eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics
Trauma, Peripheral Vascular Injuries: Treatment & Medication
Updated: Jul 11, 2007
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Prehospital Care
- Secure airway as needed.
- Fluid resuscitation requires vascular access.
- Control hemorrhage by external compression.
- Splint extremity as needed.
Emergency Department Care
- As with all traumas, maintain ABCs as the first priority.
- If intravenous access is required, place a large-bore intravenous line in the unaffected limb or place a central line as needed.
- Conduct a more detailed secondary evaluation to assess for vascular injury. Include a thorough neurovascular examination, as described in Physical, looking for hard and soft signs of vascular injury.
- Look for historical or physical findings that indicate a high risk of vascular injury. Proximity wound, bite from a large animal, high-velocity bullet or shotgun wound, severely crushed limb, associated dislocation (especially posterior knee dislocation), and others.
- Obvious vascular injury with evidence of ischemia indicates emergent surgical exploration once the patient is stabilized.
- Frequently assess vascular status.
- Doppler examination for pulses helps in patients with diminished pulses.
- Measure blood pressure in an injured and uninjured extremity. A 10 mm Hg difference suggests vascular injury, as does an ABI less than 1.0.
- Control hemorrhage with direct pressure. Do not blindly attempt to clamp a vessel because the potential for damaging accompanying peripheral nerves is high.
- Generally, extremity tissues tolerate 4-6 hours of ischemia. Carefully monitor popliteal artery injuries because of minimal collateral circulation present in the lower extremity. After 6-8 hours of ischemia, permanent disability of the limb and/or amputation will occur.
- Anatomic repositioning and splinting may help restore circulation in dislocations or fractures.
- Monitor the patient closely for development of compartment syndrome.
- Wounds should be irrigated extensively with normal saline.
- No clear consensus exists regarding use of antibiotics; however, a first-generation cephalosporin is usually adequate for an uncomplicated injury. If injury is caused by an animal bite or an open fracture is present, treat accordingly.
Consultations
Prompt consultation with the trauma team is routine at most major urban trauma centers. If isolated peripheral vascular injury is present, consult the vascular surgeon as soon as the patient stabilizes to reduce ischemia time.
Medication
The goal of therapy is to control pain and infections.
Analgesics
Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and aids physical therapy regimens. Most analgesics have sedating properties that benefit patients with traumatic injuries.
Use of pain medications in trauma victims is a difficult issue. Narcotics have several drawbacks, including exacerbating hypotension in hemorrhaging patients and mental status changes in patients with head injuries. These agents also may mask pain caused by subtle injuries. Nevertheless, in cases of isolated extremity trauma in stable patients, use pain medications. Use IV administration for more precise titration.
Fentanyl (Duragesic, Fentanyl Oralet)
Potent narcotic analgesic with much shorter half-life than morphine sulfate. DOC for conscious sedation analgesia. Ideal for short-term (30-60 min) analgesic action during anesthesia and immediate postoperative period. Excellent choice for short-term pain management and sedation; easy to titrate. Easily and quickly reversed by naloxone. After initial dose, do not titrate subsequent doses more frequently than q3-6h. When using transdermal dosage form, most patients are controlled with 72-h dosing intervals, although some patients require 48-h dosing intervals.
Adult
Emergency: 0.5-2 mcg/kg/dose IV/IM
Analgesia: 0.5-1 mcg/kg/dose IM/IV q30-60min
Transdermal: Apply a 25-mcg/h system q48-72h
Pediatric
<2 years: 2-3 mcg/kg/dose IV/IM q30-60min
2-12 years: 1-2 mcg/kg/dose IV/IM q60min
>12 years: Administer as in adults
Phenothiazines may antagonize analgesic effects of opiate agonists; tricyclic antidepressants may potentiate adverse effects when coadministered
Documented hypersensitivity; hypotension or potentially compromised airway in which it would be difficult to establish rapid airway control
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Caution in hypotension, respiratory depression, constipation, nausea, emesis, and urinary retention; an idiosyncratic reaction (chest wall rigidity syndrome) may require neuromuscular blockade to increase ventilation
Morphine sulfate (Duramorph, Astramorph, MS Contin)
DOC for narcotic analgesia due to reliable and predictable effects, safety profile, and ease of reversibility with naloxone; IV administration may be dosed in a number of ways and commonly is titrated until desired effect is obtained.
Adult
Starting dose: 0.1 mg/kg IV/IM/SC
Maintenance dose: 5-20 mg/70 kg IV/IM/SC q2-4h
Relatively hypovolemic patients: Start with 2 mg IV/IM/SC and reassess hemodynamic effects of dose
Pediatric
Neonates: 0.05-0.2 mg/kg dose IV/IM/SC prn
Children: 0.1-0.2 mg/kg dose IV/IM/SC q2-4h prn
Phenothiazines may antagonize analgesic effects of opiate agonists; tricyclic antidepressants, MAOIs, and other CNS depressants may potentiate adverse effects of morphine when coadministered
Documented hypersensitivity; hypotension; potentially compromised airway in which establishing rapid airway control would be difficult
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Avoid in hypotension, respiratory depression, nausea, emesis, constipation, and urinary retention; caution in atrial flutter and other supraventricular tachycardias; has vagolytic action and may increase ventricular response rate
Antibiotics
Antibiotics should be used in all high-risk wounds. These include contaminated and devitalized wounds; patients with diabetes, HIV, or other immunocompromising disorder; and wounds caused by animal or human bites. Patients with underlying fractures should be treated with antibiotics in a similar fashion as anyone with an open fracture.
