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Grand Rounds: Woman, 30, Survives Near-Exsanguination
While waiting to cross a street, a 30-year-old woman was suddenly struck by an oncoming vehicle, which crushed her legs against a parked automobile. She sustained a life-threatening traumatic injury and nearly exsanguinated at the scene. Nearby pedestrians assisted her, including a man who applied his belt to the woman’s left thigh to prevent complete exsanguination following the crush. She was emergently transported to an adult regional trauma center and admitted to the ICU.
The patient was given multiple transfusions of packed red blood cells, platelets, and frozen plasma in attempts to restore hemostasis. She underwent emergent surgery for a complete washout, debridement, and compartment fasciotomy on the right leg. The left leg required an above-knee amputation. Following surgery, full-thickness and split-thickness wounds were present on both extremities.
Before the accident, the woman had a history of hypertension controlled with a single antihypertensive. She was obese, with a BMI of 31.9. She had no surgical history. She denied excessive alcohol consumption, illicit drug use, or smoking. She was unaware of having any food or drug allergies.
The woman was married and had a 6-month-old baby. Until her accident, she was employed full-time as an investment accountant. She expressed contentment regarding her home, family, work, and busy lifestyle.
Once the patient’s condition was stabilized and hemostasis achieved in the trauma ICU, the bilateral lower-extremity wounds were managed by application of foam dressings via negative-pressure therapy. The dressings were changed on the patient’s lower-extremity wounds three times per week for about three weeks. When the wounds’ depth decreased and granulation was achieved, split-thickness skin grafts (STSGs) harvested from the right anterior thigh were applied to the open wounds (see Figure 1) in the operating room.
Following application of the STSGs and hemostasis of the patient’s donor site, silver silicone foam dressings were applied directly over the right lower-extremity graft and the donor site in the operating room. The dressings remained in place for four days (see Figure 2). A nonadherent, petrolatum-based contact layer was then applied to the left lower-extremity amputation graft site, followed by a negative-pressure foam dressing.
The negative-pressure pump was programmed for 75 mm Hg continuous therapy for four days. The silver silicone foam and negative-pressure foam dressings were removed from the respective graft sites on the fourth postpostoperative day. The grafts were viable and intact (see Figures 3 and 4). The silver silicone foam was reapplied to the lower-extremity STSGs and donor site and changed every four days.
When a few pinpoint dehisced areas were noted on the grafts, a silver-coated absorbent antimicrobial dressing was applied. A nonadherent, petrolatum-based contact layer, followed by wide-mesh stretch gauze, was secured as an exterior dressing over the graft sites. Both lower-extremity dressings were layered with elastic wraps to prevent edema. The dressings were changed daily for two weeks.
On postoperative Day 4, the silver silicone foam was removed from the donor site. A nonadherent contact layer of bismuth tribromophenate petrolatum, followed by the silver silicone foam, was selected for placement over the donor site. Gauze and an elastic wrap were secured as an exterior dressing and removed three days later.
The donor site dressing was reduced to a layer of bismuth tribromophenate petrolatum and left open to air. As the edges of the nonadherent contact layer dried, they were trimmed with scissors (see Figure 5). A moisturizing cocoa butter–based lotion was applied daily to the exposed areas of the donor site.
During the patient’s third postoperative week at the trauma center, as she underwent a continuum of aggressive rehabilitation and wound care, the donor and STSG sites were pronounced healed (see Figures 6, 7, and 8). The donor site was left open to air, with daily use of cocoa butter lotion. Maintenance care of the graft sites included daily application of cocoa butter lotion, stretch gauze, and elastic wraps. The patient was discharged from the rehabilitation unit to home, where she awaited a prosthetic fitting.
Throughout the patient’s hospitalization and rehabilitation, surgical, medical, pain, and nutrition management were monitored on a continuum, as were laboratory values. Her vital signs remained within reasonable limits. The patient remained infection free and experienced neither medical nor surgical complications during the course of her hospital stay.
DISCUSSION
Traumatic injuries often result in bodily deformities, amputations, and death. They represent the leading cause of death among people in the US younger than 45.1,2
Compartment syndrome develops when increased pressure within a bodily cavity minimizes capillary perfusion, resulting in decreased tissue viability.3 Edema and hemorrhage are also precipitating factors for this condition.3 When it goes unrelieved, compromised circulation can lead to muscle devitalization. Amputation of the affected appendage may be necessary unless circulation is restored.
