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Managing Dislocations of the Hip, Knee, and Ankle in the Emergency Department - Calculated Decisions - Trauma CME

Bastion Classification of Lower Limb Blast Injuries

Introduction
Points & Pearls
Why and When to Use, and Next Steps
Calculator Review Author
Evidence Appraisal
Calculator Creator
References

Introduction

The Bastion Classification criteria stratify explosion related lower limb injuries into 5 categories to guide treatment.

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Points & Pearls

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.
The Bastion Classification 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 through D, respectively.
Prehospital application of a tourniquet can effectively obtain hemorrhage control. The study validating the Bastion Classification (Jacobs 2014) had 98 injuries requiring pneumatic tourniquets out of 179 injuries (55%). A recent study in 2017 by Scerbo et al reported that patients who presented without prehospital tourniquets received more transfusions in the first hour of arrival (55% vs. 34%, P = .02) and had increased mortality from hemorrhagic shock (14% vs. 3%, P = .01).

Why and When to Use, and Next Steps

Why to Use

The Bastion Classification was developed as a classification system to comprehensively describe the injury pattern of lower extremities after blast injuries. It correlates with treatment need, such as the requirement for operative proximal vascular control or amputation level. The criteria are helpful for facilitating communication between clinicians and for operative management.

When to Use

Use the Bastion Classification for 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.

Next Steps

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

Calculator Review Author

Jennie Kim, MD

Department of Surgery

Maimonides Medical Center, Brooklyn, NY

Travis Polk, MD

Commander, Medical Corps, U.S. Navy

Los Angeles County+USC Medical Center, Los Angeles, CA

Evidence Appraisal

A panel of military surgeons, Jacobs et al, developed the Bastion Classification and performed a prospective validation study with 103 patients who sustained 179 lower limb injuries caused by improvised explosive devices treated at Camp Bastion, Afghanistan, from November 2010 to February 2011.

The primary aim of the proposed classification was to provide a pragmatic, comprehensive, and clinically relevant system to better facilitate the transfer of information. Currently existing lower limb injury classification systems fail to describe the complete injury pattern or correlate with management. The Internal Committee of the Red Cross classification is broad and does not provide information on the severity of injury. The Mangled Extremity Severity Score (MESS), Gustilo and Anderson, and Müller AO classifications do not provide information on injury level. The Müller AO classification also does not take into account soft tissue injury. The secondary aim of the study by Jacobs et al was to facilitate the assessment of interventions. The Bastion Classification did show a predictable association with the level of initial musculoskeletal debridement and/or amputation and the level of vascular control.

The original study was not designed to correlate class of injury with outcomes such as mortality, transfusion requirements, or definitive amputation level, and thus, this information is not provided in the publication nor in the conclusions made.

A study in 2013 by Lundy and Hobbs looked at 67 patients with 117 injured limbs caused by dismounted blast exposure. The authors noted that the Bastion Classification appeared to be predictive of initial musculoskeletal treatment but was less useful in predicting the need for proximal vascular control, especially in the most common Class 3 injuries. The original study by Jacobs et al showed that Class 3 injuries correlated with a higher rate of intra- or extraperitoneal iliac vessel control (23% of 83 Class 3 injured limbs without associated abdominal injuries) compared to the study by Lundy et al that only had 1 patient with a Class 3 injury without associated abdominal injury and 6 (5%) of all injured limbs requiring iliac vessel control. The 2013 study does not comment on correlation of the Bastion Classification to mortality rates.