Damage control orthopedic, when and how.
- 3. Polytrauma ■ Injury to 2 or more organ systems leading potentially to a life threatening condition ■ Last updated definition ■ • At least 2 injuries with AIS ≥ 3 plus 1 or more physiological response : Hypotension, level of consciousness, acidosis and coagulopathy.
- 4. Abbreviated injury scale (AIS) classify and describe the severity of injuries AIS is an anatomical scoring system first introduced in 1969 ,Injuries are ranked on a scale of 1 to 6, with 1 being minor, 5 severe, and 6 a nonsurvivable injury.
- 5. MORTALITY Three peak times of death after trauma 50% within the first minutes of sustaining the injury caused by massive blood loss or neurologic injury 30% within the first few days most commonly from shock, hypoxia, or neurologic injury 20% within days to weeks following injury multi system organ failure and infection are leading causes
- 7. ■ The trimodal death distribution of trauma was first described by Trunkey in 1983. ■ Immediate deaths occur within minutes and consist of major lacerations to the brain, brainstem, aorta, spinal cord, and heart. These are nonsurvivable injuries in which only injury prevention can affect outcome. ■ Early deaths occurred within the first few hours and consist of potentially survivable injuries such as epidurals, subdurals, hemopneumothorax, pelvic fractures, long bone fracture, and abdominal injuries. Access to trauma center care is important for this group. ■ Late deaths can occur up to weeks later in the intensive care unit and include deaths from sepsis and multiple organ failure. Improved resuscitation and critical care can improve these outcomes.
- 8. The stress response to trauma The response is initiated by a combination of nociception (afferent pain pathways), local tissue injury (cytokine release) and higher centre (cognitive) responses.
- 9. Traumatic injuries lead to the systemic inflammatory response syndrome (SIRS) followed by a period of recovery mediated by a counter-regulatory anti-inflammatory response (CARS)
- 10. SIRS initial manifestations of the stress response are tachycardia and tachypnea, vasoconstriction, pyrexia, a raised white cell count and increased concentrations of hormones such as cortisol, and cytokines such as the interleukins systemic inflammatory response syndrome (SIRS).
- 11. Two or more of: Temperature >38ºC or <36ºC Heart rate >90 beats/min Respiratory rate >20 breaths/min or PaCO2<32mmHg White cell count <4000 or >12 000 cells/mm3
- 12. MODS A proportion of patients develop an exaggerated response with persistent hypoxaemia, peripheral tissue hypo perfusion (identified by a raised lactate and base excess), a hypercoagulable state that may manifest as DIC, fluid retention, and the development of a catabolic state with muscle wastage and negative nitrogen balance. When severe, this results in the multiple organ dysfunction syndrome (MODS).
- 13. The presence of altered organ function in an acutely ill patient such that normal homeostatic biological mechanisms cannot be maintained without intervention
- 14. ARDS In the lungs, increased membrane permeability and fluid extravasation result in heavy, waterlogged, stiff lungs with impaired oxygen transfer, a condition recognized as acute respiratory distress syndrome (ARDS)
- 15. Hypoxaemia (ratio of arterial pO2 to fraction inspired O2<26.7) Diffuse bilateral pulmonary infiltrates on plain chest radiograph No evidence of left atrial hypertension (pulmonary artery wedge pressure <18 mmHg)
- 16. Class % Blood Loss HR BP Urine pH MS Treatment I < 15% (<750ml) normal normal > 30 mL/hr normal anxious Fluid II 15% to 30% (750-1500ml) > 100 bpm normal 20-30 mL/hr normal confused irritable combative Fluid III 30% to 40% (1500-2000ml) > 120 bpm decreased 5-15 mL/hr decreased lethargic irritable Fluid & Blood IV > 40% (life threatening) (>2000ml) > 140 bpm decreased negligible decreased lethargic coma Fluid & Blood
- 17. ■ transfuse in 1:1:1 ratio (red blood cells: platelets: plasma) ■ Indicators of adequate resuscitation urine output 0.5-1.0 ml/kg/hr (30 cc/hr) serum lactate levels , most sensitive indicator as to whether some circulatory beds remain inadequately perfused (normal < 2.5 mmol/L) ■ gastric mucosal ph ■ base deficit normal -2 to +2
- 18. Improved knowledge of the pathophysiological mechanisms of trauma allowed identification of significant clinical factors. Three of them correspond to the so-called lethal triad: hypothermia, coagulopathy, and acidosis
- 19. EARLY TOTAL CARE ■ Early total care Early total care (ETC) is the definitive stabilization of all long bone fractures within 24 hours of injury once the patient is physiologically stable. It is not usually immediate total care. ETC is the most appropriate treatment for the majority of Injured patients.
- 20. Damage limitation surgery Damage limitation surgery or ‘damage control orthopaedics’ (DCO) is immediate surgery that is required to save life and limb, other reconstructive procedures being deferred until the patient’s physiological condition has improved after a period of resuscitation in the ICU. The term is rather loosely employed and there is currently no consensus as to which patients require DCO, or which procedures should be considered. However, procedures that are life or limb-saving should be considered, even in unstable patients.
