Acute Vascular Injury
Summary
Acute vascular injury is damage to blood vessels (arteries or veins) from trauma, which can cause bleeding, ischemia (lack of blood supply), or both. Think of blood vessels as pipes carrying blood throughout your body—when a vessel is injured, blood can leak out (causing bleeding and shock) or the vessel can be blocked (causing ischemia and tissue death). Vascular injuries are serious and can be life-threatening or limb-threatening if not treated promptly. They usually occur from penetrating trauma (knife, gunshot) or blunt trauma (high-energy accidents, fractures). The most common sites are the extremities (arms, legs), but can occur anywhere. The key to management is recognizing the injury (active bleeding, absent pulses, expanding hematoma, signs of ischemia), controlling bleeding immediately (direct pressure, tourniquet if life-threatening), assessing for ischemia (check pulses, color, temperature, sensation), providing resuscitation (IV fluids, blood if needed), and urgent surgical repair (repair the vessel, restore blood flow). Early recognition and prompt treatment are essential to save life and limb.
Key Facts
- Definition: Damage to blood vessels from trauma
- Incidence: Common in trauma (thousands of cases/year)
- Mortality: 5-10% overall, higher if major vessel or delayed treatment
- Peak age: Young adults (20-40 years, trauma)
- Critical feature: Active bleeding, absent pulses, signs of ischemia
- Key investigation: Clinical assessment, angiography if needed
- First-line treatment: Control bleeding, resuscitate, urgent surgical repair
Clinical Pearls
"Control bleeding first" — If there's active bleeding, control it immediately (direct pressure, tourniquet if life-threatening). Don't wait—bleeding can kill quickly.
"Check pulses immediately" — Always check pulses distal to the injury. Absent pulses = vascular injury until proven otherwise. Don't miss this.
"Hard signs = surgery" — Hard signs of vascular injury (active bleeding, absent pulses, expanding hematoma, bruit/thrill) = urgent surgery. Don't delay.
"Time is limb" — The longer a limb is without blood supply, the higher the risk of amputation. Urgent repair is essential (usually within 6 hours).
Why This Matters Clinically
Vascular injuries are life-threatening or limb-threatening emergencies that require immediate recognition and treatment. Early recognition (especially absent pulses, active bleeding), immediate bleeding control, and urgent surgical repair are essential to save life and limb. This is a condition that trauma surgeons, vascular surgeons, and emergency clinicians manage, and prompt treatment can prevent death and amputation.
Incidence & Prevalence
- Overall: Common in trauma (thousands of cases/year)
- Penetrating trauma: Most common cause
- Trend: Stable (common in trauma)
- Peak age: Young adults (20-40 years, trauma)
Demographics
| Factor | Details |
|---|---|
| Age | Young adults (20-40 years, trauma) |
| Sex | Male predominance (trauma patterns) |
| Ethnicity | No significant variation |
| Geography | Higher in urban areas (trauma) |
| Setting | Emergency departments, trauma centers |
Risk Factors
Non-Modifiable:
- Age (young adults = more trauma)
- Male sex (trauma patterns)
Modifiable:
| Risk Factor | Relative Risk | Mechanism |
|---|---|---|
| Penetrating trauma | 10-20x | Direct vessel damage |
| High-energy trauma | 5-10x | Blunt vessel damage |
| Fractures | 3-5x | Vessel damage from bone fragments |
| Dislocations | 3-5x | Vessel stretch/compression |
Common Mechanisms
| Mechanism | Frequency | Typical Patient |
|---|---|---|
| Penetrating trauma | 60-70% | Knife, gunshot |
| Blunt trauma | 20-30% | High-energy accidents |
| Fractures | 10-20% | Associated with fractures |
| Other | 5-10% | Various |
The Injury Mechanism
Step 1: Vessel Damage
- Penetrating: Direct vessel laceration/transection
- Blunt: Vessel stretch, compression, or intimal tear
- Fracture: Bone fragments damage vessel
- Result: Vessel injured
Step 2: Bleeding or Ischemia
- Bleeding: If vessel lacerated/transected
- Ischemia: If vessel blocked/compressed
- Both: Can have both
- Result: Bleeding and/or ischemia
Step 3: Clinical Manifestation
- Active bleeding: If vessel open
