A brief approach to patient with polytrauma, physiological response of body with trauma, the trimodal mortality, golden hour, lethal triad of trauma, two hit hypothesis, inflammatory mediators, prehospital care, primary survey, secondary survey, ABCDE approach, Adjucts are included. Besides thc concept of Damage control orthopedics, trend in fracture management , evolution , principle, indication , surgical stratergies, advantage, limitation, definitive fixation and EAC and ETC are included in breif.
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Appraoch to patient with polytrauma and Damage control orthopedics
1. Approach to Patient with
Polytrauma and Damage Control
Orthopedics
Presenter: Kaushal Raj Kafle
Moderator : Dr. Shirish Adhikari, MS
2. Content
• Defining polytrauma
• Physiological response to trauma
• Approach to patient with polytrauma patients and ATLS
protocol
• Definition and development of DCO concept
• Principles of DCO
• Indications, advantage and limitation of DCO
3.
4. AIS and ISS
• Injury Severity Score
– identify and classify injured
patients
– risk adjustment and
benchmarking using
mortality prediction model
– the ‘gold standard’ of injury
scoring
– Major trauma (MT) using
an ISS ≥ 16
5. Polytrauma
New Berlin Definition
• An Abbreviated Injury Scale score of ≥3 in ≥2 body regions
(2AIS ≥3)
• with the presence of ≥1 physiological risk factors (PRFs).
– Age (≥70)
– Glasgow Coma Scale (GCS≤8)
– Hypotension (SBP ≤60 )
– Acidosis (BE ≤-6 )
– Coagulopathy (aPPT ≥ 40s/INR ≥1.4 )
6. Trauma Mortality
• Trimodal Pattern
– Immediate (sec to min)
• Apnea secondary to Brain or
SC injury
• Catastrophic Hemorrhage
– Early (min to hours)
• Hemorrhage related
• Focus of the ATLS care
– Late
• MODS / Sepsis
• Optimal early management
7.
8. Golden Hour
• Critically injured patient receive definitive care within 60 min from
occurrence of injury
• Concept of 1970s, widely accepted and clinically plaused
• Golden hour isn’t a strictly defined time period
• Concept emphasises the urgency of care
• Still remains valid, but for some patients the ‘golden hour’ may only
be minutes, or for others, much later
• Platinum 10 minutes : No patient should have more than 10 min of
scene time stabilization
10. Physiological Response to Trauma
• Trauma : SIRS
• Recovery : CARS
• SIRS lead to MODS
• Immunosuppression leads
to Delayed MODS
• Persistent Inflammation,
Immunosuppression, and
Catabolism Syndrome
(PICS)
11. • Fine balance between the beneficial effects of inflammation
and potential to cause and aggravate tissue injury
12. Two hit hypothesis
• First Hit:
– Massive injury and shock
– Immediate aftermath of
trauma
• Immediate inflammatory
response
– IL 6,8
– L selectin
– CD11b Leucocyte
• Second Hit :
– sepsis, surgical procedures
• Cumulative inflammatory
response
• Hyperstimulation of
inflammatory system
• Potential worse outcome
compared to what was
expected out of the first
13.
14. Inflammatory mediators
• Inflammatory response
• Innate immune system
– Macrophage
– Leukcocytes
– NK cells
– Inflammatory cells
mediated by IL 8
– C5a, C3a
– ROS
– Eicosanoids
– Cytokines
15.