- 21. ■ Currently, DCO is the preferred approach in “unstable” and “in extremis” patients. In these patients, immediate ■ Surgery would be the cause of the “second hit”, which may lead to ARDS, MODS, or even death. ■ Accordingly, DCO should be adopted in patients with a body temperature below 33 C, ∘ ■ blood pressure less than 90mmHg, increased lactate levels, platelets count below 90,000, and major soft tissue injuries
- 23. 2 hit phenomenon ■ ETC led to exacerbation of the "second-hit" in a subset of patients with hemodynamic instability, head, and/or chest injuries
- 24. Two-Hits Theory ■ First Hit (Trauma) • Hypoxia • Hypotension • Organ and soft tissue injury • Fractures ■ Second Hit (Operation) • Ischemia/reperfusion injury • Compartment syndrome • Operative intervention • Infection • Massive transfusion
- 25. ■ therefore only potentially life-threatening injuries should be treated in this period including – unstable pelvic fracture – compartment syndrome – fractures with vascular injuries – unreduced dislocations – traumatic amputations – unstable spine fractures – cauda equina syndrome – open fractures
- 26. ■ definitive treatment delayed for – 7-10 days for pelvic fractures – within 3 weeks for femur fractures (conversion from ex fix to IMN) – 7-10 days for tibia fractures (conversion from external fixation to IMN)
- 27. Damage Control Orthopedics ■ Designed to avoid worsening patient’s condition due to “second hit” phenomenon ■ Delay definitive surgery until patient condition is optimized ■ Focuses on hemorrhagic control, management of soft-tissue injury and provisional fracture stability
- 28. 1980s Early Total Care within 24 hours (‘too sick not to operate on’) ● early fixation prevents (fat embolism) ● early mobilization facilitates nursing care and ● early mobilization prevents pneumonia, sepsis
- 29. ■ Early stabilization of major skeletal injuries was the mainstay of treatment in trauma surgery in the 80’s and early 90’s. ■ ETC involves definitive surgical stabilization of all long bone fractures during the early phase of treatment (24– 48 h)
- 30. 1990s Damage Control Orthopedics For most upper extremity injuries, simple stabilization with splints or a sling was sufficent . For closed fractures below the knee, splinting is usually the best option [For femur fractures, splinting without traction is not effective because the joint above the fracture (the hip) cannot be immobilized. In these fractures, skeletal traction was found to be equal to external fixation in terms of acute respiratory distress syndrome (ARDS), multiple organ dysfunction syndrome (MODS), pneumonia, deep venous thromboembolism(DVT), pulmonary embolism(PE) development, as well as ICU stay, and death rate
- 31. Phases of DCO • It consists of four phases. • During the acute phase, life-saving procedures are performed. • The priorities of the second phase are the control of hemorrhage, the temporary stabilization of major skeletal fractures, and the management of soft tissue injuries, while minimizing the degree of surgical insult to the patient. • Phase three consists of a monitoring period in ICU. • Phase four focuses on definitive fracture fixation.
- 32. Timing sustained immunologic changes are ongoing and fluid shifts, increasing generalized tissue edema, are not yet normalized In a large survey of over 4000 cases, the effects of the timing of surgery on MODS development were analyzed. Definitive osteosynthesis in patients who later developed MODS was performed between days 2 and 4, whereas patients without MODS were operated on between days 6 and 8 ( < 0.0001) 𝑃 Therefore, the need for a waiting period of several days before definitive osteosynthesis has emerged. However, the waiting period should preferably be shorter than 15 days, since it has been shown that contamination rates in external fixator pin sites rose substantially after 2 weeks
- 33. Clinical grading criteria ( Pape et al)
- 34. period-defined “window of opportunity” has been set between the 5th and the 10th days. The post trauma days 2 to 4 have been reported to be unsuitable for performing definitive fixation
- 35. ■ External fixation of femur – 35 minutes ,90 ml blood loss Intramedully nailing of femur - 130 minutes ,400 ml blood loss Scales et al., “ external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures : damage control orthopaedics” J.Trauma 2000;48 :613-23.
- 39. References ■ Ratto Nicola, “Early Total Care versus Damage Control: Current Concepts in the Orthopedic Care of Polytrauma Patients,” ISRN Orthopedics, vol. 2013, Article ID 329452, 9 pages, 2013. ■ H. C. Pape, M. Stalp, M. V. Griensven, A. Weinberg, M.Dahlweit, and H. Tscherne, “Optimal timing for secondary surgery in polytrauma patients: an evaluation of 4314 seriousinjury cases,” Chirurg, vol. 70, no. 11, pp. 1287–1293, 1999. ■ Court-Brown, Charles M, James D. Heckman, Margaret M. McQueen, William M. Ricci, Paul Tornetta, and Michael D. McKee. Rockwood and Green's Fractures in Adults. , 2015. Print. ■ H. C. Pape, P.V.Giannoudis, C. Krettek, andO. Trentz, “Timing of fixation of major fractures in blunt polytrauma: role of conventional indicators in clinical decision making,” Journal of Orthopaedic Trauma, vol. 19, no. 8, pp. 551–562, 2005.