Page 86 - 2022 Spring JSOM

Fasciotomy, although rarely performed by medics, is a critical Performance of Fasciotomy
procedure for the salvage of life and limb in critically injured Consideration should be given to providing periprocedural an-
patients with ACS. Statistically, young military males between algesia and sedation with ketamine or opiates alone. If within
the ages of 18 and 29 years are at a higher risk of developing the medic’s practice repertoire, peripheral nerve blocks may
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ACS following extremity injury. Ballistic injuries to the tibia be effective at minimizing the analgesia and sedation require-
and fibula are at greatest risk of developing compartment syn- ment. Antibiotics are administered if not already given for
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drome compared with other ballistic fractures. Analysis of other indications, such as penetrating wounds. Fasciotomy is
casualties with ACS early in Operation Iraqi Freedom and Op- classically performed using a two-incision, four-compartment
eration Enduring Freedom raised concern regarding delay in technique because it provides better surgical exposure than
diagnosis and inadequate management (i.e., low rate of fasci- the single-incision technique. After skin preparation with
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otomy, inadequate release of compartments) as contributing to povidone-iodine (Betadine) or chlorhexidine (ChloraPrep),
mortality. An educational program was developed to address the fasciotomy proceeds as described in the Methods sec-
surgeon knowledge gaps regarding diagnosis of ACS and the tion. Prophylactic fasciotomy may be accomplished through
use of prophylactic fasciotomy. Subsequent analysis identified small skin incisions; however, when ACS and significant mus-
marked improvement in casualty survival, increased fasciot- cle swelling are present, the skin may also act as a restrictive
omy rates, and less need for revision because of inadequate barrier to full compartment release. Because of this, acute
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fasciotomy, although time to fasciotomy was unchanged. cases should be managed by widely incising the skin to the
An additional review of 17,166 casualties from 2001 to 2010 full length of the fascial compartments. Care is taken to avoid
identified 3,313 (19%) who underwent fasciotomy. 12 injury to the superficial peroneal nerve, which runs laterally
along the intramuscular septum, and to the GSV, which lies in
Timing of Fasciotomy
In the presence of ACS and ongoing tissue ischemia, rapid the medial subcutaneous tissue. Bleeding should be managed
fasciotomy is essential because delay to compartment release with Combat Gauze (Teleflex) or similar hemostatic dressing.
has been associated with increased mortality and limb loss. 13,14 The wounds are then covered with dry sterile dressings (i.e.,
It is estimated that 37% of all cases of ACS develop muscle abdominal pads) and wrapped loosely with a gauze and/or
necrosis within 3 hours of injury. The timeframe for fasciot- elastic bandage roll. Depending on the duration of ACS prior
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omy in a combat casualty may be even shorter in the setting to compartment release, there may be significant washout of
of significant tissue destruction and ischemia compounded ischemic metabolites and myoglobin, leading to acidosis, hy-
by hemorrhagic shock or tourniquet use. Field fasciotomy is perkalemia, rhabdomyolysis, and acute kidney injury. Urine
required in casualties who are exhibiting signs of ACS (i.e., output should be monitored, and oral or intravenous fluids
tense swollen extremity, pain with passive motion, paresthesia, should be administered for a goal urine production of 100 to
4
pallor, pulselessness, cold) but who cannot be delivered to a 200mL per hour of clear yellow urine.
surgeon within 1 to 2 hours. Because of increased morbidity Risk of Infection
and mortality with delayed fasciotomy, in 2015 the PFC work- As with any surgical procedure (e.g., chest tube, fasciotomy,
ing group identified fasciotomy as a critical capability during cricothyroidotomy) performed in the austere environment,
PFC. In cases of delayed evacuation with compartment syn- infection of the operative site is of prime concern, and steps
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drome present for more that 12 hours, fasciotomy should de- should be taken to complete the procedure as cleanly as pos-
ferred in favor of intensive care with fluid resuscitation and sible. Any alternative instruments used for fasciotomy should
urine alkalization. 19 be cleaned with antiseptic or at least wiped with alcohol or ch-
lorhexidine prior to proceeding. Retrospective investigations
Measurement of Compartment Pressure
In well-resourced hospitals, compartment pressures are typi- into the risk of infection after fasciotomy in controlled op-
cally measured with handheld devices such as the STIC Intra- erative environments have had mixed results. A study of 132
compartmental Pressure Monitor System (C2Dx), which patients identified no increased incidence of infection between
utilizes a sterile needle and transducer to measure pressure in the fasciotomy and no-fasciotomy groups (14% versus 11%,
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each target compartment. Arterial line transducers and porta- respectively). In a matched cohort study comparing lower
ble vital signs monitors can also be adapted for measurement extremity fracture patients with ACS requiring fasciotomy to
of compartment pressures, but at a cost of added weight and patients without ACS, deep infection and fracture nonunion
limited battery life. The Compass (Centurion Medical Products) were both increased in the fasciotomy group (20% versus 4%
is a small, disposable pressure transducer designed for the mea- and 20% versus 5%, respectively), although the authors did
21
surement of pressure during central or arterial line insertion and note a higher proportion of smokers in the fasciotomy group.
lumbar puncture as well as muscular compartment checks. With
a battery life of more than 8 hours of continuous use, it may Although we do not have data on prehospital fasciotomy and
have the potential for additional uses in austere settings and its impact on infection rates, we can draw comparisons to
PFC; it has been used to perform forearm compartment pressure finger and tube thoracostomies, which, when performed out-
research in the developing country of Nigeria. The transducer side the operating room, are considered clean contaminated
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is attached to an 18-gauge needle and a saline-filled syringe. The procedures. In the civilian setting, a review of 2,261 trauma
device and needle are flushed with saline to prime the Compass patients receiving tube thoracostomy in the hospital posted
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prior to zeroing the transducer at the planned angle of insertion. an empyema rate of 3.1%. An evaluation of 207 trauma
The needle is advanced into the desired compartment, 0.3mL patients treated by an aeromedical crew with needle decom-
of saline is flushed to clear any tissue plug, and the compart- pression and/or tube thoracostomy identified no cases of em-
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ment pressure is displayed. The device may then be re-zeroed pyema. Two additional reviews encapsulating 169 patients
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for measurement of the next compartment. In the absence of identified no difference in rate of empyema between prehos-
25,26
measurement modalities, the decision to perform fasciotomy is pital and hospital tube thoracostomy. Unfortunately, there
based on symptoms and physical examination. are no data on rates of infection in patients who receive a chest
84 | JSOM Volume 22, Edition 1 / Sping 2022