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PubMed1989

MAST-associated compartment syndrome (MACS): a review.

Compartment syndromes occur following lower extremity injuries and have been associated with the use of pneumatic or "medical" antishock trousers (MAST). Review of 12 previously reported cases and 15 new cases suggests that lower extremity trauma and systemic hypotension are cofactors responsible for the development of compartment syndrome but MAST use also contributes to the process by prolonging muscle ischemia. Complications of lower limb compartment hypertension may be averted by early recognition and fasciotomy. Associated amputations and mortality are directly related to the severity of injury, or indirectly to delay in diagnosis and treatment of the compartment syndrome and its complications.

Abdominal Injuries↗
PubMed1989

Prospective MAST study in 911 patients.

Nine hundred eleven patients with systolic blood pressures less than or equal to 90 mm Hg were randomized to MAST and No-MAST groups, and all taken to a single Level I Trauma Center. Epidemiologic analysis of etiology, age, race, sex, Trauma Scores, and Injury Severity Scores revealed the two groups to be statistically identical. Seven hundred eighty-four patients were analyzed in detail. The principal injury location was thorax in 41%, abdomen in 32%, extremity in 16%, head in 7%, and neck in 4%. In patients with head and extremity wounds, the mortality rate was clearly not a function of MAST use. In the chest, abdomen, and neck, MAST did not improve survival. Although the total prehospital time was 35.8 + 10.4 minutes for MAST patients and 32.5 +/- 10.7 minutes for No-MAST patients, 70% of patients with MAST had prehospital times greater than 30 minutes compared to 55% of the No-MAST patients. When the prehospital time was greater than 30 minutes, 31% of the MAST patients died, compared to 21% of the No-MAST patients. MAST application adversely affected the outcome most significantly for patients with cardiac and thoracic vascular injury. The overall mortality of 31% in the MAST group, compared to 25% in the No-MAST group was statistically significant (p = 0.05).

Adolescent↗
PubMed1991

The effect of the pneumatic antishock garment (PASG) on hemodynamics, hemorrhage, and survival in penetrating thoracic aortic injury.

To determine if the increased blood pressure associated with application of a pneumatic antishock garment (PASG) affects outcome in thoracic hemorrhage, we assessed hemodynamics, blood loss, and survival in three groups of eight anaesthetized piglets with a 2.5-mm laceration of the descending thoracic aorta. Baseline measurements were made before aortic hemorrhage. During one hour of aortic hemorrhage or until death of the animal, the PASG was not inflated in Group I while the PASG in the other two groups was inflated to maintain carotid artery pressure at 15 torr below baseline (Group II) and at baseline (Group III), respectively. Survival was 100% in Group I, 50% in Group II, and 0% in Group III. Hemorrhage at 22.5 +/- 4.0 mL/min stopped after 18-24 minutes in Group I; the survivors in Group II bled at a rate of 32.5 +/- 3.0 mL/min compared with 43.6 +/- 4.0 mL/min over 26-35 minutes in the Group II nonsurvivors. Group III pigs bled at 107.5 +/- 8.0 mL/min over the 10-18 minutes of survival. The intended blood pressure could not be maintained beyond 30 minutes. Bleeding stopped in Group I when the blood pressure fell to 58.2 +/- 4.5 torr from a baseline of 119.0 +/- 10.0 torr. The blood pressure fell to 48.0 +/- 5.0 torr in the four Group-II survivors. After a transient maintenance of baseline blood pressure in Group III, a precipitous drop in blood pressure with death in 10-18 minutes occurred in all these animals. In this porcine model of thoracic aortic injury, PASG inflation increases hemorrhage and mortality.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMed1991

Ventilatory effects of medical antishock trousers in healthy volunteers.

