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

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
  • Morel-Lavallée lesion
  • Ring avulsion injury
• Fracture
  • Open 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

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

• Angiogram Complication
• Acute arterial ischemia

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