0071643192.pdf

DIAGNOSIS

■ Doppler of pulse may reveal complete loss, or change from triphasic to
biphasic/monophasic sound.
■ Ankle-brachial index (ABI) or arterial pressure index (API)
■ Measure SBP using Doppler with cuff inflated proximal to injury, and
compare to uninjured side.
■ If ratio of injured SBP/uninjured SBP < 0.9, then further testing with arterio-
graphy or ultrasonography is indicated. If ratio is 0.9–0.99 then observe/
reassess in 12–24 hours.
■ Knee dislocations have a high risk of popliteal injury and in the past have
had routine angiography. Current thinking suggests, however, that these
may be closely evaluated with less invasive techniques as long as there is
no discrepancy in blood pressures between injured and uninjured legs
(ankle-ankle index).

TREATMENT

■ Direct pressure to stop bleeding.
■ Blind clamping and tourniquets are not recommended.
■ Hypotensive resuscitation (controversial): Keep SBP around 90 mmHg
prior to surgical repair to prevent dislodging clot and persistent bleeding.
■ Major arterial injuries must be repaired within 6 hours.
■ Minor arterial injuries (intact distal circulation, no active hemorrhage, and
< 5 mm intimal flap or pseudoaneurysm on angio) can be closely observed.
Be cautious with children and vasculopaths.
■ Major venous injuries usually require repair.

COMPLICATIONS

■ As with compartment syndrome, ischemic muscle contracture resulting
from nerve and muscle damage may occur.
■ Prolonged ischemia may require amputation.

Amputation/Replantation

TREATMENT

■ To protect amputated body part:
■ Wash with sterile saline (do not scrub or use antiseptics).
■ Wrap in saline-soaked gauze and place in plastic bag and then on ice
(do not place directly on ice).
■ Amputated appendages can tolerate 6–8 hours of warm ischemia and
12–24 hours of cold ischemia at 4°C.
■ Penis may be reimplanted up to 6 hours after amputation
■ Other than great toe, toes are not usually reimplanted.
■ Fingertip amputations fit into three categories:
■ Zone I: Proximal two-thirds of nail bed intact
■ Zone II: Exposed bone
■ Zone III: Amputation of entire nail bed
■ Try to save thumb and index finger. Always attempt reimplantation in
children.
■ For fingertip amputations with wounds < 1 cm^2 , healing by secondary
intention should be adequate.
■ Rongeur exposed bone and suture to provide soft-tissue coverage. Do not
leave bone exposed.

TRAUMA

In the setting of nerve injury,

always consider vascular

injury as nerves and vessels

usually travel together.

Knee dislocations have a high

risk for popliteal injury.

Cooling extends the duration

of viability of the amputated

part.