1. Hematoma

2. Hemorrhage

3. Arteriovenous fistula

4. Arterial occlusion

5. Acute limb ischemia

6. Distal embolization

7. Nerve compression

C. Risk Factors

1. Difficulty in maintaining accurate hemostatic pressure in the groin due to obesity (Caps, 2000)

2. Advanced age of patients

3. Severe atherosclerosis

4. Concurrent use of anticoagulant therapy

5. Previous procedures

IV. Assessment

Primary goal and first priority is patient survival.

A. Evaluate Ventilatory Status and Stabilize Airway

B. Identify Circulatory Compromise and Provide Fluid Resuscitation

C. Observe for Hemorrhage and Establish Control

D. Establish Mechanism of Injury (Hess, 1999)

V. Physical Examination

A. Purpose

1. Determine location and extent of injury

2. Identify location of entrance and exit wounds

3. Document presence of hematoma or hemorrhage

B. Signs of Trauma

1. Hard signs

a. Observed pulsatile bleeding

b. Palpable thrill

c. Visible, expanding hematoma

d. Continuous murmur

e. Six P’s: pain, pallor, pulselessness, paresthesia, paralysis, and poikilothermia (Nunnelee, Sander, Oetker, Auer, & Troop, 1994)

2. Soft signs

a. Significant history of hemorrhage or shock

b. Proximity of penetrating injury to major vascular structure

c. Small, nonpulsatile and nonexpanding hematoma

d. Bony injury or proximity penetrating wound

e. Neurological abnormality (Glasgow Coma Scale)

f. Decreased pulse compared to a contralateral extremity (Bjerke, Jakubs & Stuhlmiller, 2003; Perry & Bongard, 2002)

g. Revised Trauma Score (Emergency Nurses Association, 2007)

VI. Considerations Across the Life Span

A. Most are Young and Male

B. Most Injuries Occur Suddenly

C. Injuries Often a Result of Drug or Alcohol Abuse

D. Most Injuries are Iatrogenic Injuries in Older Age Group

E. Number of Comorbidities has Significant Effect on Outcomes

VII. Pertinent Diagnostic Testing

A. Laboratory Tests

1. Essential

a. Full blood count

b. Typing and crossmatching

c. Electrolytes, urea, and creatinine

d. Prothrombin time and activated partial thromboplastin time

e. Blood glucose

f. Arterial blood gas

2. Recommended

a. Blood alcohol

b. Toxicology

c. Amylase

d. Creatine kinase (Bjerke et al., 2003)

B. Noninvasive Tests

Advanced ultrasound technology for patients with soft signs of vascular injury

1. Chest x-ray

2. CT/MRI

C. Invasive Tests (CTA/MRA)

1. Arteriography considered in cases involving:

a. Stable patients with multiple levels of injury

b. Extensive bone or soft tissue injury

c. Shotgun injuries

d. Potential injuries to the subclavian or axillary arteries

e. Pre-existence of peripheral artery disease

f. Penetrating chest and abdominal injuries

g. Injuries to extremities

2. Most patients with hard signs of vascular injury require immediate transfer to the operating room (Britt, Weireter, & Cole, 2001)

VIII. Medical Management (nonoperative management)

A. Options for Medical Management are Extremely Limited

1. Fluid resuscitation to maintain volume

2. Vasopressors to maintain blood pressure

B. Use Temporary Intraluminal Balloon Tamponade to Reduce Hemorrhage

C. Place Percutaneous Stent for Acute Traumatic Arterial Injury (Hood & Blair, 1998)

D. Nonsurgical Management of Vascular Trauma Remains Controversial (Brohi, 2002)

IX. Surgical Management (operative management)

A. Extremity Vascular Injuries

1. Injuries to subclavian, axillary, brachial, superficial femoral, profundus femoral, and popliteal arteries should always be repaired if possible

2. Injuries to the radial or ulnar arteries should be repaired if the other vessel is not functioning or is also injured (Cohen, 1998)

3. Lower-extremity injuries account for 30% to 50% of all vascular injuries (Payne, 1994)

4. Advanced ischemia is established within 6 to 8 hours after arterial disruption or occlusion (Hallet et al., 1995)

B. Intra-Abdominal Vascular Injuries

1. Frequently associated with injuries to other intra-abdominal organs

2. Mortality after surgical intervention for injuries to abdominal aorta can be as high as 50% to 70%

3. Mortality after surgical intervention for injuries to inferior vena cava can be as high as 30% to 53% (Hood & Blair, 1998)

