Mortality and Morbidity. Edward Mavashev, MD Department of Surgery Lutheran Medical Center SUNY Downstate
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1 Mortality and Morbidity Edward Mavashev, MD Department of Surgery Lutheran Medical Center SUNY Downstate
2 History of Present Illness The 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
3 Past Medical History Medical History IVDA Schizophrenia Hepatitis (HBV,HCV) Surgical History None Social History Lives alone in a private house Medications Unknown Allergies NKDA
4 Physical Exam Tm 97 BP 130/70 HR 80 RR 26 O 2 Sat 88% -> 97% Neuro: A&Ox2; GCS14 HEENT: PERRLA, EOMI, Lt. eye ecchymosis, m/m dry, hemotympany, abrasion & Lt. forehead Neck: supple; no C-spine tenderness; trachea midline Chest: good air entry bilaterally CV: RRR Abd: +BS, soft, NT, ND Back: no TLS tenderness Rectal: good tone; no gross blood; prostate wnl
5 Physical Exam Skin: 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
6 Laboratory Values CPK 58, Myog 8, Trop ABG: 7.27/ 33/ 88/ 15/ -11/ 95% Fibrinogen 407 UA: Orange, ph 6.5, Hg 4+, RBC 0
7 Imaging X-rays: C-spine, CXR, Pelvis, LUE, & LLE negative CT: Head, C-spine, abd/pelvis negative
8 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 HCO 3 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
9 Hospital Course HD#5: OR for 2 nd look and debridement of volar comp. BUN/Cr 191/6.9, UO 200/24hr; HD; WBC - 22 HD#9: OR for debridement of LUE wound; HD; WBC 44 Patient refusing amputation HD#14: OR for L. forearm amputation HD#16: WBC 19; BUN/Cr 50/4.8; UO 1000/24hrs OR for closure of LLE wound HD#20: WBC 8.6; BUN/Cr 20/1.3; UO wnl LUE & LLE wounds healing well HD#22: the patient discharged
10 Crush Injury of Upper Extremities Edward Mavashev, MD Department of Surgery Lutheran Medical Center SUNY Downstate
11 Natural History Hypotention Circulatory shock Edema of the muscular compartment Acute myoglobinuric renal failure Death
12 Causes of Mortality Immediate Severe head injury Traumatic asphyxia Torso injury with damage to intrathoracic or intra-abdominal organs Early Hyperkalemia Hypovolemia/shock Late Renal failure Coagulopathy & hemorrhage Sepsis
13 Pathophysiology Direct muscle cell injury Cells and sarcolemmal membranes start to leak Myoglobin, urate, & phosphate nephrotoxic Hypocalcemia & hyperkalemia cardiotoxicity Na and H2O movement into the cells Muscle swelling and intravascular volume depletion Hypovolemic shock Failure of Na/K ATPase Hypoperfusion => hypoxia => decreased ATP=> failure of Na/K ATPase & sarcolemma leakage
14 Pathophysiology
15 Pathophysiology Cardiac Instability Massive fluid shift into muscle Depletion of intravascular volume Hypovolemic shock Blood loss Direct toxicity Hyperkalemia & hypocalcemia Other factors
16 Pathophysiology Renal Failure Intravascular volume depletion Vasoconstriction of afferent a. Cortical ischemia Tubular obstruction Myoglobin, urate, & PO 4 precipitation Cast formation in DCT Direct oxidant injury by myoglobin
17 Indicators of Severity Peak CPK Most sensitive indicator Correlates well with ARF & mortality Both are increased with CPK>75,000 CPK >20,000 requires treatment and critical care monitoring Number of crushed limbs More practical and immediate estimate One extremity ~ CK 50,000 Incidence of ARF vs. number of effected limbs One limb (50%); two (75%); three (100%)
18 Approach to Management Initial 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
19 Fluid Management Type Quantity 0.9% NS fluid of choice Theoretical disadvantage of fluid with K + Subject of much debate Large quantity sequestered 12L/48hrs for 75kg man Invasive monitoring (i.e CVP)
20 Fluid Management Alkalinization Increases solubility of myoglobin Promotes its excretion May prevent oxidative damage Recommendations Urine ph measured and kept >6.5 Fluid (i.e. 1/2NS+40meqNaHCO3)
21 Mannitol Diuresis
22 Compartment Syndrome Symptoms Pain Out of proportion to injury With passive range of motion Numbness Paresthesias Weakness
23 Compartment Syndrome Signs Pallor Altered perfusion Diminished pulses Altered capillary refill Pain on passive muscle stretch Palpable fullness or tenderness of a compartment Altered sensibility Muscle weakness
24 Brachial Compartment
25 Compartment Syndrome
26 Compartment Syndrome Diagnosis
27 Compartment Syndrome Management l Traditional treatment Fasciotomy High complication rate Hemorrhage Sepsis Conservative treatment Mannitol Complication rate - unknown
28 Operative Intervention General Principles Longitudinal exposures Complete fasciotomy Careful muscle & nerve inspeciton Excision of necrotic muscle Measurement of tissue pressures following decompression Leave the skin open (initially) Splint the hand in a functional position
29 Forearm Compartments
30 Volar Forearm Fasciotomy Henry Fasciotomy
31 Volar Forearm Fasciotomy Henry Fasciotomy Interval closure
32 Volar Forearm Fasciotomy
33
34 UE: Salvage vs Amputation 26-year-old s/p crush injury. Fx of radius, ulna, metacarpals Skin loss at axilla, elbow, & palm Occlusion of 10cm seg of brach art. Injured deep and superficial arterial arches (no blood flow in the fingertips) Crush injury to flexor muscles.
35 UE: Salvage vs Amputation Salvage Indices Lange, et al 1985 first protocol of absolute and relative indications for primary amputation of tibial fracture Salvage Indices: MESI Mangled Extremity Syndrome Index PSI Predictive Salvage Index MESS Mangled Extremity Severity Score LSI Limb salvage Index NISSSA Nerve Injury, Ischemia, Soft-Tissue Injury, Skeletal Injury, Shock, & Age of Patient Score
36
37 UE: Salvage vs Amputation Salvage Indices Problems Algorithms based on small retrospective studies Results have not been duplicated Based on studies of lower extremity injuries LSI & PSI applicable only to lower extremities Complex and difficult to apply No measure of functional outcome
38 UE: Salvage vs Amputation Mangled Extremity Severity Score (MESS)
39 UE: Salvage vs Amputation Validity of MESS in Upper Extremity Retrospective review of 23 patients Actual Predicted N N Primary amputation Delayed amputation 3 3 Limb salvage 9 8 PPV 100% NPV 60% The American Journal of Surgery, V172, 1996
40 UE: Salvage vs Amputation Procedure: ORIF of ulna and radius Debridement on non-viable muscle & tissue Brachial artery bypass Palmar arch reconstruction with vein graft Arterial pedicle skin flaps and STSG Additional reconstructive surgery Outcome: The limb can be used effectively in day to day activity Journal of Bone and Joint Surgery, 2005
41 UE: Salvage vs Amputation Considerations in UE Salvage No guidelines for UE as limb salvage literature focuses on the LE. MESS can only be used as rough estimate UE 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, tendon transfers. consider an initial salvage attempt, observation, and subsequent early secondary amputation. maintain clear goals and communication with the patient and family amputation may be necessary at any time during the salvage attempt amputation is not failure.
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