Sonographic evaluation of vascular injuries

Point-of-Care Ultrasound-History, Current and Evolving Clinical Concepts in Emergency Medicine

Point-of-care ultrasound (PoCUS) has become an indispensable standard in emergency medicine. Emergency medicine ultrasound (EMUS) is the application of bedside PoCUS by the attending emergency physician to assist in the diagnosis and management of many time-sensitive health emergencies. In many ways, using PoCUS is not only the mere application of technology, but also a fusion of already existing examiner skills and technology in the context of a patient encounter. EMUS practice can be defined using distinct anatomy-based applications. The type of applications and their complexity usually depend on local needs and resources, and practice patterns can vary significantly among regions, countries, or even continents. A different approach suggests defining EMUS in categories such as resuscitative, diagnostic, procedural guidance, symptom- or sign-based, and therapeutic. Because EMUS is practiced in a constantly evolving emergency medical setting where no two patient encounters are identical, the concept of EMUS should also be practiced in a fluid, constantly adapting manner driven by the physician treating the patient. Many recent advances in ultrasound technology have received little or no attention from the EMUS community, and several important technical advances and research findings have not been translated into routine clinical practice. The authors believe that four main areas have great potential for the future growth and development of EMUS and are worth integrating: 1. In recent years, many articles have been published on novel ultrasound applications. Only a small percentage has found its way into routine use. We will discuss two important examples: trauma ultrasound that goes beyond e-FAST and EMUS lung ultrasound for suspected pulmonary embolism. 2. The more ultrasound equipment becomes financially affordable; the more ultrasound should be incorporated into the physical examination. This merging and possibly even replacement of aspects of the classical physical exam by technology will likely outperform the isolated use of stethoscope, percussion, and auscultation. 3. The knowledge of pathophysiological processes in acute illness and ultrasound findings should be merged in clinical practice. The translation of this knowledge into practical concepts will allow us to better manage many presentations, such as hypotension or the dyspnea of unclear etiology. 4. Technical innovations such as elastography; CEUS; highly sensitive color Doppler such as M-flow, vector flow, or other novel technology; artificial intelligence; cloud-based POCUS functions; and augmented reality devices such as smart glasses should become standard in emergencies over time.

Iatrogenic Arteriovenous Fistula Following Routine Venipuncture in an Adult Without Coagulopathy: An Uncommon Consequence of a Common Procedure

Background

According to Tonnessen BH (2011),¹ iatrogenic arteriovenous (AV) fistulas in adults most commonly occur due to endovascular access and procedures. Rarely, AV fistulas have been reported in low birth weight neonates following repeating venipuncture. This complication is extremely uncommon in adults, but has been reported after routine venipuncture for blood transfusion.

Case presentation

We report the case of an elderly female patient who presented to the office for evaluation of left upper extremity swelling, ecchymosis, and dilated vessels after routine venipuncture at an outpatient laboratory. She was subsequently found to have an acquired AV fistula from her left cephalic vein to a small branch artery.

Conclusion

This case demonstrates the rare but relevant risk in routine venipuncture and may underscore the benefit of using ultrasound guidance in high-risk populations, such as patients with coagulopathies, or thin, fragile veins, like the elderly or neonates.

Axillary Artery Transection and Brachial Plexus Injury After Open Inferior Glenohumeral Dislocation: A Case Report

CASE

A judo athlete presented with an open inferior shoulder dislocation that occurred during competition. Examination revealed a transection of the axillary artery and neuropraxia of the posterior cord. Neuropraxia was resolved within 2 weeks. The axillary artery was repaired with a femoral vein graft. He regained full strength, range of motion, and function at 8 months.

CONCLUSION

Inferior glenohumeral dislocations are rare, and their management can be complicated by vascular and neurological injuries. We emphasize the importance of examination, diagnosis, and treatment of neurovascular pathologies to avoid catastrophic outcomes.

POCUS and POCDUS: essential tools for the evaluation and management of carotid artery pseudoaneurysms after a gunshot wound

BACKGROUND

Evaluation of asymptomatic penetrating vascular injuries can be done with Point-of-care ultrasound (POCUS) and Point-of-care Doppler ultrasound (POCDUS).

