Comparison of Capillary Blood Oxygen Saturation (Sp02) Before and After Restoration of Arterial Circulation (N = 53)

- Treatment of venous injuries

Table 3.18: Treatment methods for venous injuries (n = 18)

Morphology of damage

All patients with major venous injuries had their circulation restored before treating arterial injuries, with suturing of the lateral wall laceration accounting for the highest proportion. No cases of venous injuries had their veins grafted or ligated.

- Open scale

Table 3.19: Location and indications for fasciotomy (n = 30)

Assign

Location

Of the 30 patients who underwent fasciotomy, most of them were in the lower leg (29 cases, accounting for 96.7%) with anterolateral approach, posteromedial approach, or a combination of both approaches. There was only 1 case of femoral fasciotomy (accounting for 3.3%).

Immediate opening of the fascia was performed in 15 cases to relieve compartment syndrome compression.

Prophylactic fasciotomy is performed after treatment of arterial injuries and fractures and dislocations for the remaining patients at risk of postoperative compartment syndrome.

Table 3.20: Factors associated with indication for prophylactic fasciotomy (n = 15).

TT

The majority of patients undergoing prophylactic fasciotomy had severe soft tissue injury, popliteal artery injury, and combined arterial injury.

– veins.

3.2.3. Resuscitation and anticoagulation

Surgery combined with resuscitation and anticoagulation was performed to maintain hemodynamics and prevent complications before, during and after surgery. Twenty-five patients (47.2%) were treated postoperatively in the Surgical Intensive Care Unit until their general condition was stable.

- Blood transfusion:

Table 3.21: Number of patients receiving blood transfusions

Blood transfusion

Based on clinical and peripheral blood cell testing, patients with signs of severe blood loss (according to Ha Van Quyet's criteria [21]) or traumatic shock were transfused.

Preoperative blood transfusion was low (17.0%); the average amount of blood transfused per patient was 533.3 ± 543.1 ml (250 ml - 1000 ml).

Intraoperative blood transfusion: the average amount of blood transfused per patient was 725.0 ± 543.1 ml (250 ml - 2500 ml).

Postoperative blood transfusion accounted for the highest rate (47.2%); the average amount of blood transfused per patient was 1252.4 ± 908.9 ml (250 ml - 3800 ml).

- Infusion and diuretics

All patients were infused with isotonic fluids (NaCl 9‰, Ringer lactate, Glucose 5%) and high molecular weight fluids (Haesteril 6%, Dextran) to maintain stable hemodynamics with pulse rates < 100 beats/minute, systolic blood pressure > 90 mmHg.

There were 37 patients (69.8%) with acute rhabdomyolysis syndrome (CK≥1000 units/liter, CK - MB < 5%) and urine volume < 30 ml/hour who were treated with forced diuresis to prevent acute renal failure due to rhabdomyolysis by infusing 9‰ NaCl and 5% Glucose until the central venous pressure > 7 cm H 2 0, then using the diuretic Furosemide. Forced diuresis was stopped when CK < 1000 units/liter and urine volume reached > 150 ml/hour.

- Anticoagulants

+ During surgery : 44 patients (83.0%) were given anticoagulants.

Drug: Heparin. Dosage: 100 units/kg body weight, slow intravenous infusion.

+ After surgery : 39 patients (73.6%) were given anticoagulants.

Medicine: Heparin, dose 200 units/kg body weight/24 hours. How to use: Heparin mixed with 50 ml of 5% Glucose injected slowly intravenously with an electric syringe. Anticoagulant use time is within the first 5 days after surgery.

Patients with arterial sutures or traumatic brain injury at risk for intracranial hematoma should not receive anticoagulation.

3.3. Treatment results

3.3.1. Recent results

- Successful limb preservation : 47 patients (88.7%), no patient died.

- Results of limb circulation recovery

Table 3.22: Limb perfusion results (n = 53)

Result

Assess limb circulatory recovery based on color, temperature, sensation, toe movement, peripheral pulses, capillary return, and (Sp0 2 ).

The results showed that 47 patients (88.7%) had restored peripheral circulation, of which the majority achieved excellent and good results (83.1%). There were 6 patients (11.3%) with irreversible limb ischemia (possibly associated with severe infection) requiring amputation.

- Amputation : 6 patients (11.3%). Details of 6 patients with amputation:

Patient 1 : Luu Van M., 19 years old, BALT number 1259, had a traffic accident at 1:00 p.m., surgery at 7:00 p.m. on July 3, 2009, diagnosed with open fracture of grade IIIC of both tibiae with popliteal artery rupture, treated with external fixation of the tibia, popliteal artery grafting with autologous saphenous vein, amputated on July 31, 2009 with diagnosis of total necrosis of the deep posterior muscle mass of the lower leg due to secondary embolism after severe infection.

