TRAUMA VASCULAR

NOR

 Di seluruh dunia,PENDAHULUAN
sekitar empat juta orang meninggal

setiap tahun dari Kecelakaan, kekerasan dan cidera yang

tidak disengaja, dan puluhan juta yang tersisa cacat
permanen

Perdarahan masif adalah penyebab utama dari kematian

Pasien trauma vascular dengan hemodinamik tidak stabil

harus dilakukan identifikasi yang tepat dan efektif untuk

segera dilakukan damage control surgery
Haemostatic resuscitation adalah tujuan awal, kemudian

dilakukan definitive surgical care

Ahli bedah vaskular menjadi anggota kunci dari tim

trauma untuk
vascular

kontrol

perdarahan,

dan

rekonstruksi

Krug, E.G., Sharma, G.K., and Lozano, R. The global burden of injuries. Am J Public
Health. 2000; 90: 523526

MEKANISME TRAUMA
Penetrating trauma
Trauma tusuk
Peluru
Iatrogenik

Blunt trauma
Kecelakaan lalu lintas
Jatuh
Assault
Vascular trauma, Harkin, Denis W, Surgery - Oxford International Edition , Volume 33 ,
Issue 7 , 323 - 329

PATOFISIOLOGI TRAUMA VASKULAR

(1) Haemorrhage;
lethal triad of coagulopathy, hypothermia and acidosis.
(2) Regional (arterial occlusion) and global ischaemia (shock)
(3) Systemic inflammatory response (SIRS)
Cedera jaringan dan gangguan integritas selular

menyebabkan release mediator pro-inflamasi. Interaksi

komponen darah seluler dan endotel vaskular
menyebabkan pelepasan mediator pro-inflamasi dan
aktivasi kekebalan sel, yang jika tidak terkontrol,
menyebabkan (SIRS)

Rossaint R, Bouillon B, Cerny V, et al. Management of bleeding following major trauma: an updated European guideline.
Crit Care 2010; 14: R52.

ASSESSMENT PADA TRAUMA VASCULAR

Triage and immediate care

Hard Sign

Soft Sign

Pulsatile hemorrhage
Ekspanding hematoma

Unexplained hypotension
Unexplained tachycardia
History of hemorrhage

Thrill or bruit

Small hematoma

Acute ischemia
Absent distal pulses

Peripheral nerve deficit

Schwartzs Principles of Surgery 8th edition,2004

TRIAGE AND IMMEDIATE CARE

A systematic approach is essential, using interpretation

of established guidance in Advanced Trauma Life Support

(ATLS) training.
The Definitive Surgical Trauma Care (DSTC) course may
also assist the surgeon dealing with poly-trauma in highrisk patients.

American College of Surgeons Committee on Trauma. Advanced trauma life support course for doctors
instructor manual. Chicago: American College of Surgeons, 1997.

Management
and diagnostic
imaging

Vascular trauma, Harkin, Denis W, Surgery - Oxford International Edition , Volume 33 , Issue 7 , 323 329

Rapid spiral computed tomographic angiography (CTA) has revolutionized

the management of patients with vascular trauma, and polytrauma
patients has become standard practice
Linsenmaier U, Krotz M, H auser H, et al. Whole-body computed tomography in polytrauma: techniques and management. Eur
Radiol 2002; 12: 1728e40.

Endovascular
management
of
thoracic
aortic
injury.
Deceleration injury with traumatic aortic injury (TAI). (a)
Computed tomographic angiogram (CTA) shows tear at aortic
isthmus. (b) Angiogram of deployment of endograft during
TEVAR. (c) Postoperative surveillance CTA confirms satisfactory
Vascular trauma, Harkin, Denis W, Surgery - Oxford International Edition , Volume 33 , Issue 7 , 323 - 329
repair.

HAEMOSTATIC GOAL-DIRECTED RESUSCITATION

Resuscitation in the actively bleeding patient,

should be sufficient to maintain vital organ

perfusion but not to encourage further blood
loss.
Excessive fluid resuscitation in an attempt to
normalize blood pressure in the absence of
haemorrhage control will simply encourage rebleeding.
This permissive hypotension is the key to
haemostatic resuscitation.
Cohen MJ. Towards hemostatic resuscitation: the changing understanding of acute traumatic biology, massive
bleeding, and damage control resuscitation. Surg Clin North Am 2012 Aug; 92: 877e91. viii. Review.

