What are the steps to assess and manage arterial wounds?

Assessment and Management of Arterial Wounds

Immediate assessment and intervention for arterial wounds is critical to prevent morbidity, mortality, and limb loss. 1

Initial Assessment for Arterial Injury

Strong Signs of Arterial Injury

• Externalized arterial bleeding
• Expanding or pulsatile hematoma
• Absent distal pulses
• Neurological deficits (sensory or motor)
• Presence of a bruit or thrill (indicating vascular injury)
• Visible vessel disruption 1

Weak Signs of Arterial Injury

• Wound location near a major vascular axis
• Non-expanding hematoma adjacent to arterial path
• History of significant bleeding at the scene
• Neurological deficit suggesting nerve compression 1

Immediate Management Steps

1. Control active bleeding:

   • Apply direct pressure to the wound
   • If uncontrolled, apply a pressure dressing 1
   • For exsanguinating hemorrhage, apply tourniquet proximal to the wound 1

2. Assess hemodynamic status:

   • Evaluate for signs of shock (tachycardia, hypotension, altered mental status)
   • Target systolic blood pressure of 80-100 mmHg until bleeding is controlled (if no brain injury) 1

3. Perform vascular assessment:

   • Check distal pulses (compare with uninjured side)
   • Assess capillary refill
   • Evaluate skin color and temperature
   • Perform Ankle-Brachial Index (ABI) measurement 1

Diagnostic Evaluation

Ankle-Brachial Index (ABI)

• Measure systolic blood pressure at ankle and arm
• ABI < 0.9 has 87% sensitivity and 97% specificity for vascular injury 1
• Falsely elevated readings may occur with arterial calcification (common in diabetic patients) 1

Doppler Ultrasound Assessment

• Evaluate arterial waveforms
• Biphasic or monophasic signals indicate compromised flow
• Absent signals suggest complete occlusion 1

Advanced Imaging

• CT Angiography (CTA) is the first-line imaging for suspected arterial injury 1

• Indicated for:

  • Presence of strong signs of arterial injury
  • Weak signs with ABI < 0.9
  • Inconclusive physical examination 1

• Conventional Angiography:

  • Reserved for cases requiring simultaneous intervention
  • Offers possibility for concomitant repair or embolization 1

Management Algorithm

For Exsanguinating Hemorrhage:

1. Apply tourniquet immediately
2. Proceed to emergency surgical exploration 1

For Strong Signs of Arterial Injury:

1. Stabilize patient
2. Obtain urgent CTA
3. Proceed to surgical exploration or endovascular intervention 1

For Weak Signs of Arterial Injury:

1. Measure ABI
2. If ABI < 0.9, obtain CTA
3. If ABI normal but clinical suspicion remains high, consider CTA 1

For Confirmed Arterial Injury:

• Surgical options:

  • Direct repair
  • Interposition grafting
  • Bypass
  • Ligation (for non-critical vessels) 2

• Endovascular options:

  • Stent grafting
  • Embolization
  • Balloon occlusion 3

Special Considerations

Diabetic Patients with Arterial Wounds

• Higher risk of falsely elevated ABI due to medial arterial calcification
• Toe-Brachial Index (TBI) more reliable (abnormal if < 0.7)
• Toe pressure < 30 mmHg indicates severe ischemia
• Transcutaneous oxygen pressure (TcPO2) < 30 mmHg suggests impaired healing potential 1, 4

Delayed Presentation

• Assess for signs of ischemia or infection
• Consider non-invasive vascular studies before invasive imaging
• Evaluate for development of pseudoaneurysm or arteriovenous fistula 2

Pitfalls to Avoid

1. Relying solely on physical examination - Physical findings can be unreliable with false negative rates of up to 20% 5

2. Delaying assessment - Prolonged ischemia > 6-8 hours increases risk of irreversible tissue damage and amputation

3. Missing compartment syndrome - Always assess for tense compartments and signs of neurovascular compromise

4. Overlooking concomitant injuries - Associated nerve, bone, and venous injuries are common and require assessment

5. Inadequate follow-up - Even after successful repair, patients require monitoring for complications including thrombosis, stenosis, and pseudoaneurysm formation

By following this systematic approach to arterial wound assessment and management, clinicians can minimize morbidity and mortality while optimizing functional outcomes for patients with these potentially devastating injuries.