Directly answers the question found on NBME form 11, see below:
A 17-year-old boy is brought to the emergency department 30 minutes after he was thrown through a window during an altercation. He has no history of serious illness and takes no medications. He is alert and fully oriented. He reports moderate pain in his right arm and hand. His pulse is 110/min, respirations are
22/min, and blood pressure is 110/70 mm Hg. Pulse oximetry on 2 L/min of oxygen by nasal cannula shows an oxygen saturation of 98%. Examination shows superficial abrasions over the right side of the face. A 4 × 4-cm glass shard protrudes from the right upper extremity 2 cm proximal to the medial epicondyle;
the extremity is cool and pale, and radial and ulnar pulses are not palpable. Which of the following is the most appropriate next step in management?
Answer: Operative wound exploration
{{c1::Urgent surgical exploration}}
- Other hard signs include pulsatile bleeding, an expanding hematoma, and / or the presence of a bruit / thrill over the injury
| Signs of Traumatic Arterial Injury | |
|---|---|
| Hard Signs | Distal limb ischemia (paralysis, pain, pallor, poikilothermia) Absent distal pulses Active hemorrhage Rapid expanding hematoma Bruit / thrill at site of injury |
| Soft Signs | Diminished distal pulses Unexplained hypotension Stable hematoma Documented hemorrhage at time of injury Associated neurologic deficit |
| Evaluation | Hard Signs - Immediate surgery Soft Signs - Requires further imaging |
| Extremity Vascular Trauma | |
|---|---|
| Hard Signs | Observed pulsatile bleeding Presence of bruit / thrill over injury Expanding hematoma Signs of distal ischemia (absent pulse) |
| Soft Signs | History of hemorrhage Diminished pulses Bony Injury Neurologic abnormality |
| Evaluation | If hard signs or hemodynamic instability - Surgical exploration If soft signs, consider - Injured extremity index - CT Scan or conventional angiography - Duplex Doppler ultrasonography |
Watch Penetrating Thoracic & Abdominal Trauma
Watch Initial Trauma Assessment: Secondary Survey
