eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics

Trauma, Peripheral Vascular Injuries: Follow-up

Author: Eric J Morley, MD, Resident, Department of Emergency Medicine, State University of New York Downstate/Kings County Hospital
Coauthor(s): Christopher I Doty, MD, FAAEM, Assistant Professor of Emergency Medicine, Combined EM/IM Residency Program Director, Department of Emergency Medicine, Kings County Hospital Center, State University of New York Downstate Medical Center
Contributor Information and Disclosures

Updated: Jul 11, 2007

Follow-up

Further Inpatient Care

  • Most patients require surgical consultation and admission.

Further Outpatient Care

  • Patients should have close follow-up because many injuries can be successfully treated if detected early.

Transfer

  • If angiography or surgical consultation is not available at the primary institution, transfer the patient as quickly as possible after stabilization.

Complications

  • Associated nerve damage occurs in a large percentage of vascular injuries, which may result in permanent deficits.
  • Compartment syndrome
  • Venous thrombosis
  • Arterial embolization
  • Wound infection
  • Loss of limb may occur. Restoring blood flow to ischemic tissue within 6 hours is crucial or irreversible damage will occur.
  • Ischemic contracture of affected limb 

Prognosis

  • Blunt vascular injuries have a worse prognosis than those caused by penetrating trauma.
  • The probability of limb loss is higher with blunt injury, greater extent of soft tissue injury (muscle, skin, and major nerves), greater number of associated long bone fractures, pulseless extremity, and need for arterial repair. 
  • Injury severity score correlates with mortality rate.
  • Intraoperative hypotension, arterial intimal injury, bony fracture, and thoracic injury are all predictors of higher postoperative complications.  
  • Amputation rates are now very low. In addition, many patients with vascular injuries experience minimal disability. 

Miscellaneous

Medicolegal Pitfalls

  • Failure to promptly diagnose peripheral vascular injury is a pitfall. The legal implications of delayed diagnosis resulting in limb amputation are self-explanatory; however, amputation sometimes is necessary in severe injury. In such instances, do not delay amputation, as this results in increased risk of sepsis and higher morbidity.  
  • Failure to provide a thorough physical examination, prompt consultation, early intravenous antibiotics, and tetanus immunization if indicated also are pitfalls. The goals are stabilization of the patient and minimization of ischemic time.

Special Concerns

  • Pediatrics
    • A thorough neurovascular examination is more difficult in young children.
    • Children have a higher risk of developmental abnormalities secondary to ischemia.
    • Emergency center arteriography may be an alternative to aid rapid diagnosis in young patients.
  • Geriatrics

    • Older patients have a higher mortality rate secondary to comorbid conditions.
    • Aggressive resuscitation is needed prior to operative interventions.
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors, A Antoine Kazzi, MD, Anupama Singh, MD, and Mazen El-Sayed, MD, to the development and writing of this article.



More on Trauma, Peripheral Vascular Injuries

Overview: Trauma, Peripheral Vascular Injuries
Differential Diagnoses & Workup: Trauma, Peripheral Vascular Injuries
Treatment & Medication: Trauma, Peripheral Vascular Injuries
Follow-up: Trauma, Peripheral Vascular Injuries
References
[ CLOSE WINDOW ]

References

  1. Busquets AR, Acosta JA, Colon E, Alejandro KV, Rodriguez P. Helical computed tomographic angiography for the diagnosis of traumatic arterial injuries of the extremities. J Trauma. Mar 2004;56(3):635-28. [Medline].

  2. Gonzalez RP and Falimirski ME. The utility of physical examination in proximity penetrating extremity trauma. Am Surg. Aug 1999;65(8):784-9. [Medline].

  3. Prêtre R, Bruschweiler I, Rossier J, Chilcott M, Bednarkiewicz M, Kürsteiner K, et al. Lower limb trauma with injury to the popliteal vessels. J Trauma. Apr 1996;40(4):595-601. [Medline].

  4. Schwartz MR, Weaver FA, Bauer M, Siegel A, Yellin AE. Refining the indications for arteriography in penetrating extremity trauma: a prospective analysis. J Vasc Surg. Jan 1993;17(1):116-22; discussion 122-4. [Medline].

  5. Bynoe RP, MIles WS, Bell RM, et al. Noninvasive diagnosis of vascular trauma by duplex ultrasonography. J Vasc Surg. Sep 1991;14(3):346-52. [Medline].

  6. Kaplan LJ, Kellum JA. Initial pH, base deficit, lactate, anion gap, strong ion difference, and strong ion gap predict outcome from major vascular injury. Crit Care Med. May 2004;32(5):1120-4. [Medline].

  7. American College of Emergency Physicians: Clinical policy for the initial approach to patients presenting with penetrating extremity trauma. Ann Emerg Med. May 1999;33(5):612-36. [Medline].

  8. Asensio JA, Kuncir EJ, Garcia-Nunez LM, Petrone P. Femoral vessel injuries: analysis of factors predictive of outcomes. J Am Coll Surg. Oct 2006;203(4):512-20. Epub 2006 Aug 23. [Medline].

  9. Dennis J, Frykberg E, Henry V, Huffman S, Menawat S. Validation of nonoperative management of occult vascular injuries and accuracy of physical examination alone in penetrating extremity trauma:5- to 10-year follow-up. J Trauma. Feb 1998;44(2):243-52; discussion 242-3. [Medline].