- Absent pulses: If vessel blocked
- Shock: If significant bleeding
- Ischemia: If blood supply cut off
Step 4: Complications
- Exsanguination: If bleeding not controlled
- Tissue death: If ischemia prolonged
- Amputation: If limb not revascularized
- Death: If major vessel, not treated
Classification by Type
| Type | Definition | Clinical Features |
|---|---|---|
| Laceration | Vessel cut | Active bleeding |
| Transection | Vessel completely cut | Active bleeding, absent pulses |
| Intimal tear | Inner lining torn | May cause thrombosis, ischemia |
| Compression | Vessel compressed | Ischemia, absent pulses |
| Pseudoaneurysm | Contained bleeding | Expanding hematoma, bruit |
| AV fistula | Artery-vein connection | Bruit, thrill, high-output heart failure |
Anatomical Considerations
Common Sites:
- Extremities: Arms, legs (most common)
- Neck: Carotid, vertebral (serious)
- Chest: Aorta, great vessels (very serious)
- Abdomen: Aorta, iliac (very serious)
Why Some Sites More Serious:
- Major vessels: Aorta, carotid = life-threatening
- Proximal: Closer to heart = more bleeding
- Single supply: Some areas have single vessel = more serious if injured
Symptoms: The Patient's Story
Typical Presentation:
History:
Signs: What You See
Vital Signs (May Be Abnormal):
| Sign | Finding | Significance |
|---|---|---|
| Temperature | Usually normal | Usually normal |
| Heart rate | May be high (bleeding, shock) | Tachycardia, shock |
| Blood pressure | May be low (bleeding, shock) | Hypotension, shock |
| Respiratory rate | Usually normal (may be high if shock) | Usually normal |
General Appearance:
Local Examination:
| Finding | What It Means | Frequency |
|---|---|---|
| Active bleeding | Vessel lacerated/transected | 40-50% |
| Absent pulses | Vessel blocked/transected | 50-60% |
| Expanding hematoma | Contained bleeding, pseudoaneurysm | 20-30% |
| Bruit/thrill | Pseudoaneurysm, AV fistula | 10-20% |
| Pale, cold | Ischemia | 50-60% |
| Numbness | Nerve injury or ischemia | 30-40% |
Signs of Ischemia (Critical):
| Finding | What It Means | Significance |
|---|---|---|
| Absent pulses | No blood flow | Vascular injury |
| Pale | No blood flow | Ischemia |
| Cold | No blood flow | Ischemia |
| Numbness | Nerve ischemia | Ischemia |
| Weakness | Muscle ischemia | Ischemia |
| Delayed capillary refill | Poor perfusion | Ischemia |
Signs of Complications:
Red Flags
[!CAUTION] Red Flags — Immediate Escalation Required:
- Active bleeding — Medical emergency, control bleeding immediately
- Signs of ischemia (pulseless, pale, cold) — Medical emergency, needs urgent revascularization
- Expanding hematoma — May indicate pseudoaneurysm, needs urgent assessment
- Signs of compartment syndrome — Medical emergency, needs urgent fasciotomy
- Signs of shock — Medical emergency, needs urgent resuscitation
- Bruit or thrill (pseudoaneurysm, AV fistula) — Needs urgent assessment
Structured Approach: ABCDE
A - Airway
- Assessment: Usually patent (may be compromised if neck injury)
- Action: Secure if compromised
B - Breathing
- Look: Usually normal (may have difficulty if chest injury)
- Listen: Usually normal
- Measure: SpO2 (usually normal)
- Action: Support if needed
C - Circulation
- Look: Active bleeding, signs of shock
- Feel: Pulse (check distal pulses), BP (may be low)
- Listen: Heart sounds (usually normal), bruit (if pseudoaneurysm)
- Measure: BP (may be low), HR (may be high)
- Action: Control bleeding, resuscitate
D - Disability
- Assessment: Neurological status (numbness, weakness if ischemia)
- Action: Assess if ischemia
E - Exposure
- Look: Full examination, look for injury
- Feel: Pulses, temperature, sensation
- Action: Complete examination
Specific Examination Findings
Vascular Examination (Critical):
| Test | Technique | Positive Finding | Clinical Use |
|---|---|---|---|
| Pulses | Check distal pulses | Absent | Vascular injury |
| Color | Check color | Pale | Ischemia |
| Temperature | Check temperature | Cold | Ischemia |
| Sensation | Check sensation | Numbness | Nerve injury or ischemia |
| Capillary refill | Press nail bed | Slow (>2 seconds) | Poor perfusion |
| Bruit | Listen with stethoscope | Bruit | Pseudoaneurysm, AV fistula |
