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Huang D, Ruzicka J, León L, Ganti L. Acute Upper Extremity Arterial Occlusion Diagnosed on POCUS in the Emergency Department. POCUS JOURNAL 2023; 8:25-29. [PMID: 37152341 PMCID: PMC10155728 DOI: 10.24908/pocus.v8i1.15902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
Upper extremity acute limb ischemia (ALI) is a limb-threatening and potentially lethal pathology that is most commonly caused by vascular embolization. Outcomes of limb ischemia are time-sensitive due to the correlation between a longer time from symptom onset to intervention with a vastly higher risk of amputation. In this report, point of care ultrasound (POCUS) was utilized to rapidly diagnose a patient with a proximal right brachial artery embolic occlusion, prompting expedited surgical consultation and successful embolectomy. POCUS can provide a focused vascular examination of the limbs to expedite diagnosis of time-sensitive ALI and facilitate timely medical intervention and surgical consultation.
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Affiliation(s)
- Derrick Huang
- University of Central Florida College of Medicine/HCA Emergency Medicine Residency Program of Ocala, HCA Florida Ocala HospitalOcala, FLUSA
| | - Jacob Ruzicka
- University of Central Florida College of Medicine/HCA Emergency Medicine Residency Program of Ocala, HCA Florida Ocala HospitalOcala, FLUSA
| | - Leoh León
- University of Central Florida College of Medicine/HCA Emergency Medicine Residency Program of Ocala, HCA Florida Ocala HospitalOcala, FLUSA
- Emergency Ultrasound Director at Emergency Medicine Residency Program of Ocala, HCA Florida Ocala HospitalOcala, FLUSA
| | - Latha Ganti
- University of Central Florida College of Medicine/HCA Emergency Medicine Residency Program of Ocala, HCA Florida Ocala HospitalOcala, FLUSA
- Research Director at Emergency Medicine Residency Program of Ocala, HCA Florida Ocala HospitalOcala, FLUSA
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Brian R, Bennett DJ, Kim WC, Stein DM. Computed tomography angiography is associated with low added utility for detecting clinically relevant vascular injuries among patients with extremity trauma. Trauma Surg Acute Care Open 2021; 6:e000828. [PMID: 34993352 PMCID: PMC8689162 DOI: 10.1136/tsaco-2021-000828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 12/01/2021] [Indexed: 11/04/2022] Open
Abstract
BackgroundExtremity CT angiography (CTA) is frequently used to assess for vascular injury among patients with extremity trauma. The injured extremity index (IEI), defined as the ratio of systolic occlusion pressure between injured and uninjured extremities, has been implemented to screen patients being considered for CTA. Physical examination together with IEI is extremely sensitive for significant extremity vascular injury. Unfortunately, IEI cannot always be calculated. This study aimed to determine whether patients with normal pulse examinations and no hard signs of vascular injury benefitted from further imaging with CTA. We hypothesized that CTA has become overused among patients with extremity trauma, as determined by the outcome of vascular abnormalities that underwent vascular intervention but were missed by physical examination.MethodsThe charts of traumatically injured patients who underwent extremity CTA were retrospectively reviewed. This study was performed at a level 1 trauma center for patients who presented as trauma activations from September 1, 2019 to September 1, 2020.ResultsOne hundred and thirty-six patients with 167 injured limbs were included. Eight limbs (4.8%) underwent an open vascular operation, whereas five limbs (3.0%) underwent an endovascular procedure. One of the 167 limbs (0.6%) had a vascular injury seen on CTA and underwent intervention that was not associated with a pulse abnormality or hard signs of vascular injury. This patient presented in a delayed fashion after an initially normal IEI and examination. Proximity injuries and fractures alone were not highly associated with vascular injuries.DiscussionMany patients with normal pulse examination and no hard signs of vascular injury underwent CTA; the vast majority of these patients did not then have a vascular intervention. Given the consequences of missed vascular injuries, further work is required to prospectively assess the utility of CTA among patients with extremity trauma.Level of evidenceIII.
