[Acute therapeutic measures for limb salvage Part 1 : Haemorrhage control, emergency revascularization, compartment...

The primary care of Gustilo-Anderson type IIIC extremity injuries with relevant vessel lacerations is decisive for the success of a limb salvage procedure. This article shall present substantial emergency procedures for the salvage of the nutritive perfusion of a mangled extremity, based on the current literature. After provisory control of a peripheral haemorrhage (e. g. by manual pressure or tourniquet), an immediate decision must be made about the kind of emergency revascularization to be implemented as the limb salvage procedure. Here, the temporary intravascular shunt will be the fastest technique that can ensure a sufficient tissue perfusion in the case of vessel lacerations. Regarding the treatment of a fracture versus perfusion recovery, a shortening of ischemia time should have priority over fracture stabilization.If an acute compartment syndrome is suspected, a documented monitoring has to be performed in the limb salvage situation for 24 hours with clinical controls every 4 hours. Disproportional pain that does not respond to analgesics, and passive muscle stretching pain can be seen as cardinal symptoms. The positive predictive value of clinical findings is <15 %. During the observation period with an impending but not manifest compartment syndrome, an elevation of the extremity above heart level or its cooling are contraindicated. An intracompartmental pressure measurement is the most important instrument-based supplemental diagnostic method. The open fasciotomy of the affected compartments is the only causal therapy and should be performed as fast as possible. A decision against fasciotomy in cases of non-explicit clinical signs should not be made without a documented intracompartmental pressure measurement.