L. A. Gurien1, B. K. Yorkgitis1, J. W. Dennis1 1University Of Florida College Of Medicine – Jacksonville,Surgery,Jacksonville, FL, USA
Introduction:
Advanced imaging for penetrating limb injuries is commonly performed. The practice of relying on mandatory conventional arteriography in the 1970’s fell out of favor in the 1990’s, evolving towards a more physical examination based approach for the detection of clinically significant vascular injuries. However, with the rapid availability of CT scans in trauma centers, the use of CT arteriography (CTA) has steadily increased as a method to evaluate such patients. The purpose of this study was to evaluate the efficacy of physical exam findings compared to CTA in the detection of clinically significant vascular injuries associated with penetrating extremity trauma.
Methods:
Using an IRB approved protocol, the medical records and radiologic results of over 9000 trauma patients presenting to a single level I trauma center during a 27-month period (January 2013 – March 2015) were queried. Patient with penetrating extremity trauma to both upper and/or lower extremities were included. Extremity physical examination findings were documented in all cases permitting review.
Results:
We identified 92 patients with penetrating trauma to the extremities who underwent a CTA during their initial trauma evaluation. None of these 92 patients had documented hard signs of vascular injury on initial physical examination. Soft signs and/or diminished (yet present) distal pulse were documented in 20 (21.7%) patients. Two patients were found to have vascular injuries demonstrated on CTA, but had an initial distal pulse documented on their trauma survey. However, one of these patients had a loss of pulses in the extremity on repeat examination. The remaining 90 patients had no abnormalities requiring surgical or endovascular repair. These findings indicate that serial vascular exams, in the setting of penetrating extremity trauma, have an accuracy of 98.9% in detecting vascular injuries needing procedural intervention. The cost of the CTA with physician interpretation was over $4000 in each case and the performance of the study involved administration of intravenous contrast (155mL average).
Conclusion:
The findings from our study suggest that use of CTA is routinely performed in the evaluation and management of penetrating extremity injuries regardless of the physical exam. This imaging modality is associated with known economic and non-economic risks. Utilizing CTA in the setting of benign physical examination findings burdens the patient and healthcare system with these risks. Patients with no hard signs of vascular trauma do not require CTA for safe and accurate assessment of their injuries and need for surgical repair. Serial physical examination may provide similar detection of vascular injury requiring procedural intervention.