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Acute Traumatic Ischemia, Crush Injury and Compartment Syndrome

Acute Traumatic Ischemia, Crush Injury and Compartment Syndrome

Acute Traumatic Ischemia, Crush Injury and Compartment Syndrome

INTRODUCTION 

Treatment Protocol Guidelines

The following hyperbaric medicine treatment protocol is based upon the recommendations of the Hyperbaric Oxygen Committee of the Undersea and Hyperbaric Medical Society. Clinical protocols and/or practice guidelines are systematically developed statements that help physicians, other practitioners, case managers and clients make decisions about appropriate health care for specific clinical circumstances.  

These protocols allow health providers to offer evidence-based, appropriate, standardized diagnostic treatment and care services to patients undergoing hyperbaric oxygen therapy (HBOT). This section discusses acute traumatic ischemia, crush injury, and compartment syndrome. Evidenced-based medicine offers clinicians a way to achieve improved quality, improved patient satisfaction, and reduced costs.  Utilization Review should be initiated when clinical decisions result in deviation from or modification of treatment protocols.  This includes any course of treatment at or above the recognized threshold limits. 

Medical Necessity

Medicare.gov defines “medically necessary” as “health-care services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.” 

The conditions acute traumatic ischemia, crush injury, and compartment syndrome, meets coverage indications per the National Coverage Determination (NCD) 20.29. [1]  Continued HBOT without documented evidence of effectiveness does not meet the Medicare definition of medically necessary treatment. Thorough re-evaluation should be made at least every 30 days for documentation of response to therapy. 

TREATMENT PROTOCOL


Acute Traumatic Peripheral Ischemia

 Sample Physician Order   | $ ICD-10 Crosswalk | Treatment Table 

 Emergent / Urgent Indication                                                                   

Crush Injury/Compartment Syndrome

 Sample Physician Order   | $ ICD-10 Crosswalk |  Treatment Table

 Emergent / Urgent Indication 

Background
  • Acute traumatic ischemia occurs when there is a severe injury to a limb that results in compromise of the arterial blood supply or perfusion differential pressure to that limb.
  • The injury can be soft tissue only with disruption of the major arterial flow to the at risk/injured tissue. It may also involve fractured bones and/or disrupted joints, thus putting an extremity at risk.
  • The immediate and emergent threat is determined by whether perfusion of the limb is sufficient to maintain viability of the downstream tissues.
  • The pathophysiology is a picture of vasogenic edema as a consequence of the physical injury
    • Compromised host responses to infection and ischemia
    • Decrease in phagocytic ability of white blood cells
    • Decrease in collagen secretion by fibroblasts
    • Impairment of neovascularization due to hypoxic tissue
  • While crush injuries are a direct result from trauma, skeletal muscle compartment syndromes arise from ischemia, venous outflow obstruction, exertion, external compression, or trauma
  • Acute traumatic ischemia, crush injury, and compartment syndrome are amenable to HBOT
  • These are critically ill patients, many of whom are in the ICU, intubated, ventilated, and require aggressive fluid and pressor resuscitation. 
  • You must be comfortable treating critically ill patients in your chamber environment. If you cannot, then these patients should be transferred to a higher level facility as soon as they are stable.

Goals of HBOT

  • Serve as a bridge and adjunctive therapy until definitive surgical intervention by:
    • Increasing tissue oxygenation concentration to prevent cellular death
    • Reducing ischemia-reperfusion injury
    • Supporting host defense function of white blood cells in generating granulation tissue and fighting infection
    • Preventing WBC degranulation, thus preventing clotting and inflammatory cascade complications:
      • Increased edema
      • Increased transudate
      • RBC Rouleaux formation and capillary clogging
      • Activation of the clotting cascade
  • Enhance blood supply by:
    • Supporting neovascularization through stimulation of collagen secretion by fibroblasts and macrophages
    • Decreasing edema in injured tissue 

Diagnosis

Acute traumatic peripheral ischemia
  • History of trauma to the affected area (e.g., blunt, penetrating, laceration)
  • "Hard" signs of arterial injury: 
    • Active hemorrhage
    • Expanding or pulsatile hematoma
    • Arterial vibration upon palpation
    • Bruit near or over the artery upon auscultation 
    • Six Ps of acute ischemia: pain, pallor, poikilothermia, pulselessness, paresthesia, and paralysis

