The Mangled Extremity: Best Practice for Optimal Outcomes. Kristen Ray R.N., MSN
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2 The Mangled Extremity: Best Practice for Optimal Outcomes Kristen Ray R.N., MSN
3 Learning Objectives At the end of the session, participants will be able to: Verbalize the initial management principles and priorities for a patient with a mangled extremity. Discuss the importance of post operative vascular assessments in relation to normal and abnormal findings. Define two optimal functional outcomes for the patient with a mangled extremity.
4 Disclosure Statement I, Kristen Ray R.N., MSN disclose no conflict of interest relative to this educational activity.
5 Successful Completion To successfully complete this course, participants must attend the entire event and complete/submit the evaluation at the end of the session. Society of Trauma Nurses is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.
6 What is a Mangled Extremity?
7 What is a mangled extremity? Four functional structures of an extremity Nerves Vessels Bones Soft Tissues Definition: Injury to three of these four elements (Cannon& et al., 2012)
8
9 Causes of a Mangled Extremity Blunt Trauma Motor Vehicle Crashes Leading Causes MCC, Ped Strucks Industrial Machinery Farm Falls from Heights High- Velocity Gunshots Explosion/ Blast Injuries (Bongiovanni, Bradley & Kelley, 2005)
10 The Managed Extremity: Before the Patient Arrives
11 Prehospital Information Mechanism of Injury How did it happen? Was it High or Low energy? How did patient look during injury and after? What was the environment? Industrial, MVA, etc. Weather (Walsh,2009)(Prasarn, Helfet & Kloen, 2012)
12 Prehospital Information How long was did it take to access patient? Time is Tissue Pulses/ movement/ sensation in the extremity? Tourniquet in place? What time went on Permissive Hypotension for transport..
13 Preparing for patient arrival Warm blankets, fluid and blood available Pain Management Anesthesia at bedside ready to intubate OR tourniquets..
14 The Initial Management
15 What's First? Remember ABC s Don t get distracted by outward injuries Get information from patient PMHX, Medications Last PO Family contact Don t be fooled by distracting injuries!!
16 Initial Management Airway Breathing Circulation Warm blood or fluid Blood preferred over fluid Warm patient Even in summer use warming techniques LIFE OVER LIMB (Prasarn, Helfet &Kloen, 2012)
17 Initial Management: Control Hemorrhage EMS tourniquet Time on Time off OR tourniquets Time inflate Note any time taken down for pulse check or bleeding check Note amount of pressure Different from Limb Occlusion Pressure (McEwen, 2015)
18 Initial Management: OR Tourniquets Continued Common Complications Nerve Post- tourniquet syndrome Long term post-operative swelling Compartment Syndrome Pressure Sores Kerlix, then mesh covering Further Necrosis 6 hour perfusion time (Fryberg & Schinco, 2008) Thrombosis (McEwen, 2015)
19 The Initial Management Medication Pain and Sedation Large amounts.. Watch airway. Antibiotics Ancef 2 grams Tetanus (Frykberg & Schinco, 2008)
20 Documentation, Documentation!!! Pulses on arrival Doppler Detailed description of extremity Don t just state mangled Time tourniquet went up Anytime take down to check pulses Movement and Sensation Photos are highly recommended Get consent!!! (Prasarn, Helfet &Kloen, 2012)
21 The Managed Extremity: Surgical Management
22 Surgical Management Damage Control Surgery For life-threating bleeding in abdomen and chest LIFE OVER LIMB Reduction and stabilization for limb by splinting Amputation vs Limb Salvage Definitive control of bleeding Vascular ligation or vascular shunt placement (Prasarn, Helfet &Kloen, 2012)(Cannon et al, 2013)
23 Surgical Management Amputation Mangled Extremity Severity Score (MESS) A form of guidelines recreated in 1990 s 4 variables: Skeletal/ soft tissue injury Limb ischemia Shock Patient Age Score 7 or greater Amputation Weakness of Study Self-fulfilling nature inherent (Higgins, Klatt & Beals, 2010)
24 Surgical Management Amputation Risk Factors: MESS score 7 Gustilo III-C injury Comminuted, open tib-fib fx with vascular disruption Sciatic or tibial nerve, or 2 out of 3 upper extremity nerves transected Prolonged ischemia 4-6 hours Crush or destructive soft tissue injury Significant wound infection Multiple/ severely comminuted fx s/ segmental bones Old age/ severe comorbidities Lower versus Upper extremity Unable to re vascularize due to injury or failure of re vascularization (Higgins, Klatt & Beals, 2010)
25 (ACS, 2005) & (Scalea et al., 2011)
