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Compartment syndrome performance improvement project is associated with increased combat casualty survival

Kragh, John F. Jr MD; San Antonio, James BBA; Simmons, John W. MD; Mace, James E. MD; Stinner, Daniel J. MD; White, Christopher E. MD; Fang, Raymond MD; Aden, James K. PhD; Hsu, Joseph R. MD; Eastridge, Brian J. MD; Jenkins, Donald H. MD; Ritchie, John D. MD; Hardin, Mark O. MD; Ritenour, Amber E. MD; Wade, Charles E. PhD; Blackbourne, Lorne H. MD

Journal of Trauma and Acute Care Surgery: January 2013 - Volume 74 - Issue 1 - p 259–263
doi: 10.1097/TA.0b013e31826fc71c

BACKGROUND In 2008, we showed that incomplete or delayed extremity fasciotomies were associated with mortality and muscle necrosis in war casualties with limb injury. Subsequently, we developed an education program focused on surgeon knowledge gaps regarding the diagnosis of compartment syndrome and prophylactic fasciotomy. The program included educational alerts, classroom training, video instruction, and a research publication. We compared casualty data before and after the program implementation to determine whether the education altered outcomes.

METHODS Similar to the previous study, a case series was made from combat casualty medical records. Casualties were US military servicemen with fasciotomies performed in Iraq, Afghanistan, or Germany between two periods (periods 1 and 2).

RESULTS In both periods, casualty demographics were similar. Most fasciotomies were performed to the lower leg and forearm. Period 1 had 336 casualties with 643 fasciotomies, whereas Period 2 had 268 casualties with 1,221 fasciotomies (1.9 vs. 4.6 fasciotomies per casualty, respectively; p < 0.0001). The mortality rate decreased in Period 2 (3%, 8 of 268 casualties) from Period 1 (8%, 26 of 336 casualties; p = 0.0125). Muscle excision and major amputation rates were similar in both periods (p > 0.05). Rates of casualties with revision fasciotomy decreased to 8% in Period 2, (22 of 268 casualties) versus 15% in Period 1 (51 of 336 casualties; p = 0.009).

CONCLUSION Combat casualty care following implementation of a fasciotomy education program was associated with improved survival, higher fasciotomy rates, and fewer revisions. Because delayed fasciotomy rates were unchanged, further effort to educate providers may be indicated.

LEVEL OF EVIDENCE Therapeutic study, level IV.

From the US Army Institute of Surgical Research (J.F.K., J.S.A., J.W.S., J.E.M., D.J.S., C.E.W., J.K.A., J.R.H., B.J.E., J.D.R., M.O.H., L.H.B.), Fort Sam Houston; and Department of Surgery and Center for Translational Injury Research (C.E.W.), University of Texas–Health, Houston, Texas; Uniformed Services University of the Health Sciences (J.F.K.), F. Edward Hébert School of Medicine, Bethesda, Maryland; Landstuhl Regional Medical Center (R.F.), Landstuhl, Germany; Division of Trauma, Critical Care and General Surgery (D.H.J.), Department of Surgery, Mayo Clinic, Rochester, Minnesota; and Irwin Army Community Hospital (A.E.R.), Fort Riley, Kansas.

Submitted: December 5, 2011, Revised: July 12, 2012, Accepted: July 17, 2012, Published online: November 9, 2012.

This study was performed at Landstuhl Regional Medical Center and analyzed at the US Army Institute of Surgical Research.

The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or reflecting the views of the Department of Defense or United States Government. The authors are employees of the US government. This work was prepared as part of their official duties and, as such, there is no copyright to be transferred.

Address for reprints: John F. Kragh Jr, MD, US Army Institute of Surgical Research, Damage Control Resuscitation, 3698 Chambers Pass, Bldg BHT2, Room 222-4, Fort Sam Houston, TX 78234-6315; email:

© 2013 Lippincott Williams & Wilkins, Inc.