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    Bastion Classification of Lower Limb Blast Injuries

    Stratifies blast injuries of lower limbs to guide treatment.
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    INSTRUCTIONS

    Identify mechanism by the most proximal extent of the injury.

    When to Use
    Pearls/Pitfalls
    Why Use
    • Patients with lower extremity injuries after explosions resulting in complex blast wounds.
    • The constellation of injuries may include blunt or crush injuries, traumatic amputations, and compartment syndrome, as well as associated neurologic, thoracic, gastrointestinal, and genitourinary injuries.
    • The validation study of the Bastion Classification (Jacobs 2014) was not designed to correlate class of injury with outcomes such as mortality, transfusion requirements, or definitive amputation level.
    • Correlates better in blast injuries resulting in traumatic amputations than in segmental injuries.
    • Because not all injuries involve complete traumatic amputation of a limb, this classification is supplemented by the suffix “S” to denote a segmental injury, defined as the presence of potentially viable tissue distal to the most proximal injury.
    • Associated injuries to the intraperitoneal abdomen, genitalia and perineum, pelvic ring, and upper limbs are important in treatment and operative planning, so these are denoted by additional suffixes A-D, respectively.
    • Prehospital application of a tourniquet can effectively obtain hemorrhage control. The study validating the Bastion Classification (Jacobs 2014) had 98 injuries out of 179 (55%) requiring pneumatic tourniquets. A recent study in 2017 by Scerbo et al reports patients who presented without prehospital tourniquets received more transfusions in the first hour of arrival (55% vs 34%, p = 0.02) and had increased mortality from hemorrhagic shock (14% vs 3.0%, p = 0.01).
    • Developed to be a classification system that more comprehensively describes injury pattern of lower extremities after blast injuries.
    • Correlates with treatment need, such as requirement for operative proximal vascular control or amputation level.
    • Helpful in facilitating communication between clinicians and for operative management.
    • Other scores for lower extremity injury severity such as the MESS may not be predictive of functional recovery after limb reconstruction (Ly 2008), though we are not aware of any head-to-head comparison studies including the Bastion Classification.
    Injury confined to foot
    Injury involving lower leg permitting effective below-knee tourniquet application
    Injury involving proximal lower leg or thigh, permitting effective above-knee tourniquet application
    Proximal thigh injury, preventing effective tourniquet application
    Any injury with buttock involvement
    No
    Yes
    No
    Yes
    No
    Yes
    No
    Yes
    No
    Yes

    Result:

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    Next Steps
    Evidence
    Creator Insights

    Management

    Management depends on the injuries diagnosed. Using the Bastion Classification and suffixes, emergency physicians and trauma surgeons can anticipate the need for additional surgical consultations and the resources required for treatment.

    Content Contributors
    • Jennie Kim, MD
    Reviewed By
    • Travis Polk, MD, FACS
    About the Creator
    Dr. Neal Jacobs
    Are you Dr. Neal Jacobs?
    Partner Content
    Content Contributors
    • Jennie Kim, MD
    Reviewed By
    • Travis Polk, MD, FACS