Surgical fasciotomy can help alleviate pressure within the musculofascial compartment to improve circulation.4 Typically, such a procedure leaves large open wounds—a challenge for the clinician who cares for the affected patient. Once the wound is stabilized and the tissue becomes viable with granulation, application of an STSG can be considered.5,6
STSGs provide effective closure for open wounds. The grafting procedure entails removing, processing, and placing a portion of skin, both epidermal and partial dermal layers, on an open wound. Successful grafting requires adequate circulation, but excess bacteria can impede graft viability.7 Graft sites must be kept clean and moist without edema.5 Immediate application of negative-pressure therapy directly on an STSG has been shown to result in an outstanding graft “take,” as compared with use of traditional dressings.5,6,8
Nutritional status must be optimal for a successful graft take, with adequate intake of protein, calories, fluids, vitamins, and minerals.9,10
Treatment
Since days of old when traumatic wounds were treated with goat dung and honey, an array of methods and products has been developed, including numerous agents for cutaneous injuries alone.4 Occlusive, semiocclusive, or bacteriostatic topical ointments, foam, silver, or a combination of products can be used to manage and heal surgical wounds, grafts (including STSGs), and donor sites.11,12
Currently, negative pressure is also used in STSGs to accelerate healing.7,11 When applied to a wound, negative-pressure therapy enhances granulation, removes excess exudate, and creates a moist environment for healing.5,13
Silver-coated absorbent antimicrobial dressings appear to reduce bacteria on the surface of the wound surfaces and postoperative surgical sites without inducing bacterial resistance or adversely affecting healthy tissue.12,14-16 Silver silicone foam reduces bacterial colonization on wound surfaces and absorbs exudate into the foam dressing.17,18 Wounds with devitalized tissue and excessive drainage are at risk for infection, inflammation, and chronic duration.19
Nutrition
It has been reported that about half of all persons admitted to US hospitals are malnourished, with increased risk for morbidity and mortality.20 After experiencing hemorrhage, even well-nourished patients require additional protein and iron for successful recovery.10 Obese patients appear more susceptible to infection and surgical wound dehiscence than are their thinner counterparts, but further research is needed to study the impact of wound development and healing in this population.14
Tissue regeneration is known to require the amino acids arginine and glutamine for the construction of protein; additional research is also needed to support the theory that supplemental glutamine promotes wound healing.9,21 Surgical patients and patients with wounds benefit from protein-enhanced diets; zinc and vitamins A and C can also help improve wound healing and clinical outcomes.22 Monitoring protein and prealbumin levels is helpful in evaluating nutritional status, allowing the clinician to modify the medical nutrition plan and optimize the patient’s health and wellness.22
Rehabilitation
Surgical amputations of the lower extremities impair balance and mobility, necessitating extensive physical therapy and rehabilitation for affected patients.23,24 Aggressive rehabilitation typically is exhausting for patients. It is important to initiate a supportive team approach (including physical and occupational therapists) soon after surgery, continuing beyond the acute hospitalization into rehabilitation. Individualized, patient-centered goals are targeted and amended as necessary. Physical and occupational therapy increase in intensity and duration to optimize the patient’s functionality. Prosthetic fitting takes place after edema diminishes and the limb is fully healed.24
Patient Outcome
An obese young woman who sustained traumatic lower-extremity injuries and amputation experienced an optimal clinical outcome after 54 days of management. Exceptional surgical and medical strategies were initiated in the adult regional trauma center’s ICU and concluded at the adjoining rehabilitation center.
Strategic selection of products and interventions—negative pressure, silver silicone foam, silver-coated absorbent antimicrobial dressings, nonadherent contact layers, stretch gauze, and elastic wraps—and constant monitoring, including that of the patient’s nutritional status, resulted in expedient resolution of her traumatic wounds, STSGs, and donor site.
CONCLUSION
Despite revolutionary advances and life-sustaining measures in the surgical, medical, and wound care arena, traumatic events remain potentially debilitating and life-threatening for young adults. Triage of the trauma patient for appropriate medical care and collaborative management involving a team of trauma specialists and clinicians of all disciplines can now provide life-sustaining opportunities for these patients.
1. WISQARS™ (Web-based Injury Statistics Query and Reporting System). Leading Causes of Death Reports, 1999–2007. webappa.cdc.gov/sasweb/ncipc/leadcaus10.html. June 18, 2010.
2. Sasser SM, Hunt RC, Sullivent EE, et al; CDC. Guidelines for field triage of injured patients: recommendations of the National Expert Panel on Field Triage. MMWR Morb Mortal Wkly Rep. 2009;58(RR01): 1-35.
3. Feliciano DV. The management of extremity compartment syndrome. In: Cameron JL, ed. Current Surgical Therapy. 9th ed. Philadelphia, PA: Elsevier; 2008:1032-1036.
4. Kaufmann CR. Initial assessment and management. In: Feliciano DV, Mattox KL, Moore EE, eds. Trauma. 6th ed. New York: McGraw-Hill; 2008:169-184.