The ventilatory effects of medical antishock trousers (MAST) were investigated using 10 healthy volunteers. Use of the MAST (60-80 mm Hg) decreased forced expiratory volume (-8% +/- 4%, p less than 0.01), vital capacity (-8% +/- 5%, p less than 0.01), and functional residual capacity (-12% +/- 6%, p less than 0.01) and induced a significant decrease in tidal volume (-30% +/- 17%, p less than 0.05), but minute ventilation was unmodified because of a concomitant increase in respiratory rate (+17% +/- 8%, p less than 0.001). The MAST modified the breathing pattern: the abdominal contribution to ventilation was markedly decreased (-57% +/- 22%, p less than 0.001), suggesting a decrease in the diaphragmatic contribution to ventilation. The MAST increased both the end-expiratory (+131% +/- 115%, p less than 0.01) and inspiratory variation (delta Pgas: +42% +/- 40%, p less than 0.05) of gastric pressure, whereas the end-expiratory and inspiratory variation of esophageal pressure remained unchanged. Because of a higher delta Pgas, the dynamic compliance of the abdominal compartment markedly fell (-77% +/- 10%, p less than 0.001). Transdiaphragmatic pressure (Pdi: +28% +/- 30%, p less than 0.05) significantly increased and the pressure-time index of the diaphragm significantly increased (+32% +/- 32%, p less than 0.05) after inflation of the MAST, suggesting an increase in the diaphragmatic cost of breathing. Inspiratory activity of the parasternal intercostal muscles significantly increased after the MAST was inflated. Computerized tomography showed that the MAST induced a cephalad shift of the diaphragm, which reduced pulmonary height.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1992

The cardiorespiratory effects of increased intra-abdominal pressure in diaphragmatic rupture.

The cardiorespiratory effect of gastric herniation in diaphragmatic rupture with and without increased intra-abdominal pressure (produced by inflation of a pneumatic antishock garment [PASG] to an intraperitoneal pressure of 40 mm Hg) was studied in 16 anesthetized spontaneously breathing (80% oxygen) piglets. Four additional animals had similar measurements after PASG inflation but without diaphragmatic rupture. Arterial blood pressure (BP), cardiac output, arterial blood gases, position of the stomach relative to the diaphragm (as measured on fluoroscopy), and mortality were assessed. Gastric herniation without the PASG (group I: 8 animals) produced slight cardiorespiratory deterioration, with PO2 falling from a baseline measurement of 429 +/- 60 mm Hg to 316 +/- 5 mm Hg at 1 hour. Over this period pH decreased from 7.39 +/- 0.05 to 7.30 +/- 0.02 and PCO2 increased from 39 +/- 5 to 46 +/- 2 mm Hg. With PASG inflation (group II: 8 animals) PO2 decreased to a greater extent, from 410 +/- 30 mm Hg at baseline to 48 +/- 10 mm Hg by 1 hour; pH decreased from 7.38 +/- 0.06 to 6.8 +/- 0.2 and PCO2 increased from 39 +/- 4 to 88 +/- 6 mm Hg. Animals without diaphragmatic rupture (group III: 4 animals) showed a smaller decrease in PO2, from 480 +/- 34 mm Hg at baseline to 320 +/- 50 mm Hg by 1 hour after PASG inflation.(ABSTRACT TRUNCATED AT 250 WORDS)

Abdomen↗
PubMed1993

A study of pneumatic antishock garments in severely hypotensive trauma patients.

The effectiveness of a pneumatic antishock garment (PASG) on severely hypotensive trauma patients (BP < or = 50 mm Hg) was studied using two data sets. The first included data from eight hospitals collected over 4 1/2 years; the second included 2 years of data from an additional eight hospitals. Data were collected by trained nurse abstractors whose interrater reliability was extremely high for AIS and ISS scoring. One hundred forty-two patients had blood pressures < 50 mm Hg. The PASG patients had a higher survival rate than non-PASG patients (Pr = 0.055). The PASG appeared to have the most effect on patients with abdominal injuries since no patient with such an injury survived unless a PASG was applied. Controlling for severity using the TRISS method, z scores indicated that the survival rate in the PASG group was significantly higher than expected whereas that in the non-PASG group was similar to that predicted; the same pattern was found when blunt injury and penetrating injury patients were analyzed separately. Improvement in survival among PASG patients occurred despite an average scene time that was 4.7 minutes longer than that for non-PASG patients. No improvement in survival among PASG versus non-PASG patients with blood pressures of 50-70 mm Hg or in those with blood pressures of 90 mm Hg or less was found. We conclude that the use of PASG in severely hypotensive patients (BP < or = 50) should be considered medically acceptable pending randomized controlled studies.