4. Iliac arteries are often repaired by end-to-end anastomosis, depending on the amount of tissue loss

5. Injuries to renal, superior mesenteric, and coeliac axis arteries are usually repaired with the use of autogenous graft if necessary (Cohen, 1998)

6. Injuries to hepatic or splenic vessels may require intracaval shunting or splenectomy

C. Carotid Artery Injuries

1. Severe neurological deficit; ligation of artery recommended

2. Mild or no neurological deficit; repair usually safe and recommended (Cohen, 1998)

3. Surgical technique determined by nature of the injury and similar to those for carotid dissection

4. Majority of cases repaired by direct suture

5. Occasionally segmental resection with end-to-end anastomosis necessary

6. Other techniques include:

a. Bypass with autogenous saphenous vein or synthetic material

b. Patch angioplasty

c. Transposition using external carotid artery (Payne, 1994)

d. Covered stent or detachable balloon

7. May have additional trauma such as C-spine injury

8. Consider transcranial Doppler (TCD) monitoring

D. Vertebral Artery Injuries

1. Relatively rare

2. Often associated with other injuries to cervical structures

3. Direct surgical repair and exposure of vessel difficult because of intimate relationship with cervical vertebrae

4. If the patient has sustained both carotid and vertebral injuries, the carotid repair takes priority (Hood & Blair, 1998; Payne, 1994)

E. Thoracic Vascular Trauma

1. Most common causes of blunt injuries to intrathoracic structures are motor-vehicle accidents

2. May require immediate treatment for tension pneumothorax or cardiac tamponade

3. Knife stabbings followed by gunshot wounds are most common causes of penetrating thoracic vascular injuries

4. Underlying cause of tamponade often needs to be determined and controlled by thoracotomy (Hood & Blair, 1998; Payne, 1994).

F. Venous Injuries

1. Most commonly injured veins:

a. Superficial femoral (42%)

b. Popliteal (23%)

c. Common femoral (14%)

2. End-to-end or lateral venorrhaphy usually performed unless the patient is hemodynamically unstable

3. More extensive venous injury may require repair with an interposition or panel graft (Brohi, 2002)

G. DVT/PE

1. 50% of trauma patients experience DVTs

2. Some DVTs occur after orthopedic or abdominal repairs

a. 10% to 30% occurs proximal to injury

b. 40% to 80% occurs in calf

c. 1% fatal PE occurrence (Hallet, Mills, Earnshaw, & Reekers, 2004)

3. Consider prophylaxis use of retrievable inferior vena cava filters

H. Pseudoaneurysm (false aneurysm)

1. Most occur following catheterization of the femoral artery for cardiac or radiological procedures

2. Development can be insidious in trauma patients

3. Usually detected by ultrasound scanning or CT

4. Easily differentiated from hematoma by duplex ultrasound

5. Most require autogenous patch angioplasty or suture repair (Hood & Blair, 1998)

I. Arteriovenous Fistula

1. Often presents late

2. An audible thrill or palpable bruit may be detected

3. Can remain asymptomatic for some time in deeply placed veins

4. Surgical repair involves dividing the fistula, then repairing the venous and arterial injuries with lateral sutures

5. An autogenous patch angioplasty is sometimes required (Hood & Blair, 1998; Payne, 1994)

J. Thoracic Outlet Syndrome (Hallet et al., 2004)

1. 86% of these patients have a history of trauma

2. Clavicle injuries (auto accidents) can put subclavian vein at risk

3. Axillo-subclavian vein thrombosis

K. Nerve Injuries

1. Occur in approximately 50% of upper-extremity and 25% of lower-extremity vascular injuries

2. The nerve injury determines the long-term prognosis and ultimate functional status of the injured extremity

3. Immediate repair is rarely possible for most penetrating and blunt nerve injuries

4. Primary amputation, rather than reconstruction, is often considered in limbs with massive orthopedic, nerve, and soft tissue injuries (Weaver, Papanicolaou, & Yellin, 1996)

L. Compartment Syndrome and Fasciotomy

1. Most common site is anterior compartment of the lower leg

2. Acute arterial trauma can cause an abrupt increase in compartmental pressure (Payne, 1994)

3. More likely to represent a delayed response after a period of ischemia

4. Early recognition critical in avoiding limb loss

5. Surgical intervention via fasciotomy usually performed if pressures are greater than 30 mm Hg (Brohi, 2002; Caps, 2000)