5. Mendez-Eastman S. Guidelines for using negative pressure wound therapy. Adv Skin Wound Care. 2001;14(6):314-322.
6. Snyder RJ, Doyle H, Delbridge T. Applying split-thickness skin grafts: a step-by-step clinical guide and nursing implications. Ostomy Wound Manage. 2001;47(11):20-26.
7. Sood R. Achauer and Sood’s Burn Surgery, Reconstruction and Rehabilitation. Philadelphia: WB Saunders. 2006.
8. Hanasono MM, Skoracki RJ. Securing skin grafts to microvascular free flaps using the vacuum-assisted closure (VAC) device. Ann Plast Surg. 2007;58(5):573-576.
9. Dorner B, Posthauer ME, Thomas D; National Pressure Ulcer Advisory Panel. The role of nutrition in pressure ulcer prevention and treatment (2009). www.npuap.org/Nutrition%20White%20Paper%20Website%20Version.pdf. Accessed June 18, 2010.
10. Frankenfield D. Energy expenditure and protein requirements after traumatic injury. Nutr Clin Pract. 2006;21(5):430-437.
11. Greenhalgh D. Topical antimicrobial agents for burn wounds. Clin Plast Surg. 2009;36(4):597-606.
12. Castellano JJ, Shafii SM, Ko F, et al. Comparative evaluation of silver-containing antimicrobial dressings and drugs. Int Wound J. 2007;4(2):114-122.
13. Baharestani MM. Negative pressure wound therapy in the adjunctive management of necrotizing fasciitis: examining clinical outcomes. Ostomy Wound Manage. 2008;54(4):44-50.
14. Childress BB, Berceli SA, Nelson PR, et al. Impact of an absorbent silver-eluting dressing system on lower extremity revascularization wound complications. Ann Vasc Surg. 2007;21(5):598-602.
15. Sibbald RG, Contreras-Ruiz J, Coutts P, et al. Bacteriology, inflammation, and healing: a study of nanocrystalline silver dressings in chronic venous leg ulcers. Adv Skin Wound Care. 2007;20(10):549-558.
16. Brett DW. A discussion of silver as an antimicrobial agent: alleviating the confusion. Ostomy Wound Manage. 2006;52(1):34-41.
17. Barrett S. Mepilex Ag: an antimicrobial, absorbent foam dressing with Safetac technology. Br J Nurs. 2009;18(20):S28, S30-S36.
18. Barrows C. Enhancing patient outcomes—reducing the bottom line: the use of antimicrobial soft silicone foam dressing in home health. Home Healthc Nurse. 2009;27(5):279-284.
19. National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Prevention and treatment of pressure ulcers: clinical practice guideline. Washington, DC: National Pressure Ulcer Advisory Panel; 2009.
20. Naber TH, Schermer T, de Bree A, et al. Prevalence of malnutrition in nonsurgical hospitalized patients and its association with disease complications. Am J Clin Nutr. 1997;66(5):1232-1239.
21. Ziegler TR, Benfell K, Smith RJ, et al. Safety and metabolic effects of L-glutamine administration in humans. JPEN J Parenter Enteral Nutr. 1990;14(4 suppl):137S-146S.
22. Skin conditions, pressure ulcers, and vitamin deficiencies. In: Escott-Stump S. Nutrition and Diagnosis–Related Care. 6th ed. Baltimore: Lippincott Williams & Wilkins. 2007:108-117.
23. van Velzen JM, van Bennekom CA, Polomski W, et al. Physical capacity and walking ability after lower limb amputation: a systematic review. Clin Rehabil. 2006;20(11):999-1016.
24. Ehlers CF. Integumentary disease and disorders/wound management. In: Malone DJ, Lindsay KLB, eds. Physical Therapy in Acute Care: A Clinician’s Guide. Thorofare, NJ: Slack Inc US; 2006:585-616.
While waiting to cross a street, a 30-year-old woman was suddenly struck by an oncoming vehicle, which crushed her legs against a parked automobile. She sustained a life-threatening traumatic injury and nearly exsanguinated at the scene. Nearby pedestrians assisted her, including a man who applied his belt to the woman’s left thigh to prevent complete exsanguination following the crush. She was emergently transported to an adult regional trauma center and admitted to the ICU.
The patient was given multiple transfusions of packed red blood cells, platelets, and frozen plasma in attempts to restore hemostasis. She underwent emergent surgery for a complete washout, debridement, and compartment fasciotomy on the right leg. The left leg required an above-knee amputation. Following surgery, full-thickness and split-thickness wounds were present on both extremities.
