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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
Severity of Crush InjuriesSeverity of Crush Injuries
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
Severity of Crush InjuriesSeverity of Crush Injuries
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
in Compartment Syndromein Compartment Syndrome
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
in Compartment Syndromein Compartment Syndrome
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
in Compartment Syndromein Compartment Syndrome
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