After the initial trauma resuscitation and primary and secondary surveys are complete, specific points of the victim's past medical history should be examined: preexisting vascular and neuromuscular deficits, and the events surrounding the injury, such as the type of gun and number of shots. An extremely careful and thorough physical examination is imperative to identify significant injuries rapidly and to determine whether immediate surgical intervention is necessary or which, if any, diagnostic studies are indicated. This may be challenging in the presence of other serious trauma or distracting injuries.
The presentation of penetrating vascular injury varies widely. Prompt recognition of arterial injury is one of the fundamental goals of management. The presence and volume of the distal pulses in the affected extremity should be noted and compared with the unaffected limb. Ankle-brachial indices (ABIs) should be calculated on the affected and unaffected limbs (method described below). The color, temperature, and capillary refill time are important clinical indicators of more subtle injury to underlying vessels. Examination should also look for signs of compartment syndrome. Capillary refill alone is an unpredictable marker of vascular injury but may be useful in conjunction with other modalities. Only a small minority of patients (fewer than 6 percent) will present with classic "hard" signs of arterial injury ( IabJe 255-1).
These patients require expeditious operative management or, under certain circumstances, angiography ( Fig 2.5.5:1). A surgeon should be involved in the management of these patients as soon as possible. Patients with "soft" signs (IabJe...,25.5.-..1) of arterial vascular trauma can usually be managed without surgical intervention on an inpatient surgical service.5 Controversy surrounds the management of the patient with a wound in proximity to a major vascular structure but without clinical evidence of arterial injury. Historically, patients with these types of injuries were all surgically explored, which yielded a large number of negative exploratory surgeries, and thus angiography became popular. Angiography based on proximity alone yields abnormalities in 10 to 20 percent of the cases, with less than 2 percent requiring surgical intervention. Current practice regarding penetrating injuries in proximity to major vessels without any signs of vascular injury is to observe patients with clinically silent arterial injury. The natural course in these cases is likely benign, and these patients can be safely observed with serial examinations.
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