Most vascular emergencies are due to either disruption of the blood vessel wall with bleeding (eg, from penetrating trauma) or to occlusion of the blood vessel lumen (eg, by an embolus or thrombus). The major consequences of these events are blood loss or acute distal ischemia. If vascular injury is untreated, hypotension or tissue necrosis may occur.
VASCULAR EMERGENCIES DUE TO TRAUMA
IMMEDIATE MANAGEMENT OF LIFE-THREATENING VASCULAR INJURIES
Maintain Airway and Treat Associated Injuries
Treat associated life-threatening head, thoracic, and abdominal injuries (Chapters 12, 22, 24, and 25).
Stop active bleeding from arterial or venous hemorrhage by gentle manual compression.
Avoid clamping the bleeding vessel because this will cause further injury.
Avoid the use of tourniquets.
Do not remove embedded objects because they may be preventing further bleeding.
(See also Chapter 11.) Insert two or more large-bore (≥16-gauge) intravenous catheters. Two intravenous access sites are preferable if the patient is already in shock or is bleeding profusely.
While intravenous catheters are being inserted, draw blood for complete blood count (CBC), serum electrolytes, glucose and creatinine measurements, prothrombin time (PT), partial thromboplastin time (PTT), and typing and cross-matching (reserve 6–8 units of packed red blood cells or whole blood).
Begin intravenous infusion of crystalloid solutions (eg, normal saline or lactated Ringer) to support blood pressure. Up to 2–3 L of crystalloid solution may be given before blood products are administered. Replace blood. The number of units administered depends on the severity of existing blood loss and on anticipated loss from projected surgery.
Prevent Further Vascular and Nerve Injury
All fractures and joint dislocations associated with abnormal pulses should be carefully reduced and splinted to reduce further neurovascular damage. Control hemorrhage by pressure; avoid clamping vessels to stop hemorrhage. Consider adjunctive studies for further evaluation as appropriate (eg, computed tomography [CT] scan, angiography).
Keep ischemic limbs horizontal. Do not use tourniquets.
Provide adequate analgesia; if necessary, give narcotic analgesics.
Obtain Surgical Consultation
All documented or suspected vascular injuries should be examined promptly by a general or vascular surgeon before the patient is transferred from the emergency department.
Hospitalize Patients as Required
Hospitalize all patients with arterial or major venous injuries.
Acute vascular injury may result in either hemorrhage or tissue ischemia.