Before the accident, the woman had a history of hypertension controlled with a single antihypertensive. She was obese, with a BMI of 31.9. She had no surgical history. She denied excessive alcohol consumption, illicit drug use, or smoking. She was unaware of having any food or drug allergies.
The woman was married and had a 6-month-old baby. Until her accident, she was employed full-time as an investment accountant. She expressed contentment regarding her home, family, work, and busy lifestyle.
Once the patient’s condition was stabilized and hemostasis achieved in the trauma ICU, the bilateral lower-extremity wounds were managed by application of foam dressings via negative-pressure therapy. The dressings were changed on the patient’s lower-extremity wounds three times per week for about three weeks. When the wounds’ depth decreased and granulation was achieved, split-thickness skin grafts (STSGs) harvested from the right anterior thigh were applied to the open wounds (see Figure 1) in the operating room.
Following application of the STSGs and hemostasis of the patient’s donor site, silver silicone foam dressings were applied directly over the right lower-extremity graft and the donor site in the operating room. The dressings remained in place for four days (see Figure 2). A nonadherent, petrolatum-based contact layer was then applied to the left lower-extremity amputation graft site, followed by a negative-pressure foam dressing.
The negative-pressure pump was programmed for 75 mm Hg continuous therapy for four days. The silver silicone foam and negative-pressure foam dressings were removed from the respective graft sites on the fourth postpostoperative day. The grafts were viable and intact (see Figures 3 and 4). The silver silicone foam was reapplied to the lower-extremity STSGs and donor site and changed every four days.
When a few pinpoint dehisced areas were noted on the grafts, a silver-coated absorbent antimicrobial dressing was applied. A nonadherent, petrolatum-based contact layer, followed by wide-mesh stretch gauze, was secured as an exterior dressing over the graft sites. Both lower-extremity dressings were layered with elastic wraps to prevent edema. The dressings were changed daily for two weeks.
On postoperative Day 4, the silver silicone foam was removed from the donor site. A nonadherent contact layer of bismuth tribromophenate petrolatum, followed by the silver silicone foam, was selected for placement over the donor site. Gauze and an elastic wrap were secured as an exterior dressing and removed three days later.
The donor site dressing was reduced to a layer of bismuth tribromophenate petrolatum and left open to air. As the edges of the nonadherent contact layer dried, they were trimmed with scissors (see Figure 5). A moisturizing cocoa butter–based lotion was applied daily to the exposed areas of the donor site.
During the patient’s third postoperative week at the trauma center, as she underwent a continuum of aggressive rehabilitation and wound care, the donor and STSG sites were pronounced healed (see Figures 6, 7, and 8). The donor site was left open to air, with daily use of cocoa butter lotion. Maintenance care of the graft sites included daily application of cocoa butter lotion, stretch gauze, and elastic wraps. The patient was discharged from the rehabilitation unit to home, where she awaited a prosthetic fitting.
Throughout the patient’s hospitalization and rehabilitation, surgical, medical, pain, and nutrition management were monitored on a continuum, as were laboratory values. Her vital signs remained within reasonable limits. The patient remained infection free and experienced neither medical nor surgical complications during the course of her hospital stay.
DISCUSSION
Traumatic injuries often result in bodily deformities, amputations, and death. They represent the leading cause of death among people in the US younger than 45.1,2
Compartment syndrome develops when increased pressure within a bodily cavity minimizes capillary perfusion, resulting in decreased tissue viability.3 Edema and hemorrhage are also precipitating factors for this condition.3 When it goes unrelieved, compromised circulation can lead to muscle devitalization. Amputation of the affected appendage may be necessary unless circulation is restored.
