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Penetrating extremity trauma

Ronald Gross Rgross at harthosp.org
Fri Apr 21 14:10:03 BST 2006


Rick,
No hard signs or soft signs, intact neuro exam and an ABI of >.8, dress
the repaired would (if repair is an option) and see him in clinic in 24
hours for wound check.  Neuro deficit, figure out which nerve is out and
determine the need for repair.  Soft signs present, decreased pulse or
hard signs of vasular injury - angio.

Just my 2 cents.
Ron

>>> bensonblues at comcast.net 04/21 1:42 AM >>>
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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