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Bastion Classification: Evolution of Experience Mandates Caution when Considering Using Class as Predictor for Method of Temporary Vascular Control

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We have read with great interest and applaud Jacobs and colleagues on their production and validation of a Bastion score to classify lower extremity injuries due to improvised explosive devices.1 As the authors indicate, the ideal method of vascular control for class 3 injuries remains unclear. Jacobs and colleagues describe the use of iliac vascular control either extra- or intraperitoneal in a total of 51 of 177 limbs injured 46. After review of the authors findings, we conducted a retrospective analysis of lower extremity injuries cared for during the past 104 days during Op Herrick 15 and 16. Identical triage, resuscitative, and surgical strategies continue to be employed at Bastion hospital. During this time, we have cared for 67 patients with 117 injured limbs as a result of dismounted blast. A total of 41 n 48 of limbs injured resulted in traumatic amputation. Consistent with Jacobs report, class 3 injuries were the most common making up 78 of injured lower extremities see Table 1. Proximal vascular control with temporary occlusion of iliac vessels via laparotomy was utilised in only 6 injured limbs 5 of all injured limbs no patients underwent extraperitoneal iliac control. When considering Jacobs manuscript, we noted that of 83 class 3 injured limbs without associated abdominal injuries, iliac control was utilised in 19 23. We found iliac control in this setting class 3 injury without associated abdominal injury necessary in only one patient see Table 2. Whilst we agree that the classification system appears to be predictive of the initial musculoskeletal treatment, it was much less useful in predicting the need for proximal vascular control. As Table 2 indicates, the 6 limbs that had control of iliac vessels performed tended to be in patients with large injury burden all had bilateral lower extremity injuries all had associated injuries according to the ABCD component of the system.

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  • Medicine and Medical Research

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