Here’s some food for thought. Read through the scenario below, as well as the questions under it. I’m interested in some comments from prehospital providers, physicians and nurses in the ED on what you would do in this situation.
Scenario: Paramedics call ahead to activate your trauma team for a young male who was ejected from his car during a motor vehicle crash. He was quickly extricated and was found to be in pulseless electrical activity (PEA) arrest. IVs were inserted and the Lucas automated CPR device was attached. The patient is immobilized and will arrive at your hospital in 5 minutes.
You assemble your trauma team and are patiently awaiting when the medics arrive. The patient / Lucas / backboard are rapidly transferred over to the ED stretcher and mechanical CPR continues. At that point, you are overwhelmed by the odor of gasoline, and you note that the patient’s clothing is saturated with liquid.
What would you do?
Here are my questions for you:
Do you move the patient or keep him in your trauma bay?
What if your decontamination area is a short/moderate/longer distance from your ED?
What if this situation involved a farmer in arrest who smelled strongly of pesticide? Any different?
Or someone covered with mysterious white powder?
How do you balance patient survival and team safety?
What kind of performance improvement activities will be needed with regard to the team? The prehospital providers?
Medicine is full of conditions with eponyms. Trauma is no exception. There’s the Mattox maneuver and the Cushing response, to name two. Many times, the name is just a kind of vanity plate for the discoverer of the condition. But in the case of the LisFranc injury (or fracture), it makes some sense. This injury is tough to describe in a sentence or two, let alone a few words.
Jacques LisFranc de St. Martin was a French surgeon and gynecologist (!) who described this condition in about 1815. It entails the fracture of the heads of the metatarsal bones and possible dislocation from the tarsals (the cuboid, navicular, and three cuneiform bones). This area is known as the LisFranc joint complex.
The injury can involve any or all of the metatarsals. The typical mechanism applies high energy across the midfoot, which can often be seen in head-on motor vehicle crashes. Crush injury to the proximal foot can also do this, such as running the foot over with a car. Occasionally, this injury pattern is produced with lower energy during sports play. In this case, the top of the foot is typically contacting the ground, plantar flexing it. At the same time, another player steps on the heel, grinding the foot into the ground (ouch). Interestingly, LisFranc did not describe the injury pattern or mechanism. His name is associated with the joint complex, and it is an injury to his joint complex.
Most of the time, the injury is obvious. There is usually notable pain and swelling of the foot. X-ray findings are generally not subtle. However, lower energy mechanisms may not cause much displacement, and initial imaging may not show the injury. If your patient starts to complain of pain in the midfoot when they begin to ambulate, think of LisFranc.
Treatment depends on the degree of displacement and the amount of disruption of the tarso-metatarsal joints. If minimal, a trial of nonoperative, non-weight bearing may be sufficient. But frequently, surgical reconstruction is required.
The concept of performing 4-compartment leg fasciotomy using only one incision is not a new one. Techniques using a lateral approach, either with or without fibulectomy, have been described as early as 1967.
A new paper describes a single-incision technique for compartment syndrome using a medial approach. The authors believe that going through the anterior compartment to release the deep posterior is quicker, uses a smaller flap, and avoids injury to the peroneal nerve. They reviewed their own experience over a 5 year period.
Here are the factoids:
180 fasciotomies were performed for compartment syndrome, of which 30 were single-incision
27 had associated fractures, 2 were due to soft tissue injury and 1 was spontaneous
There was a single wound infection, nerve injury, and patient with persistent pain. There were several tethered tendons and scars.
The number and types of complications were similar to traditional fasciotomy
Traditional 4 compartment fasciotomy with 2 incisions. Source: gog.net.nz
Bottom line: Sounds great, right? Yes, it’s a small study, and statistically there is not enough power to show that it’s “better.” So if it’s not worse, and there is just one smaller incision, what’s wrong with it?
For me, the problem is that there is too much opportunity to perform an incomplete fasciotomy. The learning curve for single incision fasciotomy, either this one or the more traditional lateral approach, is steep. Seriously impaired patients who need fasciotomy are frequently not going to be awake any time soon, leaving the surgeon with no neurologic or pain exam.
My recommendation: read papers like this and smile. Then do the classic 2 incision operation, making sure that all compartments are completely released.
You’ve heard about it. You’ve read about. And maybe you’ve even gotten trained up and tried it. What is it? REBOA!
I’m devoting the February newsletter to this relatively new topic. Learn about what it is, how you do it, and what we know about the results. Subscribers will receive it over the weekend; everyone else will have to wait until the end of next week.