16. Genetics and trauma
• NOT all patient obey the roles set by predictive parameter
• Mutation in endonuclease restriction sites, SNP genes
• Genetically Susceptible predispose to sepsis, ARDS and MODS
• Future : Early identification of AT RISK patients
17. Approach to patient with poly trauma
• First : Synchronous Clinical Assessment
Life saving procedures
– ATLS Guidelines
– Control of massive visceral bleed
– Chest/Brain Decompression
• Second : Day 1 surgery
– Damage control interventions
– Debridement, decompression and temporary fracture
stabilization
• Finally
– Reconstructive surgery after physiological stabilization
18. Prehospital Care
• Field Triage
• Control of External hemorrhage and shock
• Airway management
• Immobilization
• Notification and immediate transfer
21. Triage
• Sorting (Prioritization) of patients based on resources
required for treatment and the resources actually available
• Priority is set by ABC principle
22. Primary Survey
• Primary Survey with simultaneous resuscitation
• Rapid identification of life threatening conditions
• ABCDE
– Airway and C spine stabilization
– Breathing and Ventilation
– Circulation with Hemostasis
– Disability/Neurological Assessment
– Exposure and Environment Control
• cABCDE
23. Airway and C spine control
• Assessment
– Able to talk
– Unconcsious
• Chin lift/ Jaw thrust
• Airway Adjuncts
– Protect excessive mobility
• Cervical Collar
24. Breathing and Ventilation
• Assessment
– Inspect, palpate, percuss and auscultation
• JVP, chest movement, tracheal deviation
• Lungs, chest wall, diaphragm
– Intact airway does not mean adequate ventilation
• High Flow Oxygen
• Adjunct : Saturation assessment
26. Circulation and Hemostasis
• Hemorrhage: most dominant preventable cause of death
• Hypotension is secondary to hemorrhage until proven
otherwise
• Assess: Consciousness, Skin , Pulse
• Monitor : BP , I/O
• Manage : Double wide bore cannula
– Fluid Resuscitation with Colloid/Crystalloid
– Blood Grouping and Cross matching
– Blood Transfusion
– Evaluate and manage for internal bleeding
29. Exposure and Environment Control
Complete Exposure of body
Back and log roll
Removal and reapplication of splints
Prevention of Hypothermia
30. Secondary Survey
• Head to toe examination
• Identification of non life threatening injuries
• AMPLE
– Allergies
– Medication
– Past medical history
– Last meal
– Event/ environment of injury
31. Physical Examination
• Head: Scalp, Vision, pupillary reflex, conjunctival hemorrhage
• Maxillofacial/ C spine and Neck
• Chest, abdomen and pelvis
• Perineum , rectum, vagina
• MSK system
• Neurology
32. Adjunct to secondary survey
• X Ray of Spine and Extremities
• CT head, Chest, Abdomen and Spine
• Contrast Urography, Angiography, bronchoscopy and
Endoscopy
34. Definitive Care
Multi Specialty Approach
Neurosurgeons
Thoracic Surgeons
Genitourinary/ GI Surgeons
Orthopedics Surgeons
Vascular Surgeons
Critical Care Physicians
Anesthesiologist
Trauma Nurse
Physiotherapist
35. Damage Control Orthopedics
• Approach that contains and stabilizes orthopedics injury so
that the patient’s overall physiology can improve.
