Vascular injury: Difference between revisions
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Revision as of 13:53, 22 March 2016
Background
Types
- Complete Occlusive
- Transection
- Thrombosis
- Embolism
- Reversible spasm
- Non-occlusive
- Lacerations
- Intimal flaps
- Pseudoaneurysm
- A/V fistula
- Compartment syndrome
Occult Upper Extremity Vascular Injury
- Clavicle fracture/1st rib => 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 hem
- Large expanding hematoma
- Pulsatile hematoma
Soft Signs
- Small nonexpanding hematoma
- Peripheral nerve deficit
- History of pulsatile or significant hemorrhage at time of injury
- Unexplained hypotension
- Bony injury (fracture, dislocation, penetration) or proximity penetrating wound
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
Diagnosis
Arterial Pressure Index (API)
- Doppler-determined arterial sys BP in injured limb divided by pressure in uninjured limb
- <0.90 abnormal
- 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
Duplex Doppler
- S 95-100%; Sp 97-100%; Acc 98-100%
- Sens for vessel injury, thrombosis, pseudoaneurysm, intimal flap and A-V fistula
Evaluation Algorithm
Hard (>90% risk of arterial injury; 50% require intervention)
- Immediate arterial exploration without further investigation
Soft (30% risk of arterial injury)
- API --> if < 0.9 obs/admit for 24h, serial API, consider:
- Doppler U/S
- CTA
- Eval of compartment syndrome
Management
- Emergency vascular surgery consult (General surgery if vascular not available)
Prognosis
Warm Ischemia Time
- 6 hours (10% irreversible damage)
- 12 hours (90% irreversible damage)