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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.
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.
Patients with hard signs of vascular injury require emergency on-table angiography and exploration which should not be delayed by obtaining further imaging.
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.
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.
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.
Patients should be examined for hard signs of vascular injury19 (p lsatile bleeding, arterial thrill on palpation, bruit over or near artery, visible expanding hematoma and signs of distal ischemia-pain, paresthesia, pallor, paralysis and pulselessness) proximity of wound to neurovascular bundle and any neurological deficit.
Frykberg et al have shown that all cases that underwent exploration on the basis of presence of hard signs had major arterial injury requiring repair indicating 100% positive predictive value for physical examination17.
1%) cases of acutely presenting MVI had obvious hard signs.