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Damage control
- 1. DAMAGE CONTROL ORTHOPAEDICS Mohamed Elshohna ,Orthopaedic registrar ,Aladan hospital
- 7. DCO • Rapid emergency surgery to save life or limb – NOT involving complex reconstructive surgery • Control bleeding • Decompress cranium, pericardium, thorax, abdomen and limbs • Decontaminate wounds and ruptured viscera • Splint fractures • Cast, traction, pelvic binder, ex-fix • Get back to ITU environment ASAP • Definitive surgery performed several days later
- 9. SIRS 1983 SYSTEMIC IMMUNE RESPONSE SYNDROME • Condition characterised by systemic inflammation, organ dysfunction, and organ failure. • Subset of cytokine storm, abnormal regulation of various cytokines • Inflammatory response to sepsis, trauma, hypoperfusion
- 11. CARS 1996 COMPENSATORY ANTI-INFLAMMATORY RESPONSE SYNDROME • CARS - systemic deactivation of the immune system tasked with restoring homeostasis from an inflammatory state • More than just cessation of SIRS Bone RC. Sir Isaac Newton, sepsis, SIRS, and CARS. Crit Care Med. 1996;24(7):1125–8
- 13. THE ‘FIRST HIT’ Threshold for fatal inflammatory response DEATH: from multiorgan failure or adult respiratory distress syndrome 1st Hit: the trauma inflammatory response time The ‘natural’ systemic inflammatory response
- 14. THE ‘SECOND HIT’ Threshold for fatal inflammatory response 1st Hit: the trauma inflammatory response time 2nd Hit: the surgery The exaggerated response brought about by the 2nd hit of surgery
- 15. THE ‘SECOND HIT’ Threshold for fatal inflammatory response 1st Hit: the trauma inflammatory response time 2nd Hit: the surgery In some individuals the lengthy surgery of early total care exacerbates the the systemic inflammatory response resulting in death
- 18. POLYTRAUMA
- 19. POLYTRAUMA • Defined as “a clinical state following injury to the body leading to profound physiometabolic changes involving multisystem’’. • Patient with anyone of the following combination of injuries TWO MAJOR SYSTEM INJURY + ONE MAJOR LIMB INJURY. ONE MAJOR SYSTEM INJURY + TWO MAJOR LIMB INJURY. ONE MAJOR SYSTEM INJURY + ONE OPEN GRADE III SKELETAL INJURY. UNSTABLE PELVIS FRACTURE WITH ASSOCIATED VISCERAL INJURY.
- 20. • The term “polytrauma” has been frequently defined in terms of a high Injury Severity Score • The internationally accepted threshold of an ISS 16 is based on the description as being predictive of a mortality risk above 10% . Boyd, C.R.; Tolson, M.A.; Copes,W.S. Evaluating trauma care: The TRISS method. Trauma Score and the Injury Severity Score. J. Trauma 1987, 27, 370–378. [CrossRef] [PubMed]
- 28. PATIENTS FOR DC SURGERY • 4 groups of patients • Stable: go for Early Total Care • Borderline: ? • Unstable: go for Damage Control Surgery • Extremis: Damage Control Surgery or ITU • Borderline patients are more difficult to define
- 32. TIMING OF RETURN AFTER DC SURGERY • Days 2-5 are not safe • During this period: • Marked inflammatory response ongoing • Increased capillary permeability leads to generalized oedema • Cardiac output is high • Patient is fragile • A 2nd hit at this stage could be fatal • Pape et al: prospective study – • multiply injured patients undergoing surgery between days 2 and 4 had a significantly increased inflammatory response compared with patients operated on between days 6 and 8
- 40. JTO; Volume 02 / Issue 02 / May 2014
- 41. EAP • Early Appropriate Care • Acceptance different patients respond differently to first and second hits • Consider severity of initial injury • Consider response to resuscitation • What further surgery required • Continued re assessment and ability to change from ETO TO DCO
- 42. 20 YO, MALE 01/02/06 – 15:48 • #BOS • #Nasal bone • APC pelvic injury • # R Supracondylar femur • # R Tibia shaft (open) • # L Tibial plateau (open) • # Bimalleolar L ankle
- 43. PRE HOSPITAL • Intubated • Pre hospital arrest • Hr 144, Systolic 60 • GCS 3
- 46. • External fixator • Pelvis • R leg • L leg • Debridement washout, fasciotomy and vac dressing • R thigh • R lower leg • L lower leg • Laparotomy 4 HRS
- 48. • Plating pubic symphysis • Intramedullary nail • R femur retrograde • R tibia • Change of Vacs Day 6
- 49. • ORIF L Tibial plateau • ORIF L fibula • Free Flap R tibia • Rotation flap L Tibia Day 9
- 52. SUMMARY • Multiply injured patients may have a profound and life-threatening inflammatory response • A ‘second hit’ of long definitive surgery can result in a fatal inflammatory response • The second hit can be avoided using early ‘damage control surgery’ followed by late ‘definitive care’