Diagnosis of Vascular Injury

Introduction

Vascular trauma presents in a variety of settings and results in findings that range from life-threatening hemorrhage secondary to major torso or extremity vessel disruption to no detectable signs in occult injuries. Effective management is based upon early diagnosis and prompt treatment. Isolated vascular injuries are becoming less common at modern urban trauma centers. There is a growing prevalence of multisystem trauma that includes vascular injury, making early diagnosis more of a challenge. Successfully identifying vascular trauma in a timely fashion requires an organized approach with attention to the mechanism of injury, presence of hemorrhage at the scene or during transport, a thorough physical examination augmented, when needed, with Doppler extremity pressure measurements, and finally, the effective use of multidetector CT angiography (MDCTA). Imaging techniques are discussed at length in subsequent chapters.

Several analyses of human error suggest that three factors play a role in most major errors: familiarity, distraction, and fatigue. The modern trauma center creates an environment where all three factors are constantly interplaying. Trauma care is, therefore, an error prone process. Avoiding error in the care of the injured requires not only an organized approach, but the use of short but effective checklists which assure the application of that organized approach. Unfortunately, most physicians are overly familiar with long, detailed, and all-inclusive checklists that were not developed in conjunction with them or by colleagues who actually provide trauma care. Most physicians do not find these types of checklists useful and they are not often used. In contrast, the experience of military and civilian aviation communities strongly supports the use of short and practical checklists created by experienced air crews and thoroughly tested at the point of service until they are effective. The essential history and physical elements that lead to the prompt diagnosis of vascular injury are displayed as a checklist in Box 7.1 .