M. Secondary Lymphadema

1. Tissue loss containing lymph nodes

2. Common after degloving injuries

X. Nursing Management

A. Diagnosis and Evaluation

1. Requires astute physical assessment and management skills

2. Initial resuscitation, assessment, and evaluation essential to a positive outcome

3. In multiple traumas, attention diverted from occult vascular injuries

4. Should proceed concurrently with management of other serious injuries (Hallet et al., 1995; Payne, 1994)

5. Teamwork is essential element of all trauma care

6. Clinical features suggesting great vessel involvement (Moore, 2006)

a. Cardiac arrest

b. Shock

c. Cardiac tamponade

d. Wide mediastinum

e. Recurring hemothorax

B. Intervention

1. Depends on type and severity of injuries

2. ACLS primary/secondary ABCD

3. Airway establishment first priority

4. Complete neurovascular assessment

5. Restore, monitor, and maintain fluid and electrolyte balance

6. Always prepare for expeditious transfer of patient to operating room

C. Expected Patient Outcomes

Overall mortality rate currently in 5% range (Hallet et al., 1995). Principal factors include:

1. Initial identification and management

2. Extent and site of injury

3. Time from injury to repair

4. Age and preinjury health status of the patient

5. Postprocedure management

6. Complications

a. Shock

b. Sepsis

c. Infection

XI. Patient Teaching and Home Care Considerations

A. Continue to Monitor Posthospitalization for Complications. Pay special attention to possible graft infection and delayed healing of the wound

B. Provide Patients and Families with Specific Instructions Regarding:

1. Wound-care techniques and infection-control procedures

2. Principles of hygiene

3. Likely signs and symptoms indicating potential or actual vascular complications

4. Pain management

5. Ongoing rehabilitation

6. Appropriate access to vascular team and follow-up requirements, keeping in mind that patients may live some distance from where their injuries were sustained and treated

7. Long-term effects of the injury

8. Importance of possible continued radiological follow-up if endovascular procedure or need for possible reinterventions

XII. Ethical Issues

A. Family Presence During Resuscitation

B. Organ Donation

C. Nursing Care of Grieving Patients and Family Members

D. Care and Stress Management of Trauma Team Members

CASE STUDY

TRAUMA CALL

Trauma call 5 minutes. An 18-year-old male found by runner at 0500 with penetrating trauma to abdomen, extremities, and chest from multiple small caliber gunshot wounds. Victim unconscious for undetermined amount of time. Witness called 911.

CLINICAL PRESENTATION

Patient is unresponsive with a blood pressure of 90/50 mm Hg, pulse of 118 beats/min; labored shallow breathing, respirations 22 breaths/min. Pupils equal and reactive. Multiple abrasions on face and limbs, possible assault. Possible head trauma as well as thoracic and abdominal injuries. Possible vascular injury to extremities from gunshots.

INITIAL INVESTIGATION

Chest x-ray showed left pnuemothorax with foreign body

Cervical x-ray showed no C-spine injury

CT to abdomen showed free air to sigmoid colon area with multiple foreign bodies (probable bullet fragments)

X-ray to left shoulder showed no fractures. Probable soft tissue injury only.

MRA to right lower extremity shows disruption in flow from femoral artery. Probable dissection from bullet fragment.

CBC, CMP, UA, Type and Cross 4 units, Toxicology screen preformed. Blood chemistry within normal limits. Toxicology screen shows alcohol and marijuana.

Physical examination: Physical examination revealed a large hematoma of the right upper thigh. This hematoma appeared to be expanding. No pedal pulses in right foot. Intravenous lines were inserted, and the patient was resuscitated with 3 L of Normal Saline. His blood pressure was 120/80 following the infusion.

RELEVANT HEALTH HISTORY

Prior health history was unknown. Awaiting contact of next of kin.

SUMMARY OF SIGNIFICANT INJURIES

Bowel and Spleen injury: Trauma surgeon alerted and patient prepared for immediate transfer to Operating Room

Thoracic injury: Thoracic trauma surgeon consulted

Vascular injury: Right thigh—Vascular surgeon consulted

OPERATIVE FINDINGS AND REPAIR

Small laceration found to sigmoid bowel and splenic laceration. Sigmoid Colectomy with Splenectomy performed. 19 fr. JP drain placed

Chest tube placed to left chest to intermittent suction

Fem-Pop bypass with in situ vein to right leg. All performed by trauma surgeon

NURSING MANAGEMENT AND CLINICAL COURSE

Following surgery, the patient was transferred to the surgical intensive care unit. He was intubated and ventilated. Nursing documentation noted the following:

• His chest was clear, and he was saturating at 99%. Drainage to chest tube was minimal.

