Vascular injury: Difference between revisions
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== | ==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]] | |||
== | ===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=== | ===Hard signs=== | ||
*Absent distal pulses | *Absent distal pulses | ||
*Signs of distal ischemia | *Signs of distal ischemia | ||
**Pain, pallor, paresthesia, paralysis, poikilothermia | **Pain, pallor, paresthesia, paralysis, poikilothermia | ||
* | *Audible bruit or palpable thrill at injury site | ||
*Active pulsatile | *Active pulsatile hemorrhage | ||
*Large expanding hematoma | *Large expanding hematoma | ||
===Soft Signs === | ===Soft Signs=== | ||
*Small nonexpanding hematoma | *Small nonexpanding hematoma | ||
*subjectively decreased pulse | |||
*Peripheral nerve deficit | *Peripheral nerve deficit | ||
* | *History of pulsatile or significant hemorrhage at time of injury | ||
*Unexplained hypotension | *Unexplained hypotension | ||
* | *High risk orthopedic injuries (fracture, dislocation, penetration) | ||
===Arterial Pressure Index (API)=== | |||
*Doppler-determined arterial | ==Differential Diagnosis== | ||
**<0. | {{Extremity trauma DDX}} | ||
==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 | **Allows for serial, objective monitoring | ||
**Only detects obstructive lesions | **Only detects obstructive lesions | ||
** | **Unreliable in proximal injuries, popliteal injuries, shotgun wounds, multiple wounds, shock | ||
** | **False negative with deep femoral artery injury | ||
=== | ===Imaging Modalities=== | ||
*S 95-100%; Sp 97-100%; Acc 98-100% | *CT Angiography | ||
*Sens for vessel injury, thrombosis, pseudoaneurysm, intimal flap and A-V fistula | **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 (>90% risk of arterial injury; 50% require intervention)=== | ====Hard Signs (>90% risk of arterial injury; 50% require intervention)==== | ||
*Immediate arterial exploration without further investigation | *Immediate arterial exploration without further investigation | ||
===Soft (30% risk of arterial injury)=== | ====Soft Signs (30% risk of arterial injury)==== | ||
*API | *Perform API → if <0.9 obs/admit for 24h, serial API | ||
*Consider: | |||
**Doppler U/S | **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== | ==See Also== | ||
*[[Angiogram Complication]] | *[[Angiogram Complication]] | ||
*[[Acute arterial ischemia]] | |||
== | ==References== | ||
<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 | |||
[[Category: | [[Category:Vascular]] | ||
[[Category:Cardiology]] | |||
[[Category:Trauma]] | [[Category:Trauma]] |
Latest revision as of 19:45, 27 July 2020
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