Management of The Mangled Extremity

In the Journal of Trauma this month, the trauma dream team of Thomas Scalea and colleagues from the Shock Trauma Centre, Baltimore, Maryland have developed an algorithm for the management of the mangled extremity. They have looked at the available literature, as well as relying on expert opinion from senior members of the association to create an easy to follow algorithm that will be useful to the emergency physician at the bedside, as well as the traumatologist who is required to make critical decisions in the planning, co-ordination and definitive management of these patients.                                                                                                                 

Background:

The operative management of mangled extremities after trauma remains controversial. We have sought to develop an evidence-based algorithm to help guide practitioners when faced with these relatively infrequent but very challenging clinical dilemmas.

Methods:

The Western Trauma Association Critical Decisions Committee queried the literature to identify high-quality managements that would help guide the care of mangled extremities. When good data were not available, the Committee relied on expert opinions, either from the literature or from our senior members.

Results:

Virtually, all the scoring systems used to guide therapy have not been proven to be valid. Hemodynamically unstable patients who failed to respond to initial resuscitation should be taken to the operating room for exploration and vascular control. Those who are stable should undergo a stepwise vascular and neurologic evaluation process. A comprehensive evaluation of factors that may help predict the appropriateness of limb salvage should be done in the operating room. Patients who are not candidates for salvage should undergo primary amputation. Those who are should undergo attempts at limb salvage.

Conclusions:

Patients with mangled extremities remain a significant management challenge. This algorithm represents a guideline based on the best evidence available in the literature and expert opinion. It does not establish a standard of care. It should provide a framework for treating physicians and other healthcare professionals to guide therapy, considering individual patients' clinical status and institutional resources. 

Western Trauma Association Critical Decisions in Trauma: Management of the Mangled Extremity

Comments

[Graham]

What, no MESS score? (Great summary Amit!)

[Amit Maini]

I like the MESS Score!
Loving the look of MDCalc.