• Peripheral pulses were returned to right foot. Right leg felt warm and color normal.

• He was hemodynamically stable and in sinus bradycardia.

• His neurovascular observations were stable.

• Foley catheter was placed in the ER. His urinary output was satisfactory. Some hematuria was noted on arrival but resolved.

• His nasogastric tube was on free drainage.

• His abdomen was soft but bowel sounds had not yet returned. Minimal drainage to JP drains.

• His dressings were dry and intact.

• He was sedated and kept pain-free with intravenous morphine. Ventilator weaning protocols were started on postoperative day 1.

• His ongoing laboratory tests remained stable.

SECONDARY DIAGNOSIS AND EVALUATION

No additional injuries were noted. Gunshot wound to left shoulder was soft tissue and wound was cleaned and closed.

CLINICAL COURSE AND PROGRESS

Postoperative day 1: Patient was weaned off the ventilator the following postoperative day. He complained to pain to his right leg and abdomen. He was started on a morphine PCA.

Postoperative day 3: His bowel sounds returned and he was given clear liquids. He tolerated this diet and his NG tube was removed. His diet was advanced as tolerated. Physical therapy evaluated him and light ambulation was encouraged once a day. His chest tube was removed with no signs of distress.

Postoperative day 4: His diet was advanced to regular. His JP drain was removed. He was ambulating several times a day and his pain was controlled with PO meds.

Post-op day 5: He was discharged home with family.

REHABILITATION AND FOLLOW-UP

Follow-up with the trauma surgeon in 1 week.

SIGNIFICANT SOCIAL HISTORY

Patient agreed to alcohol/drug rehabilitation. He and his family were encouraged to seek counseling as well.

CONCLUSION

Patient was reportedly shot by rival gang over drug deal. He did attend counseling and drug rehabilitation and with the support of his family, was attempting to cut his gang ties and return to school. He was made a full recovery from his injuries.

Review Questions

1. The overall mortality rate for vascular trauma is in the range of:

a. 5%

b. 15%

c. 20%

d. 40%

2. Blunt trauma can often be the cause of accidental death because:

a. there can be localized damage to vessels

b. it can cause extensive bone and soft tissue injury

c. it is more difficult to diagnose and treat

d. it can lead to the development of an arteriovenous fistula

3. The primary goal and first priority in trauma assessment is:

a. blood pressure control

b. patient survival

c. pain management

d. management of vascular injuries

4. Following arterial disruption or occlusion, advanced ischemia becomes established within:

a. 8 to 10 hours

b. 4 to 6 hours

c. 2 to 4 hours

d. 6 to 8 hours

5. Trauma is the leading cause of death in patients who are:

a. over age 34

b. under age 24

c. over age 64

d. under age 44

6. An important risk factor for iatrogenic vascular injury is:

a. alcohol abuse

b. cigarette smoking

c. obesity

d. diabetes

7. Hematomas are easily differentiated from false aneurysms by:

a. duplex ultrasound

b. palpation

c. plain radiograph

d. arterial blood gas

8. Signs of vascular injury include all of the following except:

a. expanding hematoma

b. inflammation

c. palpable thrill

d. pallor

9. Most patients who sustain lower-extremity trauma require:

a. an elective arterial bypass

b. primary amputation

c. urgent surgical intervention

d. intraluminal balloon tamponade

10. Injuries resulting from direct vascular intervention include all of the following except:

a. arterial occlusion

b. venous occlusion

c. hematoma

d. nerve compression

Answers/Rationale

1. a. Rapid transport of trauma patients to major surgical centers has decreased the average time from injury to treatment for most vascular injuries (Hallet et al., 1995).

2. c. Because this mechanism of injury is more difficult to diagnose and treat, it is often more deadly than a penetrating injury (Payne, 1994).

3. b. Survival of the patient is the primary goal even if the extremity injury is limb-threatening. (Hess, 1999).

4. d. Advanced ischemia becomes established within 6 to 8 hours after arterial disruption or occlusion (Hallet et al., 1995).

5. d. Trauma is the leading cause of death in persons under the age of 44 (Caps, 2000).

