Management of Major Vascular Injuries: Neck, Extremities, and Other Things that Bleed

CTA Imaging of Peripheral Arterial Injuries

Traumatic vascular injuries consist of direct or indirect damage to arteries and/or veins and account for 3% of all traumatic injuries. Typical consequences are hemorrhage and ischemia. Vascular injuries of the extremities can occur isolated or in association with major trauma and other organ injuries. They account for 1-2% of patients admitted to emergency departments and for approximately 50% of all arterial injuries. Lower extremities are more frequently injured than upper ones in the adult population. The outcome of vascular injuries is strictly correlated to the environment and the time background. Treatment can be challenging, notably in polytrauma because of the dilemma of which injury should be prioritized, and treatment delay can cause disability or even death, especially for limb vascular injury. Our purposes are to discuss the role of computed tomography angiography (CTA) in the diagnosis of vascular trauma and its optimized protocol to achieve a definitive diagnosis and to assess the radiological signs of vascular injuries and the possible pitfalls.

Prehospital Management of Penetrating Neck Injuries: An Evaluation of Practice

OBJECTIVE

Penetrating neck injuries (PNIs) can occur at multiple anatomic sites and involve airway, nerve, vascular, and gastrointestinal structures. They pose a unique challenge to clinicians, especially in the prehospital setting. Published guidance on the prehospital management of PNIs is limited, and there is no review of the current prehospital practice.

METHODS

A retrospective electronic case note review of PNIs managed within 1 UK helicopter emergency medical service (HEMS) over a 7-year period was undertaken. Data were collected on the zone of injury, mechanism of injury, prehospital times, patient demographics, prehospital interventions, and on-scene mortality.

RESULTS

Ninety-eight patients met the study inclusion criteria, 40% of whom had zone 2 neck injuries. Eighty-three percent were male with a mean age of 42 years. The predominant injury mechanism was interpersonal violence (51%) followed by self-harm (47%). Fifteen percent underwent prehospital emergency anesthesia, 17% underwent prehospital blood transfusion, and 30% had a hemostatic dressing applied. No patients underwent cervical spine immobilization. One percent underwent resuscitative thoracotomy. Five percent were pronounced life extinct after HEMS arrival following interventions by the HEMS team.

CONCLUSION

Time-critical and emergent interventions in this select patient population must be minimal and focus on optimizing care during rapid transfer to the hospital. Airway and hemorrhagic pathologies must be managed, often concomitantly. Targeted injury prevention to reduce interpersonal violence must ensue. The author group intends to devise a national Delphi and derive consensus guidelines for the management of prehospital PNIs.

Major vascular traumas to the neck, upper limbs, and chest: Clinical presentation, diagnostic approach, and management strategies

Major vascular traumas to the neck, upper limbs, and chest may arise from penetrating and/or blunt mechanisms, resulting in a range of clinical scenarios. Lesions to the carotid arteries may also lead to neurologic complications, such as stroke. The increasing use of invasive arterial access for diagnostic and/or interventional purposes has increased the rate of iatrogenic injuries, which usually occur in older and hospitalized patients. Bleeding control and restoration of perfusion represent the two main goals of treatment for vascular traumatic lesions. Open surgery still represents the gold standard for most lesions, although endovascular approaches have increasingly emerged as feasible and effective options, particularly for management of subclavian and aortic injuries. In addition to advanced imaging (including ultrasound, contrast-enhanced cross-sectional imaging, and arteriography) and life support measures, multidisciplinary care is required, particularly in the setting of concomitant injuries to the bones, soft tissues, or other vital organs. Modern vascular surgeons should be familiar with the whole armamentarium of open and endovascular techniques needed to manage major vascular traumas safely and promptly.

Applications of Vascular Imaging and Interventional Radiology Modalities in the Upper Extremity: A Review

Hand and upper extremity (HUE) vascular disorders are encountered frequently by hand surgeons in clinical practice. A wide array of imaging and vascular interventional radiology modalities exists for the diagnosis and treatment of HUE vascular disorders, some of which may not be familiar to the HUE surgeons. In this review article, we summarize the vascular imaging and vascular interventional radiology modalities and their relative advantages, disadvantages, and indications with respect to HUE pathology. We aim to familiarize HUE surgeons with the available types of diagnostic and therapeutic options for HUE vascular pathologies and aid interdisciplinary communication with vascular interventional radiology specialists during the clinical decision-making process.