TRANSFUSION AND BLOOD PRODUCTS

Meta-analyses of observational studies in

trauma patients with massive

haemorrhage have shown significant
survival benefit in patients receiving high
FFP/RBC and platelet/RBC ratios. (1:1:1)

Johansson PI, Oliveri R, Ostrowski SR. Hemostatic resuscitation with plasma and platelets in trauma. A meta-analysis. J EmergTrauma
Shock 2012; 5: 120e5.

TRANSFUSION AND BLOOD PRODUCTS

The

CRASH-2 trial assessed use of

tranexamic acid in haemorrhagic shock
after trauma, and found it reduced
mortality if given within 3 hours of injury.

CRASH-2 Collaborators Roberts I, Shakur H, Afolabi A, et al. The importance of early treatment with tranexamic acid in
bleeding trauma patients: an exploratory analysis of the CRASH-2 randomised controlled trial. Lancet 2011; 377.
1096e1101 and Lancet 2010;376: 23e32

IMMEDIATE CONTROL OF BLEEDING

In the unstable patient with major vascular trauma, immediate surgical or

endovascular control of bleeding remains a priority.

Whilst adjuncts to haemorrhage control (pressure, compressive bandaging,

haemostatic dressings, and tourniquets) may buy time, early definitive

surgical control of bleeding remains essential.
Limb tourniquet :
There is considerable evidence from military experience that tourniquet

application reduces blood loss and improves outcomes in major limb

trauma.
Prolonged application (over 2 hours) risks secondary pressure and

ischaemic
injury
to
tissues and nerves, but this can be avoided by rapid triage and definitive
surgical
control.

Kragh JF, Walters TJ, Baer DG, et al. Survival with emergency tourniquet use to stop major bleeding in major limb trauma.
Ann Surg 2009; 249: 1e7.

IMMEDIATE CONTROL OF BLEEDING

TEMPORARY INTRAVASCULAR SHUNTS

Temporary intraluminal vascular shunts control bleeding

and restore oxygenated blood flow, and allow time for a

multidisciplinary approach to complex injuries.
Shunts can also be used as part of damage control
surgery. Once flow is restored and shunt securely fixed,
definitive repair can be delayed by 24-48 hours to allow
treatment of hypothermia, acidosis and coagulopathy.

Barros DSa AA, Harkin DW, Blair PH, Hood JM, McIlrath E. The Belfast approach to managing complex lower limb vascular
injuries.
Eur J Vasc Endovasc Surg 2006 Sep; 32: 246e56. Epub 2006 Apr 18.

IMMEDIATE CONTROL OF BLEEDING

TEMPORARY INTRAVASCULAR SHUNTS

1. Patients with a vascular injury

associated with indications for
damage control laparotomy,
temperature <34C, pH <7.2,
>10 units blood transfusion,
systolic blood pressure <90
mmHg for >60 minutes and
expected operating time >60
minutes
2. Patients with a peripheral
vascular injury, whose initial
surgery was performed at a
hospital without a surgeon
Oliver, J.C., Gill, H., Nicol, A.J., Edu, S. and Navsaria, P.H. (2013) Temporary Vascular Shunting in Vascular Trauma: A 10experienced in vascular surgery.
Year Review from a Civilian Trauma Centre. The South African Journal of Surgery, 51, 6-10.
3. Patients had lower limb fractures

PRINCIPLES OF VASCULAR REPAIR

When positioning the patient for surgery, the full extent of the

injury, including any possible missile tracts, must be sterile

prepared.
Distal extremities should be transparently draped to allow

assessment of distal perfusion.

Alternative limbs may be required for vein conduit harvest.
The operating table should be compatible with the use of

angiography,
for diagnostic and therapeutic interventions.

