Kelly Sean P, Rambau Genevieve, Tennent David J, Osborn Patrick M
Brian Allgood Army Community Hospital, US Yongsan Garrison, Unit 15281, Seoul, Republic of Korea, APO, AP.
Brooke Army Medical Center, 3351 Roger Brooke Drive, San Antonio, TX.
Mil Med. 2019 Oct 1;184(9-10):e490-e493. doi: 10.1093/milmed/usz028.
Physical exam and angiography have important roles in the diagnosis of traumatic lower extremity vascular injury with similar reported high rates of sensitivity and specificity. It has been previously shown that CTA is not universally indicated in the setting of acute lower extremity trauma when a reliable physical examination is obtained. As such, the purpose of this study was to determine if obtaining a CTA following physical examination altered the clinical care of patients following high-energy lower extremity trauma and the generalizability to the military population.
Retrospective review of all patients who underwent lower extremity CTA during the initial trauma evaluation at a Level 1 Trauma Center from 2007 to 2014.
One hundred and fifty-seven patients met inclusion criteria. One hundred and seventeen patient's initial physical exam excluded limb ischemia with 67 vascular injuries on CTA (9 underwent angiogram in the OR) with no reperfusions required. 40 patients had hard signs of ischemia or ABI's <0.90, 29 had injuries on CTA, and fifteen underwent a vascular reperfusion procedure for acute vascular injury. Ten of 15 reperfusions required no further angiography after CTA. The sensitivity and negative predictive value of physical exam for needed reperfusion were both 100%. There were no instances of missed vascular injury or readmission and 53 patients were discharged directly from the emergency room after a negative CTA.
This study suggests that physical exam alone achieves a high sensitivity for vascular injury in lower extremity trauma. Physical exam excluded all lower extremity ischemia without the need for advanced imaging. While CTA was useful to confirm and localize the source of acute vascular injury, the majority of vascular injuries identified on CTA did not affect immediate clinical care and lead to additional unnecessary procedures. However, in patients with suspected vascular injury, a negative CTA was also used as rationale for immediate discharge from the emergency department without further clinical observation. When applied to the deployed military setting the results of this study support the use of physical exam to accurately diagnose limb threatening ischemia at the time of injury or Role 1 facilities with CTA reserved for diagnosing the level of the vascular injury and for potential patient clearance prior to prolonged evacuation.
体格检查和血管造影在创伤性下肢血管损伤的诊断中发挥着重要作用，据报道其敏感性和特异性都很高。先前的研究表明，当体格检查结果可靠时，急性下肢创伤患者并非都需要进行CT血管造影（CTA）检查。因此，本研究的目的是确定在体格检查后进行CTA检查是否会改变高能下肢创伤患者的临床治疗，以及该研究结果对军事人群的普遍适用性。
回顾性分析2007年至2014年期间在某一级创伤中心接受初次创伤评估时进行下肢CTA检查的所有患者。
157例患者符合纳入标准。117例患者的初次体格检查排除了肢体缺血，CTA检查发现67例血管损伤（9例在手术室接受了血管造影），均无需再灌注治疗。40例患者有缺血的硬体征或踝肱指数（ABI）<0.90，29例CTA检查发现有损伤，其中15例因急性血管损伤接受了血管再灌注治疗。15例接受再灌注治疗的患者中有10例在CTA检查后无需进一步血管造影。体格检查对是否需要再灌注治疗的敏感性和阴性预测值均为100%。没有出现血管损伤漏诊或再次入院的情况，53例CTA检查结果为阴性的患者直接从急诊室出院。
本研究表明，仅体格检查对下肢创伤血管损伤的敏感性就很高。体格检查排除了所有下肢缺血情况，无需进行高级影像学检查。虽然CTA有助于确认和定位急性血管损伤的来源，但CTA检查发现的大多数血管损伤并未影响即时临床治疗，也未导致额外的不必要检查。然而，对于疑似血管损伤的患者，CTA检查结果为阴性也被用作急诊室立即出院而无需进一步临床观察的理由。当应用于军事部署环境时，本研究结果支持使用体格检查准确诊断受伤时威胁肢体的缺血情况，而在一级医疗机构，CTA则用于诊断血管损伤的程度以及在长时间后送前评估患者是否适合后送。