Abdominal Injuries↗
PubMed1993

Efficacy of deep venous thrombosis prophylaxis in trauma patients and identification of high-risk groups.

The incidence of deep venous thrombosis (DVT) and the efficacy of prophylactic measures were prospectively evaluated in all patients admitted to a level I trauma center during 1991. Patients with Injury Severity Scores (ISS) > 9 who survived a minimum of 48 hours (n = 395) were monitored using venous Doppler and ultrasound studies during hospitalization (total, 1308 studies). Two hundred eighty-one patients (71%) were randomly assigned to low-dose heparin or sequential compression devices. There were 18 cases of lower extremity DVT (4.6%) and four cases (1.0%) of pulmonary emboli (PE), three of which were fatal. Eight patients (2.9%) on prophylaxis and 10 (8.8%) without prophylaxis developed DVT (p < 0.02 by Chi-square). There were two PEs in each group. Fourteen of these 18 patients sustained blunt trauma and included seven spinal fractures or subluxations (four paraplegic) and four severe head injuries. This represented 14.0% of 50 patients admitted with spinal injuries and 4.3% of 92 patients with severe head injuries. Compared with those with no neurologic injury (7 of 253 or 2.7%), the risk of DVT is significantly higher in the spinal injury patients (p < 0.001, Chi-square) and twice as high as in the head injury group, although not statistically significant (p = 0.4, Chi-square). Three of the four patients with penetrating trauma and DVT had venous injuries. We conclude that DVT prophylaxis can significantly reduce the incidence of DVT in trauma patients with ISS > 9. Patients with severe neurologic injuries (particularly spinal cord) are at high risk for DVT and PE and may be considered for a prophylactic Greenfield filter.

Adult↗
PubMed1995

Fluid and electrolyte deficit with prolonged pneumatic antishock garment application.

OBJECTIVE: When trauma victims are within 1 hour of definitive surgical care, prehospital pneumatic antishock garment (PASG) application has not improved outcome. A resuscitative role for PASG has been suggested when transport time is longer (e.g., 4 hours). We assessed the fluid and electrolyte cost of treating posthemorrhagic hypotension with the PASG in 16 anesthetized Yorkshire piglets (30 to 32 kg). DESIGN: Hypotension [30 mm Hg drop in carotid arterial blood pressure (CBP)] was produced by arterial line bleeding. Hemodynamics, serum electrolytes, lactate, and tissue edema (limb circumference) were monitored. MATERIALS AND METHODS: In eight animals (group 1), PASG was inflated to maintain prebleed CBP for 4 hours. In group 2, the hypotension was untreated for 4 hours. After 4 hours, shed blood (over a period of 15 minutes) and normal saline (1.5 mL/kg/minute) were infused until CBP returned to normal baseline values. MEASUREMENTS AND MAIN RESULTS: Shed blood alone did not restore baseline CBP. Serum K+ increased from a baseline of 3.9 to 9.1 mmol/L in group 1, with no significant change in group 2. Serum lactate rose from 1.8 to 24.1 and from 1.7 to 6.8 mmol/L in groups 1 and 2, respectively. After 4 1/2 hours, an increase in thigh circumference (6.4 +/- 1.4 vs. 1.9 +/- 1.0 mm) and intravenous fluid required after returning shed blood (626 +/- 36 vs. 324 +/- 22 mL) was greater in group 1 (means +/- SD, p < 0.05). Other serum electrolyte values were similar for the two groups. CONCLUSIONS: We conclude that fluid deficit, lactic acidosis, tissue edema, and hyperkalemia are all greater with prolonged PASG application when compared with the untreated hypotensive state. These findings must be considered when suggesting more prolonged PASG application.

Animals↗
PubMed1995

Pneumatic antishock garment-associated compartment syndrome in uninjured lower extremities.

Pneumatic antishock garment-associated compartment syndrome is a rare and yet underrecognized complication that when it occurs, frequently results in myonecrosis and loss of limb function, and occasionally loss of a limb or even death. We report a case of pneumatic antishock garment-associated compartment syndrome in a trauma patient without lower extremity injury and review similar published reports. It is only with a high index of suspicion, early recognition, and prompt treatment of this complication by fasciotomy and proper wound care that associated morbidity and potential mortality of this complication can be prevented or minimized.

