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Extremity Vascular Trauma: Workup

Author: H Scott Bjerke, MD, FACS, Clinical Associate Professor, Department of Surgery, Indiana University School of Medicine, Medical Director of Trauma Services, Methodist Hospital, Clarian Health Partners, Inc
Coauthor(s): David FE Stuhlmiller, MD, FACEP, EMS Medical Director, Emergency Medical Associates of Westchester Medical Center; Medical Director, LifeNet of New York, An Air Methods Company; Medical Advisor, International Association of Flight Paramedics
Contributor Information and Disclosures

Updated: Jun 18, 2009

Workup

Laboratory Studies

  • Baseline blood work should consist of a CBC count with platelet count, electrolytes, BUN, and creatinine evaluations.
  • Typing and crossmatching of packed red blood cells for 4-8 U, depending on the severity of injury and hemorrhage, is also recommended.
  • Prothrombin time and activated partial thromboplastin time may be helpful in patients who are comatose and unable to provide an adequate medical history, although statistically, findings are rarely abnormal when the medical history documents no medications (eg, warfarin) or a history of bleeding problems.
  • In acute hemorrhage without equilibration, remember that the hematocrit or hemoglobin level may appear to be within the laboratory reference range even though there may be a significant cellular volume loss.

Imaging Studies

  • Plain x-ray films of the injured extremity are a rapid means of determining the presence of fractured bones and foreign bodies. Certain fractures (eg, supracondylar femur fractures) have a higher incidence of vascular injuries, and recognition of these types of injuries alerts the clinician to the risk of vascular injury.
  • CT scanning has been used in extremity trauma to visualize bony anatomy and soft tissues but still is not proven as a diagnostic modality in peripheral vascular injury. As such, CT scanning should not be used except in unusual circumstances.
  • Arteriography in the angiography suite is reserved for patients who are hemodynamically stable and preferably without renal failure or insufficiency. Most interventional radiologists require preprocedural BUN and creatinine measurements before proceeding with these studies. As soon as practicable, blood for these assays should be drawn in the resuscitation area to avoid delays in angiography, which may lead to delays in operative intervention.
  • In many cases, the surgeon can perform on-table angiography in the operating room with minimal risk to the patient. Surgeons should be familiar with arterial access points and the contrast materials available in their institution. Knowledge of total dye load and baseline renal status minimizes complications in this situation.
  • Duplex Doppler ultrasound studies of injured extremities have been shown to be a viable alternative to angiography in many centers. This study can be performed by the surgeon in the ED or in the resuscitation bay and can provide immediate and valuable information regarding patient vascular status or injury. Duplex Doppler ultrasound may be of limited use in patients with splints, extensive orthopedic hardware, areas of large tissue and skin loss, and when used by inexperienced personnel. Johansen et al offer a more detailed discussion of noninvasive tests in a screening situation.17

Other Tests

  • Ankle-brachial index
    • Measurement of the ABI is useful with atherosclerotic peripheral vascular disease and may be helpful in determining vascular insufficiency, but ABI cannot localize the site of injury.
    • Measurement of the ABI is a helpful component of the evaluation of penetrating arterial injury; however, the ABI cannot localize the site of injury.
    • A prospective study by Lynch and Johansen18 suggests that measurement of the ABI approaches the accuracy of arteriogram in identifying arterial injuries, and, more importantly, accurately identifies injuries needing intervention. Nassoura and colleagues supported this finding in a subsequent prospective trial.19
    • No diagnostic test is perfect; nevertheless, measurement of the ABI offers a noninvasive, simple, and reproducible method to accurately screen for penetrating arterial injury.
  • Assessing for a Doppler signal in peripheral vessels is more sensitive than manual palpation and is helpful in assessing for total occlusion or transection of the arterial tree.

Staging

Organ injury scaling may be helpful in the acute setting but should not override clinical experience and individual patient needs. Vascular injury scaling is also helpful for epidemiological study, peer review, and coding and billing. For information regarding organ injury scaling of peripheral vascular injuries currently sanctioned by the American Association for the Surgery of Trauma, see the study by Moore et al.20

The Mangled Extremity Severity Score (MESS) is an objective criterion for amputation prediction after lower or upper extremity injury. A MESS of >7 has been used as a cutoff point for amputation prediction. Prichayudh et al examined the result of upper extremity vascular injury management and amputation rate as related to MESS in 52 patients. Seven of 52 patients underwent amputation (overall amputation rate, 13.46%). Multivariate analysis revealed that the only factor significantly associated with amputation was the MESS. No amputations were performed in 33 patients who had a MESS of <7. Secondary amputations (amputation after primary operation) were done in 4 of 49 patients (8.16%). All amputation patients suffered blunt injuries and had a MESS of >7 (range, 7-11). Amputation was avoided in 12 of 19 patients who had a MESS >7.21
 
A MESS of >7 does not always indicate that amputation is required; however, MESS is a better predictor for patients who do not require amputation when the score is <7. The decision regarding whether or not to amputate should be made individually based on clinical signs and intraoperative findings of irreversible limb ischemia.

