Vascular injury

Background

  • Vascular Injury can have a broad spectrum of presentations. Knowing the appropriate assessment of patients presenting with hard and soft signs of vascular injury is paramount to appropriate treatment and disposition.

Types

  • Extremity- Injury to the vasculature of the arms or legs
  • Junctional- Vascular injury where the extremity meets the torso(Hip, axilla, base of neck)
  • Non Compressible Truncal Hemorrhage- Anywhere on the torso involving large vasculature.
  • Within each of these are the following subtypes.
    • Occlusive
      • Transection
      • Thrombosis
      • Embolism
    • +Reversible spasm
    • Non-occlusive

Occult Upper Extremity Vascular Injury

Clinical Features

Hard signs

  • Absent distal pulses
  • Signs of distal ischemia
    • Pain, pallor, paresthesia, paralysis, poikilothermia
  • Audible bruit or palpable thrill at injury site
  • Active pulsatile hemorrhage
  • Large expanding hematoma

Soft Signs

  • Small nonexpanding hematoma
  • subjectively decreased pulse
  • Peripheral nerve deficit
  • History of pulsatile or significant hemorrhage at time of injury
  • Unexplained hypotension
  • High risk orthopedic injuries (fracture, dislocation, penetration)

Differential Diagnosis

Extremity trauma

Evaluation

Arterial Pressure Index (API)/Injured Extremity Index (IEI)

  • Doppler-determined arterial systolic blood pressure in injured limb divided by systolic blood pressure in uninjured limb
    • <0.9 abnormal, > 0.9 is highly sensitive for excluding major vascular injury
      • NPV of IEI >0.9 is ~96%
    • Allows for serial, objective monitoring
    • Only detects obstructive lesions
    • Unreliable in proximal injuries, popliteal injuries, shotgun wounds, multiple wounds, shock
    • False negative with deep femoral artery injury

Imaging Modalities

  • CT Angiography
    • The Gold standard for excluding vascular Injury
    • Highest sensitivity, specificity
    • Useful for detection of other injuries(Venous, neural, fractures, etc)
  • Dupplex Doppler
    • Can be operator dependent and does NOT definitively exclude arterial Injury
    • S 95-100%; Sp 97-100%; Acc 98-100%
    • Sens for vessel injury, thrombosis, pseudoaneurysm, intimal flap and A-V fistula
  • Point of care ultrasound
    • useful as an adjunct, but there are no randomized trials proving sensitivity.

Hard Signs (>90% risk of arterial injury; 50% require intervention)

  • Immediate arterial exploration without further investigation

Soft Signs (30% risk of arterial injury)

  • Perform API → if <0.9 obs/admit for 24h, serial API
  • Consider:
    • Doppler U/S
    • CT angiogram
    • Evaluation of compartment pressures

Management

  • Depends on injury type
  • Consider emergent vascular surgery consult

Disposition

  • Dependent on injury type

Prognosis

  • Warm Ischemia Time
    • 6 hours (10% irreversible damage)
    • 12 hours (90% irreversible damage)

See Also

References

    • Slama, R., & Jackson, M. (2019). Peripheral Vascular Injury. In A. Koyfman & B. Long (Eds.), The Emergency Medicine Trauma Handbook (pp. 249-259). Cambridge: Cambridge University Press. doi:10.1017/9781108647397.018
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