Vascular injury: Difference between revisions

 
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==Types==
==Background==
#Complete Occlusive
*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.
##Transection
===Types===
##Thrombosis
*Extremity- Injury to the vasculature of the arms or legs
##Embolism
*Junctional- Vascular injury where the extremity meets the torso(Hip, axilla, base of neck)
##Reversible spasm
*Non Compressible Truncal Hemorrhage- Anywhere on the torso involving large vasculature.
#Non-occlusive
##Lacerations
##Intimal flaps
##Pseudoaneurysm
##A/V fistula
##Compartment syndrome


==Warm Ischemia Time==
*Within each of these are the following subtypes.
*6 hours (10% irreversible damage)
**Occlusive
*12 hours (90% irreversible damage)
***Transection
***Thrombosis
***Embolism
**+Reversible spasm
**Non-occlusive
***Laceration
***Intimal flap
***Pseudoaneurysm
***A/V fistula
***[[Compartment syndrome]]


==Diagnosis==
===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
*Palpable bruit or audible thrill at injury site
*Audible bruit or palpable thrill at injury site
*Active pulsatile hem
*Active pulsatile hemorrhage
*Large expanding hematoma
*Large expanding hematoma
*Pulsatile hematoma
 
===Soft Signs ===
===Soft Signs===
*Small nonexpanding hematoma
*Small nonexpanding hematoma
*subjectively decreased pulse
*Peripheral nerve deficit
*Peripheral nerve deficit
*Hx of pulsatile or significant hemorrhage at time of injury
*History of pulsatile or significant hemorrhage at time of injury
*Unexplained hypotension
*Unexplained hypotension
*Bony injury (fx, dislocation, penetration) or proximity penetrating wound
*High risk orthopedic injuries (fracture, dislocation, penetration)
===Arterial Pressure Index (API)===
 
*Doppler-determined arterial sys BP in injured limb divided by pressure in uninjured limb
==Differential Diagnosis==
**<0.90 abnormal
{{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
**Unreliable in proximal injuries, popliteal injuries, shotgun wounds, multiple wounds, shock
**false negative with deep femoral artery injury
**False negative with deep femoral artery injury


===Duplex Doppler===
===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.


==Treatment==
===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 --> if < 0.9 obs/admit for 24h, serial API, consider:
*Perform API if <0.9 obs/admit for 24h, serial API
*Consider:
**Doppler U/S
**Doppler U/S
**CTA
**CT angiogram
**Eval of compartment syndrome
**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==
*[[Acute Arterial Occlusion]]
*[[Angiogram Complication]]
*[[Angiogram Complication]]
*[[Acute arterial ischemia]]


==Source==
==References==
Birnbaumer, Donaldson
<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:Cards]]
[[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

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.

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