Penetrating extremity vascular trauma

• Apply direct pressure and elevate the limb as first-line control
• Use haemostatic dressings
• If bleeding is not controlled:
  • Apply a tourniquet and document the time of application. Place as distal as safely possible to preserve viable tissue.
  • Consider a foley catheter balloon tamponade for junctional wounds
• Avoid blind clamping
• Identify and document neurovascular status early

Hard signs (indicate immediate surgery or CTA if stable)

• Active arterial haemorrhage
• Expanding or pulsatile haematoma
• Bruit or thrill
• Absent distal pulses with signs of ischaemia
• Cold, pale limb with motor/sensory deficit

Soft signs (indicate CTA)

• History of significant haemorrhage
• Non-pulsative haematoma
• Reduced or unequal pulses
• Neurological symptoms inconsistent with CT head
• Proximity to major vessels/ penetrating tract

Capillary refill, pink skin and Doppler signal do not rule out injury

• Perform CTA in all patients with soft signs, high-risk trajectory, or associated skeletal injuries.

• If shotgun wound or skeletal injury is present, CTA should be done even with hard signs, en route to theatre if there is no significant or delay and patient physiology permits.

• Surgical exploration is indicated for hard signs and unstable patients
• Temporary vascular shunts can be used in damage control to restore flow before definitive repair.
• If repair is not possible:
  • Tibial or distal vessel ligation is acceptable if there is confirmed collateral flow
  • Avoid ligation of popliteal or proximal arteries unless life saving and no other option
• Surgical access incisions should be planned with soft tissue coverage in mind.

• Consider in stable patients with:
  • Isolated pseudoaneurysm
  • AV fistula
  • Bleeding from profunda femoris or distal branches
• Should not delay surgery if patient is unstable or has hard signs

May be considered for;

• Asymptomatic non-occlusive intimal injuries
• No evidence of active bleeding or ischaemia
• Manage with antiplatelets and repeat CTA in 5-7 days

• High risk if:
  • Prolonged ischaemia (> 4-6 hours)
  • Revascularisation
  • Crush or high-energy mechanism
• Perform fasciotomy early in high risk patients
• If not performed, monitor compartment pressures

• Monitor for reperfusion injury, myoglobinuria, and renal failure
• Consider antibiotics where there is soft tissue contamination or prosthetic graft
• Continue DVT prophylaxis unless contraindicated
• Ensure clear documentation of neurovascular findings