Vascular trauma, Harkin, Denis W, Surgery - Oxford International Edition , Volume 33 , Issue 7 , 323 - 329

PRINCIPLES OF VASCULAR REPAIR

Minor injury may be repaired by ligation, direct suture, or patch angioplasty. Major injury may also require interposition grafting
with autologous vein (enlarged by spiral or panel grafting), or synthetic material in uncontaminated fields. Complex injuries with
soft-tissue loss require extra-anatomic bypass.

Vascular trauma, Harkin, Denis W, Surgery - Oxford International Edition , Volume 33 , Issue 7 , 323 - 329

SURGICAL APPROACHES IN VASCULAR

TRAUMA
In general surgical approaches follow standard exposure principles

used in elective vascular surgery in the thorax, abdomen and

extremities, and are dictated by suspected site of injury.
In the neck an oblique anterolateral incision can be extended

proximally into a sternotomy.

In the thorax, a sternotomy for heart and proximal great vessels

and a left lateral thoracotomy for the thoracic aorta, can be

extended across the sternum for a clam-shell thoracotomy. In the
abdomen a vertical midline incision with extension to through
sternum or lateral thorax is used as required.
In the extremities:
upper limb e anteromedial incision extended proximally to

infraclavicular or supraclavicular approaches, as required;

lower limb e medial incision extended proximally to anterior groin and

to supra-inguinal or midline of abdomen.

Vascular trauma, Harkin, Denis W, Surgery - Oxford International Edition , Volume 33 , Issue 7 , 323 - 329

MANAGEMENT OPTIONS

Vascular trauma, Harkin, Denis W, Surgery - Oxford International Edition , Volume 33 , Issue 7 , 323 - 329

FASCIOTOMY
Fasciotomies can prevent compartment syndrome, and should

be considered if there are major associated injuries (bone, soft

tissue),
crush
injuries,
associated venous injury, or if ischaemia is prolonged (greater
than 6 hours).
Compartment

syndrome, arises as a result of ischaemiareperfusion injury.

On reperfusion, toxic products can cause remote effects such as

myoglobin-induced acute kidney injury or SIRS.

Vascular trauma, Harkin, Denis W, Surgery - Oxford International Edition , Volume 33 , Issue 7 , 323 - 329

MANGLED EXTREMITY AND PRIMARY AMPUTATION

Tipe dan level trauma vaskuler
Sirkulasi kolateral
Shock/hypotensi
Kerusakan jaringan (crush injury)
Warm ischemia time
Faktor pasien atau kondisi medis
Sistem skoring menjadi salah satu pertimbangan

ohansen K, Daines M, Howey T, Helfet D, Hansen Jr ST. Objective criteria accurately predict amputation following lower extremity trauma. J
Trauma 1990; 30: 568e73

MANGLED SCORE SEVERITY SCORE

(MESS > 7 AMPUTASI)
Vascular Soft Tissue
Shock
Damage
1 - No shock, SBP > 0
- Low energy (stab,gunshot,
2
90
1
simple fract)
- Transient shock
2
- Medium energy (disloc,
- Prolonged shock
open fract)
3 Age
0
- High energy (high speed
4 - <30
1
MVA)
2
- 30-50
- Massive Crush (high speed
0 - >50
trauma)
1
Ischemia (> 6 jam x2)
- None
2
- Reduced Pulse Normal
3
Perfusion
ohansen
M, Howey T, Helfet
D, Hansen Jr ST. Objective
- K, Daines
Pulseless,
paresthesia,
CRTcriteria accurately predict amputation following lower extremity trauma. J

CONCLUSION

Vascular trauma is common and carries a high risk of morbidity

and mortality.
Massive haemorrhage, with associated shock and coagulopathy,

should prompt the clinician to adopt a damage control approach

to surgical care.
Goal-directed haemostatic resuscitation helps maintains vital

organ function and allows rapid progression to surgical (or

endovascular) control of bleeding.
Once stability is achieved, definitive care can then attempt to

restore functional outcome.

Vascular trauma, Harkin, Denis W, Surgery - Oxford International Edition , Volume 33 , Issue 7 , 323 - 329

TERIMAKASIH