Role of imaging in penetrating vascular injuries of the craniocervical region

Penetrating vascular injury has become the topic of interest with increased gun violence in the United States. The radiologist plays a crucial role in establishing and systemizing the signs of vascular injury such as intimal flap, dissection, pseudoaneurysm, rupture, and arteriovenous fistula. Various imaging techniques such as ultrasound Doppler, computed tomographic angiography (CTA), magnetic resonance angiography, and conventional angiography are being employed based on clinical recommendations. Of all the techniques, CTA has been shown to embrace a promising role in identifying vascular injuries with superior sensitivity, specificity, and accuracy. An acquaintance of the imaging features has been shown to improve the approach to trauma patients in clinical settings. This article details the imaging modalities and the features of the head-and-neck penetrating vascular injury.

Case report: Tree branch penetrating injury into zone III of the neck

INTRODUCTION

Penetrating trauma to the neck can result in severe morbidity and mortality. Location of the injury dictates the appropriate clinical management. Challenging traumatic injuries require resourceful treatment options.

CASE PRESENTATION

A complex traumatic case of a foreign body penetrating the neck, the parotid gland, disrupting the internal jugular vein, with the tip resting at the anterior aspect of the C1 ring is reported. In this case, the authors seek to describe the clinical management of a vascular injury that resulted from penetrating zone III of the neck.

DISCUSSION

Due to the complex and dense presence of various structures in the neck, injuries can be difficult to manage. Thus, an algorithm identifies management strategies that are based on the location of the injury, signs of vascular injury, identified injured structures and the hemodynamic stability of the patient. Balloon tamponade has been described in other organs of the body and might be a therapeutic option in patients were venous injuries are difficult to access.

CONCLUSION

Penetrating neck injuries continue to result in significant morbidity and mortality. However, with appropriate and efficient evaluation and management, better outcomes are expected as demonstrated in this case.

Management of Acute Subaxial Trauma and Spinal Cord Injury in Professional Collision Athletes

Sports-related acute cervical trauma and spinal cord injury (SCI) represent a rare but devastating potential complication of collision sport injuries. Currently, there is debate on appropriate management protocols and return-to-play guidelines in professional collision athletes following cervical trauma. While cervical muscle strains and sprains are among the most common injuries sustained by collision athletes, the life-changing effects of severe neurological sequelae (ie, quadriplegia and paraplegia) from fractures and SCIs require increased attention and care. Appropriate on-field management and subsequent transfer/workup at an experienced trauma/SCI center is necessary for optimal patient care, prevention of injury exacerbation, and improvement in outcomes. This review discusses the epidemiology, pathophysiology, clinical presentation, immediate/long-term management, and current return-to-play recommendations of athletes who suffer cervical trauma and SCI.

Life-threatening subclavian artery bleeding following percutaneous coronary intervention with stent implantation: A case report and review of literature

BACKGROUND

Vascular complications of transradial percutaneous coronary intervention (PCI) are rare and usually occur at the access site below the elbow. Life-threatening vascular complications during transradial PCI therapy, such as vessel perforation and dissection in the brachiocephalic, subclavian, internal mammary, and thyrocervical arteries, are rarely reported. Subclavian artery bleeding is a potentially serious complication of vascular interventional procedures leading to tracheal obstruction, hemothorax, respiratory failure, hemorrhagic shock, and death if not diagnosed early and treated promptly.