CASE PRESENTATION

A 21-year-old woman was admitted to the Emergency Department with a small wound and pain on the left side of her neck. The patient stated she was standing outside her home and suddenly felt acute pain in the neck. She denied trauma or being assaulted and reported no significant past medical or surgical history. On physical exam the only positive finding was a small gunshot entry wound on the left side of her neck without hard signs of vascular injury. Bedside POCUS demonstrated soft tissue swelling and a hematoma next to the left carotid artery. A round in shape bullet was visualized in contact with the posterior left common carotid artery wall and two small saccular pseudoaneurysms were seen at left common carotid artery wall. POCDUS showed a patent left carotid artery and turbulent flow in the two saccular aneurysms. A computed tomography angiogram (CTA) was performed confirming the findings and a stent in left carotid artery was placed. The patient tolerated the procedure well and was discharged 4 days after the procedure. At the sixth month follow-up, Doppler ultrasound showed patent stent and resolution of the muscular hematoma.

CONCLUSIONS

Penetrating trauma-related vascular injuries are complex cases to handle within an acute setting. POCUS and POCDUS are increasingly being used for the workup and decision-making process of gunshot-related vascular injuries to the neck and are a fundamental part of the follow-up after definitive therapy.

Doppler ultrasound diagnosis of brachial artery injury due to blunt trauma: A Case Report

The brachial artery is the most common injured vessel in the upper extremity. Although vascular injury following blunt trauma is rare, it is a condition to be considered because it can easily be overlooked unless the clinician has a high suspicion. In this paper, we present a blunt trauma case with brachial arterial injury, upper extremity ischemia, and the need for urgent management to salvage the limb. A 28-year-old male had a right arm swelling, pain, and paleness accompanied by a weak pulse in the right radial artery and right-hand numbness. Following resuscitation, preoperative Doppler ultrasound revealed to the brachial artery injury. The right brachial artery had an occlusion with a thrombus. In spectral Doppler analysis, there were demonstrated parvus et tardus waveform in the distal arteries. Doppler ultrasound provided crucial information to make an accurate and rapid management decision.

Occult Vascular Transection Identified by Point-of-care Ultrasound Demonstrating Evidence of Retrograde Flow

Acute vascular injury can be a cause of significant disability and morbidity. High clinical suspicion and a thorough physical examination are key components to facilitate a timely diagnosis. We present a case of acute vascular injury after isolated penetrating trauma. Physical examination demonstrated a strong distal radial pulse; however, point-of-care ultrasound facilitated an evaluation of the directionality of arterial flow, demonstrating that flow was retrograde via the palmar arch. We subsequently identified a proximal and complete arterial laceration.

Knee and Leg Injuries

Knee and leg injuries are extremely common presentations to the emergency department. Understanding the anatomy of the knee, particularly the vasculature and ligamentous structures, can help emergency physicians (EPs) diagnose and manage these injuries. Use of musculoskeletal ultrasonography can further aid EPs through the diagnostic process. Proper use of knee immobilizers can also improve long-term patient outcomes.

Extracranial Internal Carotid Aneurysm in a 10-Year-Old Boy Diagnosed via Ultrasound

BACKGROUND

Extracranial carotid aneurysms in children are extremely rare but carry a high mortality and morbidity. For pediatric patients, they are often complications of pharyngeal infections and surgical trauma but can also arise from congenital and inflammatory diseases. They have a wide range of presentation from an asymptomatic mass to a rapidly fatal hemorrhage.

CASE

A 10-year-old boy presented to the emergency department with complaints of a neck mass and residual cough from a recent upper respiratory infection. Ultrasound revealed a carotid aneurysm that was further characterized by magnetic resonance angiography as a 3-cm aneurysm of the internal carotid artery. The patient was taken for surgery where he underwent resection and placement of an interposition graft. The procedure was well tolerated and the boy recovered fully.