Surgical fasciotomy can help alleviate pressure within the musculofascial compartment to improve circulation.4 Typically, such a procedure leaves large open wounds—a challenge for the clinician who cares for the affected patient. Once the wound is stabilized and the tissue becomes viable with granulation, application of an STSG can be considered.5,6
STSGs provide effective closure for open wounds. The grafting procedure entails removing, processing, and placing a portion of skin, both epidermal and partial dermal layers, on an open wound. Successful grafting requires adequate circulation, but excess bacteria can impede graft viability.7 Graft sites must be kept clean and moist without edema.5 Immediate application of negative-pressure therapy directly on an STSG has been shown to result in an outstanding graft “take,” as compared with use of traditional dressings.5,6,8
Nutritional status must be optimal for a successful graft take, with adequate intake of protein, calories, fluids, vitamins, and minerals.9,10
Treatment
Since days of old when traumatic wounds were treated with goat dung and honey, an array of methods and products has been developed, including numerous agents for cutaneous injuries alone.4 Occlusive, semiocclusive, or bacteriostatic topical ointments, foam, silver, or a combination of products can be used to manage and heal surgical wounds, grafts (including STSGs), and donor sites.11,12
Currently, negative pressure is also used in STSGs to accelerate healing.7,11 When applied to a wound, negative-pressure therapy enhances granulation, removes excess exudate, and creates a moist environment for healing.5,13
Silver-coated absorbent antimicrobial dressings appear to reduce bacteria on the surface of the wound surfaces and postoperative surgical sites without inducing bacterial resistance or adversely affecting healthy tissue.12,14-16 Silver silicone foam reduces bacterial colonization on wound surfaces and absorbs exudate into the foam dressing.17,18 Wounds with devitalized tissue and excessive drainage are at risk for infection, inflammation, and chronic duration.19
Nutrition
It has been reported that about half of all persons admitted to US hospitals are malnourished, with increased risk for morbidity and mortality.20 After experiencing hemorrhage, even well-nourished patients require additional protein and iron for successful recovery.10 Obese patients appear more susceptible to infection and surgical wound dehiscence than are their thinner counterparts, but further research is needed to study the impact of wound development and healing in this population.14
Tissue regeneration is known to require the amino acids arginine and glutamine for the construction of protein; additional research is also needed to support the theory that supplemental glutamine promotes wound healing.9,21 Surgical patients and patients with wounds benefit from protein-enhanced diets; zinc and vitamins A and C can also help improve wound healing and clinical outcomes.22 Monitoring protein and prealbumin levels is helpful in evaluating nutritional status, allowing the clinician to modify the medical nutrition plan and optimize the patient’s health and wellness.22
Rehabilitation
Surgical amputations of the lower extremities impair balance and mobility, necessitating extensive physical therapy and rehabilitation for affected patients.23,24 Aggressive rehabilitation typically is exhausting for patients. It is important to initiate a supportive team approach (including physical and occupational therapists) soon after surgery, continuing beyond the acute hospitalization into rehabilitation. Individualized, patient-centered goals are targeted and amended as necessary. Physical and occupational therapy increase in intensity and duration to optimize the patient’s functionality. Prosthetic fitting takes place after edema diminishes and the limb is fully healed.24
Patient Outcome
An obese young woman who sustained traumatic lower-extremity injuries and amputation experienced an optimal clinical outcome after 54 days of management. Exceptional surgical and medical strategies were initiated in the adult regional trauma center’s ICU and concluded at the adjoining rehabilitation center.
Strategic selection of products and interventions—negative pressure, silver silicone foam, silver-coated absorbent antimicrobial dressings, nonadherent contact layers, stretch gauze, and elastic wraps—and constant monitoring, including that of the patient’s nutritional status, resulted in expedient resolution of her traumatic wounds, STSGs, and donor site.
CONCLUSION
Despite revolutionary advances and life-sustaining measures in the surgical, medical, and wound care arena, traumatic events remain potentially debilitating and life-threatening for young adults. Triage of the trauma patient for appropriate medical care and collaborative management involving a team of trauma specialists and clinicians of all disciplines can now provide life-sustaining opportunities for these patients.
While waiting to cross a street, a 30-year-old woman was suddenly struck by an oncoming vehicle, which crushed her legs against a parked automobile. She sustained a life-threatening traumatic injury and nearly exsanguinated at the scene. Nearby pedestrians assisted her, including a man who applied his belt to the woman’s left thigh to prevent complete exsanguination following the crush. She was emergently transported to an adult regional trauma center and admitted to the ICU.
The patient was given multiple transfusions of packed red blood cells, platelets, and frozen plasma in attempts to restore hemostasis. She underwent emergent surgery for a complete washout, debridement, and compartment fasciotomy on the right leg. The left leg required an above-knee amputation. Following surgery, full-thickness and split-thickness wounds were present on both extremities.
Before the accident, the woman had a history of hypertension controlled with a single antihypertensive. She was obese, with a BMI of 31.9. She had no surgical history. She denied excessive alcohol consumption, illicit drug use, or smoking. She was unaware of having any food or drug allergies.
The woman was married and had a 6-month-old baby. Until her accident, she was employed full-time as an investment accountant. She expressed contentment regarding her home, family, work, and busy lifestyle.
Once the patient’s condition was stabilized and hemostasis achieved in the trauma ICU, the bilateral lower-extremity wounds were managed by application of foam dressings via negative-pressure therapy. The dressings were changed on the patient’s lower-extremity wounds three times per week for about three weeks. When the wounds’ depth decreased and granulation was achieved, split-thickness skin grafts (STSGs) harvested from the right anterior thigh were applied to the open wounds (see Figure 1) in the operating room.
