Accuracy of Physical Examination, Ankle‐Brachial Index, and Ultrasonography in the Diagnosis of Arterial Injury in Patients With Penetrating Extremity Trauma: A Systematic Review and Meta‐analysis

deSouza, Ian S.; Benabbas, Roshanak; McKee, Sean; Zangbar, Bardiya; Jain, Ankur; Paladino, Lorenzo; Boudourakis, Leon; Sinert, Richard

doi:10.1111/acem.13227

Cited by 35 publications

(17 citation statements)

References 51 publications

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“…Multiple studies have found that IEI reduces the need for CTA in evaluating for vascular injury. 8 13 Regardless, this study supports the use of other examination findings in settings in which IEI cannot be performed. This includes pulse examination, although that itself may be limited and varied in the emergency department and trauma setting.…”

Section: Discussionsupporting

confidence: 68%

“…These include careful physical examination, calculation of an injured extremity index (IEI), ultrasound, and CT angiography (CTA). 8 The IEI is a useful index analogous to the ankle brachial index; it describes the ratio of systolic occlusion pressure between injured and uninjured extremities. There are a number of published test characteristics of these methods from the past decades.…”

Section: Introductionmentioning

confidence: 99%

“…There are a number of published test characteristics of these methods from the past decades. 9–12 For example, lack of hard signs and normal IEI together are extremely sensitive for vascular injury, 8 13 and the Eastern Association for the Surgery of Trauma practice management guidelines do not recommend further workup of patients with a normal physical examination and IEI greater than 0.9. 14 Unfortunately, IEI cannot always be calculated as it requires inflation of a blood pressure cuff, which may be difficult in those with an extensive area of injury.…”

Section: Introductionmentioning

confidence: 99%

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Computed tomography angiography is associated with low added utility for detecting clinically relevant vascular injuries among patients with extremity trauma

Brian

Bennett

Kim

et al. 2021

Trauma Surg Acute Care Open

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BackgroundExtremity CT angiography (CTA) is frequently used to assess for vascular injury among patients with extremity trauma. The injured extremity index (IEI), defined as the ratio of systolic occlusion pressure between injured and uninjured extremities, has been implemented to screen patients being considered for CTA. Physical examination together with IEI is extremely sensitive for significant extremity vascular injury. Unfortunately, IEI cannot always be calculated. This study aimed to determine whether patients with normal pulse examinations and no hard signs of vascular injury benefitted from further imaging with CTA. We hypothesized that CTA has become overused among patients with extremity trauma, as determined by the outcome of vascular abnormalities that underwent vascular intervention but were missed by physical examination.MethodsThe charts of traumatically injured patients who underwent extremity CTA were retrospectively reviewed. This study was performed at a level 1 trauma center for patients who presented as trauma activations from September 1, 2019 to September 1, 2020.ResultsOne hundred and thirty-six patients with 167 injured limbs were included. Eight limbs (4.8%) underwent an open vascular operation, whereas five limbs (3.0%) underwent an endovascular procedure. One of the 167 limbs (0.6%) had a vascular injury seen on CTA and underwent intervention that was not associated with a pulse abnormality or hard signs of vascular injury. This patient presented in a delayed fashion after an initially normal IEI and examination. Proximity injuries and fractures alone were not highly associated with vascular injuries.DiscussionMany patients with normal pulse examination and no hard signs of vascular injury underwent CTA; the vast majority of these patients did not then have a vascular intervention. Given the consequences of missed vascular injuries, further work is required to prospectively assess the utility of CTA among patients with extremity trauma.Level of evidenceIII.

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Section: Discussionsupporting

confidence: 68%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Computed tomography angiography is associated with low added utility for detecting clinically relevant vascular injuries among patients with extremity trauma

Brian

Bennett

Kim

et al. 2021

Trauma Surg Acute Care Open

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“…A recent meta-analysis by DeSouza et al,8 however, appears to support ultrasound as a viable and accurate option. The authors examined a large database of studies that included ED patients with penetrating extremity injuries.…”

Section: Discussionmentioning

confidence: 97%

Occult Vascular Transection Identified by Point-of-care Ultrasound Demonstrating Evidence of Retrograde Flow

Villarroel

Wagner

Schoenfeld

2019

Clinical Practice and Cases in Emergency Medicine

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Acute vascular injury can be a cause of significant disability and morbidity. High clinical suspicion and a thorough physical examination are key components to facilitate a timely diagnosis. We present a case of acute vascular injury after isolated penetrating trauma. Physical examination demonstrated a strong distal radial pulse; however, point-of-care ultrasound facilitated an evaluation of the directionality of arterial flow, demonstrating that flow was retrograde via the palmar arch. We subsequently identified a proximal and complete arterial laceration.

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“…The consultant was satisfied with the ultrasound images and felt in this case the injury could be safely observed without advanced imaging. This management has been previously described as satisfactory when no hard signs of limb-threatening vascular injury are present [ 14 ].…”

Section: Case Reportmentioning

confidence: 99%

Cat got your artery? Point of care ultrasound in the evaluation of penetrating trauma by a feline: a case report

Haley

MacKenzie

2022

Clin Exp Emerg Med

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Point of care ultrasound is an important tool for diagnosis of musculoskeletal and vascular pathology in patients presenting to the emergency department. Superficial vascular and soft tissue structures are well-visualized at the bedside using modern ultrasound systems and have image characteristics that can be rapidly identified. This report describes the use of point of care ultrasound to distinguish between rapidly progressive soft tissue infection and vascular injury following penetrating trauma from a cat scratch. Ultrasound allowed the physician to rapidly make accurate decisions about the next necessary steps in the patient’s care. Point of care ultrasound provides immediate diagnostic information to supplement indeterminate physical examination findings. In this case, it allowed the treating physician to make the diagnosis of arterial injury using ultrasound image characteristics. An integrative approach to ultrasonography of superficial musculoskeletal and vascular structures could enhance clinical decision making and improve care of patients with similar complaints.

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Accuracy of Physical Examination, Ankle‐Brachial Index, and Ultrasonography in the Diagnosis of Arterial Injury in Patients With Penetrating Extremity Trauma: A Systematic Review and Meta‐analysis

Cited by 35 publications

References 51 publications

Computed tomography angiography is associated with low added utility for detecting clinically relevant vascular injuries among patients with extremity trauma

Computed tomography angiography is associated with low added utility for detecting clinically relevant vascular injuries among patients with extremity trauma

Occult Vascular Transection Identified by Point-of-care Ultrasound Demonstrating Evidence of Retrograde Flow

Cat got your artery? Point of care ultrasound in the evaluation of penetrating trauma by a feline: a case report

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