Crush Injuries

8/9/2019 Crush Injuries

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Crush InjuriesCrush Injuries

And Acute Traumatic And Acute Traumatic

IschemiaIschemia

นาวาเอกนาวาเอก นรเสทธนรเสทธ

Acute Traumatic IschemiaAcute Traumatic Ischemia

Compartment SyndromeCompartment Syndrome

Threatened FlapsThreatened Flaps

BurnsBurns

FrostbiteFrostbite

Classification Systems ForClassification Systems For

Crush InjuriesCrush Injuries

ClinicalClinical JudgementJudgement

GustiloGustilo ClassificationClassification

Mangled Extremity Severity Score (MESS)Mangled Extremity Severity Score (MESS)

Evaluation of Host StatusEvaluation of Host Status

Severity of Crush InjuriesSeverity of Crush Injuries

MildMild ; Intact , but contused; Intact , but contused

ModerateModerate ; Severely contused; Severely contused

SevereSevere ; Lacerated , questionable; Lacerated , questionableviability of marginsviability of margins

Limb threateningLimb threatening ; Avulsed , nonviable; Avulsed , nonviable

Skin and subcutaneous tissues/ MusclesSkin and subcutaneous tissues/ Muscles


MildMild ; Intact; Intact

ModerateModerate ;; ParesthesiasParesthesias

SevereSevere ; Injured , but intact or; Injured , but intact or rapairablerapairable

Limb threateningLimb threatening ; Lacerated and / or; Lacerated and / or

avulsed , severe neurologic deficitsavulsed , severe neurologic deficits

Neurovascular StructuresNeurovascular Structures


MildMild ; Intact or; Intact or nondisplacednondisplaced fracturefracture

ModerateModerate ; Closed , comminuted ,; Closed , comminuted ,

minimally displaced fractureminimally displaced fracture

SevereSevere ; Markedly comminuted and displaced; Markedly comminuted and displaced

Limb threateningLimb threatening ; Severely comminuted; Severely comminuted

and displaced , missing portionsand displaced , missing portions

BoneBone


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GustiloGustilo ClassificationClassification

TYPETYPE MechanismMechanismExpectedExpected

OutcomeOutcome

II Small (


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Evaluation of Host Status (Strauss)Evaluation of Host Status (Strauss)

FactorsFactors Scoring CriteriaScoring Criteria

22 pointspoints 11 pointspoints 00 pointspoints

AgeAge > 6060 Score; HostScore; HostAmbulationAmbulation CommunityCommunity HouseholdHousehold NoneNone 88--1010 ;;

NormalNormal

Smoking /Smoking /

SteroidsSteroids

NoneNone PastPast CurrentCurrent 44--77 ;;

ImpairedImpaired

Cardiac /Cardiac /

RenalRenal

NormalNormal CompenCompen--

Sated withSated with

medsmeds

DecompDecomp.. 00--33 ;;

SevereSevere

ImpairedImpaired

NeuropathyNeuropathy

DeformityDeformity

NoneNone ModerateModerate SevereSevere

NON – VIABLE DEAD TISSUE

NORMAL VIABLE TISSUE

T R A U M A

T R A U M A

INFECTION

ISCHEMIA HYPOXIA EDEMA

RECOVERYRECOVERY

OROR

LOSS OFLOSS OF

FUNCTIONFUNCTION

P A R T I A L L Y

V I A B

L E

T I S S U E

P A R T I A L L Y

V I A B

L E

T I S S U E

:: PathophysiologyPathophysiology of crush injuryof crush injury

ATPIsATPIs – – Unifying FactorsUnifying Factors

IschemiaIschemia

EdemaEdema

Gradient of InjuryGradient of Injury

Reperfusion InjuryReperfusion Injury

Ischemia in ATPIs a result of:Ischemia in ATPIs a result of:

Direct injury to blood vesselsDirect injury to blood vessels

Indirect injuryIndirect injury – – Decreased blood flowDecreased blood flow

due to fluid leakagedue to fluid leakage

External pressure (Compartment syndrome)External pressure (Compartment syndrome)

StasisStasis

VasoconstrictionVasoconstriction

OcclusionOcclusion

Edema in ATPIs a result of:Edema in ATPIs a result of:

VasogenicVasogenic – – extravasationextravasation of intravascular fluidof intravascular fluid

Direct trauma to vessels /Direct trauma to vessels / lymphaticslymphatics

Increased tissue perfusion pressureIncreased tissue perfusion pressure

Decreased venous outflowDecreased venous outflow

Decreased intravascularDecreased intravascular oncoticoncotic pressurepressure

CytogenicCytogenic

Hypoxic cells lose waterHypoxic cells lose water

Massive EdemaMassive Edema

Increases diffusion distance from capillaryIncreases diffusion distance from capillary

to cellsto cells

Decreases ODecreases O22 to cells which haveto cells which have

increased Oincreased O22 needsneeds

Pressure causes collapse of capillariesPressure causes collapse of capillaries


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Ischemia / Reperfusion (I/R) InjuryIschemia / Reperfusion (I/R) Injury

