Annals of the Royal College of Surgeons of England (I979) vol 6i
ASPECTS OF TREATMENT*
Hyperbaric oxygen therapy in acute trauma R E Loder FFARCS Consdilant Anaesthetist, Peterborough District Hospital
Summary The usefulness of hyperbaric oxygen therapy in the ireatment of acute trauma is described. The results in 71 such cases are given. Introduction There is some evidence that oxygen under pressure increases the oxygen supply and utilisation in experimental acute limb ischaemia1'2. Hyperbaric oxygen therapy has been used clinically with success in one case of acute limb ischaemia due to allergic vasculitis3 and in 2 cases duie to purpura fulminans4'5. There has been only one report of its use in severe trauma, i6 such cases being treated, with success in I2 of them6. In 7 years at this hospital 7I cases of acute trauma with varying degrees of ischaemia have been referred for hyperbaric oxygen therapy, I I from other hospitals and the rest from our own surgeons. The criterion for referral used by clinicians was any degree of ischacmia, from the tip of a V of skin on an arm to a whole limb, whenever it was observed. Forty-five cases were referred immediately after primary surgical treatment and the rest at varying times after injury. This depended on distance involved or the timing of the first dressing or the changing of the first plaster of Paris.
had a chest X-ray to see that there were no cysts or cavities in the lungs and a haemoglobin estimation to make sure that anaemia was not present which might deter healing. All other treatment, such as surgery, antibiotic therapy, dressings to wounds, and physiotherapy, was continued as if hyperbaric oxygen was not being given.
Results Of the 7' patients, 53 recovered completely, Io recovered partially, and in 8 the ischaemic area was not helped by hyperbaric oxygen. The overall results can be considered in three categories. I) ISCHAEMIC SKIN LESIONS FROM RELATIVELY MINOR INJURIES
There were I8 cases of this type, all stitched wounds. Either the skin flaps or edges were white or blue at the end of the first operation or the flaps and edges looked unhealthy at the first dressing. In I5 cases the wound healed by first intention, in 2 a small area of skin died, and in I all the skin area involved died. The causes of these injuries were falls, glass, knives, a circular saw, and a bacon slicer. The ages of the patients ranged from 3 to 84 years and the length of treatment from 2 to 73 h. There were 5 circumferential incisions, 3 of fingers and 2 of noses which were completely cut off and replaced. These all healed completely save for a small area at the corner of one nostril.
Treatment The patients were treated in a Vickers singlechamber hyberbaric oxygen machine at 21 atmospheres absolute pressure. A treatment 2) ISCHAEMIC SKIN LESIONS AS PART OF MAJOR was for i h at pressure. In successful cases this INJURIES would be 3 times a day to start with and then, There were 33 of these cases. Some of the as ischaemia was obviously corrected, gradu- lesions were sutured wounds following deally reduced to once a day until healing was bridement of skin and deep tissue with, when complete. necessary, suitable treatment of fractures. In the unsuccessful cases treatment was Others were amputation flaps and partially given several times to make sure it was really sutured wounds with immediate skin grafts. ineffective and then stopped. All patients In all cases the skin survival looked doubtful. The Editor would welcome any observations on this paper from readers. '-"Fellows and Members interested in submitting papers for consideration with a view to publication in this series should first write to the Editor.