Abdominal Injuries↗
PubMed1995

PASG: does it help in the management of traumatic shock?

A prospective, randomized study was designed to determine the efficacy of pneumatic antishock garment (PASG) in the treatment of traumatic shock in a medium-size urban community. A total of 291 traumatic shock patients were assigned to either the PASG or No-PASG treatment groups. Of these, data from 248 patients were analyzed in detail. Analysis of demographic factors--such as age, sex, and mechanism of injury--as well as prehospital evaluative tools--such as trauma and CRAMS scores, and injury severity scores--revealed that the two groups were well-matched. This study did not demonstrate significant differences in hospital stay or mortality between PASG and No-PASG patients. Similarly, in the subset of patients with blunt trauma, PASG was not found to be beneficial.

Adult↗
PubMed1995

Preventable death evaluation of the appropriateness of the on-site trauma care provided by Urgences-Santé physicians.

The study is based on 44 preventable deaths occurring in a cohort of 360 patients with major trauma. These cases were reviewed by a committee of nine experts. The mean Injury Severity Score (ISS) was 28, and most cases had injuries to the head/neck (68%) and chest (64%). The mean (+/- SD) observed prehospital times, and those considered the maximum allowable by the committee, were 40.6 +/- 12.0 minutes for head/neck injuries and 23.9 +/- 12.2 minutes for chest injuries (p < 0.05). Intravenous (i.v.) lines were started in 38 (86%) of the patients. The committee classified this procedure as harmful for 16 (42%) and neutral for 19 (50%). Among the 18 (46%) that were intubated, this intervention was considered harmful for 17% and neutral for 39%. In two of the three patients for whom a pneumatic antishock garment was applied, this procedure was considered harmful. Of the 34 patients that required direct transport at a level I trauma center, 50% were transferred to such a hospital. These results show significant prehospital delays and high rates of inappropriate IV line initiation and intubation in trauma patients receiving on-site care by physicians. We conclude that prehospital care protocols for trauma patients should emphasize prompt transport and specific on-site care algorithms.

Adult↗
PubMed1997

Venous thromboembolism in the high-risk trauma patient: do risks justify aggressive screening and prophylaxis?

OBJECTIVE: Deep venous thrombosis (DVT) and pulmonary embolism (PE) are considered to be a major source of morbidity and mortality among trauma patients. Several reports have identified high-risk patients with recommendations for management ranging from frequent duplex scanning to placement of prophylactic inferior vena cava (IVC) filters. We reviewed our experience with a large trauma population to determine whether such approaches are justified. METHODS: We analyzed 2,868 consecutive trauma admissions over 22 months and identified 280 patients (10%) in high-risk groups who survived > or = 48 hours: (1) severe closed head injury with mechanical ventilation > or = 72 hours, (2) closed head injury with lower extremity fractures, (3) spinal column/cord injury, (4) combined pelvic and lower extremity fractures, and (5) major infrarenal venous injuries. The remaining nonthermal injury patients constituted the low-risk group. RESULTS: There were 280 high-risk patients, 213 of whom (76%) received prophylaxis with compression therapy. There were 12 cases of DVT (5%) with four nonfatal PE (1.4%). Six patients (2%) had therapeutic IVC filters inserted and only one patient had prophylactic placement. There were 38 deaths in this group, attributable primarily to severe closed head injury or spine injuries, and none were caused by PE. In the 2,249 low-risk patients, there were three cases of DVT (0.1%, p < 0.05 vs. high risk) and no PE (p < 0.05 vs. high risk). CONCLUSIONS: Although these patients were at increased risk for thromboembolic events, the overall incidence of DVT was still extremely low with no apparent PE deaths. In our patient population, aggressive screening and prophylactic IVC filters would not have benefited 95% of "high-risk" patients without DVT and would not have prevented any deaths. We could not identify any population, except perhaps venous injuries, where such expensive and potentially harmful maneuvers seemed justified. Our experience with DVT and PE does not support either aggressive screening or prophylactic IVC filters as the standards of care.

Adolescent↗
PubMed1999

Calf-thigh sequential pneumatic compression compared with plantar venous pneumatic compression to prevent deep-vein thrombosis after non-lower extremity trauma.

