Optimal treatment window
UHMS recommendation
4-6 hrs
Number needed to treat
Cochrane analysis
NNT 3
Control group healing
Sham HBOT
56%
Complete healing with HBOT
Retrospective review
94%
Saline manometry positive
Clinical signs present (see 5 P's below)
Delta pressure <30 mmHg (diastolic − compartment)
Compartment pressure >30 mmHg
Develops when pressure within a muscle compartment rises above capillary perfusion pressure, compromising blood flow and threatening tissue viability.
Random Pattern Flap Ischemia
Diagnosis is confirmed when:
The 5 P's of Compartment Syndrome
Late sign — indicates advanced injury
Paralysis
Very late sign — limb at severe risk
Pulselessness
Numbness, tingling in distribution of affected nerves
Paresthesias
Tense, swollen compartment on palpation
Pressure
Out of proportion to injury; worse with passive stretch
Pain
Potential renal failure
Myoglobin release (rhabdomyolysis)
Ischemia-reperfusion injury
Tissue edema and swelling
Massive cellular destruction
The injury triggers a cascade of:
Occurs when significant compressive force damages muscle and soft tissue. Common causes include industrial accidents, motor vehicle trauma, building collapse, and farm equipment injuries.
Crush Injury
Understanding Crush Injury & Compartment Syndrome
Restores fibroblast and leukocyte function requiring O₂ >30 mmHg
Host Response Support
Reduces neutrophil adhesion and reactive oxygen species damage
Reperfusion Protection
20% decrease via vasoconstriction while maintaining oxygen delivery
Edema Reduction
Plasma oxygen increased 10× (1000%), sufficient to sustain tissue without hemoglobin
Hyperoxygenation
The Critical Oxygen Threshold
How HBOT Addresses Crush Injury Pathophysiology
Normal tissue healing requires oxygen tensions above 30 mmHg. In crushed tissue with massive edema, oxygen must diffuse much further from capillaries to cells. HBOT creates a 3-fold "driving force" for oxygen diffusion, compensating for this increased distance and keeping borderline tissue alive.
Crush injuries create a vicious cycle: tissue trauma causes edema, edema increases compartment pressure, elevated pressure reduces blood flow, ischemia worsens tissue damage. HBOT breaks this cycle through multiple mechanisms:
"The skeletal muscle-compartment syndrome (SMCS), especially in its incipient stages before a fasciotomy is required, is a therapeutic challenge since no means to arrest its progression other than hyperbaric oxygen (HBO₂) exist."
— Undersea and Hyperbaric Medical Society (UHMS)
Total sessions (typical)
10-14
Acute phase (first 5-7 days)
BID
Session duration
90 min
Treatment pressure
2.0-2.5 ATA
HBOT Protocol for Crush Injury / Compartment Syndrome
Treatment Protocol
Bouachour G et al. J Trauma 1996;41(2):333-339
NNT: 3 patients to prevent one case of incomplete healing
Re-operation rate: 6% with HBOT vs. 33% with sham (p<0.05)
Results: 94% complete healing with HBOT vs. 56% with sham (p<0.01)
Primary outcome: Complete healing without tissue necrosis
HBOT protocol: 100% O₂ at 2.5 ATA, 90 min, twice daily × 6 days
Population:36 patients with crush injuries, treated within 24 hours of surgery
Study design: Randomized, double-blind, placebo-controlled (sham HBOT)
Bouachour RCT — The Landmark Trial
Sources: PMC 2024; StatPearls 2023; Undersea Hyperb Med 2022; ECHM Consensus 2017
ECHM recommendation: Grade B (moderate evidence) for open fractures with crush injury
Complication reduction: Deep soft tissue infection 2× less likely, flap necrosis 3× less likely with HBOT
Earthquake injuries: 54% sensory recovery, 51% functional recovery with HBOT in severe crush
Fasciotomy timing: Normal function in 68% if performed <12 hours; only 8% if >12 hours
Gustilo III fractures: 91% successful outcome with HBOT, only 13% amputations
Additional Evidence
Clinical Evidence for Trauma Teams
- High-energy trauma with compromised perfusion
- Replantation or avulsion injuries
- Gustilo IIIB/IIIC fractures
- Massive swelling with threatened tissue viability
- Post-fasciotomy for residual ischemia, neuropathy, or unclear demarcation
- Incipient compartment syndrome (before fasciotomy is required)
The UHMS recommends HBOT when injury severity threatens survival of deep tissues and/or skin flaps:
When to Consider HBOT
The window for HBOT intervention in acute traumatic ischemia is narrow. Earlier treatment correlates directly with better outcomes. Here's why timing matters:
Focus shifts to supporting remaining viable tissue and wound healing.
Salvage Phase
>24 hours
Permanent damage likely in some tissue. HBOT can still limit progression and support healing.
Late Intervention
12-24 hours
Significant tissue at risk. HBOT still beneficial but window narrowing rapidly.
Urgent Intervention
6-12 hours
Muscle necrosis may begin. Nerve damage possible. HBOT highly effective if started now.
Critical Window
2-6 hours
Ischemia-reperfusion cascade just beginning. Maximum potential for tissue preservation.
Optimal Window
0-2 hours
Timing Is Critical
HBOT is valuable for: ischemic muscle with unclear viability, residual neuropathy, massive swelling, compromised flaps or grafts, and high-risk wound beds. It can also prepare challenging wounds for delayed closure or grafting.
What post-surgical complications can HBOT help with?
Crush injury and compartment syndrome are FDA-approved indications. Most commercial insurers and Medicare cover HBOT for these conditions when documented appropriately. We expedite authorization for urgent trauma cases.
Is HBOT covered by insurance for crush injury?
Our chamber accommodates patients requiring IV access and monitoring. For critically ill patients, we coordinate with the care team to ensure safe treatment. Some monitoring (telemetry, certain IV medications) is possible during treatment.
What about patients who need ongoing monitoring?
For acute trauma cases, we prioritize immediate access. Call us when the patient is in the ED or OR — we can coordinate treatment initiation as soon as the patient is stable for transfer. We understand that in crush injuries, hours matter.
How quickly can you start treatment?
No. When compartment syndrome is established and pressures require surgical decompression, fasciotomy remains the standard of care. HBOT is an adjunct — it can arrest progression in incipient cases and support healing post-fasciotomy, but it doesn't replace indicated surgery.