• Focuses on
– Hemorrhage control
– Management of soft tissue injury
– Provisional stabilization of fracture
– Avoid additional insult
36. Damage Control Surgery and
Abdominal Trauma
• Sum total of all maneuvers required to ensure survival over
definitive repair
• Improved lethal triad
• Coined by Rotondo and Zonies 1993
• Systematic three phase approach
– Immediate laparotomy : hemorrhage control and containment
– Resuscitation in ICU (Hemodynamics, rewarming, coagulopathy,
ventilatory support, continued identification of injuries )
– Planned reoperation to remove packing, definitive repair,
closure and possible repair of extra abdominal injuries
37. Trends in Fracture Management
• Early Total Care
• Damage Control Orthopedics
• Safe Definitive Surgery / Early Appropriate Care
38. Early Total Care
• 1980
• Early and immediate fixation
• Early definitive surgery and aggressive
resuscitation
• Fix all fracture in single setting
• Optimal utilization of OT
setup/personnel
• Easy handling and mobilization
• Lengthy operative procedures,
associated blood loss
39. Evolution of DCO
• Benefit of early fracture stabilization
• Fear of Fat embolism syndrome
• 1990
– Challenged the accepted immediate definitive fixation
– More selective approach
– Identification of parameters associated with adverse outcome in
multiply injured patients
– Intramedullary nailing has systemic physiological effect
• Second Hit Phenomenon
• 1993 the concept of damage control was established
40. Principle of DCO
• Early Temporary Stabilization
– Rapid splinting, external fixation
– Minimize time under anesthesia
• Resuscitation and Correction of Metabolic Derangements
– Address hypovolemia, acidosis, hypothermia
– Correct coagulopathy
41. Indication of DCO
• Physiological criteria
– Blunt trauma : hypothermia, coagulopathy, shock and
blood loss, soft tissue injury = 4 vicious cycle
– Penetrating trauma : hypothermia, coagulopathy and
acidosis (lethal triad)
• Complex pattern of severe injury
– Expecting major blood loss and prolonged reconstructive
surgery in physiologically unstable patient
42. Surgical Strategies
• Minimize extensive soft tissue dissection
– Preserve vascular supply and wound coverage
– Reduce infection risk
• External fixation
– Allows for quick stabilization without extensive soft tissue handling
– Temporary stability until patient can tolerate definitive fixation
• Definitive fixation timing
– Delayed until patient's condition improves
– Consideration of physiological parameters (hemodynamics,
coagulation)
• Collaboration between orthopedic and critical care teams
43. Advantage
• Minimal systemic insult
• Helps resuscitation
• Allows better operative plan
• Reconstruction under best
circumstances
• Best team possible for
difficult task
44. Staging of Patients Physiological Status
• Stable
– No immediate life threatening
injuries
– Respond to initial therapy
– Hemodynamically stable with
out ionotrop support
– No coagulopathy, ARDS,
shock, hypothermia
• ETC
• Borderline (Patients at Risk)
– Respond to initial therapy but
risk of deterioration
• Cautious ETC
• Invasive monitoring and ICU
45. Staging of Patients Physiological status
• Unstable
– Hemodynamically unstable
despite intervention
– Rapid deterioration
• DCO
• ICU transfer and
monitoring
• In Extremies
– Close of death
– Ongoing uncontrolled
blood loss
– Severely unstable despite
ongoing resuscitative effort
• Deadly triad
• ICU with advanced
hematological, pulmonary
and CVS support
51. Definitive Fixation
• After 5 days when the level
of interleukins drop
• 5-14 days : Window of
Opportunity
• Delay beyond 15 days due
to other injuries
– Continue with Exfix
– Increased risk of pin tract
infection
.
52. Limitations of DCO
• Developed under the studies of femoral fractures
• Unstable pelvic and acetabulum fractures
• Thoracolumbar spine fractures
• Need of further surgery
• Additional Implants and cost
• Lack of rigorous prospective designs
• Confounding effects of associated head, chest, abdomen
injury and its severity have not been accounted
53. Staging of management period
1. Acute “reanimation” period (1 to 3 hours)
– Control of acute life threatening conditions
– ATLS with secondary survey
2. Primary “stabilization” period (1 to 48 hours)
– Fracture with vascular injuries
– Acute compartment syndrome
– Temporarily stabilized with external fixation
3. Secondary “regeneration” period (2 to 10 days)
– Re-evaluate the constantly evolving clinical picture
4. Tertiary “reconstruction and rehabilitation” period (weeks)
– Complex surgical procedures
54.
