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Traumatic injury to an extremity can compromise arterial inflow, venous outflow, or microvascular perfusion, leading to acute traumatic peripheral ischemia characterized by tissue hypoxia, edema, and progressive cellular injury. Common causes include crush injuries, fractures, penetrating trauma, and high-energy blunt mechanisms. Clinical manifestations often include pain out of proportion to the examination, pallor, coolness, diminished or absent pulses, sensory deficits, and impaired motor function. Timely recognition is critical, as delayed intervention can result in irreversible tissue necrosis, infection, systemic complications, and poor functional outcomes. Hyperbaric oxygen therapy augments plasma oxygen delivery, promotes diffusion into ischemic tissue, reduces edema, and supports cellular metabolism while definitive surgical management proceeds. Indications include threatened limb viability following trauma, revascularization, or reimplantation with persistent ischemia, whereas contraindications include untreated pneumothorax and select cardiopulmonary instability. This activity equips clinicians with the knowledge and skills to appropriately select patients for hyperbaric oxygen therapy and deliver effective treatment for acute traumatic ischemia. Participants review indications, contraindications, preparation, equipment, technique, benefits, and potential complications, strengthening clinical decision-making. Emphasis on interprofessional collaboration among surgeons, hyperbaric technicians, nurses, and rehabilitation specialists supports coordinated care, improves patient outcomes, reduces complications, and fosters a team-based approach to managing ischemic extremities. Objectives: Compare treatment modalities, including hyperbaric oxygen therapy, revascularization, fasciotomy, and adjunctive medical management, for efficacy, risk, and timing. Identify candidates with acute traumatic ischemia suitable for hyperbaric oxygen therapy based on clinical presentation, injury characteristics, and established indications and contraindications. Implement hyperbaric oxygen therapy for acute traumatic ischemia with attention to procedural accuracy, patient monitoring, and mitigation of potential adverse events.

Identify candidates with acute traumatic ischemia suitable for hyperbaric oxygen therapy based on clinical presentation, injury characteristics, and established indications and contraindications. Implement hyperbaric oxygen therapy for acute traumatic ischemia with attention to procedural accuracy, patient monitoring, and mitigation of potential adverse events. Collaborate with all members of the interprofessional team, including specialists such as emergency physicians, trauma surgeons, and hyperbaric medicine specialists, to provide efficient, comprehensive, and coordinated care for individuals with acute traumatic ischemia. Access free multiple choice questions on this topic.

Trauma to a limb causes direct tissue damage and local hypoxia secondary to edema, resulting in acute traumatic peripheral ischemia. The severity of trauma ranges from mild to irreversible and may involve major blood vessels and nerve injuries. Severe injuries may necessitate amputation. Vascular repair and reimplantation may be required to preserve limb viability. Examples of trauma include crush and thermal injuries. Even in the absence of a major vascular insult, tissue damage can produce edema, which exacerbates hypoxia and further increases edema. This pathophysiologic cycle may precipitate compartment syndrome within noncompliant muscle compartments, representing a surgical emergency to salvage the limb. Threatened flaps also constitute acute traumatic peripheral ischemia, for which hyperbaric oxygen therapy (HBOT) has demonstrated improvement in ischemic conditions.[1] Surgical intervention and HBOT are complementary, not exclusionary, modalities, and should be employed in coordination to optimize patient outcomes. Management of acute traumatic peripheral ischemia is included among the 15 approved indications for HBOT by the Undersea and Hyperbaric Medical Society.[2] The procedure is also approved by the Centers for Medicare and Medicaid Services. The organization states that acute traumatic peripheral ischemia or crush injuries, particularly after surgical reattachment of severed limbs, represent a scenario in which HBOT serves as a valuable, supplementary treatment. HBOT may be used in combination with established therapeutic measures when patients are at risk of functional loss, limb loss, or mortality. In addition to numerous case studies and reports, results from 2 randomized controlled studies conducted nearly 20 years apart showed that incorporating HBOT into standard surgical management reduces the incidence of complications, including amputation, additional surgical procedures, and tissue necrosis.[3][4]

HBOT is generally well tolerated. Occasionally, patients with difficulty equalizing middle-ear pressure develop barotrauma of the ears. Management usually involves nasal decongestants, and myringotomy tube placement by an otolaryngologist is rarely required. Pulmonary barotrauma is very uncommon. However, the possibility should be considered if patients develop chest pain during ascent. Pulmonary and cerebral oxygen toxicity is typically not a concern with the relatively short exposures used for acute traumatic peripheral ischemia, but remains a potential risk. Neurologic oxygen toxicity may result in seizures. Convulsions may be prevented with antiepileptic medications or managed during the episode with benzodiazepines. Reducing treatment depth or oxygen concentration usually resolves these episodes. Introducing a 5-minute air break during treatment further minimizes the risk of oxygen-induced seizures.[9] Changes in eye refraction generally occur only after prolonged HBOT courses of 40 to 60 sessions and are often reversible. Blood glucose levels may decrease during or after treatment in patients with diabetes, necessitating careful monitoring.[10] Individuals with poorly controlled hypertension also require monitoring and appropriate management during HBOT sessions.[11]

The management of acute traumatic peripheral ischemia is complex and challenging. Trauma surgeons and orthopedic specialists direct care, while additional healthcare team members provide expertise to enhance patient outcomes. The Undersea and Hyperbaric Medical Society has proposed a treatment algorithm to identify patients most likely to benefit from HBOT. The algorithm incorporates trauma type and severity, based on the Gustilo classification, as well as patient host factors that may influence therapeutic decisions. Optimal treatment planning for severe traumatic injuries relies on interprofessional collaboration.

HBOT-trained nurses are essential members of the healthcare team for both monoplace and multiplace chamber operations. Responsibilities include patient care tasks, such as medication administration, blood glucose monitoring, and wound dressing. Multiplace chambers allow nurses to attend to patients within the chamber. In contrast, monoplace chambers position the patient inside, with the technologist supervising from outside. Certified hyperbaric technicians prepare and maintain the technical components of the hyperbaric program to ensure safety and operate the chambers during treatments.

Hyperbaric nurses and technicians monitor patients during HBOT by direct visual observation and verbal communication or by cameras and display screens. Vital signs are measured with appropriate sensors connected via specialized pass-throughs in the chamber hulls.