| Thrill | Feel with hand | Thrill | AV fistula |
Hard Signs (Urgent Surgery):
- Active bleeding: Pulsatile bleeding
- Absent pulses: Distal to injury
- Expanding hematoma: Growing hematoma
- Bruit/thrill: Pseudoaneurysm, AV fistula
Soft Signs (May Need Investigation):
- History of bleeding: Stopped but may have re-bled
- Proximity: Injury near vessel
- Neurological deficit: May be from ischemia
Special Tests
| Test | Technique | Positive Finding | Clinical Use |
|---|---|---|---|
| Ankle-brachial index | Compare ankle and brachial BP | Low ratio | Vascular injury |
| Doppler | Check pulses with doppler | Absent pulses | Confirms absence |
First-Line (Bedside) - Do Immediately
1. Clinical Assessment (Most Important)
- History: Trauma, mechanism
- Examination: Pulses, bleeding, ischemia
- Action: Usually sufficient for diagnosis
2. Control Bleeding (Immediate)
- Direct pressure: Apply pressure
- Tourniquet: If life-threatening, can't control
- Action: Save life first
Laboratory Tests
| Test | Expected Finding | Purpose |
|---|---|---|
| Full Blood Count | May show anemia (blood loss) | Assesses blood loss |
| Group and Save/Crossmatch | Blood type | May need transfusion |
| Coagulation | May be abnormal (if significant blood loss) | Assesses coagulation |
Imaging
Angiography (If Needed):
| Indication | Finding | Clinical Note |
|---|---|---|
| Soft signs | May show injury | If uncertain, soft signs |
| Planning surgery | Detailed vessel anatomy | If surgery planned |
CT Angiography (If Needed):
| Indication | Finding | Clinical Note |
|---|---|---|
| Uncertain diagnosis | Vessel injury visible | If uncertain |
Doppler Ultrasound (If Needed):
| Indication | Finding | Clinical Note |
|---|---|---|
| Uncertain diagnosis | May show injury | If uncertain |
Diagnostic Criteria
Clinical Diagnosis:
- Trauma + hard signs (active bleeding, absent pulses, expanding hematoma, bruit/thrill) = Vascular injury (urgent surgery)
Hard Signs (Urgent Surgery):
- Active bleeding: Pulsatile bleeding
- Absent pulses: Distal to injury
- Expanding hematoma: Growing hematoma
- Bruit/thrill: Pseudoaneurysm, AV fistula
Soft Signs (May Need Investigation):
- History of bleeding: Stopped
- Proximity: Injury near vessel
- Neurological deficit: May be from ischemia
Management Algorithm
SUSPECTED VASCULAR INJURY
(Trauma + hard signs: bleeding, absent pulses)
↓
┌─────────────────────────────────────────────────┐
│ IMMEDIATE BLEEDING CONTROL │
│ • Direct pressure (first) │
│ • Tourniquet (if life-threatening, can't control) │
│ • Don't probe wound │
│ • This saves lives │
└─────────────────────────────────────────────────┘
↓
┌─────────────────────────────────────────────────┐
│ RESUSCITATION (ABCDE) │
│ • Airway, Breathing, Circulation │
│ • IV fluids, blood if needed │
│ • Support organ function │
└─────────────────────────────────────────────────┘
↓
┌─────────────────────────────────────────────────┐
│ VASCULAR ASSESSMENT │
│ • Check pulses (distal to injury) │
│ • Check color, temperature, sensation │
│ • Assess for ischemia │
│ • Hard signs = urgent surgery │
└─────────────────────────────────────────────────┘
↓
┌─────────────────────────────────────────────────┐
│ URGENT SURGICAL CONSULTATION │
│ • If hard signs (urgent) │
│ • If soft signs (may need investigation) │
│ • Don't delay if hard signs │
└─────────────────────────────────────────────────┘
↓
┌─────────────────────────────────────────────────┐
│ URGENT SURGERY │
│ • Explore wound │
│ • Identify injury │
│ • Repair vessel (suture, graft, ligation) │
│ • Restore blood flow │
│ • Time is limb (usually within 6 hours) │
└─────────────────────────────────────────────────┘
↓
┌─────────────────────────────────────────────────┐
│ POST-OPERATIVE │
│ • Monitor pulses, perfusion │
│ • Monitor for complications │
│ • Rehabilitation │
└─────────────────────────────────────────────────┘
Acute/Emergency Management - The First Hour
Immediate Actions (Do Simultaneously):
-
Control Bleeding (Immediate)
- Direct pressure: Apply firm pressure
- Tourniquet: If life-threatening, can't control with pressure
- Don't probe: Don't probe wound
- Action: Save life first
-
Resuscitation (ABCDE)
- IV access: Large-bore IVs (2 if significant bleeding)
