Chapter 40. Vascular Emergencies

Most vascular emergencies are due to either disruption of the blood vessel wall with bleeding (eg, from penetrating trauma) or to occlusion of the blood vessel lumen (eg, by an embolus or thrombus). The major consequences of these events are blood loss or acute distal ischemia. If vascular injury is untreated, hypotension or tissue necrosis may occur.

Immediate Management of Life-Threatening Vascular Injuries

Maintain Airway and Treat Associated Injuries

Treat associated life-threatening head, thoracic, and abdominal injuries (Chapters 12, 22, 24, and 25).

Stop Hemorrhage

1. Stop active bleeding from arterial or venous hemorrhage by gentle manual compression.

2. Avoid clamping the bleeding vessel because this will cause further injury.

3. Avoid the use of tourniquets.

4. Do not remove embedded objects because they may be preventing further bleeding.

Treat or Prevent Shock

(See also Chapter 11) Insert two or more large-bore (≥16-gauge) intravenous catheters. Two intravenous access sites are preferable if the patient is already in shock or is bleeding profusely.

While intravenous catheters are being inserted, draw blood for complete blood count (CBC), serum electrolytes, glucose and creatinine measurements, prothrombin time (PT), partial thromboplastin time (PTT), and typing and crossmatching (reserve 6–8 units of packed red blood cells or whole blood).

Begin intravenous infusion of crystalloid solutions (eg, normal saline or lactated Ringer's) to support blood pressure. Up to 2–3 L of crystalloid solution may be given before blood products are administered. Replace blood. The number of units administered depends on the severity of existing blood loss and on anticipated loss from projected surgery. Use fresh whole blood whenever possible.

Prevent Further Vascular and Nerve Injury

All fractures and joint dislocations associated with abnormal pulses should be carefully reduced and splinted to reduce further neurovascular damage. Control hemorrhage by pressure; avoid clamping vessels to stop hemorrhage. Consider adjunctive studies for further evaluation as appropriate (eg, computed tomography [CT] scan, angiography).

Minimize Ischemia

Keep ischemic limbs horizontal. Do not use tourniquets.

Relieve Pain

Provide adequate analgesia; if necessary, give narcotic analgesics.

Obtain Surgical Consultation

All documented or suspected vascular injuries should be examined promptly by a general or vascular surgeon before the patient is transferred from the emergency department.

Hospitalize Patients as Required

Hospitalize all patients with arterial or major venous injuries.

General Considerations

Acute vascular injury may result in either hemorrhage or tissue ischemia.

Arterial Injury

Hemorrhage

Obvious external hemorrhage is present in many patients. Occult bleeding ...