Rapid Review·Cardiovascular
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Vascular: Peripheral
T2High yieldVascular Trauma
Focus on
Hard signs — pulsatile bleeding, expanding hematoma, bruit or thrill, distal ischemia — go straight to the operating room. Soft signs get an injured-extremity index: under 0.9 means CT angiography, 0.9 or above with a normal examination means observation. Tourniquet the exsanguinating limb, realign the fracture, and watch for compartment syndrome after repair — a palpable pulse does not exclude it.
Key takeaways
What it is
Vascular trauma
injury to a named artery or vein by a penetrating (gunshot, stab, iatrogenic) or blunt (fracture, dislocation, crush) mechanism.- Transection, intimal flap with thrombosis, pseudoaneurysm, arteriovenous fistula.
The stakes
exsanguination and limb loss; 6 hours of warm ischemia is the limit.High-risk injuries
posterior knee dislocation (popliteal artery), supracondylar humerus fracture (brachial artery), distal femoral and proximal tibial fractures, shoulder dislocation (axillary artery), penetrating neck wounds.| Hard signs (immediate operative or endovascular control) | Soft signs (structured evaluation) |
|---|---|
| Pulsatile external bleeding | Significant bleeding at the scene, now stopped |
| Rapidly expanding or pulsatile hematoma | Stable, non-expanding hematoma |
| Palpable thrill or audible bruit over the wound | Wound in proximity to a major vessel |
| Distal ischemia (the six P's) or absent distal pulses | Diminished but palpable distal pulse |
| Shock unexplained by other injuries | Neurologic deficit in an adjacent nerve |
Diagnosis
Primary survey first
control hemorrhage before imaging anything.Hard signs: no imaging, to the operating room
on-table angiography if the level is unclear; computed tomography (CT) angiography first only for shotgun wounds or multiple levels of injury.Soft signs or doubt: the injured-extremity index
the Doppler systolic pressure distal to the injury divided by the uninjured arm.- 0.9 or more with a normal examination: observe with serial examinations.
- Under 0.9, or an abnormal examination: CT angiography.
A palpable pulse does not exclude an intimal flap
reduce a fracture or dislocation and reassess; a persistent deficit still needs imaging.| Finding | Next step |
|---|---|
| Hard sign or limb-threatening hemorrhage | Immediate operative or endovascular control, no CT |
| No hard sign, normal examination, index 0.9 or more | Observation with serial examination |
| Soft sign, diminished pulse, index under 0.9, or equivocal examination | CT angiography (or duplex) |
| Fracture or dislocation with a pulse deficit | Reduce and splint immediately, reassess; a persistent deficit gets angiography or exploration |
| Tense compartment, pain with passive stretch, paresthesia | Fasciotomy (pulses may still be present) |
Management
Hemorrhage control
direct pressure, then wound packing with hemostatic gauze.- A tourniquet proximal to life-threatening compressible bleeding (record the time; convert to definitive control within 2 hours if possible).
- Never blindly clamp in the wound.
Resuscitation
blood products, tranexamic acid within 3 hours, permissive hypotension until control (Hypovolemic & Hemorrhagic Shock).Definitive repair
primary repair for small lacerations, an interposition graft with reversed saphenous vein from the uninjured leg for segmental loss, endovascular stent grafts for difficult sites (subclavian, iliac, aorta; Traumatic Aortic Injury).Ligation
acceptable for many veins and for non-critical arteries (radial or ulnar with an intact arch, a single tibial vessel).Temporary intravascular shunts
restore flow during damage-control surgery or while a fracture is stabilized.Fasciotomy
prophylactic after over 4 to 6 hours of ischemia, combined arterial and venous injury, crush or massive soft-tissue injury; therapeutic for any compartment syndrome.Complications
Compartment syndrome
pain out of proportion and with passive stretch, a tense compartment, paresthesia.Reperfusion injury
rhabdomyolysis, hyperkalemia, myoglobinuric kidney injury.Others
graft thrombosis, pseudoaneurysm and fistula (Femoral Artery Disease), nerve injury, amputation.After a posterior knee dislocation is reduced, the patient has a diminished dorsalis pedis pulse and an injured-extremity index of 0.8, with no active bleeding or expanding hematoma. What is the next step, and what would send him straight to the operating room?
Soft signs with an index under 0.9: get CT angiography (popliteal artery injury is the concern). Hard signs (pulsatile bleeding, an expanding hematoma, a thrill or bruit, absent pulses with ischemia, unexplained shock) mean the operating room without imaging.
How it's tested
A stab wound to the thigh with pulsatile bleeding and an expanding hematoma: hard signs — direct pressure or tourniquet and immediate operative exploration; no CT angiography.
Gunshot to the calf, distal pulses present but weaker than the other side, index 0.8: soft signs with an abnormal index — CT angiography.
Same wound, normal pulses, normal examination, index 0.95: observe with serial examinations.
Posterior knee dislocation with a cold pulseless foot: reduce immediately and reassess; if the pulse does not return (or the index stays < 0.9), angiography/exploration of the popliteal artery within the 6-hour window.
Eight hours after brachial artery repair the forearm is tense and exquisitely painful on finger extension, radial pulse present: compartment syndrome — fasciotomy; the pulse is the distractor.
Go deeper
Guidelines: ACS Trauma Quality Programs Best Practices Guidelines
Related Step 2 pages: Hypovolemic & Hemorrhagic Shock, Acute Limb Ischemia, Traumatic Aortic Injury, Femoral Artery Disease, Approach to Leg Pain & Ulcers, Blunt Cardiac Injury
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