Mortality and Morbidity

Edward Mavashev, MDDepartment of SurgeryLutheran Medical CenterSUNY Downstate

History of Present IllnessThe patient is a xx-year-old man

with long history of IVDA and Xanax abuse

Passed out on the floor and remained

laying on the left side for over 12 hours.

Brought in by EMS after the

patient was discovered by a relative

On presentation the patient is A&Ox2, with GCS 14.

Reporting numbness & weakness of the LUE and LLE.

Denies CP, SOB, abdominal pain

Past Medical History

Medical History IVDASchizophreniaHepatitis (HBV,HCV)

Surgical HistoryNone

Social History Lives alone in a private house

MedicationsUnknown

AllergiesNKDA

Physical ExamTm 97 BP 130/70 HR 80 RR 26 O2Sat 88% -> 97%Neuro: A&Ox2; GCS14HEENT: PERRLA, EOMI, Lt. eye ecchymosis, m/m dry,

hemotympany, abrasion & blister @ Lt. foreheadNeck: supple; no C-spine tenderness; trachea midlineChest: good air entry bilaterallyCV: RRRAbd: +BS, soft, NT, NDBack: no TLS tendernessRectal: good tone; no gross blood; prostate wnl

Physical ExamSkin: blisters/abrasions at L. forehead, L. chest, L.

forearm, and L. knee & leg.Extremities

LUE: tense forearm, pain on passive extension of fingers & wrist, no movement of fingers, no palpable radial pulse; no feeling in L. hand, decreased ROM of forearm.LLE: tense calf, pain on dorsiflexion of the foot, decreased DP, able to move toes.RUE & RLE wnl

EKG: NSR FAST: negative

Laboratory Values19 133 98 51 CPK – 58,000

23 296 100 Myog – 8,50056 8.1 20 3.3 Trop – 3.2

3.5 434 55 1.1 12

2.2 1505 0.1 24

ABG: 7.27/ 33/ 88/ 15/ -11/ 95%

Fibrinogen – 407 UA: Orange, pH 6.5, Hg 4+, RBC 0

Imaging

X-rays:C-spine, CXR, Pelvis, LUE, & LLE – negative

CT:Head, C-spine, abd/pelvis – negative

Hospital Course

Emergent LUE & LLE fasciotomy

Volar compartment dusky

No muscle contraction upon stimulation w/ bovie

Postop: dopplerable DP/PT & radial pulses

HD#2: Intubated, ARF (UO-50cc/24hrs), acidosis,

on HCO3 drip, dialysis.

HD#4: Extubated; Pain in LUE/LLE;

Motor: L. forearm/LLE 3/5, L.hand/wrist 0/5,

no sensation in L. forearm/hand; BUN/Cr – 74/5.7, K - 5.3

Hospital CourseHD#5: OR for 2nd look and debridement of volar comp.

BUN/Cr – 191/6.9, UO – 200/24hr; HD; WBC - 22HD#9: OR for debridement of LUE wound; HD; WBC – 44

Patient refusing amputationHD#14: OR for L. forearm amputationHD#16: WBC – 19; BUN/Cr – 50/4.8; UO – 1000/24hrs

OR for closure of LLE woundHD#20: WBC – 8.6; BUN/Cr – 20/1.3; UO – wnl

LUE & LLE wounds healing wellHD#22: the patient discharged

Crush Injury of Upper Extremities

Edward Mavashev, MDDepartment of SurgeryLutheran Medical CenterSUNY Downstate

Natural History

Hypotention

Circulatory shock

Edema of the muscular compartment

Acute myoglobinuric renal failure

Death

Causes of MortalityImmediate

Severe head injuryTraumatic asphyxiaTorso injury with damage tointrathoracic or intra-abdominal organs

EarlyHyperkalemiaHypovolemia/shock

LateRenal failureCoagulopathy & hemorrhageSepsis

Pathophysiology

Direct muscle cell injuryCells and sarcolemmal membranes start to leak

Myoglobin, urate, & phosphate – nephrotoxicHypocalcemia & hyperkalemia – cardiotoxicityNa and H2O movement into the cells

Muscle swelling and intravascular volume depletionHypovolemic shock

Failure of Na/K ATPaseHypoperfusion => hypoxia => decreased ATP=>

failure of Na/K ATPase & sarcolemma leakage

Pathophysiology

Pathophysiology

Cardiac InstabilityMassive fluid shift into muscle

Depletion of intravascular volumeHypovolemic shock

Blood lossDirect toxicity

Hyperkalemia & hypocalcemia

Other factors

Pathophysiology

Renal FailureIntravascular volume depletion

Vasoconstriction of afferent a.Cortical ischemia

Tubular obstructionMyoglobin, urate, & PO4 precipitation

Cast formation in DCT

Direct oxidant injury by myoglobin

Indicators of Severity

Peak CPKMost sensitive indicatorCorrelates well with ARF & mortality

Both are increased with CPK>75,000CPK >20,000 requires treatment and critical care monitoring

