Vascular Trauma of Extremities - Emergency Management

Related Summaries

● Gunshot wounds - emergency management

● Laceration - emergency management

● Major trauma - emergency management

General Information

Description

● Any disruption in the vasculature of an extremity secondary to traumatic mechanism

● Gunshot wounds, due to their high velocity, produce greater injury to vessels than stab wounds

● Blunt trauma creates a similar risk of injury as gunshot wounds

● The most signi cant independent risk factor for amputation is failed revascularization, thus early
surgical consultation is critical

Anatomy

● Major arteries of the upper extremities are (from proximal to distal): subclavian, axillary, brachial,
radial, and ulnar
⚬ Easy places to palpate pulses in the upper extremities are in the antecubital fossa and at the wrist

● Major arteries of the lower extremities are (from proximal to distal): iliac, femoral, popliteal, peroneal,
tibial (anterior and posterior), and bular
⚬ Easy places to palpate pulse in the lower extremities are the groin, popliteal fossa, ankle, and foot

Etiology

● Crush injury

● Displaced fracture

● Dislocation of joint

● Penetrating injury (gunshot wound, stab wound, or impaled object)

● Splinted extremity after injury

● Traumatic amputation

Epidemiology

● Any victim of trauma can be at risk for vascular injury and must be evaluated if the mechanism

warrants a high suspicion 1 , 2 , 3

● Vascular injuries to the extremities are relatively low (5%) in civilian populations but much more

common in warfare conditions 1 , 2 , 3

● Patients with diabetes, hypertension, or known peripheral vascular disease are at increased risk due

to already compromised blood ow to the extremities 1 , 2 , 3

● Increased incidence with vessels in close proximity to bones/joints, super cial vessels 1 , 2 , 3

● Blunt vascular injury has been shown to have over a 2-fold higher rate of amputation than penetrating

injury 1 , 2 , 3

● Most frequently lower extremity injured vessel is the super cial femoral artery (30%-40%) 1 , 2 , 3

History and Physical

History

● Vascular injury should always be suspected in the setting of clinical evidence of vascular insu ciency
that is associated with a suspicious mechanism (for example, blunt, crushing, or penetrating)

● TIP: healthy patients may not clinically manifest vascular injuries immediately

● Symptoms vary depending on location of injury but can include

⚬ Bleeding
⚬ Bruising
⚬ Numbness or weakness distal to the injury
⚬ Pain
⚬ Swelling

Physical

● Perform ABCs (airway, breathing, circulation), with hemorrhagic extremity injury under C for
Circulation

● Perform full trauma evaluation for other injuries

● Extremity evaluation

⚬ Hard signs 2

– Absent distal pulses

– Large expanding pulsatile hematoma
– Palpable thrill or audible bruit over injury
– Distal ischemia: pain, pallor, pulselessness, poikilothermia, paralysis paresthesias

⚬ Soft signs 2

– Injury to an adjacent nerve

– Proximity of trauma to major vessels
– Small stable hematomas
– Unexplained hypotension
Diagnostic Studies

Laboratory tests

● Highly consider obtaining

⚬ Creatinine phosphokinase
⚬ Urine myoglobin (if suspect compartment syndrome)
⚬ Serial hemoglobin or hematocrit to evaluate on-going hemorrhage and need for blood products

● May consider obtaining

⚬ Baseline chemistry, prothrombin time (PT)/INR, partial thromboplastin time (PTT), and venous
blood gas /arterial blood gas (VBG/ABG)

Imaging Tests

● Highly consider obtaining

⚬ Radiography of involved extremity to detect fractures

⚬ Duplex scan to evaluate vascular ow
⚬ TIP: if concerning mechanism is present, have a high degree of clinical suspicion, perform a
thorough physical exam, and appropriate imaging tests
⚬ Computed tomography (CT) angiogram with runo if patient is clinically stable to diagnose source
of insu ciency and provide a “road map” for the surgeon, especially if patient manifests hard
signs 4

Other Diagnostic Tests

● Ankle brachial index (ABI) is the systolic pressure at the ankle, divided by the systolic pressure at the
arm: abnormal is < 0.9

● Arterial pulse indices (API)

● Doppler ultrasound: presence of signal does not exclude injury

Management

Overview

● Initial assessment: focus on the primary survey, as described in Advanced Trauma Life Support (ATLS),

aimed at recognizing and treating immediate life threats 5 , 6

⚬ Vascular injuries associated with major hemorrhage should be identi ed and managed during the
primary survey
⚬ Digital pressure and/or careful packing and pressure dressings should be applied to hemorrhagic
wounds
⚬ Tourniquets are used as a last resort but are becoming more utilized due to recent military
experience
– Early tourniquet use in patients with severe hemorrhage is associated with decreased

mortality 7
⚬ Volume resuscitation to reverse hemorrhagic shock
● Secondary survey: once patient is stabilized, assess for related injuries 5 , 6

⚬ Acute vascular injury should be recognized and treated quickly (best if accomplished within 6
hours)
⚬ Many vascular extremity injuries will be identi ed during the secondary survey
⚬ Early operative intervention is required to restore ow
⚬ Reduction of dislocation or fracture is essential and may restore blood ow

● Early revascularization is key, thus it is important to consult surgeons early when vascular injury is
suspected

Medications

● Pain medications

⚬ Fentanyl 1-2 mcg/kg IV, if concern for hemodynamic instability or early in resuscitation because of
short-acting duration (typical adult dosage 50-100 mcg IV)
⚬ Morphine 0.1 mg/kg IV (typical adult dosage 4-10 mg IV)

