EXCERPT FROM: Case Report: Attempted Revascularization and Limb Salvage Converted to Above-Knee Amputation in a Case of Field Trauma

  A 23-year-old female Field Medic presented to Triage with significant lower limb trauma sustained from a Jungle-hound attack in the field. Upon initial inspection, the main presenting problem was a near transection of the left upper thigh and open fracture of the left femur with associated extensive soft tissue injuries.

  Field-based first response was provided by a party member and a medical staff who had accompanied the party as a civilian attachment. It consisted of partial traction, bandaging, analgesia, and rudimentary fluid support by the Aqua-attuned party member. The patient arrived in Triage after hours, approximately six hours post-injury, severely hypotensive and tachycardic with fluctuating levels of consciousness. Full fluid resuscitation and thermoregulatory support were commenced in Triage, and the patient was transported directly to theatres for urgent surgical intervention.

  Further elucidation of the tissue and bony damage was provided by Radiology, showing extensive lacerations involving the anteromedial aspect of the left thigh with comminuted midshaft fracture of the femur. There were partial or complete tears involving the sartorius, all four quadriceps muscles, the gracilis, and adductors. The femoral as well as the deep femoral arteries were obliterated at the level of the injury. Angiological assessment revealed extensive partial ischaemia involving the length and peripheries of the left lower limb distal to the injury. It is thought that any circulation at this stage was sustained by collateral vessels and unlikely to be viable for healing or return to function. Haemological analysis was mostly normal save for elevated markers of Maladous inflammation and the onset of rhabdomyolysis.

  At this point, a brief discussion took place regarding the relative prognoses of limb salvage versus amputation. Despite the comprehensive vascular damage, the ongoing ischaemic process involving the inferior portions of the lower limb, as well as the high risk of haemodynamic instability, the decision was made to attempt surgical revascularization and limb salvage.

  This book is hosted on another platform. Read the official version and support the author's work.

  The site was first debrided of all non-viable tissue and bony fragments. The fracture was reduced and temporary fixation applied via Aurous rods. Revascularization was attempted via ligation of the femoral artery. Anastomosis was achieved via Arboreal sutures, however, despite attempts at Aquatic stabilization, reperfusion was not achieved. Owing to multiple failed attempts at reperfusion, the patient's haemodynamic instability, and symptomatic manifestation of systemic Maladous inflammation including febrility, the decision was made to abandon limb salvage and convert to above-knee amputation.

  Following amputation, stump viability was observed via further Angiological and Plastical assessments. Via consultation with Endology, a loading dose of athracomycin was administered intravenously and therapeutic infusion commenced [Meng et al, 1586]. The patient continued to exhibit fluctuant haemodynamics and elevated inflammatory markers, and was transported to ICU for further stabilization.

  DISCUSSION

  When making emergent judgments regarding limb salvage versus amputation, multiple factors need consideration in a holistic approach, including the nature and extent of the vascular injury, the time since the initial insult, observable viability of the peripheries, systemic stability, surgical risk, the age and occupation of the patient, and functional outlook [Patel and Rao, 1604]. It is difficult to synthesize multiple, complex factors in the unstable patient. More case experience and tabulation of patient characteristics, surgical reports, and outcome parameters are needed to better inform future practice, with a view for a systematic and algorithm-based approach to management decisions. Continued sharing of relevant data and formal review of the existing literature are recommended.

  The author would like to declare that certain elements of questionable practice came to light during the initial treatment of this patient, including potential breach of professional objectivity and conflict of interest. Until further internal investigations are concluded, discussions regarding the potential breach are beyond the scope of this report. Should the results of the investigation deem the episode appropriate for and worthy of academic scrutiny, the author shall endeavour to provide subsequent discourse along with a follow-up report on the patient's outcomes.