Peripheral Vascular Injury Management in the Emergency Department Clinical Presentation

Updated: Apr 30, 2020
  • Author: Niels K Rathlev, MD, FACEP; Chief Editor: Trevor John Mills, MD, MPH  more...
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Presentation

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. A single institutional retrospective analysis of patients with blunt lower extremity fractures found that open tibia-fibula fractures, particularly those involving a mid-shaft location, were independent predictors of vascular injuries. [19]

A number of case reports of upper limb arterial injury secondary to dog bites have been published. Dog bites in the upper limbs have particular significance, because despite the small size of the puncture wounds, penetration is deep, causing serious injuries to deeper structures that may result in residual neurologic deficit. [20]

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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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 because of trauma to adjacent structures. The risk of eventual limb amputation is higher with blunt mechanisms of injury.

  • Iatrogenic injury accounts for more than 10% of cases. Endovascular procedures such as cardiac catheterization and central line placement are the 2 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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