DISCUSSION

Carotid aneurysms in children can present with 1 or more of the following: a pulsatile neck mass, hematemesis, epistaxis, neurologic symptoms, and symptoms of airway compression. Although ultrasound is the preferred initial test, the choice of additional imaging for further characterization will depend most on the patient age, hemodynamic stability, airway status, and availability of pediatric anesthesia. Hemodynamic and neurologic status should be monitored closely, and clinicians must also be prepared for a potentially complicated airway. Surgery is indicated for children owing to high risk of neurologic complications.

CONCLUSIONS

Although these lesions are rare, it is crucial that physicians recognize when there is a need for further evaluation so that these children have the most favorable outcomes possible.

Evaluation, Surgical Management and Outcome of Traumatic Extremity Vascular Injuries: A 5-year Level-1 Trauma Centres Experience

Objective: We aim to share our experience regarding the surgical management and outcome of extremity vascular trauma in level-1 trauma centres in Pakistan.

Patients and methods: All consecutive patients with traumatic extremity vascular injury (TEVI) fulfilling the inclusion criteria; between June 2012 and June 2017 were included. The demographics, clinical presentation, management, and outcome measures were recorded.

Results: The study included 81 patients. The mean age±standard deviation was 28.6±14.5 years and 81.5% (n=66) of the patients were males. Blunt TEVI was found in 65.4% (n=53) of the cases. Partial laceration was the most common type of arterial injury (64.2%, n=52) and autologous interposition venous grafting was the most common repair performed (60.5%, n=49). Fasciotomy was performed in 67.9% (n=55) of the patients. The limb salvage rate was 82.7%. The amputation rate was higher in the blunt trauma group when compared with that of the penetrating trauma group. The length of the intensive care unit stay and the use of polytetrafluoroethylene as interposition graft were two independent predictors of limb loss. The mortality rate in this series was 8.6%.

Conclusion: Blunt TEVI is associated with higher morbidity and limb loss. The use of synthetic graft should be discouraged. The liberal use of autologous interposition venous graft and the judicious use of fasciotomies are helpful to achieve favorable outcomes.

Duplex ultrasound for evaluation of deep venous blood flow in fractured lower extremities

Purpose

Early identification of deep venous thrombosis (DVT) in trauma patients would result in an early initiation of treatment, thereby decreasing the frequency of complications. The aim of the current study was to evaluate the role of duplex ultrasound (DUS) in the evaluation of deep venous blood flow in fractured lower extremities to rule out DVT prior to orthopedic surgery.

Material and methods

In this prospective study a total of 58 patients (42 males and 16 females; mean age of 51.5 ± 19.5 years) with fractured lower extremities were thoroughly evaluated prior to surgery with respect to medical history, fracture pattern, associated injuries, comorbid conditions, and venous duplex ultrasound (VDUS) findings. Each affected limb was assessed for the presence of DVT using a Sonoline G 60S ultrasound unit. The analysis was performed with the Statistical Package for the Social Sciences (SPSS) version 20.

Results

DVT was found in 36 (62.1%) patients with single closed fractures, 9 (15.5%) patients with single opened fractures, 10 (17.2%) patients with multiple closed fractures, and in 3 (5.2%) patients with multiple opened fractures. Sensitivity and specificity of the findings of compressibility and phasicity for DVT detection in patients with fractured lower extremities were 81.25% and 87.50% and 100% and 100% respectively. In addition, the absence of compressibility and phasicity had positive predictive value of 100% and 100% and negative predictive value of 93.75% and 95.65% respectively.

Conclusions

US of DVs in the brightness mode (B-mode) with compression maneuvers should be the first-line imaging modality for suspected DVT in patients with fractured lower extremities.

The FAST D protocol: a simple method to rule out traumatic vascular injuries of the lower extremities

Background

The aim of this study is to assess the accuracy of a Fast Doppler protocol for the examination of an injured lower limb, namely 2-Point Fast Doppler (2PFD), in order to rapidly triage arterial lesions after penetrating trauma.