Hyperbaric oxygen therapy in acute trauma
473
In 28 cases the skin survived, in 2 some skin Complications died but most survived, and in 3 the skin in- In this series of cases no symptoms of oxygen volved all necrosed. There were io immediate toxicity were observed. A 59-year-old man skin grafts, of which 9 healed completely, ancd was diagnosed as having Parinaud's syndrome, there was I delayed graft on the 4th day which is caused by arterial thrombosis in the which survived. These were all severe acci- midbrain area, 2 days after hyperbaric oxygen dents, the causes including motor vehicles, a treatment was stopped. potato harvester, a bacon derinder, a milling Discussion machine, and other industrial and agri- It is sometimes difficult when operating on cultural machines. One case was iatrogenic accident cases to decide when to amputate in that the whole foot looked devascularised any limb or part of a limb and when to excise after an operation for the correction of club skin which looks doubtful. Putting the foot. The patients' ages ranged from 4 to patient in hyperbaric oxygen often gives the 68 years and the length of treatment from 5 to answer quickly and it is surprising how often the doubtful limb or skin area survives. A 54 hours. bonus is that the surgeon does not have to 3) MAJOR INJURIES INVOLVING WHOLE-LIMB worry about the possibility of gas gangrene infection. Indeed, it is also noticeable that IS CHAEMIA There were 20 of these cases, with I o com- aerobic infection does not take place even if whole limb dies. If hyperbaric oxygen plete recoveries, 6 partial recoveries, and 4 isthecontinued mummification takes place and failures. The failures all needed major ampu- allows amputation to be done as a planned tations. The successes included an arm procedure. almost completely torn off, the primary It is not suggested that hyperbaric oxygen operation involving arterial and venous re- therapy takes the place of any normal proconstruction and the suturing of muscles, cedure in the treatment of these injuries. It tendons, and nerves, the skin loss being does allow the surgeon greater latittude in not grafted I4 days after the accident. There removing doubtful tissue, often to the were 4 immediate skin grafts, all of which eventual benefit of the patient. survived. The partial successes were all with References gross crush injuries of limbs in which the I Stalker, C G, McEwan, A J, and Ledingham, main part survived but some fingers or toes I McA (I973) British Journal of Surgery, 6o, 14z4. died. The 4 failures were with 2 crushed Stalker, C G, and Ledingham, I McA (1973) lower limbs and an arm, all of which eventu- 2 British Journal of Surgery, 6o, 959. ally had to be amputated, and a hand 3 Monies-Chass, I, Herer, D, Alon, U, and crushed in a 300-ton press in which the Birkhahn, H J (1976) Anaesthesia, 31, I22I. fingers never recovered and had to be ampu- 4 Hjort, P F, Rapport, S I, and Jorgensen, L (i964) Scandinavian Journal of Haematology, tated. The injuries were caused by road I, i69. traffic accidents, crushings by huge weights, 5 Kuzemko, J A, and Loder, R E (1970) British and a railway accident. The patients' ages Medical Journal, 4, I57 ranged from I i to 69 years and the length 6 Szekely, 0, Szanto, G, and Takats, A (1973) Injury, 4, 294. of treatment from 3 to 49 hours.
ASPECTS OF TREATMENT*
Hyperbaric oxygen therapy in acute trauma R E Loder FFARCS Consdilant Anaesthetist, Peterborough District Hospital
Summary The usefulness of hyperbaric oxygen therapy in the ireatment of acute trauma is described. The results in 71 such cases are given. Introduction There is some evidence that oxygen under pressure increases the oxygen supply and utilisation in experimental acute limb ischaemia1'2. Hyperbaric oxygen therapy has been used clinically with success in one case of acute limb ischaemia due to allergic vasculitis3 and in 2 cases duie to purpura fulminans4'5. There has been only one report of its use in severe trauma, i6 such cases being treated, with success in I2 of them6. In 7 years at this hospital 7I cases of acute trauma with varying degrees of ischaemia have been referred for hyperbaric oxygen therapy, I I from other hospitals and the rest from our own surgeons. The criterion for referral used by clinicians was any degree of ischacmia, from the tip of a V of skin on an arm to a whole limb, whenever it was observed. Forty-five cases were referred immediately after primary surgical treatment and the rest at varying times after injury. This depended on distance involved or the timing of the first dressing or the changing of the first plaster of Paris.
had a chest X-ray to see that there were no cysts or cavities in the lungs and a haemoglobin estimation to make sure that anaemia was not present which might deter healing. All other treatment, such as surgery, antibiotic therapy, dressings to wounds, and physiotherapy, was continued as if hyperbaric oxygen was not being given.
Results Of the 7' patients, 53 recovered completely, Io recovered partially, and in 8 the ischaemic area was not helped by hyperbaric oxygen. The overall results can be considered in three categories. I) ISCHAEMIC SKIN LESIONS FROM RELATIVELY MINOR INJURIES
There were I8 cases of this type, all stitched wounds. Either the skin flaps or edges were white or blue at the end of the first operation or the flaps and edges looked unhealthy at the first dressing. In I5 cases the wound healed by first intention, in 2 a small area of skin died, and in I all the skin area involved died. The causes of these injuries were falls, glass, knives, a circular saw, and a bacon slicer. The ages of the patients ranged from 3 to 84 years and the length of treatment from 2 to 73 h. There were 5 circumferential incisions, 3 of fingers and 2 of noses which were completely cut off and replaced. These all healed completely save for a small area at the corner of one nostril.
