Matej Cimerman

University Clinical Centre Ljubljana

Slovenia

Treatment algorithms for the polytrauma patient

Objectives

• To understand politrauma and “two hit” model

• To understand DC concept

• A short owerview of resuscitation phase

• Clarify what is stable, borderline and unstable patient

• Set the priorities of fracture treatment

Polytrauma

• Syndrome of multiple injuries (ISS > 17) with sequential systemic

traumatic reactions which may lead to dysfunction or failure of remote

organs and vital systems, which have not been directly injured (Trentz

2000)

• No1 cause of death in 18 – 40y age group

First hit

• Organ injury

• Skeletal inury

• Soft tissue injury

• Hipotension

• Hipoxemia

Second hit

• Sepsis

• Prolonged hipotension

• Invasive surgery

Pathophysiology of

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Multiple Organ Dysfunction Syndrome (MODS)

Host Defense Response- reversible -

„Two Hit“ – Model Keel, Trentz. Injury 2005;36:691

Moore et al. J Trauma 1996;40:501

First Hits

- Hypoxia- Hypotension- Organ injuries- Soft tissue injuries- Fractures

Systemic Inflammatory Response Syndrome (SIRS)

-Temperature- Pulse- Breathing- Leukocytes

Crit Care Med 1992;20:864

Multiple Organ Failure (MOF)

Host Defense Failure Disease - irreversible -+Bacteria

Sepsis

Second Hits

Endogenic (antigenic):- Hypoxia- Hypotension, Azidosis- Ischemia/Reperfusion- Cellular detritus- Contamination/Infection

Exogenic (interventional):- Surgery with blood loss, Tissue

damage, Hypothermia- Neglected Trauma- Missed Injuries- Massive transfusions

Courtesy M Keel

Damage control concept (from US Navy)

“…keeping afloat a badly damaged ship by procedures to limit flooding,

stabilize the vessel, isolate fires and explosions and avoid their

spreading…definitive repair where logistically possible”

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History of DC surgical procedures

• Pringle-maneuver Pringle. Ann Surg. 1908; 48:541

• Intra-abdominal packing Feliciano, et al. J Trauma. 1981; 21:285

• Damage Control as approach Rotondo, et al. J Trauma. 1993; 35:375

• Early packing – Outcome Garrison, et al. J Trauma. 1996; 40:923

• Timing of fracture treatment – DCO (Damage Control

Orthopaedic Surgery) Pape, et al. Am J Surg. 2002; 183:622

What is orthopedic damage control surgery?

• Simple Safe Short fracture fixation: external fixation

• Debridement and necrectomy

• Decompression of compartments: fasciotomy

1. primary survey

2. resuscitation phase

3. secondary survey

4. definitive care

Treatment of polytraumatised patient

Resuscitation (ATLS protocol)

Airway with C spine protect

Breathing /ventilation/ oxygenation

Circulation: stop the bleeding

Disability: neuro status

Expose, environment, body temperature

Resuscitation (ATLS protocol)

Airway with C spine protect

Breathing /ventilation/ oxygenation

Circulation: stop the bleeding

Disability: neuro status

Expose, environment, body temperature

Role of the surgeon?

Endotracheal intubation

• Indications...

Surgical cricotomy

• Maxillofacial trauma

• Neck trauma

• Laryngeal trauma

Airway

• Inadequate delivery of oxygenated blood to the brain is the

quickest killer of the injured

• Pneumothorax (open, tension)

• Haematothorax

• Chest tubes

Breathing

SHOCK

• Inadequate tissue perfusion and oxygenation

• Hemorrhagic

• Nonhemorrhagic (cardiogenic, tension pneumothorax,

neurogenic)

C: Surgical task

Circulation

Hemoragic shock: close the taps

laparothomy pelvic stabilization

thoracotomy

After resuciation phase...

Stable patient: stable hemodynamics, no inotropic support, stable

coagulation, urinary output, normotermic, lactate >2... ETC

Borderline: BP 80-100, lactate 2.5, slightly impaired coagulation, BT 33-

35, ISS >20 with chest trauma, ISS>40 without chest trauma....DC

Unstable and in extremis: BP 60, severe acidosis, coagolopathy,

severe risk of deterioration....DC or life saving surgery

Fracture management

• What needs to be done?

• When needs to be done?

• How much can be done safely?

What needs to be done

• Stabilization of hemodinamic unstable pelvis

• Fractures with vascular injuries

• Compartment sindrome

• Early stabilization of long bones

• Debridement and stabilzation of open fractures

• Unstable spine injuries with neurological deficit

When needs to be done?

• In resuscitation phase (bleeding)

Stabilization of hemodynamically unstable pelvic

fracture

• After the patient is stabilized

Compartment syndrome IN 1 - 2 h

Fr. with vascular injuries

Early stabilization of long bones IN 6 - 8

Excision and stabilization of open fractures

Unstable spine injury with neurologic def.

When needs to be done?

PHYSIOLOGICAL STATUS

SURGICAL INTERVENTION TIMING

Resuscitation response

- “life – saving” OP

? “damage control” OP

+ early OP

Day 1

hyperinflamation second look onlyDay

2. – 3.

“window of oportunity” definitive delayed OPDay

5. – 10.

immunosupression NO SURGERYDay

10. – 21.

recovery secundary reconstructive OPAfter week

3

Trentz, 2000

How much can be done sefely?

Stable patient: stable hemodynamics, no inotropic support, stable

coagulation, urinary output, normotermic, lactate >2... ETC

Borderline: BP 80-100, lactate 2.5, slightly impaired coagulation, BT 33-

35, ISS >20 with chest trauma, ISS>40 without chest trauma....DC

Unstable and in extremis: BP 60, severe acidosis, coagolopathy,

severe risk of deterioration....DC or life saving surgery

You are on duty...

• 18 y old male, conscious, told that he sustained a collision with the

bus as a motor bike driver, pain in pelvic and abdominal region

• Affected with pains

• SBP 80, pulse 100

• Anestesiologist intubated him and started with fluid support

• SBP after 10 minutes 90, pulse 100

Emergeny room: scout film of thorax: 3 ribs fractured

left, FAST OK, emergency x ray of pelvis:

After resusciation phase

• BP 90

• Pulse 100

• Lactate 3.0 mmol/l

Stable?

After resusciation phase

• BP 90

• Pulse 100

• Lactate 3.0 mmol/l

Stable?

Borderline.

After resusciation phase

• BP 90

• Pulse 100

• Lactate 3.0 mmol/l

Stable?

Borderline.

What to do?

After resusciation phase

• BP 90

• Pulse 100

• Lactate 3.0 mmol/l

Stable?

Borderline.

What to do?

Stabilize hemodinamically unstable pelvis (close the taps!)

Suttures of rectum, Hartmann procedure

ICU for 10 days, intraabdominal abscess, 2 X

drained, after 20 days conversion to ORIF (only

anterior)

After 6 months, EMG of pelvic floor: reinervation

of levator any improved, reconstruction of rectum,

closing of colostomy

Functional result (sfincter function recovered

completely)

• Politrauma is systemic surgical emergeny

• Rsusciation phase: treat first what kills first

• Shock: close the taps

• Stable, borderline, unstable, in extremis

• Two hit concept: extensive surgery can be a second hit

• Consider DCO vs. ETC: STAY ON THE SAFE SIDE

Take home message