Crush injury

  • History of trauma to the affected area
  • Typically presents with involvement of multiple tissues (skin, subcutaneous tissue, muscles, bones, nerves, vessels)

Skeletal muscle compartment syndrome

  • History of severe trauma, especially involving crush injuries or fractures of long bones of the arm or leg
  • Pain levels disproportionate to apparent injury
  • Tense muscle compartment, painful to passive extension of affected limb
  • Increased measured intra-compartmental pressure (not required for diagnosis)
  • 5 P's:
    • Pallor, paresthesias, pulse deficit, paralysis, and pain on passive extension of the compartment 
    • Pain is usually very severe and occurs early
    • Paresthesias may occur early as well
    • Paralysis is a late sign
    • Pulse loss is a late sign
Hyperbaric Criteria
  • Diagnosis of acute traumatic peripheral ischemia or crush injury
  • Ischemic limb or tissue, at risk of amputation 
  • Treatment or prevention of ischemia-reperfusion injury
  • Increased compartment pressure 
Evaluation
  • History: if possible have patient relay a detailed history of the mechanism of injury (traumatic vs non-traumatic event), presence of diabetes and vascular disease 
  • Physical examination: assess if cardiovascular instability, renal failure, metabolic acidosis, disseminated intravascular coagulopathy, hypothermia, myoglobinuria, skin injury and swelling, paralysis, and paresthesia
  • Initiate tetanus prophylaxis if necessary
  • Labs to order or review:
    • Complete Blood Count (CBC)
    • Compehensive Metabolic Panel (CMP)
    • Creatinine phosphokinase (CPK)
    • Urinalysis; urinary myoglobin
    • Arterial Blood Gas (ABG)
  • Electrocardiogram (ECG)
  • Chest X-ray
  • Review current clotting studies
  • Photograph extremity for signs of continued hypoxia or demarcation.
  • Anaerobic and aerobic wound cultures
  • Compartment pressure measurement (if applicable)
  • Consult with surgeon for surgical intervention and debridement as necessary
  • Transcutaneous oxygen (TCOM) assessment, if indicated 
Treatment
  • Early application of HBOT within 4-6 hours of injury is recommended. 
  • Hyperbaric oxygen therapy, at 2.0-2.5 ATA oxygen for 90 minutes (Table 1). Use 2.5 ATA If an ischemia-reperfusion component has occurred, which requires two 5-10 minute air breaks (Table 3).
  • Treat three times within the first 48 hours for critical ischemias, if possible. Logistics in critically ill patients frequently do not allow this schedule.
  • Treat twice daily after 48 hours until the tissue at risk stabilizes or amputation is inevitable.
  • Daily HBOT may be given once the injured tissue is stable and the neovascular status is improved.
  • If the tissue begins to show evidence of recurring ischemia or progression of tissue destruction, twice daily treatments can be extended or renewed.
  • These patients are typically in inpatient settings receiving critical care, therefore, blood pressure (arterial line), central pressures (Swan Ganz), ECG, and urinary output may be monitored, as directed.
  • Aggressive fluid resuscitation is the mainstay of treatment for crush injury. The earlier fluid resuscitation is started, the more likely acute renal failure will be prevented. 
    • Crystalloid or Colloid resuscitation for trauma is best left to the intensive medicine physicians. Be aware that there are significant fluid shifts in the first 3-5 days after major trauma.
  • Photograph for signs of continued hypoxia even if vital signs are initially normal.
  • Re-evaluate and document daily
  • Transcutaneous oxygen assessment if indicated. This may require TCOM in-chamber.
Follow-Up
  • Repeat wound photography, usually weekly, but daily initially can be helpful
  • Repeat transcutaneous assessment, if amenable
Treatment Threshold
3 – 9 treatments (Peer review should be based on the pathophysiology of the indication and the number of HBOT treatments needed to mitigate it. While the number of treatments is variable due to the extent of trauma, peer review is important for assessment of HBOT effect.The decision whether to extend HBOT treatments or stop them should be the consensus of the HBOT physician, the trauma/orthopedic surgeon, the plastic/reconstructive surgeon, and or the primary care physician.)
Coding
Refer to the ICD-10 Guideline for the appropriate ICD-10 code
Comments
  • There are two trauma grading scales in current use. The Gustilo Scale applies:
  • Grade III makes up the injuries amenable to HBOT. Grade I and II injuries are generally not limb threatening.
    • IIIA There is no arterial injury and sufficient tissue remains to close the injury primarily (Does not usually require HBOT)
    • IIIB Exposed bone remains. Will require secondary coverage.
    • IIIC With concomitant injury to major blood supply.
  • Be aware that there is a 50% complication rate with Gustilo IIB/C injuries, including:
    • Osteomyelitis
    • Fracture non-union
    • Failed tissue flaps
    • Amputations
  • The second grading scale is usually an academic or research scale: The Johansen Mangled Extremity Severity Score (MESS).
    • Scores > 7 predict most severe injuries, amputations, and poor outcomes.
  • If diabetes mellitus is present, blood glucose should be checked within an hour prior to treatment and immediately post-HBOT. 
  • Avoid petroleum-based dressings and ointments whenever possible. If these are a necessary part of the surgical dressing, ensure that they are not exposed to air and are completely covered with 100% moistened cotton during HBOT.
  • There is one randomized controlled trial using HBOT in severe trauma/crush injury patients. The HBOT group required fewer surgical exposures and had less amputations than the sham/control group.  [2] 
Primary Sources: Whelan and Kindwall [3]Weaver [4], Thom [5], Bouachour [2] 

