9 四肢 Crush Injuries何時輔以 HBO2 ? ~ 用 Gustilo Open Fracture Classification System 來評估TypeMechanismExpected OutcomeHBO2 IndicationsISmall (< 1 cm) laceration from inside to outsideUsually not different from a closed fractureNoneIILarge laceration, but minimal soft tissue damageCompromised hosts such as diabetics, advanced peripheral vascular disease, collagen vascular diseases, etc., where concern is raised about primary healing of flapsIIICrush tissue: A. Sufficient soft tissue to close wound (primary and delayed) B. Flaps or grafts required to obtain soft tissue coverage C. Major (macrovascular) vessel injuryA. Infections and/or nonunion rates < 10 % B. About 50% incidence of complications (infection, nonunion) C. About 50% incidence of complications (infections, nonunion)A. Same as for type II fractures B. All injuries C. All injuries
10 四肢 Crush Injuries何時輔以 HBO2 ? ~ 用 Mangled Extremity Severity Score (MESS) 來評估A. Skeletal/soft tissue injury Low energy (stab, simple fracture; low velocity gun shot wound) Medium energy (open or multiple fractures, dislocations) High energy (close-range shot gun or high velocity GSW, crush injury) Very high energy (above plus gross contamination, soft tissue avulsion) B. Limb ischemia Pulse reduced or absent, but perfusion present Pulselessness, paresthesias, diminished capillary refill 2* Cool, paralyzed, insensate, numb 3* *Double score if ischemia time > 6 hoursC. Shock Systolic BP always > 90 mmHg Hypotension transiently Persistent hypotensionD. Age < > 50Points * 2* 3*0 1 2MESS=A+B+C+D Johansen et al 建議當 MESS 7 分以上時應行截肢。MESS 在 3~8分時，依以下原則決定HBO2輔助治療。MESS （甲） 7 (possibly 8)（乙） 5, 6 （丙） 3, 4HB02 Indications （甲） 分數主要來自B,C,D三項的健常患者。 （乙） 糖尿病、周邊動脈硬化、凝血或膠原蛋白功能異常、、、等不良癒傷因子，輕或中度者。 （丙）糖尿病、周邊動脈硬化、凝血或膠原蛋白功能異常、、、等不良癒傷因子，重度者。
11 下二項任一時建議輔以 HBO2： 在 I. 臨床症狀 內有3項以上。 在 II. 骨骼肌腔室壓力測量 內有任何一項。 評估骨骼肌群 Compartment SyndromeI. 臨床症狀：1. Severe pain in muscle compartment 2. Marked increase in pain with passive stretch of muscles in the compartment 3. Marked swelling of the compartment 4. Marked tenseness of the muscle compartment 5. Neuropathy, myelopathy, and/or encephalopathyII. 骨骼肌腔室壓力測量：1. Greater than 40 mmHg in the uncompromised host 2. Rising serial compartment pressure measurements as values approach 35 mmHg mmHg in mildly compromised host (diabetic, peripheral vascular disease, collagen vascular disease, etc.) mmHg in hypotensive patients where systolic blood pressure is 33 to 50% lower than is expected.下二項任一時建議輔以 HBO2：在 I. 臨床症狀 內有3項以上。在 II. 骨骼肌腔室壓力測量 內有任何一項。
12 ATPIs時，併用HBO2的建議： HBO不能完全取代手術與藥物！ 創傷後4-6 小時內開始HBO預後較佳。 第一個48 小時 90 min, 2.0~2.5 ata HBO2, q8h。第二個48 小時 90 min , 2.0~2.5 ata HBO2, q12h。第三個48 小時 90 min , 2.0~2.5 ata HBO2, qD。*特別注意，類似的protocol尚有許多，都需更多臨床數據來驗證。六天後，症狀應減輕至不需HBO2，否則需全面重新評估。
13 ADJUNCTIVE HYPERBARIC OXYGEN TREATMENT FOR 8 PATIENTS WITH CRUSH SYNDROME IN DEVASTATING EARTHQUAKE. SY Yu. Wound Care and Hyperbaric Medicine Center, Department of Surgery, Changhua Christian Hospital, Changhua City, Taiwan 500BACKGROUND: Hyperbaric oxygen therapy (HBOT) has been reported as an useful adjunct for the management of crush injuries. A devastating earthquake scaled 7.3 hit central Taiwan in the early morning on Sep. 21, 1999, and aftershocks scaled between 5 to 6 persisted for months. Changhua Christian Hospital, the nearest medical center to the quake region, has received more than 2000 emergent trasferral during the disaster.CASE REPORT: There were 8 severely injured patients managed with both traditional treatments and adjunctive hyperbaric oxygen treatment. Two of them received amputation finally. An 8-year-old girl with severe crush over both lower limbs lost her left leg by a below-knee amputation because of irreversible gangrenous change and uncontrolled sepis. Hypoxia of her right leg was reversed by fasciotomy and intensive HBOT. A 6-year-old girl with duodenal perforation and totally crushed left lower limb underwent emergent laparotomy, fasciotomy and early HBOT. An inevitable transmetatarsal amputation was done for her to remove the gangrenous part of foot. A back hoes tilted over a 25-year-old young man resulting in an open tibial fracture and severe crush, which was corrected by repeated operations and HBOT. Compartment syndrome also developed in another 4 patients, and relieved with no or mild neurologic deficit after 5 to 20 dives of HBOT. A 6-year-old girl with cardiac tamponade underwent emergent cardiac ventricle repair and depended on ventilator for pulmonary contussion postoperatively. The sternotomy wound was dehescenced and deeply infected, but healed well after repeated operations and 12 dives of HBOT.CONCLUSION: With the benefit of promoting wound healing, decreasing infection and shortening hospital day, these cases are to be presented to conclude that early adjunctive hyperbaric oxygen therapy plays an important role in the treatment of crush syndrome.