![]() In the military setting where these injuries are more common, the tourniquet application has been proven to save lives. The application of tourniquets may be necessary in more extensive injuries and also to secure safe transfer to definitive treatment. īleeding control of the arterial or venous limb injury can be achieved in most cases by manual compression and pressure bandages. ![]() If CT angiography is not available, conventional angiography can be performed in the operating room with a C-arm or in a hybrid suite depending on local facilities.ĭepending on available resources and early access of endovascular treatment, the algorithm at the Karolinska University Hospital in Stockholm which is a slightly modified version of the one presented by the Western Trauma Association is shown in Fig. ![]() However, when metal fragments remain in the wound, streak artifacts may be a limiting factor for adequate diagnosis. ![]() CT angiographic signs of arterial injury include active extravasation of contrast, abrupt narrowing of artery or loss of opacification of an arterial segment, pseudoaneurysm, and arteriovenous fistula. When computed tomography (CT) is available and the patient physiology and injury allow for further evaluation, the CT angiography (CTA) has become the gold standard for diagnosing and to further decide whether the vascular injury can be treated by open surgery or by endovascular techniques. There is no role for routine imaging in penetrating extremity trauma. If vascular status is difficult to assess, further investigations are required by calculating the ankle-brachial index followed most frequently by imaging with CT angiography. The presence of hard signs in penetrating trauma during the physical examination usually determines the anatomic level of vascular injury and the need for immediate surgery. The presence or not of hard clinical signs may decide whether the patient needs an immediate operation, can undergo further investigation, or may only need continuous observation. The soft signs are as follows: history of arterial bleeding at the scene of injury, diminished distal unilateral pulse, small hematoma, neurological deficit, abnormal flow velocity wave on Doppler examination, or abnormal ankle-brachial pressure index (ABI, <0.9). The hard signs are as follows: active hemorrhage, rapidly expanding hematomas, absent pulses, pallor, paresthesia, pain, paralyses, poikilothermia, or palpable thrill or audible bruit. Clinical signs of vascular injury are generally divided into “hard” or “soft” signs of injury. The clinical evaluation of the injured extremity after penetrating trauma is of outmost importance. This article focuses on the specific management of vascular injuries in the upper and lower limbs but will also briefly mention some principles of general management as well as wound evaluation and surgical wound debridement. Shotgun injuries cause vascular injuries in 5 % of the time. Stab wounds cause the majority of injuries in Europe although gunshot injuries are dominating in countries where firearms are more commonly used. In the civilian setting, penetrating injuries to the limbs are observed in between 5 and 15 % according to, for example, trauma registries in the USA, Germany, or Sweden, although the number of injuries can be higher in some other countries. In the military setting, the use of body armor protects to some extent from lethal injuries but combined severe soft tissue, bone, vascular, and nerve injuries of the extremities are common. Although high-energy injuries are more frequent in the military setting, they can be seen also in the civilian setting and in particular after terror attacks. Penetrating injuries to the upper and lower limbs may cause a large variety of complex injuries depending on the penetrating energy transferred into the tissues.
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