DOCUMENTATION

History 

Sample history for crush/traumatic ischemia is shown below:

"Peggy S. is a 26 y/o woman who was involved in an auto/pedestrian accident earlier this morning. She had a work truck malfunction along the highway. A second work truck was parked in front of her and offering assistance. She was standing on one leg with the other raised up to the bumper of her work truck. A 16 y/o driver in a car was distracted and crashed into the rear of Peggy's work truck at 50 mph. The ensuing destruction pinned Peggy's left leg between the two trucks. She was extricated and taken to the University Level 1 trauma center. Both orthopedic and vascular surgeons took her to the operating room the begin the process of saving her left leg. 

Plain X-Ray and CT scan of the left leg revealed a compound, comminuted fracture of both tibia and fibula of the left leg. The tibial plateau of the left leg is shattered with a short section of tibia remaining. Should reconstruction fail, this short section of tibia and a shattered tibial plateau is unlikely to support a below knee amputation. Hence, should limb salvage fail, an above the knee amputation will be required. 

In the operating room, the vascular supply at the trifurcation was disrupted requiring emergency bypass surgery and arterial repair by the vascular surgeons. This makes her trauma a Gustilo 3B trauma score with a 50% likelihood of permanent injury and complications. 

Her pertinent past history includes treated depression and body image disorder. 

We have been asked to see Peggy and to provide hyperbaric oxygen therapy as an adjunctive therapy to assist limb salvage and healing her multiple fractures. We are happy to do so with a diagnosis of crush injury to the left lower leg."

[Note that compartment syndrome would be a similar history of closed leg crush, fracture, or injury with resultant impending/established compartment syndrome. Brief sample:

"John T. is a 36 y/o man with short history of work injury this evening. A 400 pound piece of steel fell and trapped his right leg between the steel and bench. He did not sustain any fractures but came to the emergency room with a tight, swollen right leg below the knee. The emergency room physician measured compartment pressures using ultrasound and needle measurements. Pressures were at least 30mmHg higher than diastolic pressure in each compartment. He has been taken to the operating room for emergent compartment releases. 

In the operating room, the surgeon noted that several muscles were hypoxic and dying. When stimulated by the electrical cautery, there was no muscle movement. Because of this finding, the surgeon asked us to provide hyperbaric oxygen in adjunctive fashion to attempt limb/muscle salvage. We will start therapy this evening with a diagnosis of acute, established compartment syndrome of the right lower leg."

Physical Exam

Acute traumatic peripheral ischemia

"Hard" signs of arterial injury: 

  • Active hemorrhage
  • Expanding or pulsatile hematoma
  • Arterial vibration upon palpation
  • Bruit near or over the artery upon auscultation
  • Six Ps of acute ischemia: pain, pallor, poikilothermia, pulselessness, paresthesia, and paralysis

Crush injury

  • Typically presents with involvement of multiple tissues (skin, subcutaneous tissue, muscles, bones, nerves, vessels)

Skeletal muscle compartment syndrome

  • History of severe trauma, especially involving crush injuries or fractures of long bones of the arm or leg
  • Pain levels disproportionate to apparent injury
  • Tense muscle compartment, painful to passive extension of affected limb
  • Increased measured intra-compartmental pressure (not required for diagnosis)

