mortality and morbidity - suny downstate medical center · mortality and morbidity edward mavashev,...
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Mortality and Morbidity
Edward Mavashev, MDDepartment of SurgeryLutheran Medical CenterSUNY Downstate
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History of Present IllnessThe 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
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Past Medical History
Medical History IVDASchizophreniaHepatitis (HBV,HCV)
Surgical HistoryNone
Social History Lives alone in a private house
MedicationsUnknown
AllergiesNKDA
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Physical ExamTm 97 BP 130/70 HR 80 RR 26 O2Sat 88% -> 97%Neuro: A&Ox2; GCS14HEENT: PERRLA, EOMI, Lt. eye ecchymosis, m/m dry,
hemotympany, abrasion & blister @ Lt. foreheadNeck: supple; no C-spine tenderness; trachea midlineChest: good air entry bilaterallyCV: RRRAbd: +BS, soft, NT, NDBack: no TLS tendernessRectal: good tone; no gross blood; prostate wnl
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Physical ExamSkin: 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
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Laboratory Values19 133 98 51 CPK – 58,000
23 296 100 Myog – 8,50056 8.1 20 3.3 Trop – 3.2
3.5 434 55 1.1 12
2.2 1505 0.1 24
ABG: 7.27/ 33/ 88/ 15/ -11/ 95%
Fibrinogen – 407 UA: Orange, pH 6.5, Hg 4+, RBC 0
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Imaging
X-rays:C-spine, CXR, Pelvis, LUE, & LLE – negative
CT:Head, C-spine, abd/pelvis – negative
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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 HCO3 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
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Hospital CourseHD#5: OR for 2nd look and debridement of volar comp.
BUN/Cr – 191/6.9, UO – 200/24hr; HD; WBC - 22HD#9: OR for debridement of LUE wound; HD; WBC – 44
Patient refusing amputationHD#14: OR for L. forearm amputationHD#16: WBC – 19; BUN/Cr – 50/4.8; UO – 1000/24hrs
OR for closure of LLE woundHD#20: WBC – 8.6; BUN/Cr – 20/1.3; UO – wnl
LUE & LLE wounds healing wellHD#22: the patient discharged
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Crush Injury of Upper Extremities
Edward Mavashev, MDDepartment of SurgeryLutheran Medical CenterSUNY Downstate
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Natural History
Hypotention
Circulatory shock
Edema of the muscular compartment
Acute myoglobinuric renal failure
Death
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Causes of MortalityImmediate
Severe head injuryTraumatic asphyxiaTorso injury with damage tointrathoracic or intra-abdominal organs
EarlyHyperkalemiaHypovolemia/shock
LateRenal failureCoagulopathy & hemorrhageSepsis
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Pathophysiology
Direct muscle cell injuryCells and sarcolemmal membranes start to leak
Myoglobin, urate, & phosphate – nephrotoxicHypocalcemia & hyperkalemia – cardiotoxicityNa and H2O movement into the cells
Muscle swelling and intravascular volume depletionHypovolemic shock
Failure of Na/K ATPaseHypoperfusion => hypoxia => decreased ATP=>
failure of Na/K ATPase & sarcolemma leakage
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Pathophysiology
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Pathophysiology
Cardiac InstabilityMassive fluid shift into muscle
Depletion of intravascular volumeHypovolemic shock
Blood lossDirect toxicity
Hyperkalemia & hypocalcemia
Other factors
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Pathophysiology
Renal FailureIntravascular volume depletion
Vasoconstriction of afferent a.Cortical ischemia
Tubular obstructionMyoglobin, urate, & PO4 precipitation
Cast formation in DCT
Direct oxidant injury by myoglobin
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Indicators of Severity
Peak CPKMost sensitive indicatorCorrelates well with ARF & mortality
Both are increased with CPK>75,000CPK >20,000 requires treatment and critical care monitoring
Number of crushed limbsMore practical and immediate estimateOne extremity ~ CK 50,000Incidence of ARF vs. number of effected limbs
One limb (50%); two (75%); three (100%)
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Approach to ManagementInitial 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
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Fluid ManagementType
0.9% NS – fluid of choiceTheoretical disadvantage of fluid with K+
QuantitySubject of much debate Large quantity sequestered
12L/48hrs for 75kg man
Invasive monitoring (i.e CVP)
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Fluid Management
AlkalinizationIncreases solubility of myoglobin Promotes its excretionMay prevent oxidative damage
RecommendationsUrine pH measured and kept >6.5Fluid (i.e. 1/2NS+40meqNaHCO3)
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Mannitol Diuresis
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Compartment Syndrome
SymptomsPain
Out of proportion to injury
With passive range of motion
Numbness
Paresthesias
Weakness
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Compartment Syndrome
SignsPallorAltered perfusion
Diminished pulsesAltered capillary refill
Pain on passive muscle stretch Palpable fullness or tenderness of a compartmentAltered sensibilityMuscle weakness
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Brachial Compartment
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Compartment Syndrome
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Compartment Syndrome
Diagnosis
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Compartment Syndrome
Management l
Traditional treatmentFasciotomy
High complication rateHemorrhageSepsis
Conservative treatmentMannitol
Complication rate - unknown
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Operative Intervention
General PrinciplesLongitudinal exposuresComplete fasciotomyCareful muscle & nerve inspecitonExcision of necrotic muscleMeasurement of tissue pressures following decompressionLeave the skin open (initially)Splint the hand in a functional position
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Forearm Compartments
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Volar Forearm Fasciotomy
Henry Fasciotomy
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Volar Forearm Fasciotomy
Henry Fasciotomy
Interval closure
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Volar Forearm Fasciotomy
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UE: Salvage vs Amputation
26-year-old s/p crush injury.Fx of radius, ulna, metacarpalsSkin loss at axilla, elbow, & palmOcclusion of 10cm seg of brach art.
Injured deep and superficial arterial arches (no blood flow in the fingertips)Crush injury to flexor muscles.
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UE: Salvage vs Amputation
Salvage IndicesLange, et al 1985 – first protocol of absolute and relative
indications for primary amputation of tibial fracture
Salvage Indices:MESI – Mangled Extremity Syndrome IndexPSI – Predictive Salvage IndexMESS – Mangled Extremity Severity ScoreLSI – Limb salvage IndexNISSSA – Nerve Injury, Ischemia, Soft-Tissue Injury,
Skeletal Injury, Shock, & Age of Patient Score
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UE: Salvage vs Amputation
Salvage IndicesProblems
Algorithms based on small retrospective studiesResults have not been duplicatedBased on studies of lower extremity injuries
LSI & PSI applicable only to lower extremities
Complex and difficult to applyNo measure of functional outcome
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UE: Salvage vs AmputationMangled Extremity Severity Score (MESS)
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UE: Salvage vs AmputationValidity of MESS in Upper Extremity
Retrospective review of 23 patients
Actual Predicted N N
Primary amputation 11 11Delayed amputation 3 3Limb salvage 9 8
PPV – 100% NPV – 60%
The American Journal of Surgery, V172, 1996
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Procedure:ORIF of ulna and radiusDebridement on non-viable muscle & tissueBrachial artery bypassPalmar arch reconstruction with vein graftArterial pedicle skin flaps and STSGAdditional reconstructive surgery
Outcome: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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UE: Salvage vs AmputationConsiderations in UE Salvage
No guidelines for UE as limb salvage literature focuses on the LE.MESS can only be used as rough estimateUE 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, tendontransfers.
consider an initial salvage attempt, observation, and subsequent early secondary amputation.
maintain clear goals and communication with the patient and familyamputation may be necessary at any time during the salvage attemptamputation is not failure.