Management of the Mangled Extremity

Annotation for Point D

Blunt vascular extremity injuries may be associated with the need for amputation in as much as 20% of patients.¹⁷ Among patients with multiple injuries because of blunt mechanisms, competing priorities of initial treatment may delay diagnosis of extremity vascular injury. In addition, pulse examination alterations are common sequelae of displaced fractures in these patients. An early vascular assessment will permit for the rapid identification of these injuries and minimize subsequent ischemic time. After restoration of anatomic alignment and adequate resuscitation, this examination should begin with an attempt to palpate the pulse. If the pulse is not palpable, or weaker than anticipated, then an attempt at bedside Doppler assessment should be undertaken. If a Doppler assessment reveals a signal and tissue loss does not preclude measurement, an Ankle-Brachial Index or Brachial- Brachial Index can be used to guide the need for additional vascular imaging.^18–20 Doppler indices less than 0.9 or absent/ diminished pulse in the affected extremity indicate the need for additional radiographic characterization in appropriately stable patients²⁰ (see G). Both Ankle-Brachial Indexes and Brachial-Brachial Indexes can be altered by a number of factors not directly related to vascular injury, including obesity, hypotension, and peripheral vascular construction because of hypothermia or hemorrhage. It is imperative to use blood pressure cuffs for this purpose that are appropriately sized to patient body habitus. Efforts should also be taken to adequately resuscitate and warm the patient to optimize the reliability of Doppler Indices.

Level of Supporting Evidence: Level 3