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Affiliation(s)
- Riley Brian
- Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Daniel J Bennett
- School of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Woon Cho Kim
- Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Deborah M Stein
- Department of Surgery, University of California San Francisco, San Francisco, California, USA
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Stuebing E, Lieberman H, Vu T, Mazzini FN, De Gregorio L, Gigena A, Iglesias E, Gonzalo R, Perez-Alonso AJ, Asensio JA. Shank vessel injuries: the forgotten vascular injuries. Eur J Trauma Emerg Surg 2012; 38:393-401. [PMID: 26816120 DOI: 10.1007/s00068-012-0196-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2011] [Accepted: 05/04/2012] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Vascular injuries in branch vessels of the popliteal artery, such as the tibioperoneal trunk, and shank vessels, such as anterior, posterior tibial, and peroneal vessels, occur in both blunt and penetrating trauma. Their management has evolved significantly in the past few decades. While their incidence is variable, limb loss and morbidity remain significant. MATERIAL AND METHODS Physical examination, along with measuring an Ankle-Brachial Index (ABI), is still sometimes all that is required for diagnosis and can expeditiously triage those that require urgent operation. Despite our technological advancements and newer algorithms for lower extremity vascular trauma, operative intervention and exposure still remain difficult and pose a great challenge for surgeons that normally do not operate on this area. CONCLUSIONS Shank vessel injuries still comprise a significant proportion of combat and civilian vascular injuries, and modern advances have led to a dramatic decrease in amputation rates.
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Affiliation(s)
- E Stuebing
- Division of Trauma Surgery and Surgical Critical Care, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, 1800 NW 10 Avenue Suite T-247, Miami, FL, 33136-1018, USA
| | - H Lieberman
- Division of Trauma Surgery and Surgical Critical Care, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, 1800 NW 10 Avenue Suite T-247, Miami, FL, 33136-1018, USA
| | - T Vu
- Division of Trauma Surgery and Surgical Critical Care, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, 1800 NW 10 Avenue Suite T-247, Miami, FL, 33136-1018, USA
| | - F N Mazzini
- Division of Trauma Surgery and Surgical Critical Care, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, 1800 NW 10 Avenue Suite T-247, Miami, FL, 33136-1018, USA
| | - L De Gregorio
- Division of Trauma Surgery and Surgical Critical Care, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, 1800 NW 10 Avenue Suite T-247, Miami, FL, 33136-1018, USA
| | - A Gigena
- Division of Trauma Surgery and Surgical Critical Care, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, 1800 NW 10 Avenue Suite T-247, Miami, FL, 33136-1018, USA
| | - E Iglesias
- Division of Trauma Surgery and Surgical Critical Care, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, 1800 NW 10 Avenue Suite T-247, Miami, FL, 33136-1018, USA
| | - R Gonzalo
- Division of Trauma Surgery and Surgical Critical Care, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, 1800 NW 10 Avenue Suite T-247, Miami, FL, 33136-1018, USA
| | - A J Perez-Alonso
- Division of Trauma Surgery and Surgical Critical Care, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, 1800 NW 10 Avenue Suite T-247, Miami, FL, 33136-1018, USA
| | - J A Asensio
- Division of Trauma Surgery and Surgical Critical Care, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, 1800 NW 10 Avenue Suite T-247, Miami, FL, 33136-1018, USA.
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Talving P, DuBose J, Barmparas G, Inaba K, Demetriades D. Role of Selective Management of Penetrating Injuries in Mass Casualty Incidents. Eur J Trauma Emerg Surg 2009; 35:225-39. [PMID: 26814899 DOI: 10.1007/s00068-008-8153-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2008] [Accepted: 12/08/2008] [Indexed: 12/19/2022]
Abstract
Terrorist violence has emerged as an increasingly common cause of mass casualty incidents (MCI) due to the sequelae of explosive devices and shooting massacres. A proper emergency medical system disaster plan for dealing with an MCI is of paramount importance to salvage lives. Because the number of casualties following a MCI is likely to exceed the medical resources of the receiving health care facilities, patients must be appropriately sorted to establish treatment priorities. By necessity, clinical signs are likely to prove cornerstones of triage during MCI. An appropriate and effective application of experiences learned from the use of selective nonoperative management (SNOM) techniques may prove essential in this triage process. The present appraisal of the available literature strongly supports that the appropriate utilization of these clinical indicators to identify patients appropriate for SNOM is essential, critical, and readily applicable. We also review the initial emergent triage priorities for penetrating injuries to the head, neck, torso, and extremities in a mass casualty setting.
