Acute Traumatic Ischemia

Crush Injuries
And Acute Traumatic
Ischemia

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

Gustilo Classification
TYPE
I
II

Mechanism
Small (<1
(<1cm) laceration
Inside to outside
Large laceration, minimal
soft tissue damage

III

Crush Injuries

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%
%
Complications50
Complications
50%
%
Complications50
Complications
50%
%

Mangled Extremity Severity Score

MESS Johansen
LIMB ISCHEMIA

POINTS

Mangled Extremity Severity Score

MESS Johansen
SKELETAL / SOFT TISSUE

POINTS

Low Energy (Stab , Simple Fx

Fx))

Medium Energy (Open , multiple Fx

Fx))

High Energy (Crush , High velocity GSW)

Very High Energy ( Above +

contamination, soft tissue avulsion)

Mangled Extremity Severity Score

MESS Johansen
SHOCK

POINTS

Perfusion normal

Systolic BP always > 90 mm/Hg

Pulse reduced / Perfusion present

Transient hypotension

Pulseless / Paresthesia

Persistent hypotension

Cool / Paralyzed / Insensate

Mangled Extremity Severity Score

MESS Johansen
AGE

POINTS

< 30

30 50

> 50

MESS (Johansen)
Double ischemia score if ischemia time
greater than six hours
Recommend primary amputation if
MESS score 7 or greater

Scoring Criteria

2 points
1 points 0 points
Age
< 40
40 60
> 60
Score; Host
Ambulation Community Household None
8-10 ;
Normal
Smoking /
None
Past
Current 4-7 ;
Steroids
Impaired
Cardiac /
Compen-- Decomp
Normal Compen
Decomp.. 0-3 ;
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

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. Hyperoxygenation
2. Vasoconstriction
3. Reperfusion
4. Host factors
5. Red Blood Cell Deformability

Hyperbaric OxygenOxygen-100
100%
% @ 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

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

56

No

Yes

Yes (?amp)

34

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. Bouachour et al.

Fractures (Bouachour
(Bouachour))

Blinded randomization after surgery

HBO 2.5 ATA , 90 min , BID
Air 1 ATA , 90 min , BID

HBO

Air

Tibia

Anticoagulant , antibiotics , dressings

standardized

Metatarsals

Radius / Ulna

TCOMs , Bilateral Perfusion Index (BPI)

Metacarpals

Outcome (Bouachour
(Bouachour))

Clinical Data (Bouachour

(Bouachour))

HBO (18
(18))

Air (18
(18))

Complete healing

17

10

Tissue necrosis

III B

Additional
procedures

III C

Amputation

50..2
50

55..8
55

Soft Tissue Injuries

Grade

HBO (18
(18))

Air (18
(18))

II

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

Success

Failure

Failure

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.

Criteria for using HBOT

in Compartment Syndrome

Compartment Syndrome ; 3 stages

1. Suspected Stage
2. Impending Stage (Lag Phase)
3. 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. 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

HBOT Protocols
Crush Injuries / ATPIs
HBO Committee Report
2.0 2.5 ATA ; 90 120 min
TID (2d) , BID (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 , there may be
benefit (in theory at least) to treatment
with HBO while awaiting surgery

The End