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Penetrating extremity trauma

bensonblues at comcast.net bensonblues at comcast.net
Fri Apr 21 06:42:10 BST 2006

Good Morning,
Have an issue in my facility regarding penetrating trauma (specifically knife stabwound) to an extremity. What is appropriate standard of care? Admission with neurovascular checks, standard CT with contrast or CT angiography. And if CT angiography is appropriate under who's direction radiolgist or vascular surgeon or trauma surgeon? All comments appreciated.
Rick Moore

Rick, Standard of care depends on the mechanism of injury and the nature of the wound, as well  as your hospital and its resources. [Remember, I'm an ER doc]. Certain stab and hand gun wounds (low velocity) with low probabilty for vascular injury we give a dose of prophylactic A/Bs IV and send them hope on oral A/Bs to f/u in the surgery clinic. If suspicion of vascular injury based on trajectory or hard signs (bleeding, hematoma, thrill, bruit, and the 7 "Ps"), they are always seen immediately by sugery (delay in repair increases morbidity). I think all rifle (high velocity) wounds to the extremity should be seen by surgery (increased risk of remote vascular injury, thrombosis). In terms of imaging, you have several options, but these are often dictated by politics, priveldges, and contracts in the hospital. Angiography is the gold standard, and if the vascular surgeons have angiography priveledges and routinely do their own, they should do it (they fix the problem). In some place
s, the radiologist does the angiography under direction of the surgeon. In some places, the trauma surgeon is the vascular surgeon. Contrast CT and ultrasound w/ Doppler are other imaging options, and if angiography is not immediately available, which to use is often a matter of availability and expertice. Where I trained, we used to do so-called "one stick angiograms" using an arterial line kit to cannulate the vessel up-stream and take a couple AP films while injecting contrast. I don't know if they do that anymore, but it was cheap, quick, and revealing. GSWs resulting in fractures are attended to by orthopedic surgeons unless vascular injury also exists, which may be the case because of the proximity of things. DB

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