Ankle/Brachial (lower extremity) or Wrist/Brachial (upper
extremity) indices using Doppler (DPI)
of 1.0 or greater with normal PE excludes peripheral vascular injury in one
large, retrospective study Doppler pressure indices (DPI) were determined by
placing a blood pressure cuff on the ankle or wrist of the injured extremity
and obtaining Doppler pressure measurements in both distal arteries. This
pressure was then compared with the Doppler pressure of the brachial artery in
an uninvolved arm. The ratio of these two numbers (ankle or wrist over brachial
pressure) constitutes the index. The DPI was considered normal if it was 1.0 or
greater whereas a DPI of less than 1.0 was considered abnormal.
(Am Surg 68:269 2002)
| Hard Signs of Arterial Injury |
| Absent distal pulses or distal ischemia |
| Bruit or thrill at injury site |
| Active pulsatile hemorrhage |
| Large, pulsatile, or expanding hematoma |
(soft signs)—small or stable hematoma, injury adjacent to nerve, history of unexplained hypotension, history of brisk hemorrhage, or proximity of injury to major vessels
aneurysm
pseudoaneurysm
av fistula
intimal flap
transection
Fasciotomies
Consider putting the stitches (vertical mattress) in the OR initially and tape them to the leg
Best review article on arterial side (Am J EM 2005;23:689)
Warm ischemia interval is 6 hours
arterial pressure index=ABI ankle brachial index
place on supine patient, use doppler on the brachial and then DP or PT
API of >0.9=very low risk for injury in blunt and penetrating
API may not detect injuries to profunda femoris, profunda brachii, or peroneal arteries.
Lesions that do not decrease blood flow (minor intimal flaps) may not be detected.
apply traction and correct gross deformities prior to APIs
World J Surg. 1999 Mar;23(3):252-5. Related Articles, Links
Distal pulse palpation: is it reliable?
Lundin M, Wiksten JP, Perakyla T, Lindfors O, Savolainen H, Skytta J, Lepantalo
M.
Department of Surgery, Division of Vascular Surgery, Helsinki University Central
Hospital, P.O. Box 262, 00029 HUCH, Helsinki, Finland.
The aim of this study was to evaluate the reliability of distal pulse palpation.
The dorsalis pedis and the tibialis posterior arteries of 25 patients with
suspected lower limb arterial disease were independently palpated by three
vascular surgeons and three medical students in the outpatient clinic and by two
vascular nurses and one physician in the vascular laboratory. The palpation
findings were compared to the ankle/brachial index (ABI). The degree of
misdiagnosis was unacceptably high, with an underdiagnosis of more than 30%. The
poor agreement and the high proportion of misdiagnosis obtained in the
outpatient clinic argue against the use of pulse palpation as a single
diagnostic method. Palpable pulses with low ABIs clearly state the need for more
objective measurements whenever ischemia is suspected.
Ann R Coll Surg Engl. 1992 May;74(3):169-71. Related Articles, Links
Peripheral pulse palpation: an unreliable physical sign.
Brearley S, Shearman CP, Simms MH.
Department of Surgery, Selly Oak Hospital, Birmingham.
Fifty observers, including two fully trained vascular surgeons, were asked to
determine the presence or absence of the femoral and distal pulses of four
patients with peripheral vascular disease and one asymptomatic subject (50
pulses assessed). Pulses felt by both vascular surgeons were deemed to be
palpable. Among the other observers, the sensitivity of palpation was 95% or
over for the femoral pulse, but 33% to 60% for observers of varying experience
feeling for the posterior tibial pulse. Up to 20% false-positive observations
were reported. Accuracy was greater among more experienced observers, suggesting
that careful teaching of this skill is likely to be beneficial. Even so, pulse
palpation alone is an unreliable physical sign and should only be used in
combination with objective measurements as a guide to clinical management
Am Surg. 1996 Apr;62(4):315-9. Related Articles, Links
Assessment of noninvasive lower extremity arterial testing versus pulse exam.
Kazmers A, Koski ME, Groehn H, Oust G, Meeker C, Bickford-Laub T, Abson K, Bass
N.
Vascular Surgery Laboratory, Harper Hospital, Detroit, Michigan, 48201, USA.
Palpation of pedal pulses was compared to noninvasive testing in 100 patients
referred to a vascular laboratory. Given the frequent disparity of pulse exam
and ankle pressures, noninvasive Doppler testing may be necessary for many
patients to accurately assess the vascular status of the leg.
n R Coll Surg Engl. 1992 May;74(3):166-8. Related Articles, Links
Should we palpate foot pulses?
Magee TR, Stanley PR, al Mufti R, Simpson L, Campbell WB.
Royal Devon and Exeter Hospital Wonford.
Palpation of foot pulses is traditionally used to evaluate patients with
arterial disease. This study investigated observer variation in assessment of
pedal vessels by pulse palpation and Doppler auscultation. Pedal pulse palpation
in patients with arterial disease is subject to substantial observer error.
Doppler pressure measurement is preferable unless pulses are bounding.
Multi-slice CT for eval of lower extremity arterial injuries (J Trauma
2006;60:502) It was sensitive and specific