55. Early Appropriate Care
• 2013
• Aka Safe Definitive Surgery
• Offers benefit of ETC and Safety of DCO
• Unstable fracture of axial skeleton and long bones
– Definitive fixation within 36 hours
– Demonstrable response to resuscitation
• reversal of acidosis: serum lactate <4 mmol/L, pH ≥7.25
or base excess more than 5.5 mmol/L
• Best suited for borderline patients
• Team based Case to case decision
56. • Chest injury is identified as Strongest independent predictor
of pulmonary complication regardless of MSK injury and type
of fixation
• Patient’s physiological status measured by acidosis seems to
be predictive of complications
– Admission pH and Base excess proportional to magnitude
of resuscitation and prognostic of mortality and morbidity
– No improvement in Acidosis over 24hrs with resuscitation
progressed to pneumonia, ARDS or pulmonary
complications
• Early reamed nails is safe provided they have been adequately
resuscitated
57. Conclusion
• Trauma is a surgical disease, and surgery is a carefully
choreographed trauma.
• Individually adjusted surgical “damage control” and “immune
control” are important interactive concepts in polytrauma
management.
• ATLS is life-saving strategy with standardised process and care
of patient.
• DCO is staged and adaptable approach to treating unstable
polytrauma patient to minimize complication and optimize
outcomes.
58. References
• Rockwood and Greens Fracture in adults, 8e
• Apleys Textbook of Orthopedics.
• ATLS 10e, 2016
• Various Articles
Trauma is wound/hurt/ defeat in Greek Bailey and Love: Physical force exerted on a person leading to physical injury
Common forces being mechanical, along with chemical thermal ionizing
Majority of causes: RTAs, Accidental falls, and Phyiscal violence
RTA being the most documented ones.
disproportionate impact on the young, working age population.
Though the data is more on the causation of the injury, it can high light the gravity of problem on public health, the increasing number of injuries, the proportionate number of lives that can be saved with proper intervention at various level.
World Bank 2020 report on delivering road safety in Nepal https://openknowledge.worldbank.org/server/api/core/bitstreams/ae34a0d8-c59c-51c5-82bd-7d8ef13b17ff/content
AIS is an anatomically based, consensus derived, global severity scoring system that classifies an individual injury by body region according to its relative severity on a 6 point scale (1=minor and 6=maximal).
1974
identify and classify injured patients within trauma systems,
component of risk adjustment and benchmarking using mortality prediction
Anatomic : ISS AIS NISS OIS Physiological RTS < GCS, APACHE Combined : TRISS ASCOT
An international consensus meeting in
polytrauma by combining the concept of injuries in different body regions
parameters of physiological response
swift transport is beneficial for patients suffering neurotrauma and the haemodynamically unstable penetratingly injured patient. For haemodynamically stable undifferentiated trauma patients, increased on-scene-time and total prehospital time does not increase odds of mortality. For undifferentiated trauma patients, focus should be on the type of care delivered prehospital and not on rapid transport.
https://sci-hub.ee/10.1016/j.injury.2015.01.008
period of time when life threating and limb threatening injuries should be treated in order to decrease mortality
estimated 60% of preventable deaths can occur during this time ranging from minutes to hours
era characterised by a lack of an organised trauma system and inadequate prehospital care.
the preference for a ‘scoop and run’ approach to prehospital care rather than “stay and play”
share a complex relationship; each factor can compound the others,
high mortality if this positive feedback loop continues uninterrupted
Hypothermia: blood loss, exposure, decreased metabolic activity Coaguloapthy : blood loss, impaired metabolic activity of shock
Acidosis: hypoperfusion mediated lactic acid built up interferes with normal cellular process and leads to organ dysfunction
Local and systemic inflammatory response: increased catecholamines and adrenocorticoids : General Adaptation syndrome : HR RR fever
Simulatenous immune system activation : hemostasis, prevention of infection and initiation of tissue repair
Compensatory anti-inflammatory response syndrome
Bodys attempt to balance overwhelming proinflammatory response with anti-inflammatory response to prevent excessive tissue damage.
