polytrauma and damage control orthopaedics
TRANSCRIPT
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POLYTRAUMA AND DCO: RECENT
CONCEPTS
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Polytrauma Injury to 2 or more organ systems
leading potentially to a life threatening condition
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Physiological response to injury Inflammatory immune response
Innate immune response Adaptive immune response
Systemic Inflammatory Response Syndrome (SIRS)
Compensatory Anti-inflammatory Response Syndrome (CARS)
Multi Organ Dysfunction Syndrome (MODS)
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Inflammatory immune response EARLY innate immune response DELAYED adaptive immune response
Innate = Hyperinflammation = SIRS
Adaptive = Immunosuppression = CARS
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Early innate immune response Neutrophils (major cellular ‘player’) are
drawn to the site of injury by IL-8 and C5a (chemokines)
Priming neutrophils for defence and debridement of injured tissue, and mediating inflammation
Activation of PMN, monocytes, macrophages, NKC and endothelial cells
Release of pro-inflammatory mediators (cytokines and molecular mediators)
Considered the hyperinflammatory period
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SIRS DEFINITION Heart rate: > 90 bpm WBC: <4000/mm3 or >12000/mm3 or
>10% immature PMNs Respiratory rate: >20/min with
PaCO2<32mmHg Core temperature: <360C or >380C
2 of 4 parameters = SIRS
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Delayed adaptive immune response
Non-apoptotic necrotic/dead cells produce alarmins plus Endogenous triggers (DAMPs = damage-associated molecular patterns)
CD5+ B-cells to produce natural antibody without prior exposure and subsets of T-cells to inflict self-reactivity → autoimmune tissue destruction
Considered the immunosuppression period or CARS
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Interplay of SIRS and CARSSy
stem
ic Re
spon
se
SIRS
CARS
D14D7
Adaptive Immune Response
Innate ImmuneResponse
Resolution
Resolution
Insu
lt
Homeostasis
Mild-Moderate Injury
Pro-
infla
mm
ator
yAn
ti-in
flam
mat
ory
Balanced SIRS-CARS maintains homeostasis
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Pathological immune response
1st Hit
Moderate Injury
1st Hit
Amplification of SIRSDelayed-onset MODS/death
Incomplete Resolution
2nd Hit
2nd Operation within D3-5Sepsis
Severe injury
Intense CARSEarly MODS/death
IMBALANCE BETWEEN SIRS AND CARS
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Pathological immune response
Syst
emic
Resp
onse SIRS
CARS
Adaptive Immune Response
Innate Immune
Response
Insu
ltSevere Injury
Pro-
infla
mm
ator
yAn
ti-in
flam
mat
ory
Imbalanced CARS>SIRS leads to hypo-inflammation or early MODS
Early MODS
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Pathological immune response
Syst
emic
Resp
onse
SIRS
CARS
Adaptive Immune Response
Insu
ltModerate to severe injury
Pro-
infla
mm
ator
yAn
ti-in
flam
mat
ory
Imbalanced SIRS>CARS leads to hyper-inflammation or delayed MODS
Late MODS
Innate ImmuneResponse
2nd H
it
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MODS Cerebral - Cerebral edema CVS - Hypotension and shock Respiratory - Acute lung injury, ARDS Liver - High APR and cytokines,
hepatocytes dysfunction GI - Increased mucosal permeability
Bacterial translocation Renal - Renal tubular necrosis, acute renal
failure Hematologic - DIVC
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Polytrauma (2 hit phenomenon)
‘First Hit’ Impacts by Trauma The Limb/Organ System
The Patient
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Polytrauma (2 hit phenomenon)
‘Second Hit’ Impacts by Surgery and Resuscitation
The Limb The Patient
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New concept in resuscitation
First Hit Impacts
How do you decide your fluid replacement?
What is your fluid replacement regimen?
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Class I Class II Class III Class IV
Blood loss (liter) Up to 0.75 0.75-1.5 1.5-2.0 > 2% TBV 15% 30% 40% >40%Pulse rate < 100 > 100 >120 >140Blood pressure Normal Normal Decreased DecreasedPulse pressure Normal or inc Decreased Decreased DecreasedRespiratory rate 14-20 20-30 30-40 >35Urine output > 30 ml/hr 20-30 5-15 NegligibleMental status Slightly
anxiousMildly
anxiousAnxious/confused Confused/
lethargicFluid Replacement
Crystalloid Crystalloid Crystalloid and blood
Crystalloid and Blood
Classification of Hypovolaemic Shock and Physiologic Changes
What is your fluid replacement regimen?
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Fluid resuscitation Bolus administration of saline? Colloids? GXM or GSH?
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Fluid resuscitation
Shock due to primary
haemorrhage Ongoing bleeding 2O
resuscitation regimen Lethal Triad of Death
First Hit
Second Hit?