Following application of the STSGs and hemostasis of the patient’s donor site, silver silicone foam dressings were applied directly over the right lower-extremity graft and the donor site in the operating room. The dressings remained in place for four days (see Figure 2). A nonadherent, petrolatum-based contact layer was then applied to the left lower-extremity amputation graft site, followed by a negative-pressure foam dressing.
The negative-pressure pump was programmed for 75 mm Hg continuous therapy for four days. The silver silicone foam and negative-pressure foam dressings were removed from the respective graft sites on the fourth postpostoperative day. The grafts were viable and intact (see Figures 3 and 4). The silver silicone foam was reapplied to the lower-extremity STSGs and donor site and changed every four days.
When a few pinpoint dehisced areas were noted on the grafts, a silver-coated absorbent antimicrobial dressing was applied. A nonadherent, petrolatum-based contact layer, followed by wide-mesh stretch gauze, was secured as an exterior dressing over the graft sites. Both lower-extremity dressings were layered with elastic wraps to prevent edema. The dressings were changed daily for two weeks.
On postoperative Day 4, the silver silicone foam was removed from the donor site. A nonadherent contact layer of bismuth tribromophenate petrolatum, followed by the silver silicone foam, was selected for placement over the donor site. Gauze and an elastic wrap were secured as an exterior dressing and removed three days later.
The donor site dressing was reduced to a layer of bismuth tribromophenate petrolatum and left open to air. As the edges of the nonadherent contact layer dried, they were trimmed with scissors (see Figure 5). A moisturizing cocoa butter–based lotion was applied daily to the exposed areas of the donor site.
During the patient’s third postoperative week at the trauma center, as she underwent a continuum of aggressive rehabilitation and wound care, the donor and STSG sites were pronounced healed (see Figures 6, 7, and 8). The donor site was left open to air, with daily use of cocoa butter lotion. Maintenance care of the graft sites included daily application of cocoa butter lotion, stretch gauze, and elastic wraps. The patient was discharged from the rehabilitation unit to home, where she awaited a prosthetic fitting.
Throughout the patient’s hospitalization and rehabilitation, surgical, medical, pain, and nutrition management were monitored on a continuum, as were laboratory values. Her vital signs remained within reasonable limits. The patient remained infection free and experienced neither medical nor surgical complications during the course of her hospital stay.
DISCUSSION
Traumatic injuries often result in bodily deformities, amputations, and death. They represent the leading cause of death among people in the US younger than 45.1,2
Compartment syndrome develops when increased pressure within a bodily cavity minimizes capillary perfusion, resulting in decreased tissue viability.3 Edema and hemorrhage are also precipitating factors for this condition.3 When it goes unrelieved, compromised circulation can lead to muscle devitalization. Amputation of the affected appendage may be necessary unless circulation is restored.
Surgical fasciotomy can help alleviate pressure within the musculofascial compartment to improve circulation.4 Typically, such a procedure leaves large open wounds—a challenge for the clinician who cares for the affected patient. Once the wound is stabilized and the tissue becomes viable with granulation, application of an STSG can be considered.5,6
STSGs provide effective closure for open wounds. The grafting procedure entails removing, processing, and placing a portion of skin, both epidermal and partial dermal layers, on an open wound. Successful grafting requires adequate circulation, but excess bacteria can impede graft viability.7 Graft sites must be kept clean and moist without edema.5 Immediate application of negative-pressure therapy directly on an STSG has been shown to result in an outstanding graft “take,” as compared with use of traditional dressings.5,6,8
Nutritional status must be optimal for a successful graft take, with adequate intake of protein, calories, fluids, vitamins, and minerals.9,10
Treatment
Since days of old when traumatic wounds were treated with goat dung and honey, an array of methods and products has been developed, including numerous agents for cutaneous injuries alone.4 Occlusive, semiocclusive, or bacteriostatic topical ointments, foam, silver, or a combination of products can be used to manage and heal surgical wounds, grafts (including STSGs), and donor sites.11,12
Currently, negative pressure is also used in STSGs to accelerate healing.7,11 When applied to a wound, negative-pressure therapy enhances granulation, removes excess exudate, and creates a moist environment for healing.5,13
Silver-coated absorbent antimicrobial dressings appear to reduce bacteria on the surface of the wound surfaces and postoperative surgical sites without inducing bacterial resistance or adversely affecting healthy tissue.12,14-16 Silver silicone foam reduces bacterial colonization on wound surfaces and absorbs exudate into the foam dressing.17,18 Wounds with devitalized tissue and excessive drainage are at risk for infection, inflammation, and chronic duration.19