CASE SUMMARY

A male patient with typical angina pectoris underwent coronary angiography and stent implantation. During the procedure, the patient felt pharyngeal pain and tightness, which we mistook for myocardial ischemia. After PCI, swelling in the right neck and supraclavicular area was observed. The patient experienced dyspnea, emergency endotracheal intubation was performed, and then a sudden drop in blood pressure was observed. Ultrasound and contrast-enhanced computed tomography scans demonstrated a cervical hematoma severely compressing the trachea due to subclavian artery bleeding. Brachiocephalic angiography revealed a vascular injury site at the root of the right subclavian artery at the intersection of the right common carotid artery. A covered stent was deployed to the right subclavian artery with successful sealing of the perforation, and a bare stent was implanted in the junction of the right common carotid and brachiocephalic arteries to prevent obstruction of blood flow to the brain.

CONCLUSION

Subclavian artery bleeding is a lifethreatening complication of PCI. Early prevention, rapid recognition, and prompt treatment may improve the prognosis.

Pediatric peripheral vascular injuries and associated orthopedic considerations

Pediatric peripheral vascular trauma is a rare but highly morbid injury in children and is frequently associated with concomitant orthopedic injuries. These children require multidisciplinary care by pediatric, vascular, and orthopedic surgery. In this review, we describe elements of the complex care required for children with peripheral vascular trauma.

Fatal Outcome After Reduction of a Superior Shoulder Dislocation, A Case Report and Literature Review: A Case Report and Literature Review

CASE

An 81-year-old woman presented a superior glenohumeral dislocation after a low-energy fall, with a mechanism of axial load while the shoulder was in adduction and extension. After successful closed reduction, the patient presented sudden symptoms of severe vascular injury with a protruding axillary hematoma and hypovolemic shock.

CONCLUSION

Superior shoulder dislocations and vascular injuries are extremely rare among shoulder dislocations, especially after low-energy trauma. Vascular injuries may result in limb compromise and death. We highlight the importance of high clinical suspicion, particularly in superior dislocations, and the importance of prompt management of vascular complications to avoid catastrophic outcomes.

Penetrating angle grinder injury to the neck causing subclavian artery injury

Penetrating injuries to the neck present a unique challenge due to the confined space of the thoracic outlet for haemorrhage control and repair. This results in high mortality rates when the major vascular structures of the neck are transected, as well as potential neurological compromise. We present the case of a penetrating injury to the proximal subclavian artery from a broken angle grinder disc which is a unique mechanism of injury that can have fatal consequences. The patient described in this case underwent an emergent median sternotomy for proximal control of the brachiocephalic trunk and ligation of the right vertebral artery to facilitate a primary repair of the injured vessel segment. Post operatively the patient made a complete recovery with no central or peripheral neurologic deficits and requiring no further interventions. The key points from this case are that angle grinders pose a significant injury burden and early specialised medical attention should be sought, rapid control of the proximal neck vessels can be obtained via a median sternotomy and that the vertebral artery can be ligated in an emergent situation without neurological consequence.

The Prevalence and Management of Stingers in College and Professional Collision Athletes

PURPOSE OF REVIEW

Particularly common in collision sports such as American football or rugby, stingers are a traumatic transient neuropraxia of a cervical nerve root(s) or brachial plexus that may last anywhere from minutes to hours. This review summarizes the knowledge on the diagnosis and management of stingers in college and professional collision athletes by providing an overview of their epidemiology and pathophysiology, followed by a discussion on current treatment guidelines and return-to-play recommendations.

RECENT FINDINGS

Despite modifications to tackling technique, increasing awareness, and various equipment options, American football continues to have a high rate of cervical spine injuries, the majority of which occur in preseason and regular season competition settings. The incidence of stingers has slowly increased among collision athletes, and nearly half of all players report sustaining at least one stinger in their career. Recent studies have shown certain anatomical changes in the cervical spine are related to acute and reoccurring stingers. Most players who experience stingers do not miss practices or games. Despite their prevalence, literature highlighting the impact of stingers on college and professional collision athletes is limited. Advances in imaging modalities and novel radiographic parameters have provided tools for screening athletes and can guide return-to-play decisions. Future research regarding appropriate screening practices for athletes with reoccurring stingers, use of protective equipment, and rehabilitation strategies are needed to identify predisposing factors, mitigate the risk of injury, and restore full functional strength and ability.

