Evaluation and Management of Peripheral Vascular Injury. Part 1. Western Trauma Association/Critical Decisions in Trauma

• DOI: 10.1097/ta.0b013e31821b5bdd
• Publication Date: 2011-06-10T12:00:11Z
• Authors: David V. Feliciano; Frederick A. Moore; Ernest E. Moore; Michael A. West; James W. Davis; Christine S. Coca...; Rosemary A. Kozar; Robert C. McIntyre
• Keywords: Severe trauma

This is a position article from members of the Western Trauma Association (WTA). Because there are no prospective randomized trials on evaluation and management peripheral vascular trauma, algorithm (Fig. 1) based expert opinion WTA published observational studies. It may not be applicable at all hospitals caring for injured patients. The contains letters that correspond to lettered text intentionally concise. Part I emphasizes evaluation, diagnosis, need operation versus therapeutic procedure performed in interventional radiology, while II (2011) will focus operative techniques.Figure 1.: Algorithm patient with possible injury.Peripheral injures defined as axillobrachial branches upper extremity femoropopliteal lower account 40% 75% injuries treated civilian trauma centers.1–4 With exception axillary artery, long tracks named arteries veins extremities make them particularly susceptible either penetrating or blunt trauma. fact coupled smaller diameter many these vessels (as compared those thorax abdomen) ability others control external hemorrhage compression contribute low incidence death field. HISTORIC PERSPECTIVE Urgent repair an injury brachial artery was first by Hallowell June 13, 1759, site "blood letting."5 After 145-year delay, techniques arterial were developed Nobel Prize winner (1912) Alexis Carrel Charles C. Guthrie University Chicago 1904 1906.6 Operative repairs early part 20th century, most delayed fashion after wounding, reported V. Soubbotitch Balkan Wars, George H. Makins World War I, R. Weglowski during Polish-Russian 1920.7–9 Less than 150 American military personnel DeBakey Simeone10 their classic review 1946. small number reflection magnitude wounds, delays medical care, lack antibiotics, significant risk late infection soft tissues extremities. Vascular frequently later stages Korean routinely throughout Vietnam War.11,12 Over past 50 years, urban centers United States have extraordinary patients gunshot wounds.3 ETIOLOGY In States, commonly (75–80%) caused trauma.13 Approximately 50% missiles handguns muzzle velocity kinetic energy (<1,000 ft lbs).13 Stab wounds 30% but much more common cause countries which firearms difficult obtain.14 Shotgun only 5% time. Peripheral such fractures, dislocations, crush injuries, traction 25% being treated.15,16 LOCATION series location.3,13 Among extremities, 60% occur femoral popliteal artery.3,13 TYPES OF VASCULAR TRAUMA five recognized types follows: (1) intimal (flaps, disruptions, subintimal/intramural hematomas); (2) complete wall defects pseudoaneurysms hemorrhage; (3) transections occlusion; (4) arteriovenous fistulas; (5) spasm.17 Intimal subintimal hematomas secondary occlusion associated defects, transections, fistulas usually Spasm can young When intima intima/media dilatation occurs, this traumatic true aneurysm extravasation blood outside lumen artery. A full-thickness defect acute pulsatile hematoma immediately false when surrounding encapsulate blood. Traumatic aneurysms venous extraordinarily rare, seem heal if local tissue pressure prevents RISK TO THE PATIENT primary loss life exsanguination development multiple organ failure prehospital near-exsanguination.18 As manual application dressing elevation almost always bleeding field, should infrequent setting. successful use tourniquets Operation Enduring Freedom (Afghanistan) Iraqi forces, however, surely lead increased emergency services future.19,20 distal injury. due delay diagnosis and/or revascularization, thrombosis repair, tissue, bones, nerves (i.e., Gustilo III C open fracture close-range shotgun wound). large environment, 2% 4% undergo immediate amputation 1.5% amputation.21 fractures C), rates continue least 10% 20%.16,22 ANNOTATED TEXT FOR FIGURE 1 Bleeding affects "Circulation" Primary Survey Advanced Life Support managed direct compressive ongoing resuscitation. absence bleeding, assessed Secondary Support. assessment dependent presence normal diminished absent pulses physical examination Doppler device. Therefore, dislocation joint realigned relocated, respectively, palpation document difference between contralateral uninjured hemodynamically stable patient.16,17 "Hard" overt signs bleeding; rapidly expanding hematoma; any classical (pulselessness, pallor, paresthesias, pain, paralysis = 5 "P"s); palpable thrill/audible bruit.17,23 