ICD 10 CM S45.301A | Description & Clinical Information

ICD 10 S45.301A describes an injury that occurs in a superficial vein located in the upper limb, specifically at the shoulder or upper arm level, resulting from blunt or penetrating trauma, injury by displaced fracture fragments, or injury during surgery, where the provider does not specify the nature or type of injury but does document that the injury affects a superficial vein in the right arm at the initial encounter for the injury.

Official Description Of S45.301A

The ICD 10 CM book defines ICD 10 code S45.301A as:

When To Use S45.301A

The diagnosis described by the ICD-10-CM code S45.301A is an unspecified injury of a superficial vein at the shoulder or right upper arm level. This type of injury can have severe consequences, including heavy bleeding and the formation of a blood clot, also called thrombosis. When a thrombosis forms, there is a risk that it can break off and travel to the heart, which can cause a heart attack. Other possible complications may include thrombophlebitis or vein inflammation, low blood pressure from blood loss, and cool, pale skin.

When a medical provider suspects an injury to the shoulder or upper arm level, they will use a variety of tools to diagnose the condition. This may include taking a thorough medical history and performing a physical examination, with a focus on nerve and vascular assessment. Laboratory studies of the blood can also be important for evaluating coagulation factors, platelets, and kidney function. If contrast imaging studies are planned for the patient, the provider may also check the patient’s blood urea nitrogen (BUN) and creatinine levels to evaluate kidney function. Imaging studies such as X-rays, ultrasound, venography, and arteriography may also be used to assess adjacent arteries.

The treatment options for an injury with this diagnosis code are varied, and will depend on the severity and nature of the injury. One of the first steps is often immediate pressure over the wound to help control bleeding. Anticoagulation or antiplatelet therapy can also be useful for treating and preventing blood clots. Pain relief through the use of analgesics may also be necessary. In some cases, surgery may be indicated to suture or tie off the vessel.

Ultimately, a timely and accurate diagnosis of an injury at the shoulder or upper arm level is crucial for ensuring a positive outcome for the patient. By using the ICD-10-CM code S45.301A as a diagnostic tool, medical providers can better understand the nature of the injury and develop targeted treatment plans. With proper care and attention, patients can expect to make a full recovery and return to their daily lives.