Traumatic Acute Limb Ischemia

Aka: Traumatic Acute Limb Ischemia, Extremity Vascular Injury, Extremity Vascular Compromise in Trauma

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II. Findings

  1. Hard Signs of Vascular Injury (indications for emergent surgery)
    1. Hypotension or shock
    2. Rapidly expanding or pulsatile Hematoma
    3. Pulseless limb (or obviously ischemia)
    4. Palpable thrill or audible bruit (Traumatic AV-fistula)
  2. Soft Signs of Vascular Injury (indications for further diagnostics)
    1. Large volume blood loss at scene of injury
    2. FractureHematoma (common, expected)
    3. Pulse discrepancy (when compared with opposite extremity)

III. Precautions

  1. Start with a thorough exam and bedside Ankle Brachial Index

IV. Diagnostics

  1. Ankle Brachial Index (or Arterial Pressure Index)
    1. First-line study
    2. May be performed with Blood Pressure cuff (or with Doppler Ultrasound)
    3. ABI (or API) >=0.9 excludes major arterial injury
    4. ABI (or API) <0.9 indicates Extremity CTA
  2. Extremity CTA
    1. Indications in patients stable enough for CT
      1. Soft signs (esp. pulse discrepancy)
      2. Significant Soft Tissue Injury and maceration with risk of distal extremity ischemia
      3. High-mechanism, multisystem Trauma
    2. Positive CTA
      1. Consult vascular surgery early in presentation
    3. Negative CTA
      1. Negative CTA is associated with a low likelihood of major vascular injury
      2. Observe patients with frequent pulse checks if high level of suspicion for vascular injury
      3. CTA Pelvis without arterial blush reliably excludes significant arterial bleeding from Pelvis

V. References

  1. Werner and Kim (2026) Extremity CTA in Trauma, EM:RAP, 2/16/2026

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