Methods

The presence of flow and the aspects of the Doppler waveform of the dorsalis pedis artery (DPA) and posterior tibial artery (PTA) of the injured lower limb (2PFD) were evaluated immediately before the execution of a standardized Color Duplex Doppler (SD) evaluation in 149 limbs of 140 patients with gunshot penetrating injuries. We considered 2PFD normal exams as the ones with triphasic patterns in both the DPA and PTA, and 2PFD pathologic exams as the ones with absent, biphasic, or monophasic flow patterns in the DPA and/or PTA. 2PFD data were then analyzed to assess accuracy variables, using SD results as matching test reference. According to the trauma center standard protocols, SD positive cases underwent also angiography and surgical exploration, whose findings were used to further match the 2PFD specificity.

Results

The 2PFD protocol showed a sensitivity of 100%, and a specificity of 100% compared with the SD, in the diagnostic workup of arterial injuries of the lower limbs after penetrating trauma. Furthermore, all the pathologic cases that resulted in all true positives (TP), compared with SD, were confirmed as TP also when matched with the angiography evaluation results.

Conclusions

The 2PFD protocol can rapidly identify arterial flow and differentiate between normal and pathologic spectral Doppler analyses in distal arteries. The presence of the normal triphasic flows in DPA and PTA is as sensitive as the standardized Color Doppler Duplex assessment of the entire limb in ruling out arterial lesions in lower-limb penetrating trauma. The absence of flow or the presence of a biphasic or monophasic pathologic flow in DPA and PTA is pathologic and should be always followed by further investigation. 2PFD is faster and easier to perform compared with the SD approach. It could become a new first-line screening technique, both in pre-hospital and hospital critical scenarios, particularly in contexts where advanced diagnostic performance is limited by time concerns or scarce resources.

Point-of-care ultrasound and Doppler ultrasound evaluation of vascular injuries in penetrating and blunt trauma

BACKGROUND

The aim of this study is to describe point-of-care ultrasound and Color flow Duplex Doppler characteristics of penetrating and blunt trauma-related vascular injuries of the limbs and neck.

METHODS

Penetrating and blunt trauma-related vascular injuries such as vein disruption, intimal flap, deep vein thrombosis, arterial dissection, pseudoaneurysm, and arteriovenous fistulae are discussed in this manuscript. Images of the most significant lesions of our personal clinical experience are presented to illustrate point-of-care ultrasound and Color flow Duplex Doppler ultrasound findings.

RESULTS

Penetrating and blunt trauma-related vascular injuries represent a big challenge. While patients with hard signs of arterial damage must be sent immediately to surgical exploration, when there are soft signs or no clear signs of vascular injury at the physical examination, and the patient is stable, imaging investigation and observation can be useful in the diagnosis and management of these patients. Although angiography is the gold standard of the imaging methods, point-of-care ultrasound and Color flow Duplex Doppler ultrasound are widely available, cheaper, noninvasive, and faster to obtain. They can provide bedside valuable information for the identification of some vascular injuries allowing to an integrated management of the trauma patient, enriched by the use of ultrasound.

CONCLUSIONS

Point-of-care ultrasound and Color flow Duplex Doppler examination are increasingly used in the decision making process of trauma-related vascular injuries.

Review of the current management of upper urinary tract injuries by the EAU Trauma Guidelines Panel

CONTEXT

The most recent European Association of Urology (EAU) guidelines on urological trauma were published in 2014.

OBJECTIVE

To present a summary of the 2014 version of the EAU guidelines on upper urinary tract injuries with the emphasis upon diagnosis and treatment.

EVIDENCE ACQUISITION

The EAU trauma guidelines panel reviewed literature by a Medline search on upper urinary tract injuries; publication dates up to December 2013 were accepted. The focus was on newer publications and reviews, although older key references could be included.

EVIDENCE SYNTHESIS

A full version of the guidelines is available in print and online. Blunt trauma is the main cause of renal injuries. The preferred diagnostic modality of renal trauma is computed tomography (CT) scan. Conservative management is the best approach in stable patients. Angiography and selective embolisation are the first-line treatments. Surgical exploration is primarily for the control of haemorrhage (which may necessitate nephrectomy) and renal salvage. Urinary extravasation is managed with endourologic or percutaneous techniques. Complications may require additional imaging or interventions. Follow-up is focused on renal function and blood pressure. Penetrating trauma is the main cause of noniatrogenic ureteral injuries. The diagnosis is often made by CT scanning or at laparotomy, and the mainstay of treatment is open repair. The type of repair depends upon the severity and location of the injury.

