Volume 1 Issue 6 December 1996

Contents:

• When to Amputate a Limb
• Update on Last Month's Case
• Case of the Month
• What's New in Trauma
• Backchat

Introduction

It has been a hectic 2 months in the Liverpool Hospital, with anecdotally what appeared to have been one of our busiest clinical trauma loads of recent times. Our two year trauma registry report is currently being compiled by Erica Caldwell and if you wish to have a copy please contact her ( 0298283929).

The Trauma Department would like to thank those who helped with recent educational forums. We are glad to report that Dr Tim Hodgetts and Dr Ken Boffard returned safely to their respective continents, but Carol Shagoury has been sighted off Hayman Island.

WHEN TO AMPUTATE A LIMB

Dr PJ McGrath
Director of Trauma Services
Westmead Hospital

Johansen and Co-workers in 1990 described MESS (The Mangled Extremity Severity Score). This was a simple rating scale for lower extremity trauma based on skeletal and soft tissue damage, limb ischaemia, shock and patient age. They found both in retrospective surveys and prospective trials that amputation was predicated with 100% accuracy if the sum of these four variable scores was equal to or greater than 7

(1). Robertson in a similar study found that some limbs scoring 6 or less would eventually come to amputation (2),

MESS (Mangled Extremity Severity Score) Variables

Points A. Skeletal / soft-tissue injury

B. Limb lschaemia

C. Shock

D. Age of patient

Although MESS applies to the lower limb only. the principles would apply to the severely mangled upper limb. Lengthy upper limb reconstruction especially of a limb which is severely contaminated almost inevitably will be followed by major sepsis which if not recognised early could endanger the life of a patient.

Before primary amputation of a traumatised limb is contemplated, and providing the patient condition warrants it an urgent second opinion from a senior colleague in any doubtful case should be sought. If two senior surgeons could independently assess the limb and conclude that it should be amputated, then the procedure should take place. At times it is clear that amputation will be necessary the main decision remaining being the level at which amputation should take place. Under these circumstances and provided ruthless excision of dead and devitalised tissue has taken place at the time of the initial operation a delay may not endanger the patient's life.

Early amputation will lead to the fitting of an effective prosthesis. and a return to the workforce in a relatively short period of time. Performance of a below knee amputee can be quite impressive as vividly shown in the recent Para-Olympics in Atlanta. However once the decision not to amputate has been made, the patient is locked into a lengthy period of surgery and rehabilitation. It will be very difficult for the surgeon and the patient to decide to abort this lengthy reconstructive process and carry out amputation. I would urge that you be guided by the patient's attitude to his limb and to the prospect of a lengthy treatment program, and under these circumstances it may be helpful to offer him expert counseling.

In conclusion, be aware of MESS and apply it each time you are confronted with a severely injured lower limb. It may help you make up your mind to do what as surgeons we are always reluctant to do primarily, - to amputate the limb at the appropriate place. You may however be doing the patient a very considerable service by making such a decision.

REFERENCES AND FURTHER READING

2. Robertson P. A.: Prediction of amputation after severe lower limb trauma. J Bone. Joint. Surg. Br. Sept 1991; 73(6): 816-8

Update on last issues Case of the Month

The questions posed during the discussion last month were

Should a chest drain have been inserted in the primary survey prior to the Chest X-Ray?

The indication for a chest drain prior to x-ray is when there is significant respiratory or circulatory instability that could be respiratory in origin (such as a tension pneumothorax). However our patient had a respiratory rate of 24/m, which while increase does not indicate a life threatening respiratory problem. His circulation was compromised but as there was no clinical evidence of a tension pneumothorax an immediate chest drain was not indicated.

Tips: » Have your radiographer prepared and ready to shoot the chest xray as soon as possible once the patient airway is stabilized.

» This requires an organized approach to trauma resuscitation. Ideally the team should be gowned for the arrival of serious trauma. This allows simultaneous resuscitation and radiology of the trauma patient.

» An erect xray in the seriously injured trauma patient is not a realistic option as there is a risk of spinal injury which may be clinically undetected due to the severity of other injuries, administration of analgesia or a decreased level of consciousness. It is preferable to perform a supine chest x-ray and then after a detailed secondary survey an erect chest may be performed if there is no indication of a possible spinal injury.

» In general where there is a significant chest injury with tachypnoea it is preferable to perform the chest x-ray first. The cervical spine can be protected with in line immobilization and a c-collar. If the patient is to be intubated great care should be taken to maintaining in-line immobilization.

What are the 5 major potential sites of bleeding?

