A 27-yrs-old man sustains a single gunshot wound to the left

Discussion in 'MRCS Forum' started by Lona., Dec 17, 2007.

  1. Lona.

    Lona. Guest

    A 27-yrs-old man sustains a single gunshot wound to the left thigh. In the emergency room, he is noted to have a large hematoma of his medial thigh. He complains of paresthesias in his foot. On examination, there are weak pulses palpable distal to the injury and the patient is unable to move his foot. The appropriate initial management of this patient is -
    a- Angiography
    b- Immediate exploration and repair
    c- Fasciotomy of the anterior compartment
    d- Observation for resolution of spasm
    e- Local wound exploration
  2. Lona.

    Lona. Guest

    Answer: b. (Sabiston, 15/e, pp 332-333) the five P’s of arterial injury include pain, paresthesias, pallor, pulselessness and paralysis. In the extremities, the tissues most sensitive to anoxia are the peripheral nerves and striated muscle. The early developments of paresthesias and paralysis are signals that there is significant ischemia present, and immediate exploration and repair are warranted. The presence of palpable pulse does not exclude an arterial injury because this presence may represent a transmitted pulsation through a blood clot. When severe ischemia is present, the repair must be completed within 6 to 8 h to prevent irreversible muscle ischemia and loss of limb function. Delay to obtain an angiogram or to observe for change needlessly prolongs the ischemic time. Fasciotomy may be required but should be done in conjunction with and after reestablishment of arterial flow. Local wound exploration is not recommended because brisk hemorrhage may be encountered without the securing of prior vascular control.

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