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A new ischemic grading system to aid combat extremity vascular injury decision making

By Amila S. Ratnayake, Viktor A Reva, Miklosh Bala, Achala Upendra Jayatilleke, Sujeewa PB Thalgaspitiya, David S Kauvar, Tamara J Worlton

Posted 07 Aug 2020
medRxiv DOI: 10.1101/2020.08.03.20166827

Abstract Introduction In resource limited combat settings with frequent encounters of mass casualty incidents, the decision to attempt limb salvage versus primary amputation is refined over time based on experience. This experience can be augmented by grading systems and algorithms to assist in clinical decisions. Few investigators have attempted to explicitly grade limb ischemia according to clinical criteria and study the impact of limb ischemia on clinical outcome. We suggest a new ischemia grading system based on the Rutherford ischemic classification and the V.A. Kornilov classification which we adapted to apply to the combat setting. This new tool was then retrospectively applied to combat trauma patients from the Sri Lankan Civil War. Method We retrospectively queried a prospectively maintained, single surgeon registry containing 129 extremity vascular injuries managed at a Role 3 military base hospital (MBH) from 2008 December to June 2009 during the last phase of Sri Lankan Civil war. 89 patients were analyzed for early limb salvage according to the modified Kornilov extremity ischemia index (MKEII). Result According to the MKEII, subcohort analysis of C1 (viable), C2 (threatened), and C3 (irreversible) classified injuries demonstrated a statistically significant (P < 0.001) difference in limb salvage. Further statistical evaluation demonstrated injury to popliteal region (P=0.006), severe arterial injury (P=0.018) and venous injuries (P< 0.001) had statistically significant differences in distribution between C1, C2 and C3. Conclusion By application of the MKEII, combat surgeons can rapidly and correctly select and prioritize vascular injured extremities to optimally use limited resources to achieve realistic limb salvage goals. A rigid ankle was correlated with the worst index of extremity ischemia. Further investigation into this sign as an indication for primary amputation is warranted.

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