Problems of diagnosis and treatment of tourniquet syndrome in gunshot wounds of the upper and lower extremities

Abstract

The article presents topical issues of diagnostic monitoring of changes in vascular status when using a tourniquet during a combat injury, diagnosis of tourniquet syndrome. An alternative diagnostic approach in the form of additional use of multifocal express muscle biopsy and dynamic digital thermography has been demonstrated.

Purpose - to conduct an analysis of the problematic issues of diagnosis and treatment of tourniquet syndrome in gunshot wounds of the limbs in order to reduce the number of organizational and technical errors in wounds of the limbs where a tourniquet was used.

Materials and methods. In the 16 months since the beginning of Russia’s full-scale aggression against Ukraine, 28 wounded people with tourniquet limb syndrome were treated in the Military Medical Clinical Center of the Northern Region (MMCC of the Northern Region). All the wounded were male, the average age was 34.2±0.6 years. The analysis of the following indicators was carried out: the timing of applying a tourniquet before arrival at ROLE 2, the localization of the tourniquet, the amount of surgical intervention at ROLE 2, the length of stay at ROLE 2, the amount of pre-operative examination in the MMCC of the NR, the amount of surgical interventions in the conditions of the MMCC of the NR, the number of cases of acute kidney injury, the need for renal replacement therapy, the average bed-day on ROLE 3, the level of mortality. Classical general clinical studies were carried out in combination with thermographic and histological research.

Results. In terms of localization, in gunshot wounds with tourniquet syndrome, wounds of the lower extremities prevail 28 (82.4%) over the upper extremities 6 (17.6%). There were 12 (35.3%) cases of gunshot fractures in tourniquet syndrome. All (28 patients) injured people arrived with tourniquets on their limbs. The terms of applying a tourniquet before hospitalization on ROLE 3 - from 3 hours 10 minutes to 11 hours 25 minutes, on average - 5 hours 35 minutes ±20 minutes. In 5 (14.7%) cases, there were attempts to remove the tourniquet when it was applied for more than 3 hours at the ROLE 1 level. In 6 (21.4%) of the wounded, there were 2 tourniquets on one anatomical and functional site, which led to amputation on proximal level. The average length of stay at ROLE 2 with tourniquet syndrome was 60±10 hours. All wounded (28 patients) with tourniquet syndrome underwent 34 amputations. 16 (57.1%) wounded with tourniquet syndrome had acute kidney injury and were on prolonged renal replacement therapy. This category of wounded had a tourniquet syndrome at the level of the thigh. Polyfocal express muscle biopsy and dynamic digital thermography were used to diagnose tourniquet syndrome.

Conclusions. Improving the training of combat medics will lead to a decrease in the number of organizational and technical errors in limb injuries where a tourniquet is used. A tourniquet applied for a long time leads to a high level of limb amputation in case of irreversible changes in the muscles. There is a need for further development of objective methods for the diagnosis of tourniquet syndrome. The proposed additional methods of diagnosis in the form of polyfocal express biopsy and thermography make it possible to objectify the extent of damage due to standing of the tourniquet.

The research was carried out in accordance with the principles of the Helsinki Declaration. The study protocol was approved by the Local Ethics Committee of the participating institution. The informed consent of the patient was obtained for conducting the studies.

No conflict of interests was declared by the authors.