Overview

What are vascular Injuries?

In any injury involving blood vessels two things can happen :

• Massive bleeding or hemorrhage
• No bleeding at all or ischemia

The consequences of both are disastrous. Massive bleeding is life-threatening and can kill the patient if left unrecognized. If there is no bleeding and the limb becomes ischemic, it can lead to limb loss, stroke, gangrene bowel and multiple organ failure leading to the death of the patient.

How common are they?

The incidence of Vascular Trauma injury is on the increase due to fast cars and motorcycles, increase in violence all over the world leading to penetrating injuries in the form of gun-shot and knife wounds.

Limb injuries are mostly penetrating and may be due to violence, industrial accidents or rarely in hospitals due to vessel catheterization as in angiograms.
Sometimes the injuries are blunt but I have caused Vascular Trauma leading to the cutting of the blood supply to the concerned limb.

Of late there is a sharp increase in injury due to bomb blasts and explosions.

How does the body try to protect you?

• The vascular tree has some inherent protective properties against stretching and bending causing fewer blunt injuries to the blood vessels.
• The smooth muscle within the blood vessel protects against stretching type injury and minor puncture wounds that heal spontaneously.
• Smooth muscle within the vessel also protects against massive hemorrhage that could cause death.
• If the vessel is totally cut vascular spasm along with low blood pressure promotes clotting and helps vital organ perfusion.
• In acute stoppage of blood flow, the oxygen supply to the limb or organ suffers and so anaerobic respiration takes place producing lactic acid that activates various inflammatory pathways.
• If the blood supply is not established then cell death occurs.
• If the blood supply is cut for 6 hours the muscles can recover.
• Nerves are very sensitive and short term ischemia will lead to long term numbness.

Will all be well if the blood supply is restored?

Sudden restoration of blood supply will wash the poisons accumulated in the ischemic muscles into circulation and cause myocardial depression, generalized vasodilation, severe hypotension, sepsis and even sudden death.

How do they present?

• Massive bleeding from cut vessels, needing urgent surgical exploration.
• Cold pale limb
• Absent distal pulses
• Expanding hematoma

In these conditions, urgent surgery is needed. A cold, pulseless limb may be in a patient with low blood pressure and is not an indication for surgical exploration.

How is one sure that the blood supply has stopped when there has been no bleeding?

Just remember the six ‘Ps’ given below:

1. The limb will be very Painful.
2. The limb will be Pale or look white
3. There will be Pulseless when the doctor feels it.
4. There will be Paresis or numbness
5. There will be Paralysis or lack of movement
6. The limb will feel like Perishing with cold.

What should we do in injury cases?

If there is obvious bleeding just take a clean cloth and put pressure to control the blood loss. Get the patient to the hospital as soon as possible. Do not mess around.

What should we expect when we reach the hospital?

The first thing the doctor would do is to stop obvious bleeding and get someone to pump in fluids through the uninjured arm vein or a vein in the neck. Then he would examine the patient from head to toe. He would ask the relatives or the patient if he has any other ailment like diabetes, hypertension or heart disease