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Penetrating extremity trauma

docrickfry at aol.com docrickfry at aol.com
Fri Apr 21 15:09:21 BST 2006


You have misrepresented our paper below--you should read it before citing it to support what you say.  In fact, the paper clearly asserts all the reasons and lack of evidence for any benefit whatever in the use of nonvasives to assess penetrating (or, in fact any) extremity trauma for vascualr injury.  One whole section of the discussion reviews this issue.  They have never ever been shown to have any advantage whatever over and above what you can determine and decide from physical exam alone.  Also reviews the evidence out there for 15 years showing that the whole concept of soft signs is obsolete, no evidence whatever that they predict or mandate anything at all.  Simply whether hard signs are presnet or absent tells you all you need to know, the evidence supporting this quite abundnat, the evidence refuting it simply nonexistent.  Soft signs only equates to no hard signs, may be discharged home  if no other injuries requiring attention.  Also, many penetraitng extrtemity wounds in fact have NO risk of vascular injury just based on location, unless a hard sign present--il.e. lateral thigh stab--D/C home just on basis of location--in asymptomatic wounds, only those in proximity to a major vessel are at risk, and only a small minority of them have any associated injury whteever, and even then, the absence of hard signs predicts with an accuracy approaching 100% that any injury present, being asyumptomatic, will not reuire repair--thus almost no need whatever for any imaging nowadays for any uncomplicated injured extremity.  Yes all these refs are on the EAST website.  If you do not have to do anything with any injury found, then of course there is no reason to find it...18 years of practicing this approach at our institution has shown it to clearly be valid.
ERF
 
-----Original Message-----
From: Roy Danks <roydanks at hotmail.com>
To: Trauma &amp; Critical Care mailing list <trauma-list at trauma.org>
Sent: Fri, 21 Apr 2006 08:27:01 -0500
Subject: RE: Re: Penetrating extremity trauma


ABI of > 0.8??!!!  That's not standard thinking in vascular surgery, last I 
knew.

ABI of <0.95 is considered abnormal.  This, to me, indicates you must at least 
image the vessel.  
Doesn't mean you have to do anything, as evidenced by this paper:  

Validation of Nonoperative Management of Occult Vascular Injuries and Accuracy 
of Physical Examination Alone in Penetrating Extremity Trauma: 5- to 10-Year 
Follow-up. 
Journal of Trauma-Injury Infection & Critical Care. 44(2):243-253, February 
1998.
Dennis, James W. MD, FACS; Frykberg, Eric R. MD, FACS; Veldenz, Henry C. MD, 
FACS; Huffman, Susan BA; Menawat, Sunil S. MD 

So, Ron, if you feel an ABI of 0.85 is "OK", then why bother trying to "figure 
out which nerve is affected"?  You're obviously
not interested in repairing the potential arterial injury and you can't do much 
with a severed nerve (within limits and reason)...
so, why bother?  Medicolegal?  If that's the case, I suggest you review the 
vascular literature.  We image those with ABIs <0.95 who have PVD.

Any other thoughts out there?

RD

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