● Broad spectrum antibiotics for open dirty wounds

⚬ Unasyn 3 g IV
⚬ Piperacillin/tazobactam 4.5 g IV
⚬ Cefotetan or other second-generation cephalosporin
⚬ Ampicillin 2 g IV every 6 hours + gentamicin 2 mg/kg load then 1.7 mg/kg every 8 hours +
metronidazole 1 g IV

● Tetanus prophylaxis for open wounds

● In the setting of obvious ischemia, systemic anticoagulation with heparin should be instituted
immediately if no other sites of hemorrhage or intracranial trauma are suspected (check institutional
protocols)
⚬ Heparin bolus of 60 units/kg IV (maximum 5,000 units)
⚬ Heparin infusion of 12 units/kg/hour IV (maximum 1,000 units/hour)

Disposition

Prognosis and complications

Prognosis

● Depends on magnitude of injury, location of injury, and timing to resolution of injury 8 , 9

● Popliteal vascular injuries have the highest rate of limb loss of all peripheral vascular injuries 8 , 9

● De nitive resolution of injury within 6 hours predict a 95% successful result 8 , 9

● PEDIATRIC TIP: good results can be achieved with revascularization but often require multiple

operations 10

Complications

● Amputation 8 , 9
● Blood loss 8 , 9

● Compartment syndrome 8 , 9

● Death 8 , 9

● Infection 8 , 9

● Ischemia 8 , 9

● Muscle necrosis 8 , 9

● Nerve injury 8 , 9

● Rhabdomyolysis leading to acute renal failure 8 , 9

● Thrombosis 8 , 9

Associated conditions

● Limb fractures (open or closed) 8 , 9

⚬ Femoral shaft: femoral artery

⚬ Distal femur: popliteal artery
⚬ Supracondylar humerus: brachial artery
⚬ Shoulder fracture: axillary artery

● Compartment syndrome 8 , 9

● Joint dislocation 8 , 9

⚬ Shoulder: axillary artery

⚬ Elbow: brachial artery
⚬ Knee: popliteal artery

● Nerve injury

● Other traumatic injuries

Indications for hospital admission

● Patients with acute vascular injuries require admission for operative management and postoperative

monitoring of the involved extremity 8 , 9

Discharge planning

● Patients with vascular injuries should not be discharged from the emergency department 8 , 9

Consultations

● Vascular surgery
 ● Trauma surgery

● Orthopedic surgery (if associated fracture or dislocation)

References

General references used

1. Mullenix PS, Steele SR, Andersen CA, Starnes BW, Salim A, Martin MJ. Limb salvage and outcomes
among patients with traumatic popliteal vascular injury: an analysis of the National Trauma Data
Bank. J Vasc Surg. 2006 Jul;44(1):94-100

2. Pereira BM, Chiara O, Ramponi F, et al. WSES position paper on vascular emergency surgery. World J
Emerg Surg. 2015;10:49

3. Hafez HM, Woolgar J, Robbs JV. Lower extremity arterial injury: results of 550 cases and review of risk
factors associated with limb loss. J Vasc Surg. 2001 Jun;33(6):1212-9

4. Babar S, Amin MU, Kamal A, Rana A. The Role of 320 Slice CT Angiography in Predicting Vascular
Trauma. J Coll Physicians Surg Pak. 2016 Jan;26(1):23-6

5. Kortbeek JB, Al Turki SA, Ali J, et al. Advanced trauma life support, 8th edition, the evidence for change.
J Trauma. 2008 Jun;64(6):1638-50

6. Feliciano D, Mattox K, Moore E. Trauma. 6th ed. New York, NY: McGraw Hill Medical; 2008

7. Scerbo MH, Holcomb JB, Taub E, et al. The trauma center is too late: Major limb trauma without a pre-
hospital tourniquet has increased death from hemorrhagic shock. J Trauma Acute Care Surg. 2017
Dec;83(6):1165-1172

8. Keeley J, Koopmann M, Yan H, et al. Factors Associated with Amputation after Popliteal Vascular
Injuries. Ann Vasc Surg. 2016 May;33:83-7

9. Kim JJ, Alipour H, Yule A, et al. Outcomes after External Iliac and Femoral Vascular Injuries. Ann Vasc
Surg. 2016 May;33:88-93

10. Kirkilas M, Notrica DM, Langlais CS, Muenzer JT, Zoldos J, Graziano K. Outcomes of arterial vascular
extremity trauma in pediatric patients. J Pediatr Surg. 2016 Nov;51(11):1885-1890

DynaMed Editorial Process

● DynaMed topics are created and maintained by the DynaMed Editorial Team and Process .

● All editorial team members and reviewers have declared that they have no nancial or other
competing interests related to this topic, unless otherwise indicated.

● DynaMed content includes Practice-Changing Updates, with support from our partners, McMaster
University and F1000.

How to cite
National Library of Medicine, or "Vancouver style" (International Committee of Medical Journal Editors):

● DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. T913036, Vascular
Trauma of Extremities - Emergency Management; [updated 2018 Nov 30, cited place cited date
here]. Available from https://www.dynamed.com/topics/dmp~AN~T913036. Registration and login
required.

Published by EBSCO Information Services. Copyright © 2020, EBSCO Information Services. All rights reserved. No part of
this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying,
recording, or by any information storage and retrieval system, without permission.

EBSCO Information Services accepts no liability for advice or information given herein or errors/omissions in the text. It is
merely intended as a general informational overview of the subject for the healthcare professional.