6. c. Obesity is a risk factor due to the difficulty in maintaining accurate hemostatic pressure in the groin (Caps, 2000).

7. a. Hematomas are easily differentiated from false aneurysms by duplex ultrasound (Nehler, Taylor, & Porter, 1998).

8. b. See text: Signs of trauma (1a–e, 2a–f) (Bjerke et al., 2003; Perry & Bongard, 2002).

9. c. Most patients with lower-extremity trauma require urgent surgical intervention (Payne, 1994; Savage & Walker, 1995).

10. b. See text: III. Iatrogenic Vascular Damage, B. Injuries.

REFERENCES

Bjerke, H. S., Jakubs, E. J., & Stuhlmiller, F. E. (2003). Extremity vascular trauma. Retrieved from http://www.emedicine.com/med/topic2812.htm

Britt, L. D., Weireter, L. J., Jr., & Cole, F. J. (2001). Newer diagnostic modalities for vascular injuries. Surgical Clinics of North America, 81(6), 1263–1279.

Brohi, K. (2002). Peripheral vascular trauma. Vascular trauma basics. Retrieved from http://www.trauma.org/vascular/PVTintro.html, accessed February 29, 2012.

Caps, M. T. (1998). The epidemiology of vascular trauma. Seminars in Vascular Surgery, 11(4), 227–231.

Caps, M. T. (2000). The epidemiology of vascular trauma. In R. B. Rutherford (Ed.), Vascular surgery (5th ed., pp. 857–862). Philadelphia, PA: W.B. Saunders.

Cohen, J. R. (1998). Vascular trauma. In R. Faust & J. Cohen (Eds.), Vascular surgery (3rd ed., pp. 47–51). Baltimore, MD: Williams & Wilkins.

Emergency Nurses Association. (2007). Trauma nurse core course (6th ed.). Des Plaines, IL: ENA.

Gupta, R., Rao, S., & Sieunarine, K. (2001). An epidemiological view of vascular trauma in Western Australia. Australian and New Zealand Journal of Surgery, 71, 461–466.

Hallet, J. W., Brewster, D. C., & Clement Darling, R., Jr. (1995). Vascular trauma. In J. Hallet, D. Brewster, & R. Clement Darling, Jr (Eds.), Handbook of patient care in vascular surgery (3rd ed., pp. 290–297). Boston, MA: Little, Brown and Company.

Hallett, J. W., Mills, J. L., Earnshaw, J. J., & Reekers, J. A. (2004). Comprehensive vascular and endovascular surgery. London, UK: Mosby (Elselvier).

Hess, A. V. (1999). Treatment of vascular injuries from penetrating and nonpenetrating trauma. Hand Clinics, 15(2), 249–295.

Hood, J. M., & Blair, P. H. (1998). Vascular trauma. In J. Beard & P. Gaines (Eds.), Vascular and endovascular surgery (pp. 171–199). London, UK: W.B. Saunders.

Moore, W. (2006). Vascular and endovascular surgery: A comprehensive review (7th ed.). Philadelphia, PA: Saunders Elsevier.

Nehler, M. R., Taylor, L. M., & Porter, J. M. (1998). Iatrogenic vascular trauma. Seminars in Vascular Surgery, 11(4), 283–293.

Nunnelee, J., Sander, R., Oetker, D., Auer, A., & Troop, B. (1994). Emergency department nursing vascular assessment: A retrospective study. Journal of Vascular Nursing, 12(2), 35–37.

Payne, J. (1994). Vascular trauma. In V. Fahey (Ed.), Vascular nursing (2nd ed., pp. 536–557). Philadelphia, PA: W. B. Saunders.

Perry, M. O., & Bongard, F. S. (2002). Vascular trauma. In W. S. Moore (Ed.), Vascular surgery (6th ed., pp. 677–695). Philadelphia, PA: W. B. Saunders.

Savage, L. S., & Walker, E. (1995). Vascular trauma on the rise. Journal of Vascular Nursing, 13(4), 106–111.

Weaver, F. A., Papanicolaou, G., & Yellin, A. E. (1996). Difficult peripheral vascular injuries. Surgical Clinics of North America, 76(4), 843–859.

SUGGESTED READING

Spade, K., Aziz, F., & Sumpio, B. E. (2008). The use of retrievable inferior vena cava filters in the trauma population. International Journal of Angiology, 17(1), 23–26.