VCUDEATH 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?

DeepPeronealNerve

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

Privileged & Confidential: Subject to Peer Review and Medical Review Protections, O.C.G.A. 31-7-130 et seq. and 31-7-140 et

seq.

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) 1486-1491

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) 199-202

Mullins et al. The natural history following venous ligation for civillian injuries. Journal of Trauma 20(1980) 727-743

Cargile et al. Acute trauma of the femoral artery and vein. The Journal of trauma 32 (1992) 364-370