Acute Traumatic Ischemia

Crush Injuries
And Acute Traumatic
Ischemia
นาวาเอก นรเสทธ์

Classification Systems For
Crush Injuries
 Clinical Judgement
 Gustilo Classification
 Mangled Extremity Severity Score (MESS)
 Evaluation of Host Status

Severity of Crush Injuries
Neurovascular Structures
 Mild

; Intact

 Moderate ; Paresthesias
 Severe ; Injured , but intact or rapairable
 Limb threatening ; Lacerated and / or
avulsed , severe neurologic deficits

 Compartment Syndrome
 Threatened Flaps
 Burns
 Frostbite

Severity of Crush Injuries
Skin and subcutaneous tissues/ Muscles
 Mild

; Intact , but contused

 Moderate ; Severely contused
 Severe

; Lacerated , questionable
viability of margins

 Limb threatening ; Avulsed , nonviable

Severity of Crush Injuries
Bone
 Mild

; Intact or nondisplaced fracture

 Moderate ; Closed , comminuted ,
minimally displaced fracture
 Severe ; Markedly comminuted and displaced
 Limb threatening ; Severely comminuted
and displaced , missing portions

soft tissue avulsion) Mangled Extremity Severity Score MESS – Johansen SHOCK POINTS Perfusion normal 0 Systolic BP always > 90 mm/Hg 0 Pulse reduced / Perfusion present 1 Transient hypotension 1 Pulseless / Paresthesia 2 Persistent hypotension 2 Cool / Paralyzed / Insensate 3 Mangled Extremity Severity Score MESS – Johansen AGE POINTS < 30 1 30 – 50 2 > 50 3 MESS (Johansen)  Double ischemia score if ischemia time greater than six hours  Recommend primary amputation if MESS score 7 or greater . High velocity GSW) 3 Very High Energy ( Above + 4 contamination. multiple Fx Fx)) 2 High Energy (Crush . Simple Fx Fx)) 1 Medium Energy (Open . minimal soft tissue damage III Crush Injuries A Sufficient soft tissue to closed wound Flaps or grafts for closure Major vascular injury B C Expected Outcome Like closed fracture Like closed fracture Infection/non-union Infection/non<10 10% % Complications––50 Complications 50% % Complications––50 Complications 50% % Mangled Extremity Severity Score MESS – Johansen LIMB ISCHEMIA POINTS Mangled Extremity Severity Score MESS – Johansen SKELETAL / SOFT TISSUE POINTS Low Energy (Stab .Gustilo Classification TYPE I II Mechanism Small (<1 (<1cm) laceration Inside to outside Large laceration.

0-3 . Host Ambulation Community Household None 8-10 . Steroids Impaired Cardiac / Compen-.. Renal Sated with Severe meds Impaired Neuropathy None Moderate Severe Deformity ATPIs – Unifying Factors  Ischemia TRAUMA Factors PARTIALLY VIABLE TISSUE Evaluation of Host Status (Strauss) NON – VIABLE DEAD TISSUE ISCHEMIA HYPOXIA EDEMA INFECTION NORMAL VIABLE TISSUE : Pathophysiology of crush injury RECOVERY OR LOSS OF FUNCTION Ischemia in ATPIs a result of:  Direct injury to blood vessels  Edema  Indirect injury – Decreased blood flow due to fluid leakage  Gradient of Injury  External pressure (Compartment syndrome)  Reperfusion Injury  Stasis  Vasoconstriction  Occlusion Edema in ATPIs a result of:  Vasogenic – extravasation of intravascular fluid  Direct trauma to vessels / lymphatics  Increased tissue perfusion pressure  Decreased venous outflow  Decreased intravascular oncotic pressure  Cytogenic  Hypoxic cells lose water Massive Edema  Increases diffusion distance from capillary to cells  Decreases O2 to cells which have increased O2 needs  Pressure causes collapse of capillaries .Decomp Normal Compen Decomp.Scoring Criteria 2 points 1 points 0 points Age < 40 40 – 60 > 60 Score. Normal Smoking / None Past Current 4-7 .