Number of crushed limbsMore practical and immediate estimateOne extremity ~ CK 50,000Incidence of ARF vs. number of effected limbs

One limb (50%); two (75%); three (100%)

Approach to ManagementInitial Assessment

Primary survey – assess ABCs

Control bleeding from the injured extremity

Diagnostic evaluation of other injuries

(FAST/CT)

Fluid resuscitation and UO monitoring

Lytes, ABG, and muscle enzyme

CVP and a-line should be considered

Fluid ManagementType

0.9% NS – fluid of choiceTheoretical disadvantage of fluid with K+

QuantitySubject of much debate Large quantity sequestered

12L/48hrs for 75kg man

Invasive monitoring (i.e CVP)

Fluid Management

AlkalinizationIncreases solubility of myoglobin Promotes its excretionMay prevent oxidative damage

RecommendationsUrine pH measured and kept >6.5Fluid (i.e. 1/2NS+40meqNaHCO3)

Mannitol Diuresis

Compartment Syndrome

SymptomsPain

Out of proportion to injury

With passive range of motion

Numbness

Paresthesias

Weakness

Compartment Syndrome

SignsPallorAltered perfusion

Diminished pulsesAltered capillary refill

Pain on passive muscle stretch Palpable fullness or tenderness of a compartmentAltered sensibilityMuscle weakness

Brachial Compartment

Compartment Syndrome

Compartment Syndrome

Diagnosis

Compartment Syndrome

Management l

Traditional treatmentFasciotomy

High complication rateHemorrhageSepsis

Conservative treatmentMannitol

Complication rate - unknown

Operative Intervention

General PrinciplesLongitudinal exposuresComplete fasciotomyCareful muscle & nerve inspecitonExcision of necrotic muscleMeasurement of tissue pressures following decompressionLeave the skin open (initially)Splint the hand in a functional position

Forearm Compartments

Volar Forearm Fasciotomy

Henry Fasciotomy

Volar Forearm Fasciotomy

Henry Fasciotomy

Interval closure

Volar Forearm Fasciotomy

UE: Salvage vs Amputation

26-year-old s/p crush injury.Fx of radius, ulna, metacarpalsSkin loss at axilla, elbow, & palmOcclusion of 10cm seg of brach art.

Injured deep and superficial arterial arches (no blood flow in the fingertips)Crush injury to flexor muscles.

UE: Salvage vs Amputation

Salvage IndicesLange, et al 1985 – first protocol of absolute and relative

indications for primary amputation of tibial fracture

Salvage Indices:MESI – Mangled Extremity Syndrome IndexPSI – Predictive Salvage IndexMESS – Mangled Extremity Severity ScoreLSI – Limb salvage IndexNISSSA – Nerve Injury, Ischemia, Soft-Tissue Injury,

Skeletal Injury, Shock, & Age of Patient Score

UE: Salvage vs Amputation

Salvage IndicesProblems

Algorithms based on small retrospective studiesResults have not been duplicatedBased on studies of lower extremity injuries

LSI & PSI applicable only to lower extremities

Complex and difficult to applyNo measure of functional outcome

UE: Salvage vs AmputationMangled Extremity Severity Score (MESS)

UE: Salvage vs AmputationValidity of MESS in Upper Extremity

Retrospective review of 23 patients

Actual Predicted N N

Primary amputation 11 11Delayed amputation 3 3Limb salvage 9 8

PPV – 100% NPV – 60%

The American Journal of Surgery, V172, 1996

Procedure:ORIF of ulna and radiusDebridement on non-viable muscle & tissueBrachial artery bypassPalmar arch reconstruction with vein graftArterial pedicle skin flaps and STSGAdditional reconstructive surgery

Outcome:The limb can be used effectively in day to day activity

Journal of Bone and Joint Surgery, 2005

UE: Salvage vs Amputation

UE: Salvage vs AmputationConsiderations in UE Salvage

No guidelines for UE as limb salvage literature focuses on the LE.MESS can only be used as rough estimateUE loss has a greater impact on function than LE loss.The UE tolerates shortening. The UE has better reconstruction options than LE

much better results with nerve repair and nerve grafting, tendontransfers.

consider an initial salvage attempt, observation, and subsequent early secondary amputation.

maintain clear goals and communication with the patient and familyamputation may be necessary at any time during the salvage attemptamputation is not failure.