Why hyperbaric oxygen therapy may be useful in treating crush injuries and skeletal muscle-compartment syndrome.

As an actively practicing orthopedic surgeon and one convinced of the value of hyperbaric oxygen (HBo2) for specific orthopedic-related conditions, I am frustrated that my orthopedic and trauma surgeon colleagues have not embraced this modality for crush injuries and compartment syndromes. I am not without experience in managing orthopedic trauma. I was the orthopedic surgeon coordinator of our hospital’s level 2 trauma center for 10 years, and an attending orthopedic staff physician/resident mentor for one of los Angeles County’s most active trauma centers. In addition, I provided orthopedic care for the victims of the 1999 Turkey and the 2010 Haiti earthquakes. It is my opinion that the problem of underutilization of HBo2 for trauma is not just because of surgeons, but unfortunately, the HBo2 community is equally responsible. There is much interest (and government-generated funding) in mitigating injury from trauma. All abound with impressive acronyms such as CWIP (Combat Wound Initiative Program), CCC (Combat Casualty Care) initiative, IMCWlS (Interservice Military Complex Wound and limb Salvage) Center, lEAP (lower Extremity Assessment Project), DCo (Damage Control orthopedics, and more. It is a paradox that all seek to improve trauma care and lessen injury, but none consider HBo2 in their evaluation and treatment study limbs of their research. To further demonstrate the need to investigate the role of HBo2, the “first hit” (initial trauma) and “second hit” (surgical procedures and sepsis) concept of damage control include hypoxia [of injured tissue] as an element of each limb of the “hit.” Hyperbaric oxygen excels in improving tissue hypoxia, but appears to be totally excluded in any of the limbs of studies by the above groups. When I confront orthopedic surgeon colleagues about using HBo2 for managing severe orthopedic trauma, their responses are uniformly smug in deprecating the role of HBo2. They appear to accept disconcerting complication rates (which are summarized in the next paragraph) as acceptable for their trauma patients. They always end their caveats with comments like: “who needs it”; “there is no evidence to support its use”; “no randomized control studies are available”; “our patients are too sick to be moved to a chamber”; and “even if we wanted to use HBo2, chambers are not available.” The following are some of the disconcerting statistics from a review of the trauma literature over the past two years where conventional (i.e., without the use of HBo2 as an adjunct to management) care was given for severe traumatic injuries. The citations in parentheses are included in an abbreviated format.