Review Question - QID 214158

The most indicated test or clinical decision would be a vascular surgery consult following an ankle-brachial index (ABI) of < 0.9.

Following penetrating trauma vascular injuries can be identified using both hard and soft signs. Hard signs consist of pulsatile bleeding, expanding hematoma, thrill or bruit, pulse deficit, or ischemic limb. Soft signs are a hematoma, a history of hemorrhage at the scene, or unexplained hypotension. However, a limb with an intact and symmetric pulse does not exclude arterial injury following penetrating trauma. CT angiography is very sensitive and specific but is expensive, risky, and can detect occult findings that might not be clinically relevant. Arterial duplexes are non-invasive, but are not always available and are user-dependent. On the other hand, ABIs are highly sensitive and specific, non-invasive, quick, and easy to obtain to screen for a vascular injury requiring surgery.

Bartlett reviewed gunshot wound (GSW) ballistics. He discussed that the decision to explore wounds should not be solely based on high versus low-velocity weapons, but on energy transfer through the body/tissues. He discusses that most low-energy GSWs can be treated with local wound care, but that high-energy and associated bony injuries likely need appropriate debridements and fixation.

Johansen et al. evaluated the ability of noninvasive vascular tests to exclude clinically significant arterial damage. They looked at 100 limbs following trauma and used the arterial pressure index (API/ABI) to determine arteriography. They found in limbs with an API < 0.9 16 of the 17 limbs had positive findings and 7 required arterial reconstruction. They concluded that API is safe, accurate, and cost-effective.

Incorrect Answers:
1. An expanding hematoma is considered a hard sign and warrants potential operative exploration.
2. Observation over time alone is incorrect for a delayed capillary refill in the injured limb.
3. While symmetric pulses do not exclude a vascular injury, CT angiography is not the baseline screening test for penetrating limb injury without hard or soft signs. A documented ABI should be the next step for the justification of CTA.
5. Wound location alone does not mandate urgent exploration. Hard signs or findings from CT angiography or ABIs < 0.9 would indicate more urgent operative exploration.