Host factors 5. Reperfusion 4.Ischemia / Reperfusion (I/R) Injury  Adhesion of polymorphonuclear leukocytes (PMNL) to vascular endothelium  Stasis (No reflow phenomenon)  Free radical damage Effects of HBOT In Crush Injuries 1. Red Blood Cell Deformability Hyperbaric OxygenOxygen-100 100% % @ 2. Vasoconstriction 3. Hyperoxygenation 2.4 ATA  Tenfold increase in O2 dissolved in plasma  Threefold increase in O2 diffusion through tissue fluid  Sufficient to maintain cellular function without any Hgb  May be very important if there is sludging of red cells HBOT – Protects Against Reperfusion Injury HBOT – Vasoconstrictive Effect  20% 20% decrease in blood flow (numerous investigators)  Increased O2 compensates for decreased blood flow  Net Effect – Increased oxygenation with 20 20% % decrease in edema Crush Injuries/ATPIs : Surgical Principles  Revascularization  Antagonizes lipid peroxidation of cell membrane by toxic O2 radicals  Debridement  Stops sequestration of neutrophils  Soft Tissue Repair / Coverage  Allows reperfused tissues to generate O2 radical scavengers  Fluid / Blood Resuscitation  Stabilization of Fractures  Antibiotics  Tetanus Prophylaxis .

HBOT – Gustilo / Host Status Criteria for using HBOT in Crush Injuries Gustilo Type Normal Host Impaired Host Severe Compromised I No No Yes II No Yes Yes IIIA No Yes Yes IIIB Yes Yes Yes IIIC Yes Yes Yes HBOT – MESS / Host Status MESS Score Normal Host Impaired Host Severe Compromised 7 (? (?8 8) Yes Amputate Amputate 5–6 No Yes Yes (?amp) 3–4 No No Yes  36 patients with crush injuries HBOT in The Management of Crush Injuries : A Randomized Double--Blind PlaceboDouble Placebo-Controlled Clinical Trial G. Fractures (Bouachour (Bouachour))  Blinded randomization after surgery  HBO 2. BID  Air 1 ATA . BID HBO Air Tibia 9 8  Anticoagulant . Bouachour et al. 90 min . antibiotics . dressings standardized Metatarsals 3 2 Radius / Ulna 1 1  TCOMs . 90 min . Bilateral Perfusion Index (BPI) Metacarpals – 1 .5 ATA .

2 50 55.Outcome (Bouachour (Bouachour)) Clinical Data (Bouachour (Bouachour)) HBO (18 (18)) Air (18 (18)) Complete healing 17 10 7 Tissue necrosis 1 8 9 8 1 6 III B 3 3 Additional procedures III C 2 0 Amputation 0 2 50.. Criteria for using HBOT in Compartment Syndrome .8 55 Soft Tissue Injuries Grade HBO (18 (18)) Air (18 (18)) II 4 III A Time to healing (d) Outcomes (Bouachour (Bouachour)) Patients < 40 years old Outcomes (Bouachour (Bouachour)) Patients > 40 years old HBO HBO Air Air HBO HBO Air Air Tissue Injury II III II III Tissue Injury II III II III Success 2 6 3 1 Success 2 7 3 3 Failure 0 0 0 0 Failure 0 1 1 7 Bouachour  HBO is indicated as an adjunctive therapy in the treatment of severe crush injuries (grade III) in patients over the age of 40 years..

Suspected Stage 2. Impending Stage (Lag Phase) 3. 3 stages 1. Established Stage Recommendations for HBO in Compartment Syndrome Clinical Findings (3 ( 3)  Pain in the muscle compartment  Discomfort with passive stretch  Swelling in / fullness feeling of compartment  Hypesthesia and / or muscle weakness Recommendations for HBO in Compartment Syndrome Clinical Findings (3 ( 3) Recommendations for HBO in Compartment Syndrome Pressure Measurements (1 ( 1)  Impaired or marginal host  Increasing serial pressure measurements  Myelopathy and / or neuropathy  Up to 40 mmHg – Healthy host  Hypotension  30 – 40 mmHg – Impaired host  Prolonged (> 6 hr) ischemia time  20 – 30 mmHg – Marginal or shocky host Recommendations for HBO in Compartment Syndrome Established Stage (Post – fasciotomy fasciotomy)) (1 ( 1)  Residual ischemic muscle  Viable vs.Compartment Syndrome . nonviable demarcation unclear  Threatened skin flap or graft  Residual neuropathy Recommendations for HBO in Compartment Syndrome Established Stage (Post – fasciotomy fasciotomy)) (1 ( 1)  Massive swelling  Impaired or marginal host  Prolonged (> 6 hr) ischemia time .

5 ATA . there may be benefit (in theory at least) to treatment with HBO while awaiting surgery The End . BID (2d) . 90 – 120 min TID (2d) . Daily (2d) (2d) Hyperbaric oxygen therapy in no way supercedes the surgical principles for management of crush injuries / ATPIs HOWEVER . if surgical intervention is going to be delayed .HBOT Protocols Crush Injuries / ATPIs HBO Committee Report 2.0 – 2.