Immediate appropriate without other life-threatening (see "C' "D" below). intracranial midline shift brain, chest, abdomen pelvis, gastrointestinal contamination abdomen, two teams, appropriate. One team manage elsewhere, second (or venous) correct insert temporary intraluminal shunt vein.24 Patients anywhere operation. Other presumed major (limb threatened) clinical fistula (thrill/bruit) extremity, thigh (excluding profunda femoris artery), proximal anterior tibial tibioperoneal bifurcation leg operation, well.13,17 remaining artery(i.e., doralis pedis pulse absent, foot clearly well perfused) third diagnostic imaging "I," "J," "K") embolization nonoperative "M").25 If hard sign present, localization necessary wound fractures), rapid options available. Either preliminary surgeon-performed arteriogram center operating room duplex ultrasonography study experienced surgeon registered technologist it done timely fashion.26–28 "Soft" history scene transit; proximity artery; nonpulsatile over neurologic deficit originating nerve adjacent artery.17,23 ranges 3% 25%, depending combination present.29–32 documents wrist ankle equal excellent evidence limited injury) present.32–34 addition comprehensive examination, one following performed: Ankle Brachial/Brachial Index (ABI BBI systolic area injury/systolic extremity); Arterial Pressure (API= injury/Doppler uninvolved extremity).35–38 Using cutoff ≥0.9 rule out studies, sensitivity specificity outcome been >95%.36,38 older greater preexisting occlusive disease, ABI API accurate younger For reason, some ≥0.1 comparing indication study. discharged room. would include who had reduction posterior knee.34 Follow-up described "G." 1% patients, primarily eventually come original undetected pseudoaneurysm) progresses rather heals, compulsive follow-up outpatient clinic mandatory.29,32,33,39,40 noninvasive examination. Any abnormality evaluations mandate performance ultrasound standard computed tomographic (CT) arteriogram. <0.9 location likely injury.36–38,41 choice varies expertise, data available arteriography, CT Standard arteriography conventional film, digital subtraction intra-arterial intravenous injection contrast agent, "one-or two-shot" studies.26,42–44 Digital has replaced film centers, because decreases time amount material, discomfort patient, costs films.42,43 mobile unit even used resuscitation surgeon-angiographers available.45 angiography (CTA) below) available, using films injections 25 mL meglumine diatrizoate dye. room, under fluoroscopy films. Surgeon-performed percutaneous studies complication rate sensitivity/specificity 95%.44,46 certain agents renal toxicity, adequate fluid mandatory before described. Multidetector row helical CTA advantages contrast, readily evaluating having accuracy comparable arteriography.47–50 same evaluations, cost effective well.50 Since risks children, particular benefit group. Limitations quality metallic fragments bullets artifacts, problem recent hospital.51 Also, interventions Finally, load needed detrimental insufficiency concurrent Duplex real-time B (brightness)-mode pulsed velocimetry demonstrates anatomic relationships flow.52 Flow point represented color scale well. Numerous documented assessing injuries. While ranged 100%, consistently exceeded 95%.28,53–55 Disadvantages approach initial equipment, 24-hour availability trained duplex, concerns about axilla bifurcated studies.56 An extravasation, pseudoaneurysm, occlusion, mandates emergent location. "C," excluding leg. femoris, tibial, peroneal followed observation (occlusion) (extravasation, fistula). repeat 3 days pseudoaneurysm developing backflow. expected 87% 95% operation.33,57 solid viscera extensive initiate prophylaxis against heparin aspirin period observation. maintains flow hand findings suggestive home discretion attending surgeon. then reexamined G). develop abrupt changes perfusion new urgent imaging. finding imaging, whether injured. intact, warming affected Before spasm thought ischemic foot, situ thrombosis, embolism, advanced compartment syndrome must ruled out.58 arteriographic measurement pressures both limb. Severe limb-threatening bolus papaverine 60 mg infusion 30 mg/h past.59 Another option rare occasions solution 1,000 saline; units heparin; 500 tolazoline mL/h mL/h.60,61 Currently vasodilators suites nitroglycerin (50–100 mg) nifedipine (10 per os sublingual). assess measure ABI, BBI, obese shock hypothermic. oversized cuff patient's size index patient. hypothermic resuscitated usual maneuvers. Palpation another attempt measuring performed. comparison (between extremity) wrists ankles cannot completed now extremity. necessary, well, seems cooler slower capillary refill fingernails/toenails