CRUSH INJURY, COMPARTMENT SYNDROME,
AND OTHER ACUTE TRAUMATIC ISCHEMIASRationale
Acute traumatic ischemia (ATI) occurs when an injury compromises the circulation to an extremity. This compromise may place portions of the extremity or the entire extremity at risk of necrosis or amputation. Secondary complications such as infection, nonhealing wounds, and ununited fractures frequently develop. Ischemia can result either from injury to the macrosized blood vessels, as in open fractures with interruption of major arteries, at the microcirculation level, as in severe crush injuries and skeletal muscle compartment syndromes, or from combinations of the two.
Whenever hyperbaric oxygen (HBO,) is used for an ATI, the injury should be classified by a Standard Classification Method such as the Gustilo Grading System (Table 1) or The Mangled Extremity Severe Score (MESS) (Table 2) (1,2). For skeletal muscle-compartment syndromes the use of HB02 should be based on clinical findings coupled, when available, with interstitial fluid pressure measurements of the compartment (Table 3). Tables 1-3 provide specific criteria for using HB02 with these grading systems.
The rationale for using HB02 in ATIs is based on the pathophysiology of these conditions and how the mechanisms of HBO, influence them. The immediate threat to the limb is whether perfusion is sufficient to maintain viability of the tissues. Posttraumatic edema which is associated with traumatic injuries and ischemia further reduce oxygen availability to tissues. When tissue oxygen tensions fall below 30 mmHg, the host responses to infection and ischemia are compromised (3). Specifically, white blood cell killing becomes defective or nonexistent and host repair processes such as fibroblast migration, fibroblast proliferation and fibroblast secretion of collagen are arrested (4-6). Without a collagen matrix in the wound, neovascularization and wound healing cannot occur. The primary rationale for using HBO2, is that it increases tissue oxygen tensions in hypoxic tissues to levels which make it possible for the host responses to become functional. With HB02 at 2 atmospheres absolute (ata) the blood oxygen content is increased by 25 % whereas plasma and tissue oxygen tensions increase tenfold (i.e., 1000 %) (79). The net effect is that oxygen diffusion through tissue fluids is increased by a threefold factor (10, 11). Sufficient oxygen becomes physically dissolved in plasma to keep tissues alive despite inadequate hemoglobin-borne oxygen (9).
Edema reduction secondary to vasoconstriction is another effect of oxygenation. This mechanism reduces blood flow by 20 % (8). The benefit of vasoconstriction is a concomitant (i.e. 20 %) reduction in posttraumatic vasogenic edema (12-16). HBO, maintains oxygen delivery while the blood flow that contributes to edema formation is reduced. Concomitantly, blood flow m the microcirculation is improved through the edema reducing effects of vasoconstriction. In summary, the immediate effects of HBO are threefold in acute traumatic ischemias: (a) Enhanced oxygen at the tissue level, (b) Increased oxygen delivery per unit of blood flow, and (c) Edema reduction.
Finally, HBO may mediate the effects of the reperfusion injury in ATI's especially in those injuries where tissue ischemia is severe and/or prolonged (e.g. revascularization, replantations, etc.) by preventing sequestration of neutrophils on the endothelial wall, lipid peroxidation of cell membranes, and depletion of radical scavengers at the reperfusion site (19-30). Please refer to Section 1 1, Skin Graft and Flaps, Compromised for further discussion of the benefits of HBO in the reperfusion injury.
Ninety-three cases using HBO, in crush injuries were reported in the English language literature (31-37). Although none were controlled studies, all showed benefits from HBO2, for traumatic ischemias. In addition, Strauss summarized the reports of 634 cases from the Eastern European literature (38). The benefits of HB02 in these cases included "positive effects on local reparatory processes," "reduction of tissue damage," "accelerated recovery of neutrophile phagocytic activity," "accelerated diminution in edema," and "healing without suppuration." Recently published articles by Bouachour, et. al., Radonic, et. al., Shupak, et al., and Strauss and Hart offer additional reports consistent with the above series (39-42).