- IV fluids: Normal saline, blood if needed
- Action: Support circulation
-
Vascular Assessment (Critical)
- Pulses: Check distal pulses (doppler if needed)
- Color, temperature: Check for ischemia
- Sensation: Check for numbness
- Action: Assess for ischemia
-
Surgical Consultation (Urgent)
- If hard signs: Urgent (within hours)
- If soft signs: May need investigation first
- Action: Don't delay if hard signs
-
Surgery (Urgent)
- Explore: Explore wound
- Repair: Repair vessel
- Time: Usually within 6 hours (time is limb)
- Action: Urgent surgery
Medical Management
Bleeding Control:
| Method | Indication | Notes |
|---|---|---|
| Direct pressure | First-line | Apply firm pressure |
| Tourniquet | Life-threatening, can't control | Use if needed |
Resuscitation:
| Intervention | Details | Notes |
|---|---|---|
| IV fluids | Normal saline, blood | Support circulation |
| Blood transfusion | If significant blood loss | May need multiple units |
Surgical Management
Vessel Repair (Essential):
| Procedure | Indication | Notes |
|---|---|---|
| Primary repair | Clean laceration | Suture vessel |
| Graft | If can't repair primarily | Vein or synthetic graft |
| Ligation | If small vessel, collateral flow | Only if adequate collateral |
Timing:
- Usually within 6 hours: Time is limb
- Don't delay: If hard signs
Disposition
Admit to Hospital:
- All cases: Need surgery, monitoring
- ICU: If significant bleeding, shock
Discharge Criteria:
- Post-operative: After surgery, stable
- No complications: No complications
- Clear plan: For follow-up
Follow-Up:
- Pulses: Monitor pulses, perfusion
- Wound: Monitor wound healing
- Long-term: May need further treatment
Immediate (Days-Weeks)
| Complication | Incidence | Presentation | Management |
|---|---|---|---|
| Amputation | 5-10% (if not revascularized) | Limb loss | Prevention through early revascularization |
| Exsanguination | 5-10% (if not controlled) | Death from bleeding | Prevention through bleeding control |
| Compartment syndrome | 10-20% | Tense swelling, pain | Urgent fasciotomy |
| Infection | 5-10% | Wound infection | Antibiotics, may need debridement |
Amputation:
- Mechanism: Prolonged ischemia
- Management: Amputation if not revascularized
- Prevention: Early revascularization (within 6 hours)
Early (Weeks-Months)
1. Persistent Ischemia (5-10%)
- Mechanism: Incomplete revascularization
- Management: May need further surgery
- Prevention: Complete revascularization
2. Pseudoaneurysm (5-10%)
- Mechanism: Contained bleeding
- Management: May need surgery
- Prevention: Proper repair
Late (Months-Years)
1. Chronic Ischemia (5-10%)
- Mechanism: Incomplete recovery
- Management: Ongoing management
- Prevention: Early, complete revascularization
Natural History (Without Treatment)
Untreated Vascular Injury:
- Bleeding: Exsanguination, death
- Ischemia: Tissue death, amputation
- Poor outcomes: If not treated
Outcomes with Treatment
| Variable | Outcome | Notes |
|---|---|---|
| Limb salvage | 80-90% | Most limbs saved with prompt treatment |
| Mortality | 5-10% | Lower with prompt treatment |
| Amputation | 5-10% | If not revascularized promptly |
| Time to revascularization | Usually within 6 hours | Time is limb |
Factors Affecting Outcomes:
Good Prognosis:
- Early treatment: Better outcomes (within 6 hours)
- Prompt bleeding control: Better outcomes
- Complete revascularization: Better outcomes
- No complications: Better outcomes
Poor Prognosis:
- Delayed treatment: Higher amputation risk
- Prolonged ischemia: Higher amputation risk
- Major vessel: Higher mortality
- Multiple injuries: Worse outcomes
Prognostic Factors
| Factor | Impact on Prognosis | Evidence Level |
|---|---|---|
| Time to revascularization | Every hour matters | High |
| Bleeding control | Prompt = better | High |
| Ischemia duration | Longer = worse | High |
| Vessel size | Major = worse | Moderate |
Key Guidelines
1. EAST Guidelines (2012) — Evaluation and management of vascular injuries. Eastern Association for the Surgery of Trauma
Key Recommendations:
- Control bleeding immediately
- Urgent surgery if hard signs
- Revascularization within 6 hours
- Evidence Level: 1A
Landmark Trials
Multiple studies on timing of revascularization, outcomes.
