VCU DEATH AND COMPLICATIONS CONFERENCE

Brief Overview of Case  GSW to left groin, left common femoral artery and left external iliac vein injuries  GSW left forearm  Left superior pubic ramus fx extending into acetabulum  Intubated/ventilated (received 7 units PRBC's and 4 units FFP)  Ischemia, compartment syndrome LLE

Introduction for Every Case  Complication  Ischemia, left leg, limb loss  Procedure  Left external iliac vein ligation, repair left common femoral artery injury  Primary Diagnosis  GSW to left groin with vascular injuries

Clinical History  TRJveranda 16 yo male trauma team echo alert after sustaining GSWs to the left arm and groin  On arrival initial vital signs: hr 139 bp 190/36 rr 24 98% RA  Pertinent findings: rigid llq with anterior groin wound, confused, GCS 13, blood in urethral meatus, 2 wounds left forearm  1 unit of pRBC, NS was given, taken emergently to the OR

Clinical History  0R  Once abdomen was opened hemorrhage from the pelvis, packed and then carefully explored  Left external iliac vein torn, ligated with 2-0 silk  Left common femoral artery injury noted, once inguinal ligament was divided; repaired end to end with 4-0 prolene  Abthera wound vac therapy applied to abdomen once soft tissue was reapproximated over repair  The left leg was wrapped in ace bandage and the patient transferred to STICU intubated at 1:00am  He received 6 pRBC and 4FFP intraop, EBL 2.5L

RESIDENT QUESTION #1 Which nerve is earliest affected by lower extremity compartment syndrome?

Deep Peroneal Nerve

Post-op events  Vascular exam: nondopplerable or palpable bilateral pedal pulses, in STICU left was dopplerable, right palpable

RESIDENT QUESTION #3 When measuring compartment pressures – when is a fasciotomy indicated?

When pressure difference between the compartment pressure and mean arterial pressure is less than 40 mmHg Or When the pressure difference between the compartment pressure and diastolic pressure is less than 10 mmHg

Post-op events  13 hours post-op he was noted to have weakly dopplerable left pedal signals, apparently improved with ace bandage removal, decreased sensation left foot (He had self-extubated and was alert)  PE with notable tense calf  Emergent left leg fasciotomy was performed  Lateral compartment weakly twitched to electrocautery  All muscles deemed viable at that time  CKs were trended post-op: peaked at 54,800  Vascular surgery consulted 24 hours later  Taken to the OR, re-explored  Anterior compartment and deep posterior compartment incised, tibilias anterior was non-viable and debrided  Thigh was noted to be edematous and fasciotomy was performed

RESIDENT QUESTION #2 How many and what are the names of the calf compartments?

Anterior Lateral Posterior Deep Posterior Superficial

RESIDENT QUESTION #4 What are the compartments of the thigh?

Anterior Medial Posterior

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Figure 4. Thigh fasciotomies. The anterior and posterior compartments are decompressed through a lateral incision and the medial compartment through a medial incision.

Post-op events  Next day 11/25 pod 3 abdomen was closed, anterior tibialis further debrided  Over next days vac therapy to thigh and leg fasciotomy sites, during changes concern for necrotic leg compartments  12/3 pod10 taken for exploration: gastrocnemius was only viable muscle in leg  12/4 pod 11 LEFT AKA was performed  Recovering from most recent operation

Analysis of Complication Was the complication potentially avoidable? – Possibly Would avoiding the complication change the outcome for the patient? – Yes What factors contributed the complication? – Possibly not performing prophylactic fasciotomies of the leg – Incomplete decompression during the first fasciotomy – Patient injuries

Take home points  If there is a venous injury that is ligated, it is prudent to measure compartment pressure and even possibly perform prophylactic fasciotomy  In the setting of venous injury elevation of the extremity is crucial to reduce extremity edema  It is possible to have compartment syndrome in the setting of incomplete fasciotomy so we should always have this on the differential

References  Farber, et al. Early fasciotomy in patients with extremity vascular injury is associated with decreased risk of adverse limb outcomes:A review of the National Trauma Data Bank. Injury 43(2012)  Oliver et. Al. A ten year review of civilian iliac vessel injuries from a single trauma center. European journal of Vascular and Endovascular surgery. 44 (2012)  Mullins et al. The natural history following venous ligation for civillian injuries. Journal of Trauma 20(1980)  Cargile et al. Acute trauma of the femoral artery and vein. The Journal of trauma 32 (1992)