A 28-year-old man is brought to the emergency department 30 minutes after sustaining a stab wound to his right medial thigh. He reports excruciating pain in his right leg. His blood pressure is mm Hg, and his heart rate is /min. Physical examination reveals a 3-cm linear laceration over the right anteromedial thigh. There is a rapidly expanding, pulsatile hematoma surrounding the wound. Palpation of the right lower extremity reveals absent dorsalis pedis and posterior tibial pulses, whereas the left lower extremity pulses are normal and symmetric. The right foot is pale and cool to the touch compared to the left. Which of the following is the most appropriate next step in the management of this patient?
- AComputed tomography angiography of the right lower extremity
- BLocal wound exploration and application of a pressure dressing
- Immediate surgical explorationAnswer
- DDuplex ultrasonography of the right lower extremity
- EIntravenous administration of broad-spectrum antibiotics and observation
Answer
Immediate surgical exploration is the most appropriate next step due to the presence of hard signs of vascular injury.
The correct answer is immediate surgical exploration. This patient presents with penetrating trauma to the extremity accompanied by 'hard signs' of vascular injury. Hard signs include an expanding or pulsatile hematoma, absent or diminished distal pulses, palpable thrill or audible bruit, active pulsatile bleeding, and signs of distal ischemia (e.g., pale, cool extremity). The presence of any hard sign mandates immediate surgical exploration in the operating room to repair the vascular injury and restore perfusion, as any delay for imaging increases the risk of limb loss.
Step-by-Step Solution
Key Concept
Management of penetrating extremity trauma with hard signs of vascular injury