Nutrition
It has been reported that about half of all persons admitted to US hospitals are malnourished, with increased risk for morbidity and mortality.20 After experiencing hemorrhage, even well-nourished patients require additional protein and iron for successful recovery.10 Obese patients appear more susceptible to infection and surgical wound dehiscence than are their thinner counterparts, but further research is needed to study the impact of wound development and healing in this population.14
Tissue regeneration is known to require the amino acids arginine and glutamine for the construction of protein; additional research is also needed to support the theory that supplemental glutamine promotes wound healing.9,21 Surgical patients and patients with wounds benefit from protein-enhanced diets; zinc and vitamins A and C can also help improve wound healing and clinical outcomes.22 Monitoring protein and prealbumin levels is helpful in evaluating nutritional status, allowing the clinician to modify the medical nutrition plan and optimize the patient’s health and wellness.22
Rehabilitation
Surgical amputations of the lower extremities impair balance and mobility, necessitating extensive physical therapy and rehabilitation for affected patients.23,24 Aggressive rehabilitation typically is exhausting for patients. It is important to initiate a supportive team approach (including physical and occupational therapists) soon after surgery, continuing beyond the acute hospitalization into rehabilitation. Individualized, patient-centered goals are targeted and amended as necessary. Physical and occupational therapy increase in intensity and duration to optimize the patient’s functionality. Prosthetic fitting takes place after edema diminishes and the limb is fully healed.24
Patient Outcome
An obese young woman who sustained traumatic lower-extremity injuries and amputation experienced an optimal clinical outcome after 54 days of management. Exceptional surgical and medical strategies were initiated in the adult regional trauma center’s ICU and concluded at the adjoining rehabilitation center.
Strategic selection of products and interventions—negative pressure, silver silicone foam, silver-coated absorbent antimicrobial dressings, nonadherent contact layers, stretch gauze, and elastic wraps—and constant monitoring, including that of the patient’s nutritional status, resulted in expedient resolution of her traumatic wounds, STSGs, and donor site.
CONCLUSION
Despite revolutionary advances and life-sustaining measures in the surgical, medical, and wound care arena, traumatic events remain potentially debilitating and life-threatening for young adults. Triage of the trauma patient for appropriate medical care and collaborative management involving a team of trauma specialists and clinicians of all disciplines can now provide life-sustaining opportunities for these patients.
1. WISQARS™ (Web-based Injury Statistics Query and Reporting System). Leading Causes of Death Reports, 1999–2007. webappa.cdc.gov/sasweb/ncipc/leadcaus10.html. June 18, 2010.
2. Sasser SM, Hunt RC, Sullivent EE, et al; CDC. Guidelines for field triage of injured patients: recommendations of the National Expert Panel on Field Triage. MMWR Morb Mortal Wkly Rep. 2009;58(RR01): 1-35.
3. Feliciano DV. The management of extremity compartment syndrome. In: Cameron JL, ed. Current Surgical Therapy. 9th ed. Philadelphia, PA: Elsevier; 2008:1032-1036.
4. Kaufmann CR. Initial assessment and management. In: Feliciano DV, Mattox KL, Moore EE, eds. Trauma. 6th ed. New York: McGraw-Hill; 2008:169-184.
5. Mendez-Eastman S. Guidelines for using negative pressure wound therapy. Adv Skin Wound Care. 2001;14(6):314-322.
6. Snyder RJ, Doyle H, Delbridge T. Applying split-thickness skin grafts: a step-by-step clinical guide and nursing implications. Ostomy Wound Manage. 2001;47(11):20-26.
7. Sood R. Achauer and Sood’s Burn Surgery, Reconstruction and Rehabilitation. Philadelphia: WB Saunders. 2006.
8. Hanasono MM, Skoracki RJ. Securing skin grafts to microvascular free flaps using the vacuum-assisted closure (VAC) device. Ann Plast Surg. 2007;58(5):573-576.
9. Dorner B, Posthauer ME, Thomas D; National Pressure Ulcer Advisory Panel. The role of nutrition in pressure ulcer prevention and treatment (2009). www.npuap.org/Nutrition%20White%20Paper%20Website%20Version.pdf. Accessed June 18, 2010.
10. Frankenfield D. Energy expenditure and protein requirements after traumatic injury. Nutr Clin Pract. 2006;21(5):430-437.
11. Greenhalgh D. Topical antimicrobial agents for burn wounds. Clin Plast Surg. 2009;36(4):597-606.
12. Castellano JJ, Shafii SM, Ko F, et al. Comparative evaluation of silver-containing antimicrobial dressings and drugs. Int Wound J. 2007;4(2):114-122.
13. Baharestani MM. Negative pressure wound therapy in the adjunctive management of necrotizing fasciitis: examining clinical outcomes. Ostomy Wound Manage. 2008;54(4):44-50.
