From the Guidelines
Suspected vascular or nerve injuries require immediate evaluation and treatment to prevent permanent damage and improve outcomes, with CT angiography being the preferred imaging modality for vascular assessment, as recommended by the latest guidelines 1. The initial assessment should include a thorough physical examination focusing on pulses, capillary refill, sensation, and motor function in the affected area.
- Key findings that necessitate further investigation include externalised bleeding of arterial origin, vicinity of the injury site to a main vascular axis, presence of a non-expanding haematoma, isolated neurological deficit, and an ankle-brachial index (ABI) less than 0.9 1.
- Imaging studies are essential, with CT angiography providing more detailed visualization of vascular structures, and MRI being preferred for evaluating nerve injuries.
- Laboratory tests should include a complete blood count, coagulation profile, and metabolic panel.
- Treatment depends on the severity of injury but may include surgical exploration and repair for complete transections, vascular bypass grafting for extensive vascular damage, or microsurgical nerve repair.
- Pharmacological management often includes pain control with NSAIDs or opioids as needed, and some cases may benefit from anticoagulation therapy to prevent thrombosis, as recommended by the 2024 ESC guidelines 1.
- Physical therapy should be initiated early to maintain function and prevent contractures. The urgency of intervention is critical, as delayed treatment of vascular injuries beyond 6-8 hours significantly increases the risk of permanent tissue damage, while prompt nerve repair (ideally within days to weeks) offers the best chance for functional recovery.
- A comprehensive medical history and determination of the cause of thrombosis and/or embolization are also crucial in managing patients with acute limb ischemia, as emphasized in the 2024 ESC guidelines 1.
From the Research
Further Investigation
- In cases of suspected vascular or nerve injury, further investigation is crucial to determine the extent of the damage and to guide treatment decisions 2, 3.
- Imaging studies such as Doppler sonography, duplex sonography, and angiography can be used to evaluate vascular injuries and detect conditions such as pseudoaneurysms, arteriovenous fistulas, and thrombosis 3, 4, 5.
- The ankle-brachial index (ABI) can be used to assess the severity of vascular injury, with an ABI of greater than 1.0 indicating no significant vascular injury 2, 4.
Treatment
- Immediate surgery is recommended for patients with critical ischemia, squirting hemorrhage, or a rapidly expanding hematoma 2.
- For patients with soft signs or no clear signs of vascular injury, imaging investigation and observation can be useful in the diagnosis and management of these patients 3.
- Color Doppler duplex sonography can be used to monitor the effectiveness of treatment and to detect any complications such as pseudoaneurysms or thrombosis 5, 6.
- Angiography is considered the gold standard for imaging vascular injuries, but point-of-care ultrasound and Color flow Duppler ultrasound are widely available, cheaper, noninvasive, and faster to obtain 3.