Second patient : Hoang Tien D., 18 years old, BALT number 1394, had a traffic accident at 7:00 p.m. on August 1, 2009, had surgery for 2 hours on August 2, 2009, diagnosed with open knee dislocation, popliteal artery occlusion, underwent surgery to reduce and fix the knee joint with Steimann nails, popliteal artery grafting with autologous saphenous vein, amputated on August 3, 2009 due to irreversible limb ischemia.

Third patient : Nguyen Thanh S., 52 years old, number BALT577, had a traffic accident at 8:00 a.m., surgery at 2:00 p.m. on August 24, 2009, diagnosed with open fracture of the tibial plateau with rupture of the popliteal artery, underwent surgery to reduce and fix the tibial plateau with cancellous bone screws, grafting the popliteal artery with autologous saphenous vein, amputated on September 15, 2009 with a diagnosis of total necrosis of the deep posterior muscle mass of the lower leg due to secondary embolism after severe infection.

Fourth patient : Dao Van L., 30 years old, BALT number 310, had a traffic accident at 8:00 a.m., surgery at 3:00 p.m. on August 12, 2010, diagnosed with grade IIIC open fracture of both tibiae, anterior and posterior tibial artery rupture, surgery to reduce and fix the tibia externally, grafting the anterior tibial artery with autologous saphenous vein, ligation of the posterior tibial artery, amputation on August 17, 2010 due to irreversible limb ischemia and severe infection.

Fifth patient : Vu Xuan T., 53 years old, BALT number 506, had a traffic accident at 10:00 a.m., surgery at 5:00 p.m. on December 17, 2010, diagnosed with closed fracture of the upper third of the femur, femoral artery rupture and femoral vein tear, underwent surgery to reduce and nail the femoral bone intramedullary, femoral vein anastomosis, femoral artery grafting with autologous saphenous vein, amputated on December 19, 2010 due to irreversible limb ischemia (surgery delayed by more than 6 hours).

Sixth patient : Luong Van H., 49 years old, BALT number 393, had a traffic accident at 10:00 a.m., surgery at 2:00 p.m. on August 28, 2011, diagnosed with grade IIIC open fracture of both tibiae, contusion and occlusion of anterior tibial artery and posterior tibial artery, underwent surgical reduction and external fixation of the tibia, grafting of posterior tibial artery with autologous saphenous vein, ligation of anterior tibial artery, amputation on September 2, 2011 due to severe soft tissue damage causing irreversible limb ischemia.

Factors associated with irreversible limb ischemia requiring early second-stage amputation

+ Location and morphology of arterial lesions

Table 3.23: Location and morphology of arterial lesions associated with limb amputation (n=53)

Result

• Location of arterial injury

The rate of early second-stage amputation in the group of patients with blunt trauma, arterial rupture, and combined injuries was 14% (6/43);

Other arterial lesions preserved the limb completely; The difference between groups was not statistically significant, p> 0.05.

• Arterial lesion morphology

The rate of early amputation in the group of femoral artery, popliteal artery and anterior-posterior tibial artery injuries was 15% (6/40);

Posterior or anterior tibial artery injury in patients without amputation;

The difference between groups was not statistically significant, p > 0.05.

+ Combined lesions

Table 3.24: Other injuries related to amputation (n=53)

Result

Damage

• Combined arterial-venous injury

The rate of irreversible limb ischemia requiring amputation in the group of patients with combined arterial-venous injuries was 33.3% (6/18).

The group of patients with isolated large artery injuries had complete limb preservation.

The difference between groups was statistically significant, p< 0.05.

• Software damage

The amputation rate in the group of patients with severe soft tissue injuries was 16.2% (6/37); the group of patients with moderate soft tissue injuries had their limbs completely preserved.

The difference between groups was not statistically significant, p> 0.05.

• Severity of limb injury (MESS)

The amputation rate in the group of patients with limb injury severity (MESS) ≥ 8 points was 28.6% (6/21);

The group of patients with MESS < 8 points had complete limb preservation. The difference between groups was statistically significant, p < 0.05.

+ Time of limb ischemia

Table 3.25: Time to limb ischemia (from accident to surgery) associated with amputation (n=53)

Result

Time

Most patients underwent surgery within 6 hours of the accident. The amputation rate in the two groups of patients who underwent surgery within < 6 hours was 2.8%.

much lower than the group of patients who had surgery ≥ 6 hours at 29.4%.

The difference between groups was statistically significant, p < 0.05.

- Early results of surgical recovery of fractures and dislocations

Table 3.26: Results of reduction and fixation of fractures and dislocations on X-rays in the first 3 weeks after surgery (n = 47)

Result