Mortality and Morbidity
Edward Mavashev, MD
Department of Surgery
Lutheran Medical Center
SUNY Downstate
History of Present Illness
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The patient is a xx-year-old man
with long history of IVDA and Xanax abuse
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Passed out on the floor and remained
laying on the left side for over 12 hours.
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Brought in by EMS after the
patient was discovered by a relative
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On presentation the patient is A&Ox2, with GCS 14.
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Reporting numbness & weakness of the LUE and LLE.
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Denies CP, SOB, abdominal pain
Past Medical History
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Medical History
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IVDA
Schizophrenia
Hepatitis (HBV,HCV)
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Social History
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Medications
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Surgical History
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None
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Lives alone in a
private house
Unknown
Allergies
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NKDA
Physical Exam
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Tm 97 BP 130/70 HR 80 RR 26 O2Sat 88% -> 97%
Neuro: A&Ox2; GCS14
HEENT: PERRLA, EOMI, Lt. eye ecchymosis, m/m dry,
hemotympany, abrasion & blister @ 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
Physical Exam
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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.
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LLE: tense calf, pain on dorsiflexion of the foot,
decreased DP, able to move toes.
RUE & RLE wnl
EKG: NSR
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FAST: negative
Laboratory Values
23
3.5
2.2
19
56
434
296
55
1505 0.1
133
8.1
98
51
100
20 3.3
CPK – 58,000
Myog – 8,500
Trop – 3.2
1.1 12
24
ABG: 7.27/ 33/ 88/ 15/ -11/ 95%
Fibrinogen – 407
UA: Orange, pH 6.5, Hg 4+, RBC 0
Imaging
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X-rays:
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C-spine, CXR, Pelvis, LUE, & LLE – negative
CT:
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Head, C-spine, abd/pelvis – negative
Hospital Course
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Emergent LUE & LLE fasciotomy
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Volar compartment dusky
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No muscle contraction upon stimulation w/ bovie
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Postop: dopplerable DP/PT & radial pulses
HD#2: Intubated, ARF (UO-50cc/24hrs), acidosis,
on HCO3 drip, dialysis.
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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 Course
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HD#5: OR for 2nd 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
Crush Injury of Upper Extremities
Edward Mavashev, MD
Department of Surgery
Lutheran Medical Center
SUNY Downstate
Natural History
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Hypotention
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Circulatory shock
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Edema of the muscular compartment
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Acute myoglobinuric renal failure
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Death
Causes of Mortality
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Immediate
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Early
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Severe head injury
Traumatic asphyxia
Torso injury with damage to
intrathoracic or intra-abdominal organs
Hyperkalemia
Hypovolemia/shock
Late
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Renal failure
Coagulopathy & hemorrhage
Sepsis
Pathophysiology
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Direct muscle cell injury
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Cells and sarcolemmal membranes start to leak
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Myoglobin, urate, & phosphate – nephrotoxic
Hypocalcemia & hyperkalemia – cardiotoxicity
Na and H2O movement into the cells
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Muscle swelling and intravascular volume depletion
Hypovolemic shock
Failure of Na/K ATPase
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Hypoperfusion => hypoxia => decreased ATP=>
failure of Na/K ATPase & sarcolemma leakage
Pathophysiology
Pathophysiology
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Cardiac Instability
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Massive fluid shift into muscle
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Blood loss
Direct toxicity
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Depletion of intravascular volume
Hypovolemic shock
Hyperkalemia & hypocalcemia
Other factors
Pathophysiology
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Renal Failure
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Intravascular volume depletion
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Vasoconstriction of afferent a.
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Cortical ischemia
Tubular obstruction
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Myoglobin, urate, & PO4 precipitation
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Cast formation in DCT
Direct oxidant injury by myoglobin
Indicators of Severity
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Peak CPK
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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
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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%)
Approach to Management
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Initial Assessment
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Primary survey – assess ABCs
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Control bleeding from the injured extremity
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Diagnostic evaluation of other injuries
(FAST/CT)
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Fluid resuscitation and UO monitoring
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Lytes, ABG, and muscle enzyme
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CVP and a-line should be considered
Fluid Management
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Type
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0.9% NS – fluid of choice
Theoretical disadvantage
of fluid with K+
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Quantity
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Subject of much debate
Large quantity sequestered
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12L/48hrs for 75kg man
Invasive monitoring (i.e CVP)
Fluid Management
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Alkalinization
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Increases solubility of myoglobin
Promotes its excretion
May prevent oxidative damage
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Recommendations
Urine pH measured and kept >6.5
Fluid (i.e. 1/2NS+40meqNaHCO3)
Mannitol Diuresis
Compartment Syndrome
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Symptoms
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Pain
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Out of proportion to injury
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With passive range of motion
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Numbness
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Paresthesias
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Weakness
Compartment Syndrome
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Signs
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Pallor
Altered perfusion
„ Diminished pulses
„ Altered capillary refill
Pain on passive muscle stretch
Palpable fullness or tenderness of a compartment
Altered sensibility
Muscle weakness
Brachial Compartment
Compartment Syndrome
Compartment Syndrome
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Diagnosis
Compartment Syndrome
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Management l
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Traditional treatment
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Fasciotomy
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High complication rate
Hemorrhage
Sepsis
Conservative treatment
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Mannitol
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Complication rate - unknown
Operative Intervention
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General Principles
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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
Forearm Compartments
Volar Forearm Fasciotomy
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Henry Fasciotomy
Volar Forearm Fasciotomy
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Henry Fasciotomy
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Interval closure
Volar Forearm Fasciotomy
UE: Salvage vs Amputation
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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.
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Injured deep and superficial
arterial arches (no blood flow
in the fingertips)
Crush injury to flexor muscles.
UE: Salvage vs Amputation
Salvage Indices
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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
UE: Salvage vs Amputation
Salvage Indices
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Problems
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Algorithms based on small retrospective studies
Results have not been duplicated
Based on studies of lower extremity injuries
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LSI & PSI applicable only to lower extremities
Complex and difficult to apply
No measure of functional outcome
UE: Salvage vs Amputation
Mangled Extremity Severity Score (MESS)
UE: Salvage vs Amputation
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Validity of MESS in Upper Extremity
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Retrospective review of 23 patients
Actual
N
Primary amputation
11
Delayed amputation
3
Limb salvage
9
PPV – 100%
Predicted
N
11
3
8
NPV – 60%
The American Journal of Surgery, V172, 1996
UE: Salvage vs Amputation
Outcome:
Procedure:
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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
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The limb can be used
effectively in day to day
activity
Journal of Bone and Joint Surgery, 2005
UE: Salvage vs Amputation
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Considerations in UE Salvage
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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
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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
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amputation may be necessary at any time during the salvage attempt
amputation is not failure.