arteriography

med student!luke standing you up for a coffee date and that’s really unlike him, ‘cause he’s good at organisation but most of all he loves getting out of his cramped study space to see you, so when he doesn’t show, you turn up at his place to make sure he’s okay and all you’re met with is your lanky, broad-shouldered boyfriend fast asleep in a little ball on his bed surrounded by papers and a textbook in his arms so you gently pry the book from his embrace and settle yourself next to him, poking his nose and his cheek and the shadow of his dimple until he’s stirring, muttering something about coronary arteriography and when his eyes adjust and he realises you’re curled up beside him smiling he’s groaning, ‘Did I sleep through our coffee date?’ and you just give him a little nod and a chuckle, leaning forward to kiss him quickly before you’re sitting up and offering to test him and he smirks at you, eyebrows raised, ‘What’s my reward?’ and you shake your head cause you know where he’s going and laugh out a, 'Think you’re all set with anatomy, babe. But if you get 20 questions right you might get lucky.’

a little Med School!Luke for featuringluke‘s college!5sos blurb night

Penetrating Injuries to the Extremities

Simple penetrating injuries to the arms and legs are often over-treated with invasive testing and admission for observation. Frequently, these injuries can be rapidly evaluated and disposed of using physical examination skills alone.

Stabs and low velocity gunshots (no rifles or shotguns, please) should be thoroughly examined. This includes an examination of the entire, unclothed body. If this is not carried out, there is a risk that additional penetrating injuries may be missed.

For gunshots, look at the wounds and the estimated trajectory to try to demonstrate that the object stayed clear of neurovascular structures. This exam is imprecise, and must be accompanied by a full neurovascular exam and evaluation of the bones and joints. If there is any doubt regarding bony involvement, plain radiographs with entry markers should be performed. Any abnormal findings will require more in-depth evaluation and inpatient admission.

If the exam is negative but the trajectory is “in proximity” to a major vessel, an arterial pressure index (API) should be measured. This test involves the calculation of the ratio of the systolic pressure in the injured extremity to the contralateral uninjured extremity. It should not be confused with the ankle brachial index (ABI) which compares the systolic pressure in the ipsilateral uninjured arm  or leg.

The magic ratio is 0.9. If the API is less than this, there is some likelihood that a vascular injury is present. If the API is higher, there is virtually no chance of injury.

The final test that must be performed before discharge is a function test. If the injured extremity is too painful to use or walk on, the patient may need to be admitted for pain management and therapy. Patients managed in this way can avoid arteriography, CT angiography or admission and save thousands of dollars in hospital charges.

Reference: Journal Am Coll Surgeons 2009;209:740-5.