MEDizzy - A 27-year-old man sustains a single gunshot wound to the

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Trauma II

A 27-year-old man sustains a single gunshot wound to the left thigh. In the ER, he is noted to have a large hematoma of his medial thigh. He complains of paresthesias in his left foot. On examination, there are weak pulses palpable distal to the injury and the patient is unable to move his foot. Which of the following is the most appropriate initial management of this patient?

ExplanationB. Immediate exploration and repair is mandated for acute arterial insufficiency in the presence of neurologic symptoms. Exploration is indicated in the presence of “hard signs” such as expanding hematoma, pulsatile bleeding, audible bruit, palpable thrill, and evidence of absent distal pulses or evidence of distal ischemia. “Soft signs” include a hypotension/shock, history of hemorrhage at the scene of the injury, peripheral nerve deficit, stable hematoma, and proximity of the injury to a major vessel. The 5 Ps of acute arterial insufficiency include pain, paresthesias, pallor, pulselessness, and paralysis. In the extremities, the tissues most sensitive to anoxia are the peripheral nerves and striated muscle. The early developments of paresthesias and paralysis are signals that there is significant ischemia present, and immediate exploration and repair are warranted. The presence of palpable pulses does not exclude an arterial injury because this presence may represent a transmitted pulsation through a blood clot. When severe ischemia is present, the repair must be completed within 6 to 8 hours to prevent irreversible muscle ischemia and loss of limb function. Delay to obtain an angiogram or to observe for change needlessly prolongs the ischemic time. Fasciotomy may be required, but should be done in conjunction with and after reestablishment of arterial flow. Local wound exploration at the bedside is not recommended because brisk hemorrhage may be encountered without the securing of prior proximal and distal vascular control.