(16) Dueck et al stated that, in the absence of hard signs, all significant vascular injuries can be identified by serial clinical examination and injuries discovered do not lead to limb loss.
(16,19) According to James et al, only 1.3% of proximity injuries needed surgical intervention and in their series all patients with delayed onset of hard signs presented within a week and had surgical repair without limb loss or morbidity.
Proximity wounds without hard signs of vascular trauma are further evaluated by DPI.
MVI can present early after initial surgery as persisting hypotension/falling hematocrit, expanding hematoma, unusual bleed from operation site, excessive hemorrhagic drain15, ischemic symptoms after regaining consciousness and hard signs of vascular injury noticed after initial exploration.
Rationale to present this study while considering the health infrastructure and health budget, CT angiography and further endovascular management in case of penetrating neck injuries are not a frequently available option to our surgeons, so relying upon platysmal penetration and hard signs of vascular injury to explore the neck wound can be a safe option.
Anypatient with either platysma penetration with episode of hemodynamic instability or hard signs of vascular injury was explored surgically without preoperative angiography.
Ideally however, once overall patient stability was assured, an immediate complete vascular examination of the patient's left leg should have been done to assess for the "hard signs
" of vascular injury described above.
Diagnosis of arterial trauma (3) Hard signs
Soft signs Active bleed History of bleed or shock Expanding pulsatile haematoma Stable haematoma Absent pulses Pulse discrepancy Ischaemic limb Associated nerve injury Machinery murmur Bruit Table II.
Clinical signs of arterial injury include "hard signs
" (such as pulsatile bleeding, expanding hematoma, pulse deficits, distal ischemia, and thrill/bruit due to AVFs) and "soft signs" (such as proximity of the injury to a major artery, stable hematoma, hypotension, and neurological deficit).
Patients having abdominal, thoracic, intracranial vascular injuries, mangled limbs, and positive hard signs
were excluded from the study.
Results: There were seven patients in whom hard signs
and eleven patients with soft signs were missed, five patients were diagnosed to have a major arterial injury but because of non availability of surgeons with experience in vascular trauma had adverse outcome.
When one of the hard signs
of vascular injury, palpable thrill or bruit is present on initial presentation then the diagnosis of traumatic AVF is obvious.