Adhesion of Adhesion of polymorphonuclearpolymorphonuclear leukocytesleukocytes

(PMNL) to vascular endothelium(PMNL) to vascular endothelium

Stasis (No reflow phenomenon)Stasis (No reflow phenomenon)

Free radical damageFree radical damage

Effects of HBOT In Crush InjuriesEffects of HBOT In Crush Injuries

11.. HyperoxygenationHyperoxygenation22.. VasoconstrictionVasoconstriction

33.. ReperfusionReperfusion

44.. Host factorsHost factors

55.. Red Blood Cell DeformabilityRed Blood Cell Deformability

Hyperbaric OxygenHyperbaric Oxygen--100100% @% @ 22..44 ATAATA

TenfoldTenfold increase in Oincrease in O22 dissolved in plasmadissolved in plasma

ThreefoldThreefold increase in Oincrease in O22 diffusion throughdiffusion through

tissue fluidtissue fluid

Sufficient to maintain cellular functionSufficient to maintain cellular function

without anywithout any HgbHgb

May be very important if there isMay be very important if there is

sludgingsludging of red cellsof red cells

HBOTHBOT – – VasoconstrictiveVasoconstrictive EffectEffect

2020% decrease in blood flow (numerous% decrease in blood flow (numerous

investigators)investigators)

Increased OIncreased O22 compensates for decreasedcompensates for decreased

blood flowblood flow

Net EffectNet Effect – – Increased oxygenation withIncreased oxygenation with 2020%%

decrease in edemadecrease in edema

HBOTHBOT – – Protects AgainstProtects AgainstReperfusion InjuryReperfusion Injury

Antagonizes lipidAntagonizes lipid peroxidationperoxidation of cellof cell

membrane by toxic Omembrane by toxic O22 radicalsradicals

Stops sequestration of Stops sequestration of neutrophilsneutrophils

AllowsAllows reperfusedreperfused tissues to generate Otissues to generate O22

radical scavengersradical scavengers

Crush Injuries/ATPIs : Surgical PrinciplesCrush Injuries/ATPIs : Surgical Principles

RevascularizationRevascularization

DebridementDebridement

Stabilization of FracturesStabilization of Fractures

Soft Tissue Repair / CoverageSoft Tissue Repair / Coverage

Fluid / Blood ResuscitationFluid / Blood Resuscitation

AntibioticsAntibiotics

Tetanus ProphylaxisTetanus Prophylaxis


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Criteria for using HBOTCriteria for using HBOT

in Crush Injuriesin Crush Injuries

HBOTHBOT – – GustiloGustilo // Host StatusHost Status

GustiloGustiloTypeType

NormalNormalHostHost

ImpairedImpairedHostHost

SevereSevereCompromisedCompromised

II NoNo NoNo YesYes

IIII NoNo YesYes YesYes

IIIAIIIA NoNo YesYes YesYes

IIIBIIIB YesYes YesYes YesYes

IIICIIIC YesYes YesYes YesYes

HBOTHBOT – – MESS / HostMESS / Host StatusStatus

MESSMESS

ScoreScore

NormalNormal

HostHost

ImpairedImpaired

HostHost

SevereSevere

CompromisedCompromised

77 (?(?88)) YesYes AmputateAmputate AmputateAmputate

55 – – 66 NoNo YesYes Yes (?amp)Yes (?amp)

33 – – 44 NoNo NoNo YesYes

HBOT in The Management of HBOT in The Management of

Crush Injuries : A RandomizedCrush Injuries : A Randomized

DoubleDouble--Blind PlaceboBlind Placebo--ControlledControlled

Clinical TrialClinical TrialG.G. BouachourBouachour et al.et al.

3636 patients with crush injuriespatients with crush injuries

Blinded randomization after surgeryBlinded randomization after surgery

HBOHBO 22..55 ATA ,ATA , 9090 min , BIDmin , BID

AirAir 11 ATA ,ATA , 9090 min , BIDmin , BID

Anticoagulant , antibiotics , dressingsAnticoagulant , antibiotics , dressings

standardizedstandardized

TCOMs , Bilateral Perfusion Index (BPI)TCOMs , Bilateral Perfusion Index (BPI)

Fractures (Fractures (BouachourBouachour))

HBOHBO AirAir

TibiaTibia 99 88

MetatarsalsMetatarsals 33 22

Radius / UlnaRadius / Ulna 11 11

MetacarpalsMetacarpals – – 11


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Clinical Data (Clinical Data (BouachourBouachour))

