Match each patient presentation involving a peripheral vascular pathology or injury with the most appropriate immediate next step in management.
- A 24-year-old man is brought to the emergency department after sustaining a gunshot wound to the right medial thigh. Examination reveals an expanding, pulsatile hematoma. Right pedal pulses are absent.Immediate surgical exploration in the operating room
- A 32-year-old man presents with a stab wound to the left antecubital fossa. Radial and ulnar pulses are 2+ and symmetric. A 2-cm non-expanding hematoma is noted. The injured extremity index is 0.85.Computed tomography angiography (CTA) of the affected extremity
- A 74-year-old woman with medication-noncompliant atrial fibrillation presents with 4 hours of sudden-onset left leg pain and pallor. She has new-onset weakness in ankle dorsiflexion. Arterial Doppler signals are inaudible.Intravenous heparin infusion and emergent surgical embolectomy
- A 68-year-old man presents with right foot pain that frequently awakens him from sleep and improves when he dangles his foot over the edge of the bed. The right ankle-brachial index is 0.35.Lower extremity angiography and planned elective revascularization
Answer
Penetrating trauma with hard signs requires immediate surgical exploration. Penetrating trauma with soft signs requires CTA. Acute limb ischemia with motor deficits requires emergent embolectomy. Chronic critical limb ischemia requires planned angiography and revascularization.
The correct pairings triage the patients based on the acuity and severity of their vascular compromise. Hard signs of vascular trauma require the operating room; soft signs require imaging. Acute limb ischemia with motor loss is a surgical emergency, while chronic critical limb ischemia is evaluated electively.
Step-by-Step Solution
Key Concept
Management pathways for peripheral vascular presentations rely heavily on differentiating hard versus soft signs of trauma, and acute versus chronic limb ischemia.