A 35-year-old man is brought into the emergency department by ambulance for a stab wound to the left leg near the inguinal ligament. The patient has no significant medical history, and takes no other medication. He was not stabbed or otherwise injured elsewhere. His temperature is 98.6°F (37.0°C), pulse is 130, blood pressure is 85/50, and respirations are 22. Primary and secondary survey and FAST exam are unremarkable for other associated injuries. Pressure is removed from the wound, and pulsatile bleeding from the wound is noted. Which of the following is the most appropriate next step in management?
Emergent surgical intervention
Wound closure
Observation
CT scan of the left lower extremity
Emergent surgical intervention
This patient with pulsatile bleeding from a wound to the left thigh and hemodynamic instability has hard signs of vascular injury. Patients with penetrating wounds and hard signs of vascular injury should be managed with emergent surgical intervention.

Vascular injury commonly occurs as a result of penetrating trauma, such as a stab wound as in this patient. Evaluation begins with a primary and secondary trauma survey to assess for other injuries. Hard signs of vascular injury include pulsatile bleeding, expanding hematoma, and absent pulses distal to the wound. For patients with suspected vascular injury that display either hard signs or hemodynamic instability, emergent surgical intervention is the most appropriate next step in management. For those with soft signs of vascular injury such as non-pulsatile bleeding or associated bony injury, the most appropriate next step in management is CT angiography of the affected limb.

Ball et al. discuss penetrating trauma to the extremities. They state that extremity trauma is the most common source of vascular injury (51%), with femoral artery as the most frequently injured vessel (35%). They also state that though obtaining pulses is important, distal pulses can continue to be present in many limbs with arterial injuries and therefore may require confirmatory evaluation via doppler, CT scan, or even angiography.

Incorrect Answers:
Answer A: Angiography of the left lower extremity may be utilized if this patient did not present with hard signs of vascular injury. However, this patient's presentation warrants emergent surgical intervention.

Answer B: CT scan of the left lower extremity may be utilized if this patient did not present with hard signs of vascular injury. This patient's presentation warrants emergent surgical intervention.

Answer D: Observation may be appropriate if this patient was hemodynamically stable, and showed no hard or soft signs of vascular injury.

Answer E: Wound closure may eventually be appropriate if this patient was hemodynamically stable, and showed no hard or soft signs of vascular injury.

Bullet Summary:
For patients with suspected vascular injury with hard signs of vascular injury the first step in management is emergent surgical intervention.