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Practical Application of Bedside Diagnostics in Determining Limb Viability
Sheila Coogan, MD1, Anahita Dua, MD2, Sapan S. Desai, MD, PhD, MBA1, Kristofer Charlton-Ouw, MD1, Ali Azizzadeh, MD1.
1University of Texas at Houston, Houston, TX, USA, 2Center for Translational Injury Research (CeTIR), University of Texas at Houston, Houston, TX, USA.
OBJECTIVES:
The ankle-brachial index (ABI) is regarded as a bedside test for objectively documenting the presence of lower-extremity perfusion. It is a simple, reproducible, and cost-effective assessment that can be used to identify patients at increased risk for lower-extremity arterial injury after penetrating or blunt trauma. Currently, patients with complicated lower extremity injuries undergo CTA of the lower extremity prior to orthopedic repair. Toe-brachial index (TBI) and ankle waveforms are occasionally utilized in conjunction with ABIs to determine adequacy of blood flow to the lower limb.This study aimed to determine the practical application and impact of formal ABIs, TBIs and/or ankle waveforms in patients with a concerning clinical exam in guiding vascular surgeons decision-making at a level I trauma center.
METHODS: A retrospective review of the trauma registry at a level I center was conducted from January 2009 to June 2013. All patients >16 years of age who sustained a lower limb arterial injury and had an ABI, TBI or ankle waveform study were included. Data-points included demographics, type and location of injury, absolute toe pressure, ABI, TBI, ankle waveforms and procedure type. Statistical analysis included descriptive statistics.
RESULTS: Over a 5 year period, 181 patients with lower extremity arterial injury presented to our institution. From this cohort, 13 trauma patients with documented arterial injury had ABIs, TBIs or ankle-wave forms. All 13 patients had concomitant long bone orthopedic injury to the affected extremity. 5 patients required revascularization with postoperative ABIs used to determine graft patency. 6 patients had ABIs after abnormal CT scans or clinical exam but were not intervened on if ABIs, TBIs, or waveforms were normal. 2 patients had angiography without additional intervention if bedside diagnostics were normal. None of these patients required an amputation.
CONCLUSIONS: ABI in conjunction with TBI and ankle waveforms objectively document limb viability. ABI and other bedside flow tests assess the need for intervention and/or lower limb bypass sufficiency.
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