Treatment The patients were treated in a Vickers singlechamber hyberbaric oxygen machine at 21 atmospheres absolute pressure. A treatment 2) ISCHAEMIC SKIN LESIONS AS PART OF MAJOR was for i h at pressure. In successful cases this INJURIES would be 3 times a day to start with and then, There were 33 of these cases. Some of the as ischaemia was obviously corrected, gradu- lesions were sutured wounds following deally reduced to once a day until healing was bridement of skin and deep tissue with, when complete. necessary, suitable treatment of fractures. In the unsuccessful cases treatment was Others were amputation flaps and partially given several times to make sure it was really sutured wounds with immediate skin grafts. ineffective and then stopped. All patients In all cases the skin survival looked doubtful. The Editor would welcome any observations on this paper from readers. '-"Fellows and Members interested in submitting papers for consideration with a view to publication in this series should first write to the Editor.
Hyperbaric oxygen therapy in acute trauma
473
In 28 cases the skin survived, in 2 some skin Complications died but most survived, and in 3 the skin in- In this series of cases no symptoms of oxygen volved all necrosed. There were io immediate toxicity were observed. A 59-year-old man skin grafts, of which 9 healed completely, ancd was diagnosed as having Parinaud's syndrome, there was I delayed graft on the 4th day which is caused by arterial thrombosis in the which survived. These were all severe acci- midbrain area, 2 days after hyperbaric oxygen dents, the causes including motor vehicles, a treatment was stopped. potato harvester, a bacon derinder, a milling Discussion machine, and other industrial and agri- It is sometimes difficult when operating on cultural machines. One case was iatrogenic accident cases to decide when to amputate in that the whole foot looked devascularised any limb or part of a limb and when to excise after an operation for the correction of club skin which looks doubtful. Putting the foot. The patients' ages ranged from 4 to patient in hyperbaric oxygen often gives the 68 years and the length of treatment from 5 to answer quickly and it is surprising how often the doubtful limb or skin area survives. A 54 hours. bonus is that the surgeon does not have to 3) MAJOR INJURIES INVOLVING WHOLE-LIMB worry about the possibility of gas gangrene infection. Indeed, it is also noticeable that IS CHAEMIA There were 20 of these cases, with I o com- aerobic infection does not take place even if whole limb dies. If hyperbaric oxygen plete recoveries, 6 partial recoveries, and 4 isthecontinued mummification takes place and failures. The failures all needed major ampu- allows amputation to be done as a planned tations. The successes included an arm procedure. almost completely torn off, the primary It is not suggested that hyperbaric oxygen operation involving arterial and venous re- therapy takes the place of any normal proconstruction and the suturing of muscles, cedure in the treatment of these injuries. It tendons, and nerves, the skin loss being does allow the surgeon greater latittude in not grafted I4 days after the accident. There removing doubtful tissue, often to the were 4 immediate skin grafts, all of which eventual benefit of the patient. survived. The partial successes were all with References gross crush injuries of limbs in which the I Stalker, C G, McEwan, A J, and Ledingham, main part survived but some fingers or toes I McA (I973) British Journal of Surgery, 6o, 14z4. died. The 4 failures were with 2 crushed Stalker, C G, and Ledingham, I McA (1973) lower limbs and an arm, all of which eventu- 2 British Journal of Surgery, 6o, 959. ally had to be amputated, and a hand 3 Monies-Chass, I, Herer, D, Alon, U, and crushed in a 300-ton press in which the Birkhahn, H J (1976) Anaesthesia, 31, I22I. fingers never recovered and had to be ampu- 4 Hjort, P F, Rapport, S I, and Jorgensen, L (i964) Scandinavian Journal of Haematology, tated. The injuries were caused by road I, i69. traffic accidents, crushings by huge weights, 5 Kuzemko, J A, and Loder, R E (1970) British and a railway accident. The patients' ages Medical Journal, 4, I57 ranged from I i to 69 years and the length 6 Szekely, 0, Szanto, G, and Takats, A (1973) Injury, 4, 294. of treatment from 3 to 49 hours.
