- Pulsatile bleeding
- Expanding haematoma
- Absent distal pulses
- Cold, pale limb
- Palpable thrill
- Audible bruit
The presence of hard signs of vascular injury mandates
immediate operative intervention. Usually the site of
injury is obvious, and angiography is unnecessary. If
in doubt, angiography can be performed emergently on
the operating room table. Unnecessary interventions
and investigations should be avoided to minimise the
delay to definitive care.
So-called 'soft signs' of vascular injury are peripheral
nerve deficit, history of moderate haemorrhage at scene,
a reduced but palpable pulse or an injury in proximity
to a major artery. Investigation or exploration of patients
with soft signs alone is not warranted. Patients should
be admitted and observed for 24 hours. Development of
hard signs is rare, but mandates treatment as above.
High-velocity weapons, multiple fragment injuries and
blunt trauma can make diagnosis less obvious, and angiography
can be used to locate, or exclude, an injury.
Pulse Oximetry
A reduction in oximeter readings from one limb, as compared
to another is suggestive of, but neither confirms nor
excludes a significant vascular injury. It is thereful
essentially an unhelpful test.
Doppler Ultrasound
The diagnosis of a significant (ie. requiring intervention)
vascular injury has been shown to be related to the
presence or absence of a palpable pulse. The presence
of a doppler signal in a pulseless limb only gives a
false sense of security and does not imply a less severe
or less urgent injury pattern.
A diminished, but palpable pulse is a soft sign of
vascular injury. Similarly, a reduction in the anle-brachial
pressure index (ABPI) in the presence of a palpable
pulse does not indicate the presence of a vascular injury
requiring intervention. Doppler ultrasound is therefore
adds little to careful clinical examination.
Duplex Ultrasound
Duplex imaging is a non-invasive examination combining
B-mode and Doppler ultrasound. It requires an experienced
operator and is more operator-dependent. Duplex can
detect intimal tears, thrombosis, false aneurysms and
arteriovenous fistulae. Its place in the assessment
of vascular injury is as yet not completely definded,
but it has a high sensitivity and may be appropriate
for use as a screening tool.
Angiography
Angiography remains the gold-standard investigation
for the further investigation and delineation of vascular
injury. In most traumatic injury settings, angiography
is best performed in the operating room, with the surgeon
exposing the vessel proximal to the injury for control
and expediency. Transfer to the radiology suite should
be restricted to haemodynamically stable patients eith
proximal or torso injuries. Angiography may be used
to treat certain selected injuries, and where expertise
and technical facilities are available. Proximal control
may be possible with an angioplasty catheter prior to
transfer to the operating room.
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