Point-of-care ultrasound and Doppler ultrasound evaluation of vascular injuries in penetrating and blunt trauma
© The Author(s) 2017
Received: 12 December 2016
Accepted: 10 February 2017
Published: 16 February 2017
The aim of this study is to describe point-of-care ultrasound and Color flow Duplex Doppler characteristics of penetrating and blunt trauma-related vascular injuries of the limbs and neck.
Penetrating and blunt trauma-related vascular injuries such as vein disruption, intimal flap, deep vein thrombosis, arterial dissection, pseudoaneurysm, and arteriovenous fistulae are discussed in this manuscript. Images of the most significant lesions of our personal clinical experience are presented to illustrate point-of-care ultrasound and Color flow Duplex Doppler ultrasound findings.
Penetrating and blunt trauma-related vascular injuries represent a big challenge. While patients with hard signs of arterial damage must be sent immediately to surgical exploration, when there are soft signs or no clear signs of vascular injury at the physical examination, and the patient is stable, imaging investigation and observation can be useful in the diagnosis and management of these patients. Although angiography is the gold standard of the imaging methods, point-of-care ultrasound and Color flow Duplex Doppler ultrasound are widely available, cheaper, noninvasive, and faster to obtain. They can provide bedside valuable information for the identification of some vascular injuries allowing to an integrated management of the trauma patient, enriched by the use of ultrasound.
Point-of-care ultrasound and Color flow Duplex Doppler examination are increasingly used in the decision making process of trauma-related vascular injuries.
Injuries are an important public health problem worldwide. More than 5 million people die each year as a result of injuries. This accounts for 9% of the world deaths, nearly 1.7 times the number of fatalities that result from HIV/AIDS, tuberculosis, and malaria combined. Among the causes of injury are traffic accidents, interpersonal violence, burns, drowning, falls, and poisonings. A quarter of the deaths are the result of traffic injuries, while suicide and homicide account for nearly another quarter.
For every person who died as a result of violence, many more are injured, causing a rise in costs in health care systems and in a massive burden in national economies . Moreover, violence exacts a high cost on global development .
More than 90% of injury-related deaths occur in low- and middle-income countries and in remote locations.
Increase in urban crime and violence are affecting the lives of millions of people in Latin America.
The Pan American Health Organization called violence in Latin America “the social pandemic of the 20th century” .
Social inequality and substantial increase in the size of drug markets are considered major contributing factors to the levels of violence in Latin America. Of the world’s 50 most dangerous cities, 43 are located in Latin America and the Caribbean.
Although the main goal must be to prevent injuries and violence from happening, a quick and rapid diagnosis and treatment are essential to prevent fatalities and reduce disabilities .
The majority of vascular injuries are located in the extremities. Vascular injuries present a great challenge to emergency physicians because some vascular lesions may not be immediately identified with clinical evaluation and monitoring of vital signs.
The presence of “hard signs” in the physical examination” (such as pulsatile external bleeding, expanding haematoma, absent distal pulses, cold/pale limb, palpable thrill, or audible bruit) is an indication of immediate surgical intervention.
When the site or presence of a vascular injury is less obvious, the patient is stable and there are no signs or just soft signs of vascular injuries (such as peripheral nerve deficit, history of moderate hemorrhage at scene, a reduced but palpable pulse, or an injury in proximity to a major artery) imaging investigation and observation can be useful in the diagnosis and management of these patients. [4, 14].
Angiography is the gold standard for the evaluation of trauma-related vascular injuries; however, other noninvasive imaging methods such as computer tomography angiogram, magnetic resonance angiography, and Doppler ultrasound have emerged in recent years as valid alternatives .
Bergstein et al. compared Color flow Doppler with arteriography in 67 patients without obvious vascular injuries. Using arteriography as the gold standard, Color flow Doppler had a specificity of 99%, sensitivity of 50%, and negative and positive predictive values of 66 and 7%, respectively .
Fry et al. described 100% sensitivity and specificity of Duplex Doppler compared with the conventional arteriography and operative exploration .
In a recent study, Mohd Wani et al. evaluate with Color flow Duplex Doppler 150 patients with soft signs of vascular injury of the limbs. The patients with features of vascular injury on Color Doppler (110 patients) were subjected to exploration, while patients who had normal Doppler (40 patients) were subjected to CT- angiography. Color flow Doppler had a sensitivity of 94% and specificity of 82.5% in diagnosis of vascular injury compared with CT angiography and surgical exploration .