This 20 year male is no different than any other hypovolaemic patient where the sites of major bleeding include:

External- blood loss usually evident at the scene, but can be masked by bandages or a MAST suit

Extremities- Multiple long bone fracture can result in major haemorrhage

Chest - This is often difficult to detect on clinical grounds as the chest dullness is a late sign and difficult to detect in a supine patient in a noisy resuscitation room.

Abdomen- Abdominal signs are helpful but in the multisystem unstable patient diagnostic peritoneal lavage is the investigation of choice. The approach should be through the umbilicus in an open technique using a wide bore catheter. Invariably there is a frank return in the presence of any significant bleeding.

Pelvis and retroperitoneum- Often this is initially occult unless the mechanism of injury is highly suggestive of a pelvic injury.( pedestrian hit by car, fall from a height). An early pelvic x-ray and an EARLY DPL will help sort out the source of haemorrhage.

The question was raised whether one should have waited 30 minutes before blood was administered?

Polytrauma patients who are bleeding, in the first instance need the bleeding to be stopped. In blunt trauma this process may not be clearly evident and it is important to maintain an adequate haemoglobin. Patients should not receive more than 2L of crystalloid or colloid without transfusion. In the case of our 20 year old patient, as there was no initial shock it was not unreasonable to wait for group specific blood which in reality takes 30 minutes to become available. Group O positive or negative blood should be available in the Emergency Department for administration to shocked patients.

Indications for thoracotomy in blunt trauma.

If there is drainage of more than 1500ml after initial insertion of a chest drain then a thoracotomy should be undertaken. In general in blunt trauma a postero-lateral thoracotomy through the 6th interspace will provide the best access. Continuing haemorrhage of more than 200ml/hour usually warrant a thoracotomy, however one should be cautious about operating on a hypothermic patient with a temperature <34 degrees centigrade. The indications for surgery in penetrating trauma are a little more liberal as one is more likely to find a source of bleeding. This patient did not warrant a thoracotomy after the first 900mls.

Why did the first chest drain not drain all the blood?

Intra-pleural bleeding will usually drain from a chest drain irrespective of its position. There are a couple of exception to this however:

1) Critical amount 200-300mls are usually required to drain in a non dependant position.

2)The presence of adhesions may have an adverse affect on drainage due to loculation of blood.

3)Chest drains get kinked internally by pushing them in too far so they actually bend in the pleural space and this occludes the lumen.

4)Clots in the lumen of the tube may prevent drainage. 5)It goes without saying that drains outside the pleural cavity do not drain!

What would you do next with our 20 year male patient ?

Review of primary survey

A Intact

B Unstable, with radiological and clinical fractured ribs with 1300 mls from the chest

C Deteriorating with increasing hypotension.

The team felt that while there was obvious chest bleeding that this was not the sole source of haemorrhage. PelvicXray was normal and there was no external bleeding. A DPL was performed using an open umbilical technique and there was a frank return of blood. At 58 minutes the patient was transferred to the operating theatre where an initial laparotomy revealed a ruptured spleen and 1L of blood in the peritoneal cavity. The patient remained unstable and a rapid splenectomy was performed and the anaesthetist alerted the surgeon that there was a further 800mls in the chest drain. There was no further abdominal bleeding and the packs were placed in the abdomen and a right postero-lateral thoracotomy was performed. The patient fortunately had a double lumen endotracheal tube, allowing collapse of the right lung and good visualization of the right pleural space.

At surgery there was a 3cm hole in the right lower lobe which transgressed the whole lobe. It was actively bleeding and there was bleeding also from intercostal vessels in relation to two jagged rib fractures. A right lower lobectomy was performed. The patient was oozing from all sites, and his temperature was 32 degrees C with an arterial pH of 7.03. The chest and abdomen were rapidly closed. The patient died 4 hours after surgery in ICU. There was gerenalized oozing from many sites. A post mortem revealed additional significant injuries including a severe left pulmonary and myocardial contusion.

CASE OF THE MONTH

Pre-Hospital Observations A Intact
B Not laboured. RR 20 / m
C Pale P 100 / min, BP 120 / 76
D Alert
E Large Kitchen Knife protruding from the abdomen with no external bleeding


Treatment

Oxygen
IV Cannula
Scene Time 8 mins, Transfer Time 9 mins

Resuscitation Room: Trauma Team in attendance

Question One:
The Trauma Team was given six minutes notice of the patients impending arrival. What are the critical preparations you would undertake in the resuscitation room?

Observations on arrival

A Intact
B RR 24 / m Air Entry bilateral and equal
C P 130 / m BP 96/-
D Responding to verbal commands
E Knife in the Epigastrium


Question Two:
If you were the Trauma Team leader what would be your game plan?

What's new in Trauma;

Givens et al; Trauma August 1996;41:310.