Simulated Mass Casualty Incident Triage Exercise for Training Medical Personnel

Audience

The target audience is any medical professional who requires training in mass casualty incident (MCI) triage. This could apply to pre-hospital specialists, nurses, medical students, residents, and physicians.

Introduction

Emergency medicine specialists must be able to triage patients quickly, especially in an MCI scenario. The simple triage and rapid treatment (START) system allows providers to categorize patients according to the urgency with which patients must access limited resources. Providers should be comfortable utilizing the START triage system before an MCI or disaster so that they can be prepared to implement it if necessary. This exercise uses simulation and gamification as instructional strategies to encourage knowledge of and comfort with the START triage system for emergency providers.

Educational Objectives

By the end of this exercise, learners should be able to (1) recite the basic START patient categories (2) discuss the physical exam signs associated with each START category, (3) assign roles to medical providers in a mass casualty scenario, (4) accurately categorize patients into triage categories: green, yellow, red, and black, and (5) manage limited resources when demand exceeds availability.

Educational Methods

Gamification is the use of elements of game design in non-game contexts.1 Gamification was implemented in this scenario by assigning participants to roles and teams, while creating an engaging, fun, and competitive environment. The exercise also uses low fidelity simulation (without simulation equipment) to encourage learners to practice using the START triage system in a low stakes environment.2 It is possible for the learners to be divided into two groups that each have the same patients, resources, and objectives. The team that finishes triaging all patients first would be declared the winner. However, in our implementation, we completed the exercise as a single group of learners and patients.

Research Methods

Learners were given a survey at the end of implementation and also given the opportunity to discuss feedback with the instructors in a group discussion after completing the exercise. There was no formal assessment completed after the exercise.

Results

Informal feedback was collected at the end of the exercise. Residents and medical students all enjoyed the experience. The feedback was overwhelmingly positive. All participants providing feedback stated they would enjoy participating in the exercise again and suggested that it is implemented annually for review of triage topics. We also received informal feedback for suggested changes which we will discuss in this article. An optional, anonymous survey was given to participants at the end of the exercise. There were six responses. Of those surveyed, 100% of participants stated the effectiveness and value of the exercise was outstanding (a rating of five on a scale of one to five). Regarding the quality of the exercise, and whether the participants felt engaged, 100% of responses gave a rating of five. When asked to consider the relevance of the session, 100% of participants selected a score of five ("I loved this session"). Regarding whether the content was applicable to practice of emergency medicine, 80% of respondents stated the session was highly relevant and 20% of responses selected a score of mostly relevant. One question asked for points of improvement for the session to which there were no responses.

Discussion

Learners were assigned roles in the exercise by the incident commander, fulfilling objective three. The START categories were discussed at the beginning of the exercise by the lead proctor (using PowerPoint) and then utilized throughout the exercise, thus accomplishing objectives one and two. The residents/students filling the triage roles were primarily responsible for fulfilling objective four; however, all participants assisted in categorization of patients throughout the exercise. Finally, objective five was addressed through the various social situations and complications that can be implemented during the exercise. We chose not to implement the additional "radiation contamination" scenario (details available in the article text) due to time constraints; however, this is an additional option to address objective five. The implementation was effective based on informal feedback from participants and proctors as well as evidenced by the responses to the anonymous survey. Learners found the aspects of resource management, review of START triage, repetition of the START triage system, and medical management of various types of trauma informative and meaningful. We received valuable feedback from both learners and proctors, which we will discuss in this article.

Topics

Mass casualty incident, disaster, START, gamification, simulation, emergency medicine, triage, triage category, contamination, teamwork, trauma, projectile trauma, penetrating injury, blunt trauma, intracranial hemorrhage, fracture, trauma in pregnancy, active shooter, radiation, radio communication.

Blunt Versus Penetrating Neck Trauma: A Retrospective Cohort Study

OBJECTIVES/HYPOTHESIS

Despite being common, neck injuries have received relatively little attention for important quality of care metrics. This study sought to determine the association between blunt and penetrating neck injuries on mortality and length of stay, and to identify additional patient and hospital-level characteristics that impact these outcomes.

