Diferencia entre revisiones de «Vascular injury»
| Línea 41: | Línea 41: | ||
==Evaluation== | ==Evaluation== | ||
===Arterial Pressure Index (API)=== | ===Arterial Pressure Index (API)=== | ||
*Doppler-determined arterial | *Doppler-determined arterial systolic blood pressure in injured limb divided by systolic blood pressure in uninjured limb | ||
**<0.90 abnormal | **<0.90 abnormal | ||
**Allows for serial, objective monitoring | **Allows for serial, objective monitoring | ||
**Only detects obstructive lesions | **Only detects obstructive lesions | ||
** | **Unreliable in proximal injuries, popliteal injuries, shotgun wounds, multiple wounds, shock | ||
** | **False negative with deep femoral artery injury | ||
===Duplex Doppler=== | ===Duplex Doppler=== | ||
Revisión del 16:24 13 nov 2018
Background
Types
- Complete Occlusive
- Transection
- Thrombosis
- Embolism
- Reversible spasm
- Non-occlusive
- Lacerations
- Intimal flaps
- Pseudoaneurysm
- A/V fistula
- Compartment syndrome
Occult Upper Extremity Vascular Injury
- Clavicle fracture/1st rib => 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
- <0.90 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 (>90% risk of arterial injury; 50% require intervention)
- Immediate arterial exploration without further investigation
Soft (30% risk of arterial injury)
- API → if < 0.9 obs/admit for 24h, serial API, consider:
- Doppler U/S
- CTA
- Eval of compartment syndrome
Management
- Emergency vascular surgery consult (General surgery if vascular not available)
Prognosis
Warm Ischemia Time
- 6 hours (10% irreversible damage)
- 12 hours (90% irreversible damage)