Vascular injury

Vascular injury

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1. Hard signs of vascular injury: expanding hematoma, bruit, thrill, active bleeding, severely ischemic extremity.
2. Soft signs of vascular injury: proximity of wound to major vessels, hx of hemorrhage/shock, non-expanding hematoma, diminished pulse and anatomically related nerve injury.
3. Prep contralateral saphenous vein in field, direct pressure (DP) to control bleeding (tourniquet only if DP fails).
4. Duplex scan when available.
5. Observe for evidence of compartment syndrome, change in vascular status. Ensure at least one follow-up vascular examination is performed.
6. Injured extremity to non-injured extremity systolic Doppler pressure ratio:
   1. With the patient supine (for at least 10 minutes prior), take blood pressures (B/P) in both arms. Use the higher systolic pressure as the brachial pressure in the ratio.
   2. Place the B/P cuff on the patient’s leg just above the maleoli, and the Doppler probe at 45 degrees to the dorsal pedis or posterior tibial artery.
   3. Inflate the cuff until the Doppler signal stops. Slowly deflate the cuff until the signal returns and record the numbers as the ankle systolic pressure.
   4. To get the ABI ratio, divide the highest ankle pressure by the highest brachial pressure. For example, with systolic brachial pressures of 120 and 129 and an ankle systolic of 65, the ABI is 0.5. Perform on both right and left extremities. Farther from the heart, leg pressure is supposed to be higher than or at least equal to arm pressure. Interpret your ABI results based on these guidelines:

• 0.9: Normal
• 0.5 to 0.9: Claudication mild to moderate
• < 0.5: Resting ischemic pain, claudication
• < 0.2: Gangrenous extremity; suggests near total occlusion

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