Page 83 - 2022 Spring JSOM

Austere Fasciotomy

Alternative Equipment for Performance in the Field

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Erik DeSoucy, DO ; Christopher Hewitt, DO ; Scotty Bolleter, BS 3

ABSTRACT
Background: Acute compartment syndrome (ACS) following Introduction
extremity trauma requires rapid fasciotomy to avoid significant
morbidity and limb loss. Four-compartment fasciotomy of the Advances in body armor technology and availability have im-
leg is a surgical procedure typically performed in the operating proved combat casualty survival by shielding the torso; how-
room; however, casualties who cannot be rapidly transported ever, there have been no major advances in the prevention of
may need fasciotomies in the prehospital setting. In the absence dismounted extremity injuries. In recent conflicts, 35% of
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of traditional operating instruments (e.g., scalpel, long Metzen- combat casualties sustained injuries to the extremities. Ex-
baum scissors, electrocautery), alternative means of fasciotomy tremity ACS can develop after penetrating, blunt, blast, and
may be needed. We undertook a proof-of-concept study using crush injuries. When left untreated, progression of ACS can
cadaver models to determine whether leg fasciotomies could be lead to devastating muscle and nerve damage and, in extreme
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performed with alternative devices compared with the surgical cases, a nonfunctional limb and the need for amputation.
standard. Methods: Two-incision, four-compartment fascioto- Combat-injured extremities are more susceptible to ACS be-
mies were performed on fresh, never-frozen, non-embalmed ca- cause of associated vascular injuries, high Injury Severity
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daver legs using a scalpel for the initial skin incision, followed Score, and the degree of bone and soft-tissue injury. Fasciot-
by release of the fascia using one of the following instruments: omy, the surgical release of the affected muscle compartments,
5.5-in curved Mayo scissors; Benchmade rescue hook (model must be completed within hours to salvage limbs with ACS.
BM-5BLKW); rescue hook on the Leatherman Raptor multi-
tool (model 831741-FFP); Leatherman Z-Rex multitool rescue Fasciotomy is usually performed in an operating suite with
hook (model LM93408); or No. 10 PenBlade (model PB-M-10- basic surgical instruments and involves the incision of skin and
CAS). The procedures were performed by a surgeon. Skin and subcutaneous fat and careful opening of the fascia to avoid
fascia incisional lengths were recorded along with a subjective injuring underlying tissues. The Joint Trauma System clinical
impression of the performance for each device. Post- procedural practice guideline for crush syndrome recommends that this
dissection was performed to identify associated injuries to the procedure be performed only by qualified medical personnel
muscle, superficial peroneal nerve, and the greater saphenous or through teleconsultation, ideally with real-time video ca-
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vein (GSV). Results: All devices were able to adequately re- pability. This procedure is taught to advanced medics (e.g.,
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lease the fascia in all four compartments. All rescue hooks Special Operations, pararescue) for use in austere and pro-
(Benchmade, Raptor, and Z-Rex) required a “pull technique” longed field care (PFC) environments but is rarely used. Most
and a skin incision of equal length to the fascia incision. The protocols dictate that fasciotomy be performed only when
PenBlade was used in a “push technique,” similar to the stan- the patient cannot be promptly evacuated to a surgeon. Fur-
dard scissor fasciotomy through a smaller skin incision. There ther complicating the procedure, medical equipment carried
was one superficial peroneal nerve transection with the rescue by these medics comes at a weight and space premium; thus,
hooks, but there were no GSV injuries or significant muscle multipurpose instruments are preferable to instruments with a
damage with any instrument. Conclusion: Four- compartment single indication.
fasciotomy can be performed with readily available alternative
equipment such as rescue hooks and the PenBlade. Hook-type The leg fasciotomy is the most commonly performed fasci-
devices require longer skin incisions compared with scissors otomy and classically requires the use of long Metzenbaum
and the PenBlade. In contested environments, patients with scissors, which have minimal alternative use in the medic’s
ACS may require fasciotomy prior to evacuation to surgical rucksack. We hypothesize that rescue hooks and strap cutters,
teams; training combat medics in the use of these alternative used in the extraction and initial management phases of both
instruments in the field may preserve life and limb. humanitarian and combat casualty care, or a modified scalpel
with additional indications, may be adapted to perform the
rare procedure of fasciotomy. We undertook a proof of con-
Keywords: fasciotomy; austere medicine; compartment syn- cept study using cadaver legs to explore the effectiveness of
drome; combat casualty care these nontraditional instruments for austere fasciotomy.

Correspondence to erik.s.desoucy.mil@mail.mil
1 Lt Col Erik DeSoucy is affiliated with the Department of Surgery and Lt Col Christopher Hewitt is affiliated with the Department of Emergency
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Medicine, Brooke Army Medical Center, Joint Base San Antonio–Fort Sam Houston, TX. Scotty Bolleter is director, Centre for Emergency
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Health Sciences, Spring Branch, TX.
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