Cefazolin (Ancef, Kefzol, Zolicef)
First-generation semisynthetic cephalosporin that arrests bacterial cell wall synthesis, inhibiting bacterial growth. Primarily active against skin flora, including Staphylococcus aureus. Typically used alone for skin and skin-structure coverage. IV and IM dosing regimens are similar.
Adult
250 mg to 2 g IV/IM q6-12h, depending on severity of infection; not to exceed 12 g/d
Pediatric
25-100 mg/kg/d IV/IM divided q6-8h, depending on severity of infection; not to exceed 6 g/d
Probenecid decreases renal clearance and prolongs effects; concurrent use with aminoglycosides may increase renal toxicity; administration may yield false-positive urine dip for glucose
Documented hypersensitivity
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Adjust dose in renal impairment; prolonged use of antibiotics is associated with superinfections and promotion of nonsusceptible organisms; complications usually are reversible
Tetanus immunization
Tetanus immunization is indicated when 10 years have passed since last booster shot. If immunization status is unclear, tetanus immune globulin is required.
Tetanus toxoid
Used to induce active immunity against tetanus in selected patients. The immunizing agents of choice for most adults and children >7 y are tetanus and diphtheria toxoids. Necessary to administer booster doses to maintain tetanus immunity throughout life.
Pregnant patients should receive only tetanus toxoid not a diphtheria antigen-containing product.
In children and adults, may administer into deltoid or midlateral thigh muscles. In infants, preferred site of administration is the mid thigh laterally.
Adult
Primary immunization: 0.5 mL IM; administer 2 injections 4-8 wk apart and a third dose 6-12 mo after second injection
Booster dose: 0.5 mL IM q10y
Pediatric
Administer as in adults
Patients receiving immunosuppressants, including corticosteroids or radiation therapy, may remain susceptible despite immunization because of poor immune response; cimetidine may enhance or augment delayed-hypersensitivity responses to skin-test antigens; avoid concurrent use of systemic chloramphenicol, since it may impair amnestic response to tetanus toxoid; concurrent use of tetanus immunoglobulin may delay development of active immunity by several days; this interaction is clinically insignificant and does not preclude concurrent use
Documented hypersensitivity; history of any type of neurologic symptoms or signs following administration of this product; FDA recommends that elective tetanus immunization be deferred during any outbreak of poliomyelitis because tetanus toxoid injections are an important cause of provocative poliomyelitis
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Never use to treat actual tetanus infections or for immediate prophylaxis of unimmunized individuals; instead use tetanus antitoxin, preferably human tetanus immunoglobulin; diminished antibody response to active immunization may be seen in patients receiving immunosuppressive therapy; it is better to defer primary diphtheria immunization until immunosuppressive therapy is discontinued; routinely immunize symptomatic and asymptomatic persons who are infected with HIV
Tetanus immune globulin (Hyper-Tet)
Used for passive immunization of patients with a wound that may be contaminated with tetanus spores.
Adult
250-500 U IM in extremity opposite to tetanus toxoid lesion
Pediatric
Administer as in adults
None reported
Because antibodies in globulin preparation may interfere with immune response to vaccination, do not administer within 3 mo of live-virus immunoglobulin administration; may be necessary to revaccinate patients who received immunoglobulin shortly after live-virus vaccination
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Patients with isolated IgA deficiency may develop antibodies to IgA and may have anaphylactic reactions to subsequent administration of blood products that contain IgA; do not perform skin testing because intradermal injection of concentrated gamma-globulin may cause a localized area of inflammation and can be misinterpreted as a positive allergic reaction rather than a localized chemical tissue irritation; medication mistakenly may be withheld from a nonallergic patient; true allergic responses to human gamma-globulin administered in the prescribed IM manner are extremely rare; do not mix with other medications, as they are usually incompatible
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 |
| « Previous Page | Next Page » |
References
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].
Gonzalez RP and Falimirski ME. The utility of physical examination in proximity penetrating extremity trauma. Am Surg. Aug 1999;65(8):784-9. [Medline].
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].
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].
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].
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].
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].
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].
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].
Gahtan V, Bramson RT, Norman J. The role of emergent arteriography in penetrating limb trauma. Am Surg. Feb 1994;60(2):123-7. [Medline].
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].
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].
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].
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].
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].
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].
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].
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].
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].
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].
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].
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.
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].
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].
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].
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].
Further Reading
Keywords
peripheral vascular injury, vascular trauma, tensile strain, shear strain, vessel rupture, intimal rupture, penetrating trauma, blunt trauma, stab wounds, gunshot wounds