5 P's:

  • Pallor, paresthesias, pulse deficit, paralysis, and pain on passive extension of the compartment 
  • Pain is usually very severe and occurs early
  • Paresthesias may occur early as well
  • Paralysis is a late sign
  • Pulse loss is a late sign

Impression

  • Acute Traumatic Peripheral Ischemia Refer to ICD-10 Crosswalk
  • Crush Injury Refer to ICD-10 Crosswalk
  • Compartment Syndrome Refer to ICD-10 Crosswalk

Plan

A typical hyperbaric regimen for a traumatic ischemia consists of an aggressive treatment protocol. Patients will be treated at 2.0 or 2.5 ATA with oxygen breathing from 90 minutes. Initially, treatment will be twice daily. Once the extremity is stable and the neurovascular status is improved, treatments will be once daily for several days. If the tissue begins to show evidence of advancing ischemia or progression of tissue destruction, the twice daily regimen can be extended or renewed.

Risk and Benefit of Hyperbaric Oxygen Therapy 

  • Please refer to topic "Documentation HBO: Risks and Benefits"

Indication for Hyperbaric Oxygen Therapy (HBOT)

"Acute traumatic ischemia occurs when there is a severe injury to a limb that results in compromise of the arterial blood supply or perfusion differential pressure to that limb. The immediate, emergent threat is determined by whether perfusion of the limb is sufficient to maintain viability of the tissues. Crush injuries are directly associated with trauma while skeletal muscle compartment syndromes arise from ischemia, venous outflow obstruction, exertion, external compression, or trauma. There are 3 common features: 1) ischemia and hypoxia at the injury site, 2) a gradient of injury, and 3) the potential for self-perpetuation of the injury. 

While hyperbaric oxygen is a useful adjunct, surgery and aggressive medical interventions will often be required in order to manage the condition. Conditions with related pathophysiology, which are also amenable to hyperbaric oxygen therapy, include threatened flaps, grafts, re-implantations, and frostbite. The pathophysiology is a picture of vasogenic edema as a consequence of injury exacerbated by cytogenic edema because the injured tissues are no longer able to maintain intracellular water. When tissue oxygen tensions fall below 30 mmHg, the host responses to infection and ischemia are compromised. White blood cell phagocytic killing becomes ineffective, fibroblasts are no longer able to secrete collagen, and neovascularization cannot occur. 

Hyperbaric oxygen (at 2 ATA) increases blood oxygen content by 125%, where plasma and tissue oxygen tensions are increased by 1000%. Hyperbaric oxygen also induces vasoconstriction (decreasing blood flow by 20%), thus reducing edema. In this indication, hyperbaric oxygen enhances oxygen concentration at the tissue level, increases oxygen delivery per unit of blood flow, and reduces edema."

Sample Order

  •  See Sample Physician Order - Acute Traumatic Peripheral Ischemia
  •  See Sample Physician Order - Crush Injury/ Compartment Syndrome

REVISION UPDATES

DateDescription
4/29/19Added section on Documentation


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NOTE: This is a controlled document. This document is not a substitute for proper training, experience, and exercising of professional judgment. While every effort has been made to ensure the accuracy of the contents, neither the authors nor the Wound Reference, Inc. give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omissions in the contents of the work.

REFERENCES

  1. CMS. National Coverage Determination (NCD) for Hyperbaric Oxygen Therapy (20.29) . 2017;.
  2. Bouachour G, Cronier P, Gouello JP, Toulemonde JL, Talha A, Alquier P et al. Hyperbaric oxygen therapy in the management of crush injuries: a randomized double-blind placebo-controlled clinical trial. The Journal of trauma. 1996;volume 41(2):333-9.
  3. Harry T. Whelan, Eric Kindwall et al. Hyperbaric Medicine Practice 4th Edition Best Publishing Company. 2017;volume fourth():.
  4. Michael B Strauss, MD et al. Undersea and Hyperbaric Medical Society, Hyperbaric Oxygen Indications, 13th edition: Crush Injuries and Skeletal Muscle-Compartment Syndromes .;.
  5. Thom SR. Effects of hyperoxia on neutrophil adhesion. Undersea & hyperbaric medicine : journal of the Undersea and Hyperbaric Medical Society, In.... 2004;volume 31(1):123-31.
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