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Peripheral Vascular Injuries Clinical Presentation

  • Author: Niels K Rathlev, MD, FACEP; Chief Editor: Trevor John Mills, MD, MPH  more...
 
Updated: Oct 08, 2015
 

History

In peripheral vascular injury, the mechanism is an important prognostic factor. Shotgun and military rifle injuries, as well as knee dislocations, are particularly high risk for vascular injury.

The time interval between injury and evaluation must be considered. "Warm" ischemia at body temperature for more than 6 hours results in irreversible nerve and muscle damage in 10% of patients. Cooling the extremity may avoid this complication.

Other risk factors include previous history of vascular injury or disease, extensive or pulsatile external hemorrhage, anticoagulation therapy or impaired hemostatic function, and prior venous thrombosis or embolism in the patient or a family member.

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Physical

Deciding whether the injury requires surgical intervention is a major priority of initial management.

The presence of "hard" signs of vascular injury has a 92-95% sensitivity for injuries requiring intervention. The vast majority of patients exhibiting the following "hard" signs require intervention with a positive predictive value of 95%.

  • Bruit or thrill: These are present in only 45% of patients with an arteriovenous fistula
  • Active or pulsatile hemorrhage
  • Pulsatile or expanding hematoma
  • Signs of limb ischemia and elevated compartment pressure including the 5 "P's:" Pallor, paresthesias, pulse deficit, paralysis, and pain on passive extension of the compartment." Pain on passive extension is the earliest and most sensitive physical finding.
  • Diminished or absent pulses: This is not a sensitive prognostic finding, as up to 25% of patients with major vascular injuries requiring repair have normal pulses distal to the injury.

The following "soft" signs are much less useful in predicting or excluding major vascular injuries that require intervention. The positive predictive value of "soft" signs indicating abnormal findings on an arteriogram is only 35%. The vast majority of these lesions do not require emergent repair.

  • Hypotension or shock
  • Neurologic deficit due to primary nerve injury occurs immediately after injury. In contrast, ischemic neuropathy is delayed in onset, developing within minutes to hours after injury.
  • Stable, nonpulsatile or small hematoma
  • Proximity of the wound to major vascular structures
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Causes

Causes of peripheral vascular injuries include the following:

  • Gunshot wounds, particularly high-energy rifle and close-range shotgun wounds, cause 70-80% of all vascular injuries that require intervention.
  • Stab wounds - Only 5-10% of cases require intervention.
  • Blunt trauma accounts for 5-10% of cases. The presence of a fracture or dislocation increases the risk. Blunt injuries are often more severe than penetrating injuries due to trauma to adjacent structures. The risk of eventual limb amputation is higher with blunt mechanisms of injury.
  • Iatrogenic injury now accounts for more than 10% of cases. Endovascular procedures such as cardiac catheterization and central line placement are the two most common iatrogenic causes of vascular injury that require intervention. The incidence of iatrogenic injuries is growing in concert with the increased utilization of endovascular procedures.
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Contributor Information and Disclosures
Author

Niels K Rathlev, MD, FACEP Professor and Chair, Department of Emergency Medicine, Tufts University School of Medicine and Baystate Medical Center

Niels K Rathlev, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, Massachusetts Medical Society, Society for Academic Emergency Medicine, Association of Academic Chairs of Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

David B Levy, DO, FAAEM Senior Consultant in Emergency Medicine, Waikato District Health Board, New Zealand; Associate Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine

David B Levy, DO, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, Fellowship of the Australasian College for Emergency Medicine, American Medical Informatics Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Trevor John Mills, MD, MPH Chief of Emergency Medicine, Veterans Affairs Northern California Health Care System; Professor of Emergency Medicine, Department of Emergency Medicine, University of California, Davis, School of Medicine

Trevor John Mills, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Additional Contributors

David A Peak, MD Associate Residency Director of Harvard Affiliated Emergency Medicine Residency; Attending Physician, Massachusetts General Hospital; Assistant Professor, Harvard Medical School

David A Peak, MD is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine, Undersea and Hyperbaric Medical Society, American Medical Association

Disclosure: Partner received salary from Pfizer for employment.

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