Utilization Review
The recommended treatment schedule is three 1.5-hour treatments per day over the first 48 hours followed by two 1.5-hour treatments daily over the second period of 48 hours and one 1.5-hour treatment daily over the third period of 48 hours. By the sixth day, restored perfusion, edema reduction, and demarcation or recovery should be sufficient to discontinue HBO, therapy. If HBO, therapy is to be continued beyond this time, utilization review should be obtained. The early application of HB02 therapy, preferably within 4 to 6 hours of the injury, is essential for efficacy. If surgery is delayed, HBO, therapy should be started before surgery.
Cost Impact
Hyperbaric oxygen decreases the complication rates associated with crush injuries, compartment syndromes, and other ATI'S. Complication rates approaching 50 % are reported in the management of open fractures with concomitant soft tissue defects and/or interruptions to the limb's blood supply (1,43,44). Complications include infection, nonunion, and amputation. In a recent report, it was found that when HBO, was used, presumably to arrest the progression of a skeletal muscle compartment syndrome and to obviate the need for surgical decompression, the estimated cost of management was one-fourth that of patients who had their compartment syndromes surgically decompressed. The addition of HBO2, to the management of patients with ATI's adds considerably to each patient's medical expenses. This expense is only a small percentage of the cost dealing with the complications of ATI's that could be reduced or prevented by HBO2.
Table 1: Use of HBO, for Open Fracture (Gustilo Classification), 1 Crush Injuries
|
Type |
Mechanism |
Expected Outcome |
HBO Indications |
|
I |
Small (< 1 cm) laceration |
Usually no different from a closed fracture |
None |
|
II |
Large laceration, but minimal soft tissue damage |
Usually no different from a closed fracture |
Compromised hosts such as diabetics, advanced peripheral vascular disease, collagen vascular diseases, etc., where concern is raised about primary healing of flaps |
|
III |
Crush tissue: |
|
|
Table 2: Use of HBO, for Mangled Extremities (mess score), Johansen'
A. Skeletal/soft tissue injury
Low energy (stab, simple fracture; low velocity gun shot wound)
Medium energy (open or multiple fractures, dislocations)
High energy (close-range shot gun or high velocity GSW, crush injury)
Very high energy (above plus gross contamination, soft tissue avulsion)
B. Limb ischemia
Pulse reduced or absent, but perfusion present
Pulselessness, paresthesias, diminished capillary refill 2*
Cool, paralyzed, insensate, numb 3*
*Double score if ischemia time > 6 hoursC. Shock
Systolic BP always > 90 mmHg
Hypotension transiently
Persistent hypotension
D. Age
< 30
30-50
> 50Points
1
2
3
4
1*
2*
3*
0
1
2
0
1
2
Although Johansen et al. recommended primary amputation if MESS score is seven (7) or greater, HBO, should be used in the following situations:
Mess Score
7 (possibly 8)5, 6
3, 4HB02 Indications
Uncompromised host where age, hypotension, and mild-to-moderate ischemia significantly contribute to the score
Compromised hosts with diabetes, peripheral vascular disease, collagen vascular disease, etc.
Severely compromised hosts with advanced levels of the above conditions.
Table 3: Use of HBO, for the Skeletal Muscle Compartment Syndrome
I. Clinical Findings:
1. Severe pain in muscle compartment
2. Marked increase in pain with passive stretch of muscles in the compartment
3. Marked swelling of the compartment
4. Marked tenseness of the muscle compartment
5. Neuropathy, myelopathy, and/or encephalopathy
2. Rising serial compartment pressure measurements as values approach 35 mmHg
3. 30-40 mmHg in mildly compromised host (diabetic, peripheral vascular disease, collagen vascular disease, etc.)
4. 20-30 mmHg in hypotensive patients where systolic blood pressure is 33 to 50% lower than is expected.
HBO Indications: Either or both of the following exist:
B. Any one of the above permutations for skeletal-muscle compartment pressure measurements (from Section II above).
References
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