Gonzales et al: J Trauma August 1996;41:271

Gonzales and colleagues from Christ Hospital reviewed their 3 year experience with gunshot abdomens that had sustained Penetrating Colonic Injury. 114 patients with penetrating colonic wounds were randomized into two groups, either primary repair or diversion. The diversion was either a colostomy or ileostomy. This randomization was independent of any risk factor, such as injury severity or shock. After excluding 5 deaths in the early phase of care, which were unrelated to the colonic injury, 56 received a primary repair and 53 were diverted ( 39 colostomies and 14 ileostomies). The groups were evenly matched in terms of abdominal injury and age. There was a 20% septic complication rate in the primary closure group compared to 25% in the diverted group. The authors concluded that all penetrating colonic injuries should be closed primarily.

Backchat

The Department has run 3 major trauma meetings. SWAN IV was a huge success attended by 230 people from around Australia and New Zealand. The highlight of the meeting was the expertise and polished performance of the 3 international speakers Dr Ken Boffard, Johannesburg, Dr Tim Hodgetts London and Carol Shagoury San Francisco and Dr Lawrie Malisano from Brisbane. SWAN V promises to be an even more exciting performance concentrating on Head Injury Management and Controversies in Trauma. So for more details watch this space!

The Public Forum on Trauma Injury and violence provided an interesting insight for the public on current trends in trauma care. It was attended by 150 people.

The Department ran a 2 day Rural and Remote Trauma Course in Alice Springs for 24 participants from remote location in Central Australia. The course was videod by the ABC and should be available early next year. This course has laid the foundation for future courses in rural trauma care. The Department is very grateful to the Federal Office of Road Safety and the RACS fro their support.

Liverpool Contributions to other Meetings

Dr Jon Ryan has recently presented 2 papers on our Web site. At the Australian Computers in Medical Education Conference, hosted by the University of Sydney, he discussed the development of internet based educational resources. At the Annual Scientific Meeting of the RACS's NSW State Committee, held in Wollongong, he explained the process involved in Web Site construction and discussed the benefits and implications of successsfully establishing a Web Site.

Web Site

Holiday Season

Letters to the Editor

Not all sedatives, narcotics and muscle relaxants drop blood pressure. Some actually raise it, e.g. ketamine and pancuronium. With the range of sedatives, relaxants, and adjuvant agents currently available, plus a good understanding of their pharmacokinetics in the hypovolaemic as well as the euvolaemic individual, it is just about possible to "dial in" any desired cardiovascular response. At the very least, skilled administration can avoid whichever sequelae of hypo- or hypertension is considered the least desirable.

It should also be pointed out that, in the trauma patient prior to securement of surgical haemostasis, a modest degree of hypotension (and carefully modulated) may be of value in reducing ongoing blood loss and improving survival. This appears to be the principle underlining the research suggesting delayed fluid resuscitation and the non-use of pneumatic antishock trousers (1,2,3). Intubation and ventilation in conjunction with judicious sedation and paralysis reduces tissue oxygen consumption as well as supply - a more physiologically desirable situation than hypovolaemia. There is certianly some evidence now that an earlier and more aggressive approach to intubation may improve outcome (4,5).

In summary, I believe the article in Trauma Grapevine has over stressed the risks and understressed the benefits of intubation and ventilation of the trauma patient. If the local incidence of severe cardiovascular sequelae to intubation is as frequent as suggested, then this is strongly suggestive that responsibility for this facet of management should be devolved to staff with more experience in anaesthesia than is currently the case.

Yours faithfully,

Blair Mumford.
Visiting Anaesthetist, Liverpool Hospital &
Senior Flight Physician, Careflight NSW Medical Retrieval Service.

REFERENCES:

1. Stern SA, Dronen SC, et al (1993). Effect of blood pressure on haemorrhage volume and survival in a near fatal haemorrhage model incorporating a vascular injury. Ann Emerg. Med 22, 155.

2. Martin RR, Bickell WH, et al (1992). Prospective valuation of pre-operative fluid resuscitation in hypotensive patients with penetrating truncal injury. A preliminary report. J. Trauma 33, 354.

3. Mattox KL, Bickell WH, et al (1989). Prospective MAST study in 911 patients. J. Trauma 29, 1104.

4. Schmidt U, Brame SB, et al (1992). On scene helicopter transport of patients with multiple injuries - Comparison of a German and an American System. J. Trauma 33, 548.

5. Regal G, Stalp M, et al (1996). The role of emergency measures in Air Rescue of the polytraumatised patient. Presented at AIRMED 96, 4th World Congress of Aeromedical Services, Munich, June 1996.

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