CONCLUSIONS

Renal injuries are best managed conservatively or with minimally invasive techniques. Preservation of renal units is feasible in most cases. This review, performed by the EAU trauma guidelines panel, summarises the current management of upper urinary tract injuries.

PATIENT SUMMARY

Patients with trauma benefit from being accurately diagnosed and treated appropriately, according to the nature and severity of their injury.

Abdominal vascular emergencies: US and CT assessment

Acute vascular emergencies can arise from direct traumatic injury to the vessel or be spontaneous (non-traumatic).The vascular injuries can also be divided into two categories: arteial injury and venous injury.Most of them are life-treatening emergencies, sice they may cause an important ipovolemic shock or severe ischemia in their end organ and require prompt diagnosis and treatment.In the different clinical scenarios, the correct diagnostic approach to vascular injuries isn't firmly established and advantages of one imaging technique over the other are not obvious.Ultrasound (US) is an easy accessible, safe and non-invasive diagnostic modality but Computed Tomography (CT) with multiphasic imaging study is an accurate modality to evaluate the abdominal vascular injuries therefore can be considered the primary imaging modality in vascular emergencies.The aim of this review article is to illustrate the different imaging options for the diagnosis of abdominal vascular emergencies, including traumatic and non traumatic vessel injuries, focusing of US and CT modalities.

A novel decision tree approach based on transcranial Doppler sonography to screen for blunt cervical vascular injuries

OBJECTIVES

Early detection and treatment of blunt cervical vascular injuries prevent adverse neurologic sequelae. Current screening criteria can miss up to 22% of these injuries. The study objective was to investigate bedside transcranial Doppler sonography for detecting blunt cervical vascular injuries in trauma patients using a novel decision tree approach.

METHODS

This prospective pilot study was conducted at a level I trauma center. Patients undergoing computed tomographic angiography for suspected blunt cervical vascular injuries were studied with transcranial Doppler sonography. Extracranial and intracranial vasculatures were examined with a portable power M-mode transcranial Doppler unit. The middle cerebral artery mean flow velocity, pulsatility index, and their asymmetries were used to quantify flow patterns and develop an injury decision tree screening protocol. Student t tests validated associations between injuries and transcranial Doppler predictive measures.

RESULTS

We evaluated 27 trauma patients with 13 injuries. Single vertebral artery injuries were most common (38.5%), followed by single internal carotid artery injuries (30%). Compared to patients without injuries, mean flow velocity asymmetry was higher for single internal carotid artery (P = .003) and single vertebral artery (P = .004) injuries. Similarly, pulsatility index asymmetry was higher in single internal carotid artery (P = .015) and single vertebral artery (P = .042) injuries, whereas the lowest pulsatility index was elevated for bilateral vertebral artery injuries (P = .006). The decision tree yielded 92% specificity, 93% sensitivity, and 93% correct classifications.

CONCLUSIONS

In this pilot feasibility study, transcranial Doppler measures were significantly associated with the blunt cervical vascular injury status, suggesting that transcranial Doppler sonography might be a viable bedside screening tool for trauma. Patient-specific hemodynamic information from transcranial Doppler assessment has the potential to alter patient care pathways to improve outcomes.

A proposed new system of coding and injury classification for arteries in the trunk and extremities

STUDY DESIGN

Retrospective review of arterial injury with prospective intra-observer and inter-observer analyses.

AIM

To introduce a new classification system for arterial injuries in the extremities and trunk.

METHODS

Retrospective review of all patients with arterial injuries treated at a level I trauma centre during a 3.5-year period. Major arteries were located and coded, and the arteries' lesion was categorised in reference to the alphanumeric format of the AO fracture coding system and injury classification. Each major artery was coded in a numeric format and further divided into three segments: proximal, middle and distal. The severity of artery injury was classified into different types and subtypes in an alphanumeric format. Inter-observer and intra-observer reliabilities were tested.

