the case.
a 52 year old male presents to your Emergency Department with more than 24 hours of typical sounding, retrosternal chest pain. [Read more…]
pulling apart cases from the ED...
the case.
a 52 year old male presents to your Emergency Department with more than 24 hours of typical sounding, retrosternal chest pain. [Read more…]
The Case.
A 22 year old male is retrieved to ED after a nasty workplace accident where he was pinned between a truck and wayward forklift. He had sustained injuries to his head/face, upper thorax and perineum, however our most significant concern was regarding his right lower limb. He had a displaced, angulated compound femur fracture that required sedation and pre-hospital reduction. There were reports of significant bleeding at the scene.
No immediate interventions were required following his primary survey, but his right limb revealed a nasty tissue defect and open fracture (now splinted). There was no active blood loss, but his leg distal to the injury was pale and cold with no appreciable dorsalis pedis or posterior tibial pulses.
Here are his initial xrays….
As there was concerns regarding intraabdominal and pelvic injuries; he was taken to radiology for CT, including angiography of his lower limbs….
httpv://www.youtube.com/watch?v=P8jIf50wnQw&feature=youtu.be
He went straight to theatre from radiology, and unfortunately underwent an above-knee amputation.
Whilst the decision making process was rather straight forward in this case, it did lead me to revisit the ED-based evaluation of suspected peripheral vascular injury….
Peripheral Vascular Injury – Tell me more…
Typically these injuries are divided into blunt vs penetrating, however they generally result in a similar spectrum of vascular injuries (including laceration, transection, entrapment, avulsion, intimal tears/flaps, pseudoaneurysm, AV-fistulas, thrombosis & spasm).
Detection & treatment of vascular injuries must take place within the context of overall resuscitation of a patient. This also includes the control of active bleeding.
The assessment of peripheral vascular injury can be divided into three categories;
Hard Findings of Vascular Injury.
The incidence of arterial injury is > 90% if any of these are present !! Surgical exploration is required.
Soft Findings of Vascular Injury.
Up to 35% of patients with soft-signs will have positive angiographic findings !!
High-Risk Injuries.
Meticulous examination is required to look for the above hard & soft signs. Surprisingly, these are relatively dependable (Sensitivity 92%, Specificity 95%).
Diagnostic investigations.
These must be tailored to the patient & their injury, and should never delay a definitive treatment to an obvious arterial injury (especially if the clock is approaching the all-important 6 hour warm ischaemia time).
Modalities include plain radiography, pulse-oximetry, hand-held Doppler, ultrasound (including colour-flow and duplex), CT & MRI. CT-angiography is now the most commonly used primary diagnostic study for the evaluation of penetrating lower extremity vascular injury.
The investigation that I wanted to focus on is Arterial-Pressure Index, as I feel it can be easily done at the bedside as an extension to your physical examination.
Caution w/ API: Limited usefulness in deep arteries (profunda femoris, profunda brachii & peroneal arteries) which do not produce palpable pulses & with shot-gun wounds which often cause multiple small arterial injuries.
Summary.
References.
This is the story of a 59 year old man who presented to our ED with a complaint of haemoptysis. He is otherwise well, takes no regular medications and besides his ’50 per day’ smoking history (over 40-odd years) he has no health concerns or past medical problems.
On the morning of presentation he had his usual morning ‘cough and splutter’ and was surprised to find blood in his tissue. He then proceeding to expectorate a small blood clot. “Its not that big, just a tablespoon”. He may have had some right sided pleuritic chest pain with it.
He looks well, with no increased work of breathing. Room air saturations of 94%. Good air entry with mild end expiratory wheeze. Normal cardiac examination.
This is his CXR…..