26 Don t Close Traumatic Amputations!!
27 Surgical Management Limb Salvage Debridement and removal of tissue Quick stabilization of fractures External Fixator placement Temporary closure Gauze Negative pressure dressing Antibiotic Beads (Cannon et al, 2013)
28 Surgical Management
29 Post- Operative Considerations LIFE OVER LIMB!!! Continued Resuscitation Neurovascular Checks Skin temperature Color Capillary refill Palpable Pulses If vascular repair may not be able to palpate right away Doppler Signs & Symptoms of infection Signs of Compartment Syndrome Think above area of injury too Pain Management Education & support Patient and Family (Frykberg & Schinco, 2008)
30 Complications Continued Hemorrhage Fat Embolism Pulmonary Embolism Compartment Syndrome Infection DVT Rhabdomyolysis Many operations with either amputation or limb salvage Physiological hardship Depression Thoughts of suicide (Frykberg & Schinco, 2008) (Cannon et al., 2013)
31 Outcomes of Amputation vs Limb Salvage
32 LEAP vs METAL Studies
33 High Energy Limb-Threatening Lower Extremity Injuries (LEAP) Prospective, Observational NIH funded About $6 Million 8 Level 1 trauma Centers 601 Patients 51 Traumatic Amputations 128 Immediate & delayed amputations 422 Hospital Reconstructions 26 late amputations 24 months followed patient
34 LEAP Study Sickness Impact Profile (SIP) Morbidity and complications Impairment/ functional Limitations Quality of Life Satisfaction scoring Direct / Indirect Cost High SIP rate factors Hospitalization Low education Nonwhite race Poverty No Health Insurance Poor Social Support Poor Self Efficacy Smoking Involvement with Litigation (O Toole, 2015)
35 LEAP Study. Patient Demographics Poor 38% No Health Insurance 25% Below Poverty Line Education 70% High School Grads Substance Abuse 2 times National Average as Heavy Drinkers Personality Differences Less Agreeable (MacKenzie, et al., 2000)
36 LEAP Study Outcomes No difference in: Return to Work- no change in 7 years Amps 53% Recon 49% SIP Amp Recon Rehospitalization 34% 48% Osteomyelitis 3% 9% More Surgery 5% 19% Cost Lifetime Salvage: $163k Amps: $509k Patient Satisfaction Function, Pain and Depression 7 years Limb Salvage better outcome (O Toole, 2015) (Prasan, Helfet & Kloen, 2011)
37 The Military Extremity Trauma Amputation/ Limb Salvage Study (METALS) 324 Service members deployed to Afghanistan or Iraq 87.9% Blast Injuries Higher amount of amputations Less available multi-disciplinary surgical team available First Surgical Intervention Role 3 combat hospital Trauma Bay with surgeons, OR, some x-ray (Doukas et al., 2013)
38 METALS Study No Difference: Patient Satisfaction between amps/ salvage SIP Far Less Rehospitalization Reoperations Received Earlier rehabilitations and Prosthetics Patient population Young Support (Doukas et al., 2013)
39 LEAP vs MEATALS Same Conclusion: No difference in Patient Contrast: Return to work Late Complications Rehospitalization All Amputations from METALS patients received Prosthesis METALS: no discussion of cost LEAP : Difficult population due to many factors Which Is Right???
40 In Conclusion Remember: ABC s LIFE OVER LIMB Tourniquets Documentation Damage Control Surgery Amputation vs Limb Salvage LIFE OVER LIMB
41 In Conclusion Post Operative Concerns Neurovascular Checks May have delay in palpable pulse if vascular repair Skin color, temperature and cap refill Complications Compartment syndrome Infection Intervene early!!
42 In Conclusion Amputation vs Limb Salvage Research still unclear Many algorithms available May or may not be helpful Look at patient demographics What are changes of getting a prosthesis? Communication and Education with patient and family
43 Special Thanks To: Ellen Plummer R.N., MSN, MBA, D.L., M.J., CCRN Lynn Gerber-Smith R.N., MS Diana Clapp RN, BSN, NREMT-P Robert V. O Toole M.D.
44 References:
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