Soft Tissue InjuriesSoft Tissue Injuries

GradeGrade HBO (HBO (1818)) Air (Air (1818))

IIII 44 77

III AIII A 99 88

III BIII B 33 33

III CIII C 22 00

Outcome (Outcome (BouachourBouachour))

HBO (HBO (1818)) Air (Air (1818))

Complete healingComplete healing 1717 1010

Tissue necrosisTissue necrosis 11 88

AdditionalAdditionalproceduresprocedures

11 66

AmputationAmputation 00 22

Time to healing (d)Time to healing (d) 5050..22 5555..88

Outcomes (Outcomes (BouachourBouachour))

Patients < 40 years oldPatients < 40 years old

HBOHBO HBOHBO AirAir AirAir

TissueTissue InjuryInjury IIII IIIIII IIII IIIIII

SuccessSuccess 22 66 33 11

FailureFailure 00 00 00 00

Outcomes (Outcomes (BouachourBouachour))

Patients > 40 years oldPatients > 40 years old

HBOHBO HBOHBO AirAir AirAir

TissueTissue InjuryInjury IIII IIIIII IIII IIIIII

SuccessSuccess 22 77 33 33

FailureFailure 00 11 11 77

BouachourBouachour

HBO is indicated as an adjunctive therapyHBO is indicated as an adjunctive therapy

in the treatment of severe crush injuriesin the treatment of severe crush injuries

(grade III) in patients over the age of (grade III) in patients over the age of

40 years.40 years.

Criteria for using HBOTCriteria for using HBOT

in Compartment Syndromein Compartment Syndrome


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11. Suspected Stage. Suspected Stage

22.. Impending Stage (Lag Phase)Impending Stage (Lag Phase)

33.. Established StageEstablished Stage

Compartment Syndrome ;Compartment Syndrome ; 33 stagesstages Recommendations for HBORecommendations for HBO


Clinical Findings (Clinical Findings (33))

Pain in the muscle compartmentPain in the muscle compartment

Discomfort with passive stretchDiscomfort with passive stretch

Swelling in / fullness feeling of compartmentSwelling in / fullness feeling of compartment

HypesthesiaHypesthesia and / or muscle weaknessand / or muscle weakness

Recommendations for HBORecommendations for HBO


Clinical Findings (Clinical Findings (33))

Impaired or marginal hostImpaired or marginal host

MyelopathyMyelopathy and / or neuropathyand / or neuropathy

HypotensionHypotension

Prolonged (>Prolonged (> 66 hr) ischemia timehr) ischemia time

Recommendations for HBORecommendations for HBO


Pressure Measurements (Pressure Measurements (11))

Increasing serial pressure measurementsIncreasing serial pressure measurements

Up to 40 mmHgUp to 40 mmHg – – Healthy hostHealthy host

3030 – – 40 mmHg40 mmHg – – Impaired hostImpaired host

2020 – – 30 mmHg30 mmHg – – Marginal orMarginal or shockyshocky hosthost

Recommendations for HBORecommendations for HBOin Compartment Syndromein Compartment Syndrome

Established StageEstablished Stage

(Post(Post – – fasciotomyfasciotomy) () (11))

Residual ischemic muscleResidual ischemic muscle

Viable vs. nonviable demarcation unclearViable vs. nonviable demarcation unclear

Threatened skin flap or graftThreatened skin flap or graft

Residual neuropathyResidual neuropathy

Recommendations for HBORecommendations for HBOin Compartment Syndromein Compartment Syndrome

Established StageEstablished Stage

(Post(Post – – fasciotomyfasciotomy) () (11))

Massive swellingMassive swelling

Impaired or marginal hostImpaired or marginal host

Prolonged (> 6 hr) ischemia timeProlonged (> 6 hr) ischemia time


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HBOT ProtocolsHBOT Protocols

CrushCrush Injuries / ATPIsInjuries / ATPIs

HBO Committee ReportHBO Committee Report

2.02.0 – – 2.5 ATA ; 902.5 ATA ; 90 – – 120 min120 min

TID (2d) , BID (2d) , Daily (2TID (2d) , BID (2d) , Daily (2d)d)

Hyperbaric oxygen therapy in no wayHyperbaric oxygen therapy in no way

supercedessupercedes the surgical principles forthe surgical principles for

management of crushmanagement of crush injuries / ATPIsinjuries / ATPIs

HOWEVER , if surgical intervention isHOWEVER , if surgical intervention is

going to be delayed , there may begoing to be delayed , there may be

benefit (in theory at least) to treatmentbenefit (in theory at least) to treatment

with HBO while awaiting surgerywith HBO while awaiting surgery

The End The End

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Crush Injuries