Extremity Trauma
                                ================
þ GSW to leg
 - Per Aaron Scifres (Mercy Trauma) November 2011
 - If no:
  + expanding hematoma
  + abnormal distal pulses
  + bruit
  + abnormal BP in extremity (compared to other
 then no need for CTA of extremity

Lynch K, Johansen K
Can Doppler pressure measurement replace "exclusion" arteriography in the
diagnosis of occult extremity arterial trauma?
Ann Surg 1991; 214:737-41

Although highly accurate, contrast arteriography is a costly, invasive, and
time-consuming method to rule out occult arterial damage in injured
extremities. Accordingly the authors assessed the sensitivity and specificity
of Doppler-derived arterial pressure measurements in trauma victims undergoing
evaluation for possible extremity arterial damage. Arterial pressure index
(API) was calculated (Doppler arterial pressure distal to injury/Doppler
arterial pressure in uninvolved arm), but not used in clinical decision making
in 100 consecutive injured limbs in 93 trauma victims. All patients then
underwent contrast arteriography. Twenty limbs had an API less than 0.90 and
an abnormal arteriogram, whereas 75 had both a normal API and a normal
contrast study. One limb had a significant angiographic abnormality with an
API greater than 0.90; two others had API less than 0.90 but normal
arteriograms. Two limbs with a normal API had false-positive arteriograms.
When compared with arteriography, an API less than 0.90 had a sensitivity of
87% and a specificity of 97% for arterial disruption in this series.
Sensitivity and specificity rose to 95% and 97% when API was compared with
clinical outcome. In the absence of obvious signs of arterial injury, API may
be a reasonable substitute for screening arteriography in the traumatized
extremity, particularly if close follow-up observation can be assured.


Ordog GJ, Balasubramanium S, Wasserberger J, Kram H, Bishop M, Shoemaker W

Extremity gunshot wounds: Part one--Identification and treatment of patients
at high risk of vascular injury.

Department of Emergency Medicine, Martin Luther King, Jr. General Hospital,
Los Angeles, CA.

J Trauma 1994 Mar;36(3):358-68

ABSTRACT:

Cost containment is important in this time of inner-city economic and
health-care crisis. This paper examines patients who were treated for gunshot
wounds (GSWs) of the extremities. During the study period 1978 through 1992,
16,316 patients (18,349 extremities) were treated for extremity GSWs. Nine
patients with asymptomatic injuries in proximity to vascular structures who
were treated before the use of duplex Doppler ultrasonography (DDU) were
later found to have surgically treatable vascular injuries. These were
identified and treated on an outpatient basis with no long-term morbidity or
mortality. With the advent of DDU, asymptomatic vascular injuries were no
longer missed. A conservative estimate of the cost savings from this study is
more than $47,000,000.00. The use of DDU and the enclosed protocols for
treating asymptomatic extremity wounds prevented 16,450 needless angiograms,
with an additional savings of $32,900,000.00, for a total savings of more
than $79,900,000.00. With a more liberal use of DDU and angiography to
eliminate the rare missed vascular injuries (0.09%), and the use of protocols
to analyze patients with asymptomatic injuries, many extremity GSW victims
(79% in this study) can be safely treated as outpatients, eliminating the
need for expensive in-hospital observation.