2021 Trauma/Critical Care Presentations

HK Sadeesh Niroshan, MBBS1; Rathnayaka M K D Gunasingha, MD2; Achala Jayathilake, PhD3; Tamara Worlton, MD, FACS2; Amila Rathnayake, MBBS4; 1Colombo North Teaching Hospital, Ragama, Sri Lanka; 2Walter Reed National Military Medical Center; 3Postgraduate Institute of Medicine, University of Colombo; 4Sri Lanka Army Hospital Narahenpita

Introduction: Performance of a fasciotomy in a combat surgical setting is challenging due to the uncertain tactical situation, a scarcity of resources, segregated echelon care, delay in casualty evacuation and transfer, and potential for devastating soft tissue trauma. Hence, it is recommended to keep a low threshold to proceed with both therapeutic and prophylactic extremity fasciotomy in the combat setting. Though it is a crucial point in decision making, only a few publications in literature have aimed to identify variables to be used in upfront decision-making in combat limb fasciotomy to aid combat surgeons in choosing limbs for fasciotomy while sparing others from the undue morbidity of a large wound. The aim of this study was to identify specific injury profiles in combat trauma and the risk factors for those which indicated the need for fasciotomy.

Method: Extremity vascular injuries were identified from a prospectively collected single surgeon trauma registry. The anatomy of the injury, the number of limbs that underwent fasciotomy, the location where the fasciotomy was completed (Role 2 or Role 3 military hospital), and outcome in terms of early limb salvage and hospital length of stay (LOS) were noted.  Appropriate parametric and non-parametric tests were used for statistical analysis.

Results: Eighty-one extremity vascular injuries were identified, of which 22 involved upper extremities, 23 were above the adductor hiatus, and 36 were below the adductor hiatus. The average delay in transfer to a higher level of care was 300 minutes (225 to 405 minutes). Analysis of injury variables revealed, zonal anatomy below the adductor hiatus (p <0.0002) and high ischemic grade (p<0.04) as indicators for fasciotomy. Associated fractures, severe arterial injury, associated venous injury and blood transfusion did not reach significance as indicators.  Fasciotomies below the adductor hiatus accounted for the majority of field (33%) and hospital (61%) fasciotomies, followed by upper limb fasciotomies (27%, 45%) and those above the adductor hiatus (43%, 13%).

Amputation rates were significantly different among hospital (36%), field (10%), and no fasciotomy (6%) cohorts (p <0.007). LOS was significantly longer in those who underwent hospital fasciotomies (30 days) compared to field (16 days) and no (7 days) fasciotomy cohorts (p<0.002).

Conclusion: Despite the inherent morbidity, early fasciotomy has a proven outcome benefit. The use of algorithms with emphasis to wound anatomy and ischemic grade is of value. Further research is needed to substantiate variables predicting the development of compartment syndrome.