Jerry Goldstone

Acute Intestinal Ischemia

Acute intestinal ischemia is twice as common as a ruptured AAA n n nThere is a classic triad of symptoms: n n nHistory of embolization n n nPain out of proportion n n nIntestinal emptying n n n n n n nWhen suspected, CT might make the diagnosis early enough to allow successful treatment n n nIf arterial obstruction—aggressive surgical or interventional treatment n n nIf venous obstruction—rarely surgical treatment n n nEmbolectomy is indicated if ischemia is diagnosed during laparotomy finding the jejunum to be normal

Acute Venous Problems

Thrombolysis is a viable treatment option for patients with deep vein thrombosis. n n nPhlegmasia cerulea dolens may require surgical thrombectomy or thrombolysis as well as fasciotomy. n n nLiberal use of cava filters may save patients from pulmonary embolism.

Vascular Injuries in the Upper Extremity

Suspect vascular injuries in patients with shoulder or elbow dislocation. n n nWhen blood pressures in the arms differ, exclude vascular injuries in proximal arteries. n n nIt is usually the nerve injury that determines the functional outcome of arm injuries. n n nEvaluate the brachial plexus and the median nerve function before and during vascular exploration. n n nRepair of vascular injuries in the upper limb is wise even when ischemia appears to be limited.

Abdominal Vascular Injuries

Shock out of proportion to the extent of external injury suggests abdominal vascular injury. n n nAfter the abdomen is entered, immediate control of the supraceliac aorta should be considered before continuing the operation. n n nRetroperitoneal hematomas should not be explored right away unless they are actively bleeding. n n nStopping the procedure after the initial exploration for damage control to allow time for resuscitation in the intensive care unit is often a reasonable initial treatment. n n nEndovascular methods such as aortic balloon occlusion, stent graft placement, and embolization of minor arteries are often effective measures for bleeding control.

Vascular Injuries to the Neck

Severe vascular injury after blunt neck trauma can be present even in the absence of clinical signs. n n nBe liberal with CYA or duplex when cervical vessel injuries cannot be ruled out after blunt trauma. n n nAssociated injuries on the cervical spine, airway, and digestive tract must always be considered. n n nAlways stabilize the neck of patients in all types of severe cervical trauma until the entire spectrum of injuries is known. n n nCTA or angiography should always be performed in penetrating injuries in zones I and III if the patient is stable. n n nIf available, CTA, duplex or angiography is recommended in zone II injuries in order to select patients for conservative versus surgical management.

Vascular Injuries in the Legs

Major bleeding is controlled by manual compression. n n nIn extremities with fractures, vascular injuries should always be suspected. n n nMost vascular injuries are revealed by careful and repeated clinical examination. n n nBefore exploring a wound in a patient with a history of substantial bleeding, obtain proximal control.

Acute Leg Ischemia

It is important to evaluate the severity of ischemia. n n nIf the leg is immediately threatened, operation cannot be delayed. n n nIf the leg is viable, there is no benefit of an acute operation. n n nBefore the operation it is vital to consider the etiology of the occlusion, to be prepared to perform a distal vascular reconstruction if needed, and to treat heart and pulmonary failure if present.

Acute Problems with Vascular Dialysis Access

Infections in dialysis access fistulas can cause erosion and lethal bleedings. n n nInfections in dialysis accesses should not be debrided in the emergency department. n n nThe urgency of revision of an occluded access depends on the patient’s need for dialysis and on available alternative dialysis options. n n nSteal symptoms should be worked up urgently and treated expeditiously.

Acute Upper Extremity Ischemia

History and physical examination are sufficient for the diagnosis. n n nFew patients need angiography. n n nEmbolectomy should be performed in most patients. n n nIt is important to search for the embolic source.

Acute Aortic Dissection

Aortic dissection is one of the “great masqueraders,” so the diagnosis should always be suspected in any painful illness with a new pulse deficit. n n nType A dissections involve the ascending thoracic aorta and arch regardless of distal extent; Type B involve the aorta distal to the origin of the left subclavian artery without ascending involvement. n n nTreatment of Type A dissections is always surgical. n n nTreatment of Type B dissection is medical unless there is bleeding or complicating organ or limb ischemia. n n nExperienced vascular or thoracic surgeons should be involved early in the management, especially in Type A dissections.