RESULTS

Systemic arteries were coded and arterial injuries were classified in the alphanumeric notation. The intra- and inter-observers' reliabilities were found to be acceptable in the application of the new system.

CONCLUSION

The preliminary data demonstrate that the new coding and injury classification system for arteries in the trunk and extremities are reliable and efficient for data storage and retrieval, and provide a favourable environment for discussion among different physicians or centres.

Effect of angiogenesis-related cytokines on rotator cuff disease: the search for sensitive biomarkers of early tendon degeneration

BACKGROUND

Hallmarks of the pathogenesis of rotator cuff disease (RCD) include an abnormal immune response, angiogenesis, and altered variables of vascularity. Degenerative changes enhance production of pro-inflammatory, anti-inflammatory, and vascular angiogenesis-related cytokines (ARC) that play a pivotal role in the immune response to arthroscopic surgery and participate in the pathogenesis of RCD. The purpose of this study was to evaluate the ARC profile, ie, interleukin (IL): IL-1β, IL-6, IL-8, IL-10, vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF), and angiogenin (ANG), in human peripheral blood serum and correlate this with early degenerative changes in patients with RCD.

METHODS

Blood specimens were obtained from 200 patients with RCD and 200 patients seen in the orthopedic clinic for nonrotator cuff disorders. Angiogenesis imaging assays was performed using power Doppler ultrasound to evaluate variables of vascularity in the rotator cuff tendons. Expression of ARC was measured by commercial Bio-Plex Precision Pro Human Cytokine Assays.

RESULTS

Baseline concentrations of IL-1β, IL-8, and VEGF was significantly higher in RCD patients than in controls. Significantly higher serum VEGF levels were found in 85% of patients with RCD, and correlated with advanced stage of disease (r = 0.75; P < 0.0005), average microvascular density (r = 0.68, P < 0.005), and visual analog score (r = 0.75, P < 0.0002) in RCD patients. ANG and IL-10 levels were significantly lower in RCD patients versus controls. IL-1β and ANG levels were significantly correlated with degenerative tendon grade in RCD patients. No difference in IL-6 and bFGF levels was observed between RCD patients and controls. Patients with degenerative changes had markedly lower ANG levels compared with controls. Power Doppler ultrasound showed high blood vessel density in patients with tendon rupture.

CONCLUSION

The pathogenesis of RCD is associated with an imbalance between pro-inflammatory, anti-inflammatory, and vascular ARC.

Inferior thyroid artery pseudoaneurysm caused by blunt trauma

Injury to the inferior thyroid artery (ITA) is an extremely rare complication of blunt neck trauma. The subtle initial clinical presentation and the potential life-threatening sequelae make it a diagnostic and therapeutic challenge. We report a case of an ITA pseudoaneurysm caused by seat-belt injury. Imaging findings and successful treatment with coil embolization are described. The role of noninvasive imaging techniques in establishing the diagnosis is emphasized.

An animal model for femoral artery pseudoaneurysms

PURPOSE

To prepare a porcine model for femoral artery pseudoaneurysm via a one-step surgical procedure without the need for microsurgery.

MATERIALS AND METHODS

This pseudoaneurysm model involves the preparation of an arteriovenous shunt between the femoral artery and femoral vein in which approximately 2 cm of the vein is segmented by proximal and distal closure with the use of ligatures. The femoral pseudoaneurysm models were evaluated by angiography, Doppler auscultation, and histologic examination.

RESULTS

In seven of eight pigs, angiography and Doppler auscultation showed that the pseudoaneurysm models were open and that there was communication between the pseudoaneurysm model and the femoral artery. The mean length (+/-SD) of the pseudoaneurysm model was 1.9 cm +/- 0.3 (n= 7), with a neck region of 4 mm. Histologic analysis confirmed that pseudoaneurysm models were open and no thrombi were observed.

CONCLUSIONS

The principal advantages of this model are the location of the pseudoaneurysm model, the short period of clamping, and the controllable size. The pig pseudoaneurysm model is straightforward and reproducible, and may serve as a useful tool in the evaluation of interventional strategies for treatment of pseudoaneurysms.

Role of Selective Management of Penetrating Injuries in Mass Casualty Incidents

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.