Vascular trauma in the extremities is challenging to manage. The risk to life and limb is high and the margin for error is very thin. The presentation varies from obvious life-threatening external hemorrhage to limb ischemia in the unconscious patient with multisystem injury. An organized approach with well-planned and implemented practice guidelines converts an error-prone process into one of opportunity for effective treatment (Table 41-1). Planning and preparation are essential to the success of this approach in view of the numerous causes of delayed recognition and lack of timely treatment. The need for an organized approach is made even more compelling by the advent of trauma systems and improved prehospital care with the resulting increase in the number of patients with what were previously fatal vascular injuries arriving at trauma centers still alive, but in immediate danger of death.1,2
Table 41-1 Potential Errors in the Recognition, Preoperative Preparation, and Operative Management of Extremity Vascular Trauma |Favorite Table|Download (.pdf)
Table 41-1 Potential Errors in the Recognition, Preoperative Preparation, and Operative Management of Extremity Vascular Trauma
|Phase of Care||Error||Risk Management|
|Diagnosis||Lack of recognition of life-threatening extremity vascular injury when torso workup negative||Reassess all extremity wounds|
|Undetected extremity ischemia||Use checklist to include extremity pulse exam and Doppler pressures|
|Missed compartment syndrome||Include extremity exam and pressure measurements for compartment syndrome on checklistch41_fn01|
|Preoperative preparation||Inadequate resuscitation||Create and follow guideline with appropriate checklist|
|Lack of documented extremity neurologic examination||Use checklist with standard documentation form|
|Fail to give preoperative antibiotics, systemic heparin, when indicated||Create and use checklist|
|Fail to adequate widely prep and drape and to include uninjured leg||Create and use checklist|
|Lack of appropriate instruments, sutures, graft material, etc.||Organize, list, and periodically inventory equipment, supplies|
|Absence of orthopedic surgeon, plastic surgeon consultants to plan for operative approach in complex mangled extremity or severe degloving injury extremity injuries||Include early notification in guideline and checklist|
|Operative management||Failure to recognize need for damage control techniques||Guideline and checklist to include decision-making criteria|
|Inadequate exposure and control||Guideline and checklist criteria|
|Failure to perform fasciotomy||Guideline and checklist criteria|
|Failure to recognize failure of the vascular repair||Guideline to include intraoperative assessment and postoperative monitoring|
This chapter reviews the pathophysiology, clinical presentation, diagnostic workup, management, and outcome of extremity vascular injuries. The educational objectives of this review include the following:
To identify the mechanisms of extremity vessel injury and the resulting clinical manifestations;
To describe an organized approach to rapidly assess injured patients for the presence of extremity vascular injuries;
To present management guidelines and examples of checklists to assist in the decision of which treatment options best apply and how to effectively implement them;
To articulate management guidelines that result in improved clinical outcomes following extremity vascular injuries; ...
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