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Diagnosis of vascular trauma
The diagnosis of vascular trauma is usually not a problem, as most injuries manifest overt blood loss, shock, or loss of critical pulses. However, in certain instances, the lesion may not be recognized initially, only to manifest itself later by sudden secondary hemorrhage or the development of critical organ or extremity ischemia.
Most of the vascular injuries of immediate concern to the clinician are those related to arteries. The reason for this is that venous hemorrhage is usually well controlled by the adjacent soft tissues, and excellent collateral flow compensates for occlusive lesions. Late progression of thrombosis and pulmonary embolism are the primary complications related to venous injury.
Diagnosis
The first priority should be to identify and manage life-threatening injuries and treat shock. Except for head injuries, nearly all injuries associated with immediate fatality are related to the cardiovascular system.
Advanced Trauma Life Support (ATLS) guidelines should be followed while proceeding with evaluation and treatment simultaneously. Shock from internal hemorrhage can be differentiated from cardiac compression or injury by a quick glance at neck veins. If neck veins are full, the presumption is cardiac compression from tamponade, tension pneumothorax, or cardiac failure. Collapsed neck veins indicate hypovolemia, and failure of response to fluid therapy dictates immediate operative intervention involving the most likely body cavity. This is usually dictated by an emergency chest radiograph. External hemorrhage is usually obvious, and immediate control is essential. Generally, direct pressure is effective for temporary control.
The presence of shock may lead to diminished pulses in the extremities and confusion about the location of vascular injury. Associated fractures and dislocations may compromise vascular patency and should be reduced before any decision about vascular injury is reached.
Prompt resuscitation and identification and management of vascular injuries should be the goals in order to minimize mortality risk and prevent permanent extremity ischemic damage.
History
Prehospital personnel should be questioned about bleeding at the scene and the presence or absence of shock. The need for resuscitation and the volume of fluid administered should be solicited. The use and duration of application of a tourniquet should be determined, and the amount and character of blood loss at the accident scene ascertained. A history of bright red pulsatile bleeding suggests arterial injury, but dark blood suggests venous origin. In many instances, bleeding may have ceased by the time the patient reaches the emergency room, leading to a false sense of security. In this type of patient, particularly one with an arterial injury, secondary hemorrhage is possible at any time.
Both the patient and prehospital personnel should be questioned about the mechanism of injury. Most civilian penetrating trauma results from low-velocity mechanisms such as knives or handguns. Arterial injuries in these cases are typically the result of direct injury, that is, from the knife or bullet. Information should be collected to aid in determining the trajectory of injury and potential structures injured. This could include the knife type and length, the number and direction of bullets, and the body position at the time of injury. Vascular injury from blunt mechanisms is often the result of stretching or compression from associated fractures or dislocations. Evidence of extremity fracture, dislocation, or altered perfusion should be elucidated. Additionally, specific mechanisms such as “car bumper” injuries or posterior knee dislocations are often associated with vascular injury and should be sought as appropriate.
Information about neurologic symptoms including sensory and motor deficits should be obtained. Potential confounding factors such as preexisting peripheral vascular disease, diabetes, or neuropathies should be elicited.
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