Evidence Strength
| Intervention | Level | Key Evidence | Clinical Recommendation |
|---|---|---|---|
| Bleeding control | 1A | Universal | Essential |
| Urgent surgery | 1A | Multiple studies | Essential if hard signs |
| Revascularization within 6 hours | 1A | Multiple studies | Time is limb |
What is a Vascular Injury?
A vascular injury is damage to blood vessels (arteries or veins) from trauma. Think of blood vessels as pipes carrying blood throughout your body—when a vessel is injured, blood can leak out (causing bleeding) or the vessel can be blocked (causing lack of blood supply to tissues). This is serious and can be life-threatening or cause loss of a limb if not treated promptly.
In simple terms: One of your blood vessels has been damaged. This can cause serious bleeding or cut off blood supply to a part of your body. It needs urgent treatment, but with prompt surgery, most people recover well.
Why does it matter?
Vascular injuries are life-threatening or limb-threatening emergencies. Early recognition, immediate bleeding control, and urgent surgical repair are essential to save life and limb. The good news? With prompt treatment, most people recover well and keep their limbs.
Think of it like this: It's like a pipe breaking—blood can leak out or stop flowing. It needs urgent repair, but once fixed, most people recover well.
How is it treated?
1. Control Bleeding (Immediate):
- Direct pressure: Your doctor will apply pressure to stop bleeding
- Tourniquet: If bleeding is life-threatening and can't be controlled, a tourniquet may be used
- Why: To stop bleeding and save your life
- This is done first: Before anything else
2. Resuscitation:
- IV fluids: You'll get fluids through a drip to support your circulation
- Blood: You may need a blood transfusion if you've lost a lot of blood
- Why: To support your body while the vessel is repaired
3. Assessment:
- Pulses: Your doctor will check pulses in the affected area
- Color, temperature: Your doctor will check for signs of lack of blood supply
- Why: To see how serious it is and plan treatment
4. Urgent Surgery:
- What: The surgeon will operate to repair the damaged vessel
- When: Usually within hours (the sooner the better, especially if a limb is affected)
- Why: To stop bleeding and restore blood flow
- What happens: The surgeon will find the damaged vessel, repair it (suture, graft, or tie it off if small), and restore blood flow
The goal: Stop bleeding, restore blood flow, and save life and limb.
What to expect
Recovery:
- Surgery: Usually within hours
- Hospital stay: Usually days to weeks (depends on severity)
- Limb: Most people keep their limbs with prompt treatment
- Full recovery: Most people recover well
After Treatment:
- Monitoring: Your doctor will monitor pulses and blood flow
- Wound: The surgical wound will heal
- Rehabilitation: You may need rehabilitation to regain function
- Follow-up: Regular follow-up to monitor recovery
Recovery Time:
- Simple cases: Usually days to weeks
- Complex cases: May take longer
- If limb affected: Recovery varies, but most people keep their limbs
When to seek help
Call 999 (or your emergency number) immediately if:
- You have active bleeding from an injury
- You have an injury and can't feel a pulse in the affected area
- You have an injury and the affected area is pale, cold, or numb
- You have an injury and feel very unwell or in shock
- You have an injury and have a growing lump (hematoma)
See your doctor if:
- You have an injury and are concerned about blood flow
- You have an injury and have symptoms that concern you
Remember: If you have an injury with active bleeding or signs of lack of blood supply (pale, cold, no pulse, numbness), call 999 immediately. Vascular injuries are serious, but with prompt treatment, most people recover well. Don't delay—time matters, especially for limbs.
Primary Guidelines
- Eastern Association for the Surgery of Trauma. Evaluation and management of vascular injuries. EAST Practice Management Guidelines. 2012.
Key Trials
- Multiple studies on timing of revascularization, outcomes.
Further Resources
- EAST Guidelines: Eastern Association for the Surgery of Trauma
Last Reviewed: 2025-12-25 | MedVellum Editorial Team
Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists. This information is not a substitute for professional medical advice, diagnosis, or treatment.