Extremity Vascular Injury
VBMC TRAUMA CARE SERVICES GUIDELINE
EXTREMITY TRAUMA
Extremity Vascular Injury
Any injured extremity should be
thoroughly evaluated for a possible vascular injury. The presence of obvious
arterial injury from a blunt and/or penetrating mechanism rarely requires
imaging and should not delay emergent operative exploration. The
presence of “hard signs” strongly supports vascular injury and typically
necessitates emergent repair. These “hard signs” are:
1. Bruit/Thrill
2. Active/Pulsatile hemorrhage
3. Pulsatile/Expanding hematoma
4. Signs of limb ischemia and or compartment syndrome including the
5 "P's" - pallor, paresthesias, pulse deficit, paralysis, and pain on
passive extension of the compartment (pain on passive extension is the earliest
and most sensitive physical finding)
5. Diminished or absent pulses with + Doppler signals (this is
not a sensitive prognostic finding, as up to 30% of patients with major
vascular injuries requiring repair have normal pulses or Doppler signals distal
to the injury due to collateral flow) [1]
The Arterial Perfusion Index, API, is
a validated tool for screening for peripheral vascular injury[2]. This is
performed by placing a blood pressure cuff above the ankle or on the bicep of
the limb of concern. The systolic pressure is determined with a Doppler probe
at the dorsalis pedis or brachial artery. Repeat this procedure on the
ipsilateral uninjured limb. The API is calculated by dividing the
systolic pressure in the injured limb by the systolic pressure in the uninjured
limb. An API < 0.9 has a sensitivity of 95% and specificity of 97% for a
major arterial extremity injury. In a study on blunt orthopedic extremity
injuries the negative predictive value is 100% for an API > 0.9 to exclude
an arterial injury.[3-5]
The purpose of these algorithms is to
diagnose the occult injury early before irreversible tissue ischemia is
present. In patients where the “hard” signs are NOT present it
is imperative to maintain a high suspicion of peripheral vascular injury in the
injured extremity [2, 6, 7]. If “hard signs“ are not present but
peripheral vascular injury is suspected then expedient consultation with
Vascular Surgery is indicated and the use of imaging, per Vascular Surgery,
should be liberal to avoid missed injuries.
References:
1. Drapanas,
T., et al., Civilian vascular injuries: a critical appraisal of three decades
of management. Ann Surg, 1970. 172(3): p. 351-60.
2. Bravman,
J.T., et al., Vascular injuries after minor blunt upper extremity trauma -
pitfalls in the recognition and diagnosis of potential "near miss"
injuries. Scand J Trauma Resusc Emerg Med, 2008. 16(1): p. 16.
3. Mills,
W.J., D.P. Barei, and P. McNair, The value of the ankle-brachial index for
diagnosing arterial injury after knee dislocation: a prospective study. J
Trauma, 2004. 56(6): p. 1261-5.
4. Lynch,
K. and K. Johansen, Can Doppler pressure measurement replace
"exclusion" arteriography in the diagnosis of occult extremity
arterial trauma? Ann Surg, 1991. 214(6): p. 737-41.
5. Johansen,
K., et al., Non-invasive vascular tests reliably exclude occult arterial trauma
in injured extremities. J Trauma, 1991. 31(4): p. 515-9; discussion 519-22.
6. Dennis,
J.W., et al., Validation of nonoperative management of occult vascular injuries
and accuracy of physical examination alone in penetrating extremity trauma: 5-
to 10-year follow-up. J Trauma, 1998. 44(2): p. 243-52; discussion 242-3.