Peripheral Vascular Injuries Clinical Presentation
- Author: Niels K Rathlev, MD, FACEP; Chief Editor: Trevor John Mills, MD, MPH more...
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.
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
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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