OBJECTIVE: To compare the effectiveness of calf-thigh sequential pneumatic compression devices with the effectiveness of plantar venous intermittent pneumatic compression devices in prevention of venous thrombosis after major trauma. SUBJECTS AND METHODS: We evaluated 181 consecutive patients after major trauma without lower extremity injuries that precluded the use of pneumatic compression devices. We randomly assigned 149 patients to either calf-thigh sequential pneumatic compression or plantar venous pneumatic compression. After blinding the observers to the method of prophylaxis against deep-vein thrombosis, we performed bilateral compression ultrasonography on or before day 8 after randomization. RESULTS: Among 149 randomized patients, 62 who received calf-thigh sequential pneumatic compression and 62 who received plantar venous intermittent pneumatic compression devices completed the trial. Thirteen patients randomized to plantar venous intermittent pneumatic compression (21.0%) and 4 patients randomized to calf-thigh sequential pneumatic compression (6.5%) had deep-vein thrombosis (p = 0.009). Seven of 13 patients with deep-vein thrombosis after prophylaxis with plantar venous intermittent pneumatic compression had bilateral deep-vein thromboses, whereas all 4 patients with deep-vein thrombosis after prophylaxis with calf-thigh sequential pneumatic compression had unilateral deep-vein thrombosis. CONCLUSION: Calf-thigh sequential pneumatic compression prevents deep-vein thrombosis more effectively than plantar venous intermittent pneumatic compression after major trauma without lower extremity injuries.

Adult↗
PubMed2000

Advanced or basic life support for trauma: meta-analysis and critical review of the literature.

BACKGROUND: The question of whether to use advanced life support (ALS) or basic life support (BLS) for trauma patients in the prehospital setting has been much debated and still lacks a clear answer. The purpose of this study was to conduct a comprehensive critical review of the literature regarding this controversy METHODS: A total of 174 articles on prehospital ALS or BLS for trauma were reviewed. Fifteen of these studies were found to involve mortality statistics for both ALS- and BLS-treated patients. Odds ratios were calculated for survival in ALS versus BLS and summarized across studies on the basis of multivariate scoring systems that incorporated both design and methodological assessment. Overall odds ratios for all studies were calculated on the basis of both raw data from the papers, and weighted odds ratios were calculated from the scoring systems. RESULTS: Six studies were scored as being methodologically average (5 favoring BLS and 1 favoring ALS), two were scored as good (1 favoring BLS and 1 favoring ALS), seven as excellent (6 favoring BLS and 1 favoring ALS). Ten studies had an average study design score (6 favoring BLS and 4 favoring ALS) and seven had a good study design score (6 favoring BLS and 1 favoring ALS). Weighted odds ratio for dying was 2.59 for patients receiving ALS compared with those receiving BLS. The crude odds ratio was 2.92. CONCLUSION: The aggregated data in the literature have failed to demonstrate a benefit for on-site ALS provided to trauma patients and support the scoop and run approach.

Emergency Medical Services↗
PubMed1998

Anatomical variations in pressures generated by pressure garments.

Pressure therapy is the predominant means for prophylaxis and treatment of hypertrophic scar. Despite this, there is little scientific evidence to support its use. This study examines the pressures generated by pressure garments in four subjects at 36 different anatomical sites chosen to represent the varying body geometry. Direct subdermal pressures were measured by an established method, though novel for this application. Pressure garments create a mean increase in subdermal pressures of 22.2 mmHg (range -10 to 102 mmHg). A significant objective difference exists in pressures generated at different anatomical sites. These differences correlate to local tissue compliance and to known areas of good clinical response and inversely correlate to the radius of anatomic curvature. The data suggest that pressures around 15 mmHg are required to effect a positive scar response and that close experienced monitoring of garments be performed.

Cicatrix↗
PubMed1987

Use of pneumatic antishock trousers in the management of pediatric pelvic hemorrhage.

We applied pediatric pneumatic antishock trousers to five young patients who had severe pelvic fractures with evidence of significant retroperitoneal hemorrhage. The trousers were in place for 24 to 96 hours. Utilization of the trousers resulted in stabilization of vital signs and appeared to have decreased ongoing pelvic hemorrhage. No significant complications were noted. We describe a technique for long-term maintenance of pressure within the pneumatic antishock trousers.

Child↗