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
- Laceration
- Intimal flap
- Pseudoaneurysm
- A/V fistula
- Compartment syndrome
- Occlusive
Occult Upper Extremity Vascular Injury
- Clavicle fracture/1st rib fracture → Subclavian artery
- Anterior shoulder dislocation → Axillary artery
- Proximal humerus fracture → Axillary artery
- Humeral shaft fracture → Brachial artery
- Elbow dislocation → Brachial artery
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
- Compartment syndrome
- Contusion
- Crush syndrome
- Degloving injury
- Fracture
- Laceration
- Myositis ossificans
- Open joint injury
- Peripheral nerve injury
- Rhabdomyolysis
- Tendon injury
- Vascular injury
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
- <0.9 abnormal, > 0.9 is highly sensitive for excluding major vascular 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.
Evaluation Algorithm
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