Point-of-care ultrasound is widely available in trauma centers, emergency departments and is increasingly being used in the prehospital setting and in remote locations. In many cases, it is the first diagnostic method available. In these scenarios, it is used for a whole body examination, from head to toe, allowing to an integrated management of the trauma patient .
In the extremities and neck Point of care ultrasound is used for the diagnosis of fractures, hematomas, and the identification of foreign bodies . At the same time we propose that, in stable patients without hard signs of vascular damage, it could be of great help for a prompt bedside diagnosis, characterization, and monitoring of trauma-related vascular injuries.
Vascular injuries of the extremities and neck must be investigated with high-frequency linear transducers because a higher resolution and a lower penetration are commonly needed. There are some exceptions, such as patients with large hematomas and super obese patients, in which a convex probe with higher penetration is recommended. When evaluating vascular injuries, we have to explore the region of the trauma, and transversal and longitudinal scans of the vessels should be performed with B-mode. Proximal and distal flows should be investigated with Color flow Duplex Doppler ultrasound. For comparative purposes, both limbs and both sides of the neck should be evaluated.
Normal veins usually are oval in shape and completely compressible with a controlled pressure of the probe. The pulsed wave Doppler analysis shows a continuous flow pattern with respiratory variations.
Normal arteries are round in shape, with an echogenic wall, and noncompressible with the probe. Arteries of the extremities show a triphasic pattern in the pulsed Doppler spectrum. The triphasic pattern has a first positive phase related with the systole of the left ventricle, a second negative phase related with the closure of the aortic valve, and a third positive phase produced by the elasticity of the arterial walls. The loss of this triphasic pattern is always pathologic [21, 22]. The absence of triphasic pattern can be acute (traumatic injury or obstruction) or chronic (atherosclerosis, diabetes, aging).
Although in trauma patients, the presence of obesity, large hematomas, subcutaneous air, or large open wounds of the skin can represent a technical limitation to the penetration of the sound waves, with point-of-care ultrasound and Color flow Duplex Doppler is possible to accurately rule in or rule out trauma-related vascular injuries, [15, 16, 23, 24].
The aim of this study is to review and describe point-of-care ultrasound and Doppler ultrasound characteristics of penetrating and blunt trauma-related vascular injuries of the limbs and neck, such as vein rupture, intimal flap, deep vein thrombosis, arterial dissection, pseudoaneurysm, and arteriovenous fistulae. A bedside identification of these lesions can help to a better care of these patients. Images of most significant lesions are presented to illustrate point-of-care ultrasound and Doppler ultrasound findings.
Pathologic sonographic patterns
Does the patient have a vascular lesion? Yes or no?
If the answer is yes: what kind of lesion?
Mixed arterial and venous injuries
Other common injury in trauma patients is vein thrombosis. When present, it usually appears after minutes or hours after the trauma. For the identification and diagnosis of venous thrombosis, we can use the compression technique and the Color Duplex Doppler evaluation [25–30].
Mixed arterial and venous injuries
Distal flow analysis
Eco Doppler ultrasound monitoring
When there are no hard signs of vascular injury and the patient is stable, imaging methods can aid in the localization and diagnosis of trauma-related vascular lesions. While angiography still remains the gold standard for the assessment of traumatic vascular injuries of the limbs and neck, other less invasive imaging modalities have gained popularity in the recent years and are routinely used. Point-of-care ultrasound and Color flow duplex Doppler ultrasound are widely available, noninvasive, sensible and specific techniques that can be used bedside, as a first approach for a prompt diagnosis and follow-up of trauma-related vascular injuries, and for an integrated management of trauma patients.
MAM: Manuscript writing and final review, provided figures. FP: Manuscript writing. LV: Manuscript writing. OC: Manuscript writing. SGN: Manuscript writing and edition. LMM: Manuscript writing and edition. All authors read and approved the final manuscript.
The authors declare that they have no competing interests.
Availability of data and materials
Ethics approval and consent to participate
The internal review board of the hospital approved this study and waived the requirement for informed consent.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.
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