AcidosisHypothermia
Coagulopathy
Voluminous crystalloid ● dilutes coagulation factors ● causes hyperchloremic and lactate acidosis● supplies inadequate O2 to under-perfused tissue
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DCR Priorities Beyond ABCDE of ATLS
On-going BleedingHypoperfusion
ExposureSIRS/CARS
ResuscitationContamination
Balanced Resuscitation or
Permissive Hypotension
Haemostatic Resuscitation
Damage Control Surgery
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Paradigm Shift in ResuscitationFrom ATLS in 1980s
EARLY TOTAL CARE (ETC) ATLS concept of Primary Survey
followed by Secondary SurveyTimely debridement within 6-hour Early definitive fracture fixation within 24 hours (ETC)
EDCBA
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Paradigm Shift in Resuscitation To DCR in 1990s
HD Triage: Stable, Borderline, Unstable and In Extremis DAMAGE CONTROL RESUSCITATION
Permissive hypotension and haemorrhage control Haemostatic resuscitation in ICU Damage Control Surgery Definitive fracture fixation after D5
DCBAC E
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HAEMODYNAMIC ‘TRIAGE’ PROTOCOL
Stable Borderline Unstable In ExtremisNo clinical signs
of hypovolaemicshock
SBP 80-100mmHgAIS > 2Blood transfusion 2-8/2h
Absent vital signsSevere shockUncontrolled h’hageneeding mechanical resuscitationrepeated CA infusion despite complete blood volume replacement within 2h (>12 blood transfusion/2h
Unable to maintain SBP >90mmHgPulse <100/min CVP>5cm H20 UO>30ml/hDespite adequate fluid resuscitation and bloodtransfusion over 2h
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1. Fluid Replacement in Balanced Resuscitation ● Initial fluid replacement with up to 2L crystalloid Permissive hypotension to achieve SBP to 80-90mmHg (radial pulse) until definitive control of bleeding is obtained ● Role of fluid challenge (250-500ml) tests to stratify responder, transient responder, non-responder 2. Haemostatic Resuscitation ● Early blood versus HBOC transfusion decreases MODS ● Packed RBC, FFP and Platelets in 1:1:1 ratio ● Cryoprecipitate, Tranexamic acid, Recombinant factor-VIIa ● Storage blood of < 2 weeks to minimise TRALI, MODS
Non-surgical DCR
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3. Correction of Metabolic Derangement ● Role of THAM (Tris-hydroxmethyl-amino-methane) ● Use of NaHCO3 to correct acidosis causes hypercapnia? 4. Hypothermia Prevention and Treatment Strategies ● Limit casualties’ exposure ● Warm IV fluids and blood products before transfusion ● Use forced air warming devices before and after surgery ● Use carbon polymer heating mattress
Non-surgical DCR
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Damage control orthopaedics
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Damage Control Orthopaedics An approach to contain and stabilize an
orthopaedic injury to improve patient’s physiology
Designed to avoid worsening pt’s condition due to “second hit” phenomenon
Delay definitive surgery until pt condition is optimized
Focuses on hemorrhagic control, management of soft-tissue injury and provisional fracture stability
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DCO - evolution1960s Delayed Surgery (‘too sick to operate on’) Preliminary traction → delayed definitive fixation
1980s Early Total Care within 24 hours (‘too sick not to operate on’) ATLS concepts plus Advancement in anaesthesiology and ICU care ● early fixation prevents FES ● early mobilization facilitates nursing care and ● early mobilization prevents pneumonia, sepsis, TED Patients with ISS>17 (borderline patients) are at high risk of complications
1990s Damage Control Orthopaedics
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Patient categorizationParameter Stable Borderlin
eUnstable In Extremis
Shock SBP (mmHg)Blood unit/2hLactate Base deficitUO ml/hClass
100 or more0-2< 2.0Normal>150I
80-1002-82.5No data50-150II-III
60-805-15>2.5No data<100III-IV
50-60>15Severe>6-18<50IV
Coagulation
PlateletsFactors II/VFibrinogend-Dimer
>110,00090-100%>1 g/dLNormal
90-110,00070-80%1 g/dLAbnormal
70-90,00050-70%<1 g/dLAbnormal
<70,000<50%DICDIC
Temperature
>340C 33-350C 30-320C <300C
Soft TissueInjuries
Chest AIS TTSAbd (Moore)Pelvic AOLimb AIS
2 or 20<IIAI-II
2 or moreI-II<IIIB or CII-III
2 or moreII-IIIIIICIII-IV
3 or moreIVIII or >IIICCrush
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Borderline patients (ISS>18)
Bone et al. Early versus delayed stabilization of fractures. A prospective randomized studyJ Bone Joint Surg. 1989; 71-A: 336-40Reynold et al. Is timing of fracture fixation important for the patient with multiple trauma?Ann Surg. 1995; 222:470-81
Femoralshaft #sN=105
<24 hr
24-48 hr
> 48 hr
ReamedIMN
ISS<18 ISS>18
Complications
Complications
Ecke et al. 1985
n=1127
AO Foundation
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ETC vs DCO
ETC ETC DCO DCO OR OR OR OR ICU
Stable Borderline Unstable ExtremisHaemorrhage control and/orDecompression in the ER
20 survey (end of ER workup)ABG, FAST, I/O ratio, ABP
Stable Uncertain
Ext-Fix(distractor)
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DCO surgery External fixation Nailing if ISS<25
Unreamed/retrograde Usage of new One-step Reamer-Irrigator-
Aspirator (RIA by Synthes)
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Application of DCO
Stage 1 Stage 3Stage 2
Definitive # fixation once the patient is
optimized(avoid day 2-5)
Resuscitation and ICU management1.Close monitoring2.Repletion of blood product3.Further hemodynamic stabilization
10 rapid temporary # stabilization(in trauma room/ICU/OR)
1.Control h’hage e.g. ext-fix pelvis2.Debridement of open wound3.Spanning ext-fix or unreamed nailing or reamed nailing using RIA
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Timing of surgeryTiming Physiological Status Surgical Intervention
Day 1 Normal response to resuscitation Early Total Care
Day 1Partial response to resuscitation
Damage Control Surgery
Day 1No response to resuscitation Life-saving surgery
Day 2-5 Hyperinflammation ‘Second-look’ onlyDay 6-10 Window of
opportunityDefinitive surgery
Day 12-21
Immunosuppression No surgeryWeek 3+ Recovery 20 reconstructive
surgeryAO Philosophy