Color-Flow Duplex Screening for Upper Extremity Proximity Injuries: A Low-Yield Strategy for Therapeutic Intervention

Brazilian guidelines on diagnosis and management of traumatic vascular injuries

Trauma is a leading cause of death, permanent disability, and health care cost worldwide. The young and economically active are the most affected population. Exsanguination due to noncompressible torso hemorrhage is one of the most frequent causes of early death, posing a significant challenge to trauma and vascular surgeons. The possibility of limb loss due to vascular injuries must also be considered. In recent decades, the approach to vascular injuries has been significantly modified. Angiotomography has become the standard method for diagnosis, endovascular techniques are currently incorporated in treatment, and damage control, such as temporary shunts, is now the preferred approach for the patients sustaining physiological derangement. Despite the importance of this topic, few papers in the Brazilian literature have offered guidelines on vascular trauma. The Brazilian Society of Angiology and Vascular Surgery has developed Projetos Diretrizes (Guideline Projects), which includes this publication on vascular trauma. Since treating trauma patients is a multidisciplinary effort, the Brazilian Trauma Society (SBAIT) was invited to participate in this project. Members of both societies reviewed the literature on vascular trauma management and together wrote these guidelines on vascular injuries of neck, thorax, abdomen, and extremities.

American Association for the Surgery of Trauma-World Society of Emergency Surgery guidelines on diagnosis and management of peripheral vascular injuries

The peripheral arteries and veins of the extremities are among the most commonly injured vessels in both civilian and military vascular trauma. Blunt causes are more frequent than penetrating except during military conflicts and in certain geographic areas. Physical examination and simple bedside investigations of pulse pressures are key in early identification of these injuries. In stable patients with equivocal physical examinations, computed tomography angiograms have become the mainstay of screening and diagnosis. Immediate open surgical repair remains the first-line therapy in most patients. However, advances in endovascular therapies and more widespread availability of this technology have resulted in an increase in the range of injuries and frequency of utilization of minimally invasive treatments for vascular injuries in stable patients. Prevention of and early detection and treatment of compartment syndrome remain essential in the recovery of patients with significant peripheral vascular injuries. The decision to perform amputation in patients with mangled extremities remains difficult with few clear indicators. The American Association for the Surgery of Trauma in conjunction with the World Society of Emergency Surgery seeks to summarize the literature to date and provide guidelines on the presentation, diagnosis, and treatment of peripheral vascular injuries. LEVEL OF EVIDENCE: Review study, level IV.

A Rare Case of Dynamic Popliteal Artery Occlusion After Gunshot Injury with Reconstitution of Flow in the Frog-leg Position

A 16-year-old male was transferred to our institution shortly after a gunshot injury to the right lower extremity. Physical examination was remarkable for two bullet entry points in the right posterior leg. A right lower extremity computed tomography angiogram (CTA) demonstrated a retained bullet fragment in the right popliteal fossa and a 10 centimeter (cm) in length occlusion of the proximal peroneal artery with reconstitution of flow distally. A diagnostic angiogram of the right lower extremity with the patient’s leg extended demonstrated lack of popliteal arterial flow immediately distal to the retained bullet fragment. Reconstitution of vascular flow was appreciated once the patient’s leg was placed in the “frog-leg” position.

Pit Bull attack causing limb threatening vascular trauma -A case series

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Canine attacks by Pit Bull Terriers and Rottweiler’s can occur at any age and in any anatomical area of the body particularly the limbs.

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Any attack by these large canines can result in limb loss or loss of life.

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The most common injury to a vessel was an occlusion, although penetrating injuries usually cause a puncture or laceration, the blunt injury may be the more clinically significant one.

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Immediate surgical exploration is required to prevent catastrophic outcomes, especially limb loss, since arterial thrombosis is noted to be one of the most common finding in crush injuries.

Introduction

Non-fatal human dog bites are commonplace amongst animal attacks on human beings and these present with mainly skin and soft tissue injuries. However, they can also present with life threatening head and neck injuries, massive soft tissue trauma, as well as combined orthopedic and vascular extremity injuries where a high possibility of limb loss exists.

Presentation of cases

We present two adult dog bite victims with multiple bites inflicted by large canines identified as Pit-Bull Terriers. They were presented with deep lacerations to the axillary area resulting in limb ischemia and loss of upper limb pulses. The right axillary artery was crushed in both patients whilst the axillary vein was lacerated in one. The vessels were repaired; the wounds debrided and both limbs were salvaged.

Discussion

Canine attacks by Pit Bull Terriers and Rottweiler’s can occur at any age and in any anatomical area of the body particularly the limbs. Injuries involving the extremities presenting with no pulses or pulsatile bleeding demand an urgent exploration as any undue delay is intolerable especially if there are bony injuries like fractures or fracture/dislocation. All patients with complex neurovascular injuries should be managed by a multidisciplinary team for an optimal outcome.

Conclusion

Attacks by Pit Bull Terriers are more likely to cause severe morbidity than other breeds of dogs. Immediate surgical exploration is required to prevent catastrophic outcomes, especially limb loss. Stronger animal control laws, public education and responsible dog ownership may reduce deaths from these canines.

Penetrating Vascular Injury: Diagnosis and Management Updates

Penetrating vascular injury is becoming increasingly common in the United States and abroad. Much of the current research and treatment is derived from wartime and translation to the civilian sector has been lacking. Penetrating vascular injury can be classified as extremity, junctional, or noncompressible. Diagnosis can be obvious but at other times subtle and difficult to diagnose. Although there are numerous modalities, computed tomography angiography is the diagnostic study of choice. It is hoped that care will be improved by using an algorithmic approach integrating experience from military and civilian research.