Evaluation and Management of Peripheral
Vascular Injury
Part 1

Annotation for Point E

 “Soft” signs of an arterial injury in an extremity are as follows: (1) a history of arterial bleeding at the scene or in transit; (2) proximity of a penetrating wound or blunt injury to an artery; (3) a small nonpulsatile hematoma over an artery; and (4) a neurologic deficit originating in a nerve adjacent to a named artery.17,23 The incidence of arterial injuries in such patients ranges from 3% to 25%, depending on which soft sign or combination of soft signs is present.29–32 A physical examination that documents pulses at the wrist or ankle equal to those in the contralateral uninjured extremity is excellent evidence that no arterial injury or a limited arterial injury (i.e., intimal injury) is present.32–34 In addition to a comprehensive physical examination, one of the following should be performed: (1) Ankle or Brachial/Brachial Index (ABI or BBI = systolic blood pressure in extremity distal to area of injury/systolic blood pressure in brachial artery of uninjured upper extremity); (2) Arterial Pressure Index (API = Doppler arterial pressure distal to injury/Doppler arterial pressure in uninvolved upper extremity).35–38 Using a cutoff of ≥0.9 to rule out the need for diagnostic imaging studies, the sensitivity and specificity as compared with clinical outcome have been reported to be >95%.36,38 In older patients with a greater incidence of preexisting peripheral arterial occlusive disease, the ABI and/or API may not be as accurate as in younger injured patients. For this reason, some trauma centers will use a difference in ABI or API of ≥0.1 when comparing an injured extremity with an uninjured extremity as an indication for a diagnostic imaging study.