14. Childress BB, Berceli SA, Nelson PR, et al. Impact of an absorbent silver-eluting dressing system on lower extremity revascularization wound complications. Ann Vasc Surg. 2007;21(5):598-602.
15. Sibbald RG, Contreras-Ruiz J, Coutts P, et al. Bacteriology, inflammation, and healing: a study of nanocrystalline silver dressings in chronic venous leg ulcers. Adv Skin Wound Care. 2007;20(10):549-558.
16. Brett DW. A discussion of silver as an antimicrobial agent: alleviating the confusion. Ostomy Wound Manage. 2006;52(1):34-41.
17. Barrett S. Mepilex Ag: an antimicrobial, absorbent foam dressing with Safetac technology. Br J Nurs. 2009;18(20):S28, S30-S36.
18. Barrows C. Enhancing patient outcomes—reducing the bottom line: the use of antimicrobial soft silicone foam dressing in home health. Home Healthc Nurse. 2009;27(5):279-284.
19. National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Prevention and treatment of pressure ulcers: clinical practice guideline. Washington, DC: National Pressure Ulcer Advisory Panel; 2009.
20. Naber TH, Schermer T, de Bree A, et al. Prevalence of malnutrition in nonsurgical hospitalized patients and its association with disease complications. Am J Clin Nutr. 1997;66(5):1232-1239.
21. Ziegler TR, Benfell K, Smith RJ, et al. Safety and metabolic effects of L-glutamine administration in humans. JPEN J Parenter Enteral Nutr. 1990;14(4 suppl):137S-146S.
22. Skin conditions, pressure ulcers, and vitamin deficiencies. In: Escott-Stump S. Nutrition and Diagnosis–Related Care. 6th ed. Baltimore: Lippincott Williams & Wilkins. 2007:108-117.
23. van Velzen JM, van Bennekom CA, Polomski W, et al. Physical capacity and walking ability after lower limb amputation: a systematic review. Clin Rehabil. 2006;20(11):999-1016.
24. Ehlers CF. Integumentary disease and disorders/wound management. In: Malone DJ, Lindsay KLB, eds. Physical Therapy in Acute Care: A Clinician’s Guide. Thorofare, NJ: Slack Inc US; 2006:585-616.
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13. Baharestani MM. Negative pressure wound therapy in the adjunctive management of necrotizing fasciitis: examining clinical outcomes. Ostomy Wound Manage. 2008;54(4):44-50.
14. Childress BB, Berceli SA, Nelson PR, et al. Impact of an absorbent silver-eluting dressing system on lower extremity revascularization wound complications. Ann Vasc Surg. 2007;21(5):598-602.
15. Sibbald RG, Contreras-Ruiz J, Coutts P, et al. Bacteriology, inflammation, and healing: a study of nanocrystalline silver dressings in chronic venous leg ulcers. Adv Skin Wound Care. 2007;20(10):549-558.
16. Brett DW. A discussion of silver as an antimicrobial agent: alleviating the confusion. Ostomy Wound Manage. 2006;52(1):34-41.
17. Barrett S. Mepilex Ag: an antimicrobial, absorbent foam dressing with Safetac technology. Br J Nurs. 2009;18(20):S28, S30-S36.
18. Barrows C. Enhancing patient outcomes—reducing the bottom line: the use of antimicrobial soft silicone foam dressing in home health. Home Healthc Nurse. 2009;27(5):279-284.
19. National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Prevention and treatment of pressure ulcers: clinical practice guideline. Washington, DC: National Pressure Ulcer Advisory Panel; 2009.
20. Naber TH, Schermer T, de Bree A, et al. Prevalence of malnutrition in nonsurgical hospitalized patients and its association with disease complications. Am J Clin Nutr. 1997;66(5):1232-1239.
21. Ziegler TR, Benfell K, Smith RJ, et al. Safety and metabolic effects of L-glutamine administration in humans. JPEN J Parenter Enteral Nutr. 1990;14(4 suppl):137S-146S.
22. Skin conditions, pressure ulcers, and vitamin deficiencies. In: Escott-Stump S. Nutrition and Diagnosis–Related Care. 6th ed. Baltimore: Lippincott Williams & Wilkins. 2007:108-117.
23. van Velzen JM, van Bennekom CA, Polomski W, et al. Physical capacity and walking ability after lower limb amputation: a systematic review. Clin Rehabil. 2006;20(11):999-1016.
24. Ehlers CF. Integumentary disease and disorders/wound management. In: Malone DJ, Lindsay KLB, eds. Physical Therapy in Acute Care: A Clinician’s Guide. Thorofare, NJ: Slack Inc US; 2006:585-616.