A 34-year-old man is brought to the emergency department after being shot in the right thigh during an attempted robbery. The patient is awake, alert, and in moderate distress. Blood pressure is 101/49 mm Hg and pulse is 122/min. Records indicate that his last tetanus vaccine was a year ago. Physical examination shows a gunshot entry wound on the anteromedial upper right thigh with an exit wound on the lateral thigh. There is a hematoma at the entry site but no active bleeding from either wound. The right lower extremity is cool to the touch and distal pulses are feeble. Radiography of the lower extremity shows no fracture. Which of the following is the most appropriate next step in management of this patient?

Question

A 34-year-old man is brought to the emergency department after being shot in the right thigh during an attempted robbery.  The patient is awake, alert, and in moderate distress.  Blood pressure is 101/49 mm Hg and pulse is 122/min.  Records indicate that his last tetanus vaccine was a year ago.  Physical examination shows a gunshot entry wound on the anteromedial upper right thigh with an exit wound on the lateral thigh.  There is a hematoma at the entry site but no active bleeding from either wound.  The right lower extremity is cool to the touch and distal pulses are feeble.  Radiography of the lower extremity shows no fracture.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d834_abed_bc81_63a89f606e35_MD0003_00 This patient with a penetrating injury to the anteromedial portion of the upper thigh and hard evidence of vascular injury should undergo prompt surgical exploration. The initial evaluation and management of patients with severe extremity injury includes hemorrhage control, radiography of skeletal injuries, and evaluation of the neurovascular bundle. Vascular assessment should focus on identifying hard signs of injury, including: Observed pulsatile bleeding Presence of a bruit or thrill over the injury Expanding hematoma Signs of distal ischemia (eg, absent pulses, cool extremities) In the presence of a penetrating injury, such signs (with or without hemodynamic instability) are almost universally predictive of the need for urgent surgical repair and warrant immediate exploration. If the area of damage is unclear, arteriography can be performed intraoperatively to clarify anatomy. If hard signs are absent, further evaluation for soft signs (eg, history of hemorrhage, diminished pulses, bony injury, neurologic abnormality) should occur. If present, these signs indicate the need for additional testing such as the injured extremity index (similar to ankle-brachial index), which involves comparing the systolic occlusion pressure distally in an injured extremity to the occlusion pressure at a proximal site in an uninjured extremity. If the index is abnormal (<0.9), patients should be considered for CT scan or conventional arteriography and surgery in conjunction with management of other injuries (eg, bony damage) (Choice C). < (Choice A) Although transfusion is an important component of management, it is an insufficient strategy if not coupled with surgical repair in patients with hard signs of vascular injury. (Choice B) Compression dressing should be considered during out-of-hospital management, and prophylactic antibiotics are important in cases of open fractures. However, neither is definitive or appropriate for hospitalized patients with clear evidence of vascular injury and hemodynamic instability. (Choice D) Doppler ultrasonography can be an acceptable alternative to angiography in selected settings if performed by experienced providers. However, when hard signs of vascular injury are present, it would not be the next step. Educational objective: Hard signs of vascular injury include pulsatile bleeding, bruits or thrills over the injury, an expanding hematoma, and signs of distal ischemia (eg, absent pulses, cool extremities). In the presence of a penetrating injury, such signs are almost universally predictive of the need for urgent surgical repair. References: Lower extremity arterial injury: results of 550 cases and review of risk factors associated with limb loss. (http://www.ncbi.nlm.nih.gov/pubmed/11389420)

A 34-Year-Old Man Is Brought to the Emergency Department After