More on Extremity Vascular Trauma

Overview: Extremity Vascular Trauma
Workup: Extremity Vascular Trauma
Treatment: Extremity Vascular Trauma
Follow-up: Extremity Vascular Trauma
Multimedia: Extremity Vascular Trauma
References
Further Reading
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References

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  17. Johansen K, Lynch K, Paun M, Copass M. Non-invasive vascular tests reliably exclude occult arterial trauma in injured extremities. J Trauma. Apr 1991;31(4):515-9; discussion 519-22. [Medline].

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  19. Nassoura ZE, Ivatury RR, Simon RJ, et al. A reassessment of Doppler pressure indices in the detection of arterial lesions in proximity penetrating injuries of extremities: a prospective study. Am J Emerg Med. Mar 1996;14(2):151-6. [Medline].

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Further Reading

Clinical guidelines

Guideline for management of wounds in patients with lower-extremity neuropathic disease.
Wound, Ostomy, and Continence Nurses Society - Professional Association.  2004.  57 pages.  NGC:003898

VA/DoD clinical practice guideline for rehabilitation of lower limb amputation.
Department of Defense - Federal Government Agency [U.S.]
Department of Veterans Affairs - Federal Government Agency [U.S.]
Veterans Health Administration - Federal Government Agency [U.S.].  2007 Aug.  163 pages.  NGC:006060

Guideline for management of wounds in patients with lower-extremity arterial disease.
Wound, Ostomy, and Continence Nurses Society - Professional Association.  2002 Jun (revised 2008).  63 pages.  NGC:006521

Clinical trials

 A Study to Evaluate the Efficacy and Safety of Fondaparinux for the Prevention of Venous Blood Clots in Patients With a Plaster Cast or Other Type of Immobilization for a Below-Knee Injury Not Needing Surgery

Hand Transplantation for the Reconstruction of Below the Elbow Amputations

The Role of Total Body Imaging in Asymptomatic Pediatric Trauma Patients


Related eMedicine topics

Hand, Upper Extremity Vascular Injury 

Peripheral Vascular Injuries

Compartment Syndrome, Extremity

Compartment Syndrome, Upper Extremity

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Keywords

extremity vascular trauma, extremity trauma, vascular trauma, trauma, land mines, land mine injuries, land mine trauma, motor vehicle accidents, amputation, soft tissue injury, penetrating trauma, blunt trauma

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Contributor Information and Disclosures

Author

H Scott Bjerke, MD, FACS, Clinical Associate Professor, Department of Surgery, Indiana University School of Medicine, Medical Director of Trauma Services, Methodist Hospital, Clarian Health Partners, Inc
H Scott Bjerke, MD, FACS is a member of the following medical societies: American Association for the History of Medicine, American Association for the Surgery of Trauma, American College of Surgeons, Association for Academic Surgery, Eastern Association for the Surgery of Trauma, Midwest Surgical Association, National Association of EMS Physicians, Pan-Pacific Surgical Association, Royal Society of Medicine, Southwestern Surgical Congress, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Coauthor(s)

David FE Stuhlmiller, MD, FACEP, EMS Medical Director, Emergency Medical Associates of Westchester Medical Center; Medical Director, LifeNet of New York, An Air Methods Company; Medical Advisor, International Association of Flight Paramedics
David FE Stuhlmiller, MD, FACEP is a member of the following medical societies: Air Medical Physician Association, Alpha Omega Alpha, American College of Emergency Physicians, National Association of EMS Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Ernest Dunn, MD, Program Director of General Surgery, Director of Trauma and Critical Care, Clinical Associate Professor, Department of Surgery, Methodist Hospitals of Dallas, University of Texas Southwestern
Ernest Dunn, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, Association for Academic Surgery, Society of Critical Care Medicine, and Texas Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Robert L Sheridan, MD, Assistant Chief of Staff, Chief of Burn Surgery, Shriners Burns Hospital; Associate Professor of Surgery, Department of Surgery, Division of Trauma and Burns, Massachusetts General Hospital and Harvard Medical School
Robert L Sheridan, MD is a member of the following medical societies: American Academy of Pediatrics, American Association for the Surgery of Trauma, American Burn Association, and American College of Surgeons
Disclosure: Nothing to disclose.

CME Editor

Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy
Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences
Disclosure: Nothing to disclose.

Chief Editor

William H Pearce, MD, Chief, Division of Vascular Surgery, Violet and Charles Baldwin Professor of Vascular Surgery, Department of Surgery, Northwestern University School of Medicine
William H Pearce, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, American Surgical Association, Association for Academic Surgery, Association of VA Surgeons, Central Surgical Association, New York Academy of Sciences, Society for Vascular Surgery, Society of Critical Care Medicine, Society of University Surgeons, and Western Surgical Association
Disclosure: Nothing to disclose.

 
 
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