Emergency Department Care

Perform the following for peripheral vascular injuries:

Stabilize the extremity in the anatomic position.
Control hemorrhage with direct pressure.
Apply a tourniquet proximal to the injury if direct pressure is not effective in controlling hemorrhage.

A multicenter retrospective review of 1,026 patients sustaining peripheral vascular injuries admitted to level I trauma centers found that prehospital tourniquet application was independently associated with a 6-fold mortality reduction in patients with peripheral vascular injuries. However, prehospital tourniquets were used in only 17.6% of patients. The study concluded that more aggressive prehospital application of extremity tourniquets in trauma patients with extremity hemorrhage and traumatic amputation was warranted.^[35]

Immediately reduce displaced or angulated fractures if any evidence or suspicion of vascular compromise exists. Promptly reduce dislocations of the elbow and knee to prevent further injury to neurovascular structures.

External hemorrhage usually can be controlled with direct pressure, but a blood pressure cuff or tourniquet should be applied proximally to the injury if compression fails or is not possible.

Once the patient has been stabilized, identify peripheral vascular injuries and restore normal circulation as rapidly as possible.

Do not apply clamps or hemostats to vascular structures, since this may make definitive repair more difficult and damage surrounding tissues.

A vascular surgeon must be consulted whenever a major vascular injury is a concern.

Vascular injury sustained during battlefield combat is often managed via revascularization. Reconstruction methods should be a focus of combat surgery training. Ligation is also an effective intervention.^[17]

Low-risk injuries without "hard" or "soft" signs may be managed on an outpatient basis with careful follow-up and a strict schedule for repeat evaluations. All other patients should be admitted for either definitive repair or further evaluation or observation.

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