Case Report

Mangled Extremity Severity Score in Combat Casualty Care: Time to Revise

Amila Ratnayake1 and Miklosh Bala2*
1Department of General Surgery and Trauma Unit, Military Hospital, Colombo, Sri Lanka
2Department of General Surgery and Trauma Unit, Hadassah-Hebrew University Medical Center, Jerusalem, Israel


*Corresponding author: Miklosh Bala, Department of General Surgery and Trauma Unit, Hadassah- Hebrew University Medical Center, Jerusalem, Israel


Published: 12 Oct, 2017
Cite this article as: Ratnayake A, Bala M. Mangled Extremity Severity Score in Combat Casualty Care: Time to Revise. Clin Surg. 2017; 2: 1680.

Editorial

Throughout the 20th and 2st century war theaters, extremity injuries were predominating in the range of 50 to 70% [1]. Rate of vascular trauma in current war fields is on the rise, ranging from 9 to 12% [2]. Out of those, three quarter involves major extremity vessels and close to half of these documented with concomitant venous injury.
Amputation rate of war time vascular injured limbs considerably improved from 36% in WW11 through 13% in Korea and Vietnam to 4-6% in Operation Iraqi Freedom & Operation Endurance Freedom (OIF& OEF) due to improvement in combat casualty care structure with rapid transport and far forward surgical capability allowing surgeons to perform more vascular reconstructions [3]. About one third of the combat vascular injured limbs are in association with skeletal trauma and saving these limbs will test the acumen of the military surgeon [4]. Understanding of pathophysiology of vascular injured patient, liberal application of field tourniquets, temporary intraluminal shunts and damage control resuscitation allows combat surgeons to save limbs at a commendable percentage. However, wartime amputees are still a considerable cost to society with 1715 major limb amputation in OIF and OEF by December 2012, according to congressional research service [5]. Throughout the history of war, combined vascular and skeletal trauma have fare worse outcome in comparison to isolated arterial injury [6]. Prioritizing and protocol management of these mangled limbs is order of the day. Temporary shunting of both artery and vein with four quadrant fasciotomy at second echelon of care with expedited evacuation to third echelon for definitive vascular reconstruction with skeletal stabilization then planning advanced soft tissue reconstruction and rehabilitation at continental fifth echelon of care proven effective in current combat theaters [7]. Out of these devastating injuries, there are a percentage of limbs with excess ischemic burden upon revascularization, which will result in acute multi organ dysfunction or later septic consequences leading to loss of life, if not limb. In this challenging scenario, it is pivotal to select early which limbs to reconstruct vs. which to amputate. For the above task, Mangled Extremity Severity Score (MESS) is the only prioritization selection tool used upon its simplicity and assumed reliability [8]. However, prudence of its application in combat theaters questioned by several authors in the background of its failed accuracy in civilian studies [9].
In scrutinizing MESS in the battlefield, following facts are highlighted:
• Age, in particular, is not a criterion that bears much effect on combat composite scoring system, as most of the military are young fit individuals in the age range of 20 to 40 years. In addition, skeletal/soft tissue score is often either 3 or 4, considering the high velocity automatic rifles and blast munitions in combat setting. In combat extremity composite scoring system, we could safely omit age and soft tissue criterion, as these two are more or less static in combat, making them less valued.The presence of a vascular injury in a physiologically sick patient is the main factor indicating amputation [9]. Considering vascular injury, our experience in Sri Lankan war theaters indicated popliteal anatomy and associated venous injury in the background of compound fracture challenge even the most experienced surgeons to salvage the extremity. We should include local anatomical criterion to the composite score, giving weight to each. As such, we experienced 17 primary amputations, 4 secondary amputations and 3 deaths in 39 popliteal combat vascular injuries [10]. • Combined venous and arterial injuries bled more at the field and definitive care resulting in statistically significant more amputations in comparison to arterial injury alone [10]. • Considering limb ischemia, we could refine more with inclusion of Doppler assessment in addition to manually detected peripheral pulse. Fixed ankle often predicts worse outcome, in that one should not proceed with limb [11].
Following is our proposed criteria for a Ballistic Mangled Extremity Severity Score (BMESS) (Table 1). These factors should be weighted in a statistical analysis of sufficient number of data to make the score accurately predict which limb to amputate and which to proceed with salvage protocol.

Table 1

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Table 1
Patient Demographics.

References

  1. Champion HR, Bellamy RF, Roberts CP, Leppaniemi A. A profile of combat injury. J Trauma. 2003;54(5 Suppl):S13-9.
  2. White JM, Stannard A, Burkhardt GE, Eastridge BJ, Blackbourne LH, Rasmussen TE. The epidemiology of vascular injury in the wars in Iraq and Afghanistan. Ann Surg. 2011;253(6):1184-9.
  3. Fox CJ, Starnes BW. Vascular surgery on the modern battlefield. Surg Clin North Am. 2007;87(5):1193-211, xi.
  4. Bear JR, McKay P, Nanos G, Fleming M, Rich N. Vascular injury and concomitant long-bone fracture in war wounds. Historical vignettes in vascular surgery. J Vasc Surg. 2012;56:1795-8.
  5. A Guide to US Military Casualty Statistics: Operation New Dawn, Operation Iraqi Freedom, and Operation Enduring Freedom. Fisher H. 2014.
  6. Huynh TT, Pham M, Griffin LW, Villa MA, Przybyla JA, Torres RH, et al. Management of distal femoral and popliteal arterial injuries: an update. Am J Surg. 2006;192(6):773-8.
  7. Fox CJ, Gillespie DL, O'Donnell SD, Rasmussen TE, Goff JM, Johnson CA, et al. Contemporary management of wartime vascular trauma. J Vasc Surg. 2005;41(4):638-44.
  8. Johansen K, Daines M, Howey T, Helfet D, Hansen ST Jr. Objective criteria accurately predict amputation following lower extremity trauma. J Trauma. 1990;30(5):568-72.
  9. Brown KV, Ramasamy A, McLeod J, Stapley S, Clasper JC. Predicting the need for early amputation in ballistic mangled extremity injuries. J Trauma. 2009;66(4):S93-8.
  10. Ratnayake A, Samarasinghe B, Bala M. Outcomes of popliteal vascular injuries at Sri Lankan war-front military hospital: case series of 44 cases. Injury. 2014;45(5):879-84.
  11. HUGHES CW. The primary repair of wounds of major arteries; an analysis of experience in Korea in 1953. Ann Surg. 1955;141(3):297-303.