BOAST - Diagnosis & Management of Arterial Injuries Associated With Extremity Fractures and Dislocations
Date Published: December 2020
Last Updated: December 2020
Background and justification
Rapid, accurate diagnosis of arterial injuries to the extremities is crucial for optimum outcome with immediate referral to, and joint management with, a surgeon capable of performing vascular repair.
Patients of all ages with vascular injuries to the extremity associated with musculoskeletal trauma.
Standards for Practice
- All hospitals and networks that are responsible for the management of injured patients must have clear emergency referral and transfer protocols that should include a single point of contact.
- Centres providing definitive care must have an agreed protocol and pathway standardising the management of these complex injuries.
- This protocol should include combined review and decision making in person by Consultant surgeons skilled in vascular repair and skeletal trauma on reception of the patient.
- Haemorrhage should be controlled immediately by direct pressure or tourniquet. Blind clamping should not be undertaken.
- A pulseless, deformed limb should be re-aligned, splinted and the vascular examination repeated and documented at the time of diagnosis and prior to transfer.
- Neurological examination must be documented as a timed entry in all patients with extremity trauma; associated nerve injury should be presumed until disproven.
- Any patient undergoing CT scan following major trauma should have a head to toe scanogram.
- CT angiography of the extremity should occur immediately following the scanogram, without requirement for patient repositioning.
- The ischaemic limb should be revascularised within four hours from injury.
- Where rapid definitive restoration of arterial flow cannot be achieved, arterial shunts should be used to restore flow (eg while skeletal stabilisation is placed).
- Revascularisation should be immediate utilising shunts, followed by skeletal stabilisation.
- Definitive repair or direct interposition grafts are preferred to bypass grafts.
- Where cognition allows, patients must be made aware of the possibility of amputation. Any decision to perform early amputation must be made by two consultants and clearly documented.
- Fasciotomies should always be considered. They should either be performed or the decision not to perform documented with the name of the senior decision maker. There is a low threshold for fasciotomy in these cases.
- Post-operative care should be delivered in an appropriate area with nursing and medical staff competent in the assessment of the critically injured limb.
Studies with level-1 evidence are lacking. Predominantly retrospective series, with some good prospective studies, metaanalyses, reviews and expert opinion