Extremity Vascular Injury (WTA 2024)

Algorithm Steps

1. ▶

   Start

   Extremity Trauma

   Penetrating or blunt injury with vascular concern

   1. ⚠

      Warning

      Immediate Hemorrhage Control

      Control active bleeding first

      • Direct pressure
      • Tourniquet for uncontrolled arterial bleeding
      • Wound packing if junctional
      • Document time of tourniquet application
      1. ◆

         Decision

         Hard Signs Present?

         Definitive evidence of vascular injury

         • HARD SIGNS:
         • • Pulsatile hemorrhage
         • • Expanding or pulsatile hematoma
         • • Absent distal pulses
         • • Bruit or thrill over injury
         • • Signs of distal ischemia (6 Ps)
         1. ⚠

            Warning

            Hard Signs → OR

            Immediate operative exploration

            • No imaging needed - delay is harm
            • Notify OR and vascular surgery STAT
            • May perform on-table angiogram
            • Ischemia time is critical (<6 hours ideal)
            1. ●

               Action

               Operative Repair

               Vascular surgery

               • Primary repair if possible
               • Interposition graft for significant defects
               • Autogenous vein preferred (GSV)
               • Consider fasciotomy for ischemia >4-6h
               • Assess for compartment syndrome post-repair
               1. ⚠

                  Warning

                  Consider Fasciotomy

                  Prevent compartment syndrome

                  • Ischemia >4-6 hours
                  • Combined arterial + venous injury
                  • Prolonged hypotension
                  • Extensive soft tissue injury
                  • Four-compartment release for leg
                  1. ✓

                     Outcome

                     Limb Perfusion Restored

                     Monitor for complications

                     • Monitor pulses post-repair
                     • Watch for compartment syndrome
                     • Anticoagulation per surgeon
                     • Surveillance for graft patency
         2. ◆

            Decision

            Soft Signs Present?

            Suggestive but not definitive

            • SOFT SIGNS:
            • • History of arterial bleeding (now controlled)
            • • Diminished but palpable pulse
            • • Injury proximity to major vessel
            • • Non-expanding hematoma
            • • Peripheral nerve deficit
            • • Unexplained hypotension
            1. ●

               Action

               Ankle-Brachial Index (ABI)

               Non-invasive screening tool

               • Doppler systolic pressure at ankle
               • Divide by brachial pressure
               • ABI ≥0.9: Normal - observation
               • ABI <0.9: Abnormal - imaging
               • Use API (ankle-pressure index) for lower extremity
               1. ●

                  Action

                  ABI ≥0.9: Observation

                  Serial pulse exams

                  • Serial vascular exams q4-6h
                  • Monitor for delayed presentation
                  • Consider imaging if high suspicion persists
               2. ●

                  Action

                  CTA of Extremity

                  For abnormal ABI or soft signs

                  • CT angiography of affected extremity
                  • High sensitivity and specificity
                  • Can identify location and type of injury
                  • Plan surgical approach
                  1. ◆

                     Decision

                     CTA Results

                     Injury identified?

                     1. ●

                        Action

                        Endovascular Option

                        For select injuries

                        • Pseudoaneurysm
                        • Arteriovenous fistula
                        • Some intimal injuries
                        • Covered stent or embolization
                        • Not for actively ischemic limb