STUDY DESIGN

Retrospective cohort study utilizing the American College of Surgeons Trauma Quality Improvement Program database.

METHODS

Adult patients (≥18) who sustained traumatic injuries involving the soft tissues of the neck between 2012 and 2016 were eligible. Multiple imputation was used to account for missing data. Logistic regression and negative binomial models were used to analyze 1) in-hospital mortality and 2) length of stay respectively while adjusting for potential confounders and accounting for clustering at the hospital level.

RESULTS

In a cohort of 20,285 patients, the crude mortality rate was lower in those sustaining blunt neck injuries compared to penetrating injuries (4.9% vs. 6.0%, P < .01), while length of hospital stay was similar (median 9.9 vs. 10.2, P = 0.06). In adjusted analysis, blunt neck injuries were associated with a reduced odds of mortality during hospital admission (odds ratio: 0.66, 95% confidence intervals [0.564, 0.788]), as well as significant reductions in length of stay (rate ratio: 0.92, 95% confidence intervals [0.880, 0.954]).

CONCLUSIONS

Blunt neck injuries are associated with lower mortality and length of stay compared to penetrating injuries. Areas of future study have been identified, including elucidation of processes of care in specific organs of injury.

LEVEL OF EVIDENCE

Level 3 Laryngoscope, 131:E1109-E1116, 2021.

An approach to accurate computed tomography imaging interpretation in penetrating neck trauma

Penetrating neck injury can have potentially devastating consequences due to the many vital structures contained within the neck. In patients who do not require immediate surgery, computed tomography angiography of the neck is the test of choice to characterize the injury. A systematic approach to assessment will ensure a thorough evaluation and give the reporting radiologist the best chance of identifying the significant findings, which can often be subtle. Clear communication with the trauma team at both the time of request and after the imaging has been evaluated to relay any significant findings is vital to ensure the best outcome for the patient.

Anti-coagulation management in pediatric traumatic vascular injuries

BACKGROUND

Pediatric traumatic vascular injuries are rare. Given the paucity of data to guide anti-coagulation (AC) management of these injuries in children, who have a lower overall risk for thrombosis compared to their adult counterparts, we sought to examine and summarize our recent experience.

METHOD

We conducted a retrospective review of all patients (<18 years old) who sustained traumatic vascular injuries between 2010-2018 at a Level 1 and Level 2 Pediatric Trauma Center.

RESULTS

Ninety-nine patients had traumatic vascular injuries. Eighty-four patients sustained a major arterial injury, 26 had a major venous injury, and 11 had both arterial and venous injuries. The arterial injury cohort had a median age of 13.3 years. Most of the arterial injury patients (65/84, 77%) required vascular repair. In-hospital AC management for the arterial injury patients consisted of a post-operative heparin drip (18%, 15/84), aspirin (39%, 26/84), enoxaparin (23%, 19/84), or none (42%, 43/84). Approximately one-half of the patients with arterial injuries (54%, 45/84) were discharged home on AC therapy, most commonly aspirin. Fifty-six patients (66%) followed up post-injury, of which 25% (14/56) had experienced complications.

CONCLUSION

Pediatric traumatic arterial injuries that require surgical intervention other than ligation should be considered for discharge AC - most commonly aspirin - in the absence of contraindications. Pediatric patients with vascular injuries to the aorta, carotid artery, inferior vena cava, portal vein, or lower extremities that are managed non-operatively should also be considered for AC. The preferred AC for pediatric venous injuries is enoxaparin, in the absence of contraindications.

STUDY TYPE

Treatment Study LEVEL OF EVIDENCE: IV.

Literature review of peripheral vascular trauma: Is the era of intervention coming?

