Vascular injury: Difference between revisions
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==Background== | ==Background== | ||
===Types=== | ===Types=== | ||
* | *Occlusive | ||
**Transection | **Transection | ||
**Thrombosis | **Thrombosis | ||
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**Reversible spasm | **Reversible spasm | ||
*Non-occlusive | *Non-occlusive | ||
** | **Laceration | ||
**Intimal | **Intimal flap | ||
**Pseudoaneurysm | **Pseudoaneurysm | ||
**A/V fistula | **A/V fistula | ||
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===Occult Upper Extremity Vascular Injury=== | ===Occult Upper Extremity Vascular Injury=== | ||
*[[Clavicle fracture]]/1st rib | *[[Clavicle fracture]]/1st rib fracture → Subclavian artery | ||
*Anterior [[shoulder dislocation]] | *Anterior [[shoulder dislocation]] → Axillary artery | ||
*[[Proximal humerus fracture]] | *[[Proximal humerus fracture]] → Axillary artery | ||
*[[Humeral shaft fracture]] | *[[Humeral shaft fracture]] → Brachial artery | ||
*[[Elbow dislocation]] | *[[Elbow dislocation]] → Brachial artery | ||
==Clinical Features== | ==Clinical Features== | ||
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===Arterial Pressure Index (API)=== | ===Arterial Pressure Index (API)=== | ||
*Doppler-determined arterial systolic blood pressure in injured limb divided by systolic blood pressure in uninjured limb | *Doppler-determined arterial systolic blood pressure in injured limb divided by systolic blood pressure in uninjured limb | ||
**<0. | **<0.9 abnormal | ||
**Allows for serial, objective monitoring | **Allows for serial, objective monitoring | ||
**Only detects obstructive lesions | **Only detects obstructive lesions | ||
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===Evaluation Algorithm=== | ===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 | *Perform API → if <0.9 obs/admit for 24h, serial API | ||
*Consider: | |||
**Doppler U/S | **Doppler U/S | ||
** | **CT angiogram | ||
** | **Evaluation of compartment pressures | ||
==Management== | ==Management== | ||
* | *Depends on injury type | ||
*Consider emergenr vascular surgery consult | |||
==Disposition== | |||
*Dependent on injury type | |||
==Prognosis== | ==Prognosis== | ||
*Warm Ischemia Time | |||
*6 hours (10% irreversible damage) | **6 hours (10% irreversible damage) | ||
*12 hours (90% irreversible damage) | **12 hours (90% irreversible damage) | ||
==See Also== | ==See Also== | ||
Revision as of 06:06, 15 November 2018
Background
Types
- 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
- Peripheral nerve deficit
- History of pulsatile or significant hemorrhage at time of injury
- Unexplained hypotension
- Bony injury (fracture, dislocation, penetration) or proximity to 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
Evaluation
Arterial Pressure Index (API)
- Doppler-determined arterial systolic blood pressure in injured limb divided by systolic blood pressure in uninjured limb
- <0.9 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 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 emergenr vascular surgery consult
Disposition
- Dependent on injury type
Prognosis
- Warm Ischemia Time
- 6 hours (10% irreversible damage)
- 12 hours (90% irreversible damage)