Extremity Trauma Hemorrhage: More than Just a Tourniquet


Orthopedic injury

Vascular injury

Anterior shoulder dislocation

Axillary artery

Supracondylar humeral fracture

Brachial artery

Supracondylar femur fracture

Popliteal artery

Posterior knee dislocation

Tibial plateau fracture

Popliteal artery, tibioperoneal trunk




Vascular Examination


Pulses should be checked in all four extremities, paying special attention to any discrepancies between the injured and uninjured limb. A Doppler should be available and utilized if pulses are not palpable. If there is a penetrating wound to the lower extremity, perform ankle-brachial indices (ABIs) if time and the patient’s condition allow. In addition to active hemorrhage, other hard signs of arterial injury indicate immediate operative exploration for more subtle trauma and are summarized in Table 17.2. With injuries to the forearm, it is important to perform an Allen’s test to confirm patent flow in the collateral artery, especially if considering ligation .


Table 17.2
Hard signs of arterial injury















Active hemorrhage

Absent distal pulses

Expanding, pulsatile hematoma

Palpable thrill or audible bruit

Five Ps: pain, pallor, paralysis, paresthesias, poikilothermia


Neurologic Examination


A motor and sensory exam should be performed in the injured extremity and compared to the uninjured side if the patient is awake and alert. Remember that vascular injuries can cause peripheral nerve ischemia and that nerve injury can only be excluded if deficits persist after vascular repair or if the nerve is intact at exploration .



General Principles of Exploration, Exposure, and Repair


Once obvious bleeding has been controlled and a baseline vascular and neurologic exam documented, the next step is isolating the source and deciding if the vein, artery, or both have been injured. This can be completed in the trauma bay, but when faced with hard signs of vascular injury, do not delay transfer to the OR. The color of the blood (bright red vs dark red) and the nature of the bleeding (pulsatile vs nonpulsatile ) can offer important clues to differentiate arterial and venous injury but can be misleading in a patient who is under-resuscitated or in extremis. Direct visualization of the injury and knowledge of limb-specific anatomy are crucial. Direct pressure should be maintained during sterile preparation and until the injured vessel can be identified and isolated.


Basic Operative Principles for Arterial Injuries


Always prep and drape an uninjured lower extremity in anticipation of harvesting a saphenous vein to serve as an interposition graft . Vascular repair and reperfusion of the extremity should take precedence over any other repair once threats to life in the primary survey are under control. Once exposed, obtain proximal and distal control of the injured vessel. An intraluminal catheter balloon can be used as an adjunct to obtain proximal control. Thoroughly examine the injured vessel. Systemic heparinization should be given by anesthesia prior to repair. Heparin can be weight based or can be given in doses of 2500–5000 units per hour. Ideally, if resources permit, the activated clotting time (ACT) should be followed routinely and dictate additional doses of heparin.

Primary or lateral repair of arteries should be done if possible; typically, this is an option only with stab wounds. Pay special attention to any narrowing of the lumen after repair.

If the artery is partially or completely transected, debride back to the healthy tissue on proximal and distal ends, and perform a primary anastomosis if there is not undue tension. Remember to perform balloon catheter thrombectomy both proximally and distally prior to anastomosis. It is also important to mobilize both proximal and distal ends to achieve as much distance as possible. Having the entire extremity prepped into the sterile field allows manipulation of the limb to assess the level of tension intraoperatively.

When an appropriate vein conduit is unavailable, polytetrafluoroethylene (PTFE) grafts can be used. However, PTFE is associated with overall decreased patency rates and increased risk of thrombosis and infection in comparison to vein grafts. Intraluminal shunts using various conduits can be used to reperfuse the injured limb in unstable patients until definitive repair can take place.

If severe damage to the artery has occurred and adequate collateral circulation is available, ligation can be performed in certain arteries (see Table 17.3). Always attempt to guarantee patent flow in the collateral prior to ligation.


Table 17.3
Arteries and veins that can be ligated

















Injury

Best mode of action

Brachial artery

1. Repair

2. Can ligate if distal to profunda brachii – The elbow has rich collateral blood supply

Radial and ulnar arteries

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Mar 13, 2018 | Posted by in Uncategorized | Comments Off on Extremity Trauma Hemorrhage: More than Just a Tourniquet
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