  10. Gahtan V, Bramson RT, Norman J. The role of emergent arteriography in penetrating limb trauma. Am Surg. Feb 1994;60(2):123-7. [Medline].

  11. Ianaba K, Potzman J, Munera F, et al. Multi-slice CT angiography for arterial evaluation in the injured lower extremity. J Trauma. Mar 2006;60(3):502-7; discussion 506-7. [Medline].

  12. Itani KM, Rothenberg SS, Brandt ML, Burch JM, Mattox KL, Harberg FJ, et al. Emergency center arteriography in the evaluation of suspected peripheral vascular injuries in children. J Pediatr Surg. May 1993;28(5):677-80. [Medline].

  13. 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].

  14. Knudson MM, Lewis FR, Atkinson K, Neuhaus A. The role of duplex ultrasound arterial imaging in patients with penetrating extremity trauma. Arch Surg. Sep 1993;128(9):1033-7; discussion 1037-8. [Medline].

  15. Levy BA, Zlowodzki MP, Graves M, Cole PA. Screening for extremity arterial injury with the arterial pressure index. Am J Emerg Med. Sep 2005;23(5):689-95. [Medline].

  16. Lynch K, Johansen K. Can Doppler pressure measurement replace "exclusion" arteriography in the diagnosis of occult extremity arterial trauma?. Ann Surg. Dec 1991;214(6):737-41. [Medline].

  17. Miranda FE, Dennis JW, Veldenz HC, Dovgan PS, Frykberg ER. Confirmation of the safety and accuracy of physical examination in the evaluation of knee dislocation for injury of the popliteal artery: a prospective study. J Trauma. Feb 2002;52(2):247-51; discussion 251-2. [Medline].

  18. Modrall JG, Weaver FA, Yellin AE. Diagnosis and management of penetrating vascular trauma and the injured extremity. Emerg Med Clin North Am. Feb 1998;16(1):129-44. [Medline].

  19. Moniz MP, Ombrellaro MP, Stevens SL, Freeman MB, Diamond DL, Goldman MH. Concomitant orthopedic and vascular injuries as predictors for limb loss in blunt lower extremity trauma. Am Surg. Jan 1997;63(1):24-8. [Medline].

  20. Mullenix PS, Steele SR, Andersen CA, Starnes BW, Salim A, Martin MJ. Limb salvage and outcomes among patients with popliteal vascular injury: an analysis of the national trauma data bank. J Vasc Surg. Jul 2006;44(1):94-100. [Medline].

  21. Nassoura ZE, Ivatury RR, Simon RJ, Jabbour N, Vinzons A, Stahl W. A reassessment of Doppler pressure indices in the detection of arterial lesions in proximity penetrating injuries of extremities: a prospective study. Am J Emer Med. Mar 1996;14(2):151-6. [Medline].

  22. Newton EJ. Peripheral vascular injury. In: Marx JA, Hockberger RS, Walls RM, et al. Marx:Rosen's Emergency Medicine:Concepts and Clinical Practice. 6th ed. Philadelphia, PA: Mosby Iinc; 2006:536-547.

  23. Poole GV, Agnew SG, Griswold JA, Rhodes RS. The mangled lower extremity: Can salvage be predicted. American Surgeon. Jan 1994;60(1):50-55. [Medline].

  24. Soto JA, Munera F, Morales C, et al. Focal arterial injuries of the proximal extremities: helical CT arteriography as the initial method of diagnosis. Radiology. Jan 2001;218(1):188-94. [Medline].

  25. Soto JA, Múnera F, Cardoso N, Guarín O, Medina S. Diagnostic performance of helical CT angiography in trauma to large arteries of thhe extremities. J Comput Assist Tomogr. Mar-Apr 1999;23(2):188-96. [Medline].

  26. Stain SC, Yellin AE, Weaver FA, Pentecost MJ. Selective management of nonocclusive arterial injuries. Arch Surg. Oct 1989;124(10):1136-40; discussion 1140-1. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

peripheral vascular injury, vascular trauma, tensile strain, shear strain, vessel rupture, intimal rupture, penetrating trauma, blunt trauma, stab wounds, gunshot wounds

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Eric J Morley, MD, Resident, Department of Emergency Medicine, State University of New York Downstate/Kings County Hospital
Disclosure: Nothing to disclose.

Coauthor(s)

Christopher I Doty, MD, FAAEM, Assistant Professor of Emergency Medicine, Combined EM/IM Residency Program Director, Department of Emergency Medicine, Kings County Hospital Center, State University of New York Downstate Medical Center
Christopher I Doty, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Peter MC DeBlieux, MD, Professor of Clinical Medicine and Pediatrics, Section of Pulmonary and Critical Care Medicine, Program Director, Department of Emergency Medicine, Louisiana State University Health Sciences Center
Peter MC DeBlieux, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Radiological Society of North America, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

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

Managing Editor

Eric Legome, MD, Residency Director, Assistant Professor of Emergency Medicine, Department of Emergency Medicine New York University, New York University Hospital, Bellevue Hospital Center, Manhattan VA
Eric Legome, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John Halamka, MD, Chief Information Officer, CareGroup Healthcare System, Assistant Professor of Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center; Assistant Professor of Medicine, Harvard Medical School
John Halamka, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.