Cascade of events following systemic trauma, generalized hypoxemia,
Two hit Hypothesis of SIRS
The combined levels of inflammatory mediators are high enough to cause generalised tissue damage and lead to MODS
Secondary insult can have disproportionately severe impact on the patients overall outcome potentially leading to worse outcome compared to what was expected out of the first
PICS long term physical cognitive and psychological effect that persists following a prolonged ICU stay for critical illness or injury resulting from critical illness, inflammatory response, prolonged mechanical ventilation, sedation, immobilization
…. Physical respiratory impairment, muscle weakness, neuropathies, cognitive Delirium, psychological PTSD anxiety depression
IL-6 is a reliable marker as it has a strong correlation with the magnitude of the injury, and levels in excess of 200 pcg/L are associated with poorer outcomes
Genetic constitution causes Biological variations
Single Neucleotide polymorphism
Relationship between different polymorphic variants and risk of development of post traumatic complications have been well studied.
However the studied genes are just epiphenomenon
Goal Directed therapy, use of low dose steriods, Blood glucose control and activated C protein appeared have improved outcomes in Sepsis and similar acheivements in patient with acute trauma
Speed with which lethal process is identified and halted makes difference in the survival and recovery of patient
The change of survival and extent of recovery is highly dependent on medical care
Identification and stoppage of lethal processes makes difference
Nebraska : orthopedic surgeon following airplane crash 1978
Standardised the process and care of patient
Effective initial assessment and good initial management
• Manpower: • trauma team • trained staffs • Materials: • properly functioning instruments, • medicines, fluids • Resuscitation area • Preparedness for mass casualties and disasters
an organized team approach
Rule out facial fractures, tonugue fall back, foreign body , secretions inside mouth
Adjuncts : Guedel airway, nasopharyngeal oropharyngeal airway , LMA
GCS < 8 definitive airway : tracheostomy and intubation
Breathing, adequate ventilation and oxygenation
Sites for needle thoracotomy
(once Tension Pneumothorax is ruled out)
Carotid : 60mm Hg femoral 70 radial 90 DPA 100
EFAST : Extended Focused Assessment of sonography in trauma
Maintain IV Volume, oxygen carrying capacity and preserve the coagulation cascade
Avoid provoking a severe inflammatory response
Sufficient enough to prevent further damage and possibilty of development of compartment syndrome
Allowing patient for easy mobilization for test and improved general care
1940s 1950s Griswold, kentucky, Penetrating injury if abdomen
1980 Feliciano 9/10 hepatic packing survived for exanguinating hemorrhage survived
Damage control in trauma surgery, Hirsgberg A
1993
n 2000 Scalea introduced the term “Damage Control Orthopaedics (DCO)
https://journals.lww.com/jbjsjournal/abstract/1989/71030/early_versus_delayed_stabilization_of_femoral.4.aspx
Fix long bones with in 24 hours
Resusicate aggressively
Based on principle that it decreases late complications.
However some patients are too unstable to undergo lengthy operative procedures, tolerate assosciated blood loss
80-90 ETC was promising
1990 Border et all evaluated the patients with blunt trauma
These physiological effects were Later descirbed as second hit phenomenon
Nailing a femur is a systemic insult and large enough to fill the role of second hit . Any major operative intervention carried out when the level of mediators are high has significant likelihood of serving as Second hit
IL6-IL8 remains high for atleast 5 days
DCO
Head injury with orthopedic injur : second hit : Increase mediators> systemic BP drops > Hypoperfusion of brain > more swellling and raised ICP
Local soft tissue damage :
In centres where resources (personnel, facilities, experience ) to manage polytraumais limited, restricts ETC in stable or boderline patient, DCO becomes the best option before transfering patient to appropriate institution.
Trauma-adjusted surgical techniques are crucial to limit the systemic response known to put remote organs at risk.
Stable. These patients have the physiologic reserve to withstand prolonged operative intervention where this is appropriate and they can be managed using an early total care (ETC) approach, with reconstruction of complex injuries.
