Chapter 42: Peripheral Vascular Trauma

MANAGEMENT OF PERIPHERAL VASCULAR INJURY

Introduction

Injury to the major named arteries and veins of the upper and lower extremity while infrequent still poses significant challenges for both civilian and military trauma teams. There are major differences in military and civilian mechanisms which present as different magnitudes of tissue destruction and therefore vascular injury. Effective management of peripheral vascular trauma is essential to preservation of both life and limb in trauma patients. This chapter will detail an evidence-based approach to the diagnosis, preoperative trauma management, operative management, and postoperative management of common patterns of peripheral vascular trauma.

Epidemiology

Peripheral vascular injuries account for approximately 2% to 3% of injuries in the National Trauma Data Base over the last decade. Vascular injuries are associated with approximately 7% of penetrating injuries.¹ Arterial injuries were associated with 43% concomitant bone fractures, and venous injuries occurred in 20% of patients studied.² Vascular injuries are associated with less than 0.5% of all limb fractures.³ Extremity injuries compose 50% to 60% of United States Armed Forces casualties in Iraq and Afghanistan and 12% of this cohort have combat-related vascular injuries.⁴ In the modern era, war injuries of the lower extremity occur primarily from improvised explosive devices and therefore tissue devitalization in conjunction with vessel trauma occurs.

Preoperative Trauma Management

Airway and Breathing Management

The initial evaluation of a patient presenting following traumatic peripheral vascular injury is guided by advanced trauma life support (ATLS) guidelines. The emergency medical technician’s prehospital description of mechanism of injury, scene of events, and clinical course in route to the trauma center may all lend important details relevant to determining the patient’s pattern of injury. Establishing that the patient has a patent airway and appropriate oxygenation and ventilation is the critical first priority for all trauma patients. For patients who have obvious physiologic signs of being in hypovolemic shock, orotracheal intubation and activation of the massive transfusion protocol are essential first steps.

Circulation Management

The circulation evaluation during the primary survey of ATLS is critical to understand and execute efficiently. It begins with the establishment of large bore intravenous catheters for patients in hypovolemic shock. If establishment of upper extremity catheters are not technically possible, the trauma team should quickly move to preferably establish 8 French line placement in an uninjured lower extremity. Similarly, peripheral intravenous lines should not be established in injured upper extremities. Intraosseous catheters should also not be placed in injured extremities. It is important to note that standard polyurethane or silicone central lines are 7 French and from 15 to 30 cm long and thus are not appropriate for trauma resuscitation. With the establishment of intravenous access, trauma laboratory studies should be obtained. These include a complete blood count, basic metabolic panel, ...