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Affiliation(s)
- Peep Talving
- Division of Trauma Surgery and Surgical Critical Care, University of Southern California, USC + LAC Medical Center, 1200 North State Street, Room 9900, Los Angeles, CA, 90033, USA.
| | | | | | | | - Demetrios Demetriades
- Division of Trauma Surgery and Surgical Critical Care, University of Southern California, USC + LAC Medical Center, Los Angeles, USA
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Ruppert V, Sadeghi-Azandaryani M, Mutschler W, Steckmeier B. [Vascular injuries in extremities]. Chirurg 2005; 75:1229-38; quiz 1239-40. [PMID: 15536512 DOI: 10.1007/s00104-004-0965-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Vascular injuries of the extremities account for most instances of vascular trauma (ca. 70%), and they entail a risk of amputation about 10-20%. According to the kind of force that has acted, arterial trauma is classified as direct or indirect. The scale of hemorrhage and peripheral ischemia depend on the nature and severity of the arterial lesion. In patients with multiple injuries, routine use of Doppler sonography and duplex sonography can facilitate early diagnosis and treatment of vascular injuries. With great certainty, clinical examination and an AB or WB index of >1.0 can rule out the presence of vascular injury that requires treatment. After excluding further life-threatening injuries, surgery should be performed immediately when there is critical ischemia, squirting hemorrhage, or a rapidly expanding hematoma. Angiography or duplex sonography findings determine the further procedure in vascular injuries that do not require immediate treatment. Occlusion of a reconstructed artery, manifestation of a compartment syndrome, and insufficient anticoagulation are the main factors affecting the risk of amputation.
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Affiliation(s)
- V Ruppert
- Gefässchirurgie Chirurgische Klinik und Poliklinik, Klinikum der LMU München
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Soto JA, Múnera F, Cardoso N, Guarín O, Medina S. Diagnostic performance of helical CT angiography in trauma to large arteries of the extremities. J Comput Assist Tomogr 1999; 23:188-96. [PMID: 10096324 DOI: 10.1097/00004728-199903000-00005] [Citation(s) in RCA: 79] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE The purpose of this work was to assess the performance of helical CT angiography (CTA) in the diagnosis of injuries to large arteries of the extremities. METHOD We performed helical CTA on 45 consecutive patients referred for conventional angiography for evaluation of suspected arterial injuries after sustaining trauma to the extremities (13 upper, 32 lower). Two radiologists interpreted the helical CTA studies independently. Diagnostic performance parameters evaluated included sensitivity, specificity, receiver operating characteristic (ROC) curves, and interobserver agreement (kappa statistics). Conventional angiography was used as the standard of reference for determination of final diagnoses. RESULTS Forty-three of 45 patients (96%) had diagnostic helical CTA examinations. Final diagnoses in these 43 patients were arterial occlusion (n = 7), partial obstruction (n = 3), pseudoaneurysm (n = 5), arteriovenous fistula (n = 1), pseudoaneurysm and arteriovenous fistula (n = 3), and normal findings (n = 24). Sensitivity and specificity were 90% [95% confidence interval (CI), 80-99] and 100% (95% CI, 99-100), respectively, for Reader 1 and 100% (95% CI, 99-100) and 100% (95% CI, 99-100), respectively, for Reader 2. ROC curve analysis revealed high diagnostic performance, with areas under the curve of >0.9 for both readers. Interobserver agreement was 0.9. CONCLUSION The diagnostic performance of helical CTA for detection of major injuries of large arteries of the extremities is high.
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Affiliation(s)
- J A Soto
- Department of Radiology, Universidad de Antioquia, Hospital Universitario San Vicente de Paul, Medellín, Colombia
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