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EPIDEMIOLOGY

Abdominal vascular injuries are mostly represented in major urban civilian trauma centers. This is quite different when compared to abdominal vascular injuries seen in the war, which range from 2% to 3% from World War II to the Iraqi War.1–3 Currently, blunt mechanisms are responsible for approximately 5% of these injuries while penetrating trauma accounts for 10%.4 In the classical trauma literature, gunshot wounds are responsible for up to 25% of abdominal vascular injuries.5 In a more recent 10-year review, 78% of patients experiencing abdominal vascular trauma had gunshot wounds and 42% of these patients had injuries to multiple abdominal vessels.6 In all cases, prolonged shock from uncontrolled hemorrhage is associated with mortality.

BLUNT TRAUMA

The typical mechanism associated with abdominal vascular injuries is not blunt force trauma but rather penetrating trauma. However, when blunt force trauma is the cause of abdominal vascular injuries, it results from an acceleration–deceleration pattern that produces an avulsion of branches of major vessels causing hemorrhage. The other pattern is a blunt force that produces thrombosis which typically occurs after tearing of the intimal layer of arterial wall and can be seen after renal vascular trauma. Finally, cases where there are full thickness tears to the vascular wall lead to massive hemorrhage and/or pseudoaneurysms can occur. Massive hemorrhage can result from blunt force trauma and renal vein, mesenteric vessel, or aortic disruption. Frequently, seat belt injuries present with an exquisitely tender abdominal examination and ecchymoses over the distribution of the seat belt across the abdomen. These patients with pseudoaneurysms classically are seen with blunt hepatic trauma and can present with hematemesis after high-grade liver injury. These patients require hepatic angiography and coil embolization of the pseudoaneurysm of the hepatic artery. Interventional radiology techniques for the control of hepatic hemorrhage are discussed below.

DIAGNOSIS

Physical Examination

Physical examination must always be our initial approach to a trauma patient. Fifty percent of patients who arrive at the trauma center in shock (SBP < 80 mmHg) will have major vascular injuries.7 Patients in shock will have cool skin and may have altered consciousness. Furthermore, pulse rate and character are valuable in determining the likelihood of hemorrhage from abdominal vascular trauma. Patients who are not on heart rate control medications and who manifest high pulse rates (heart rate > 100) with thready characteristics should be suspected of having an ongoing hemorrhage. A distal pulse is absent in 90% of patients who have a major arterial injury.8 Understanding the events of the scene are very helpful because the context of certain traumas will lead to greater suspicions of abdominal vascular injury (i.e., high-speed collision vs ground-level fall). Abdominal tenderness and abdominal wall hematoma at physical examination are also findings highly suspicious for intra-abdominal vascular injury. The central dictum is to locate the blood loss in ...

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