Borderline (Patients at Risk) Borderline patients have stabilized in response to the initial resuscitative attempts but they have clinical features or combinations of injury, which are often associated with poor outcome and put them at risk of rapid deterioration. These have been defined as follows. • ISS >40 • Hypothermia below 35ºC • Initial mean pulmonary arterial pressure >24 mm Hg or a >6 mm Hg rise in pulmonary artery pressure during intramedullary nailing or other operative intervention • Multiple injuries (ISS >20) in association with thoracic trauma (AIS >2) • Multiple injuries in association with severe abdominal or pelvic injury and hemorrhagic shock at presentation (systolic BP
Unstable Patients who remain hemodynamically unstable, despite initial intervention, are at a greatly increased risk of rapid deterioration, subsequent multiple organ failure, and death. Treatment in these cases has evolved to utilize a “damage control” approach. This entails rapid, essential lifesaving surgery and timely transfer to the ICU for further stabilization and monitoring. Temporary stabilization of fractures using external fixation, hemorrhagecontrol, and exteriorization of gastrointestinal injuries where possible is advocated. Complex reconstructive procedures should be delayed until stability is achieved and the acute immunoinflammatory response to injury has subsided. This rationale is intended to reduce the magnitude of the “second hit” of operative intervention or at least delay it until the patient is physiologically equipped to cope.
In Extremis These patients are very close to death having suffered severe injuries and they often have ongoing uncontrolled blood loss. They remain severely unstable despite ongoing resuscitative efforts and are usually suffering the effects of a “deadly triad” of hypothermia, acidosis, and coagulopathy. A damage control approach is certainly advocated. Only absolutely lifesaving procedures are attempted in order to avoid exhaustion of their biologic reserve. The patients should then be transferred directly to intensive care for invasive monitoring and advanced hematologic, pulmonary, and cardiovascular support. Orthopedic injuries can be stabilized rapidly in the emergency department or ICU using external fixation and this should not delay other therapy. Any reconstructive surgery is again delayed and can be performed if the patient survives.
Ex fix of femoral fracture is rapid
Involves little blood loss
Not invasive enough to trigger second hit
external fixation (whether supra acetabular or iliac crest) predominantly controls and stabilizes the anterior pelvic ring
iliac crest external fixator is problematic in obese patients.
AIIS Supraacetabular 10-20 carnial and 20-30 medial
Ilaic crest : anterior 1/3 sparing the 1.5cm of ASIS Gluteus medius pillar
Lateral cutenous femoral nerve
Delay in fixation increases risk of infection
Poor soft tissue condition : open fractures, crush injuries, and significant wounds, the condition of soft tissues dictates the ideal time for definitive fracture fixation. 10-21 days is optimal
The majority of previous studies lack the rigor of a randomized prospective design and have limitations of small group size and variable definitions of “early” fixation timing.
severe chest injury is a risk factor for pulmonary complications,
Surgical management principles of polytraumatized patients for the first 10 days based on main pathophysiological mechanisms. The upper part of the diagram pictures the main pathophysiological changes in relation to the time elapsed after the injury. The lower part describes the surgical principles adjusted to the individual injury pattern and the systemic inflammatory response (SIRS).
Vallier HA, 2013 Timing of orthopaedic surgery in multiple trauma patients:Development of a protocol for early appropriate care. J Orthop Trauma.
adults with pelvis (n = 291), acetabulum (n = 399), spine (n = 102), and/or proximal or diaphyseal femur (n = 851) fractures
Prognostic Level II
The purposes of this project were to define which injuries or clinical parameters warrant delay of definitive fracture management, with particular respect to the course of resuscitation and to determine what time interval for fracture fixation promotes optimal patient outcome, provided the patient has been adequately resuscitated.
early reamed femoral nailing is safe in patients with ISS .17 provided they have been adequately resuscitated, as defined by significant improvement in serum lactate, with ARDS occurring in only 1.5%.
a correction of a pH to >7.25 within eight hours, base excess equal to or above 5.5 mmol/L and a lactate
Surgical diease its enhancing effect is not limited to the inflicted site but has a generalized character, which can be reduced by using gentle techniques and materials.