Traumatic peripheral vascular injury is a significant cause of disability and death either in civilian environments or on the battlefield. Penetrating trauma and blunt trauma are the most common forms of vascular injuries. Besides, iatrogenic arterial injury (IAI) is another pattern of vascular trauma. The management of peripheral vascular injuries has been improved in different environments and wars. There are different types of vascular injuries, such as vasospasm, contusion, intimal flaps, intimal disruption or hematoma, external compression, laceration, transection and focal wall defects, etc. The main clinical manifestations of vascular injuries are shock following massive hemorrhage and limb necrosis due to tissue and organ ischemia. Ultrasound, computed tomography angiography (CTA) and magnetic resonance angiography (MRA) are most valuable for assessment of peripheral vascular injuries. Angiography remains the gold standard for diagnosing vascular trauma. Immediate hemorrhage control and rapid restoration of blood flow are the primary goals of vascular trauma treatment. There are many operative treatment methods for vascular injuries, such as vascular suture or ligation, vascular wall repair and vascular reconstruction with blood vessel prostheses or vascular grafts. Embolization, balloon dilation and covered stent implantation are the main endovascular techniques. Surgical operation is still the primary treatment for vascular injuries. Endovascular treatment is a promising alternative, proved to be safe and effective, and preferred selection for patients. In summary, rapid diagnosis and timely surgical intervention remain the mainstays of the treatment. However, many issues need to be resolved by further studies.

Evaluation and Management of Sports-Related Lacerations of the Head and Neck

Soft tissue injuries to the head and neck are a common occurrence in sports. These anatomical regions are somewhat predisposed because of the "athletic stance" that is utilized in many close-contact sports. Although appropriate use of protective equipment, including mouth guards, helmets, and face shields, has reduced the incidence and severity of these injuries, they still occur regularly. To provide appropriate medical care, one must possess adequate knowledge of the superficial and deep anatomical structures, fundamental knowledge and skill in regard to wound care, and awareness of potential poor outcomes related to lacerations of unique structures, such as the mouth, eye, or ear.

Traumatic Neck and Skull Base Injuries

Patients with blunt and penetrating traumatic injuries to the skull base and soft tissues of the neck present to the emergency department every day. Fortunately, truly life-threatening injuries to these regions are relatively uncommon. However, when encountered and not correctly diagnosed, these entities may result in severe morbidity or mortality. The radiologist plays a critical role recognizing these injuries, in which findings may often be subtle and the anatomy potentially challenging to identify. Multisection CT and CT angiography are commonly performed to assess these injuries in the emergency department. Vascular injury to the neck may result in dissection, occlusion, pseudoaneurysm formation, or frank extravasation resulting in stroke or death. Airway compromise may result from laryngotracheal injury. Injuries to the pharynx and esophagus may result in perforation. Injuries to the temporal bone may result in vascular injury to the internal carotid artery or facial nerve injury, which would require immediate surgery or intervention to prevent paralysis.^©RSNA, 2019.

Trauma vascular na Amazônia: atualizando o desafio

RESUMO Objetivo: avaliar dados epidemiológicos dos pacientes operados por trauma vascular em hospital de referência para traumatismos vasculares do Estado do Pará, determinar as variáveis que aumentam o risco de óbito e fazer uma análise comparativa com os resultados previamente publicados pela mesma instituição. Métodos: estudo retrospectivo analítico realizado através da coleta de dados de pacientes operados por lesões vasculares, entre março de 2013 e março de 2017. Foram analisados dados demográficos e epidemiológicos, como o mecanismo e topografia da lesão, distância entre o local do trauma e o hospital, tipo de tratamento e complicações. Foi feito ainda o estudo de uma matriz de correlação com regressão logística entre as variáveis e a ocorrência de óbito. Resultados: foram estudados 288 pacientes, com 430 lesões; 92,7% era do sexo masculino, 49,7% entre 25 e 49 anos de idade; 47,2% das lesões foi ocasionada por projéteis de arma de fogo; 47,2% das lesões situava-se nos membros superiores, 42,7% nos membros inferiores, 8% em região cervical, 3,1% torácicas e 0,7% abdominais; 52,8% dos pacientes teve hospitalização por sete dias ou menos. Amputação foi necessária em 6,9% e a mortalidade foi 7,93%. Conclusão: distâncias superiores a 200km foram associadas à internação prolongada e maior probabilidade de amputação de membros. Foi encontrada correlação significativa entre a ocorrência de óbito e o fato de haver lesão arterial, lesão vascular na topografia cervical e lesão vascular na topografia torácica.