Medical ppt

1. Mr Lee Van Rensburg
Mr Alan Norrish
October 2015

2.  ISS 57
 SAH, DAI
 R Haemothorax
 Pelvic ring fracture
 (Dissociation R hemipelvis)
 # L Acetabulum
 # L Femur
 Compartment syndrome both lower legs and
thighs

4.  Laparotomy
 Pelvis packed, Vac dressing
 C clamp and pelvic ex fix
 Angiogram
 Embolisation

5. Theatre to CT
Then ICU

6.  Retrograde femoral nail
 Fasciotomy
 Both thighs both calves
8 HRS

7.  Angiogram
 IVC filter
 Repeat bleeding
 Laparotomy change of packs
 Bladder repair
 Pubic symphysis ORIF
36 Hrs

8.  Angiogram
 IVC filter
 Repeat bleeding
 Laparotomy change of packs
 Bladder repair
 Pubic symphysis ORIF
 2 hour rewarming on table

9.  Removal of C clamp
 Anterior plating
 R Sacroiliac joint
 Debridement washout
closure C clamp and Ex
fix wounds

10.  Vac dressing change 17/05/06
 Closure of thigh wounds
 Vac dressing change 23/05/06
 Closure of L lower leg wound
 Vac dressing change 28/05/06
 Closure R lower leg wound

11.  Planned ORIF acetabulum
 Wound breakdown
 L iliac crest
 Both thighs
 Washout and vac dressings
Day 6

12.  #BOS
 #Nasal bone
 APC pelvic injury
 # R Supracondylar femur
 # R Tibia shaft (open)
 # L Tibial plateau (open)
 # Bimalleolar L ankle

13.  Intubated through window
 Pre hospital arrest
 Hr 144, Systolic 60
 GCS 3

16.  CT brain
 BOS
 Angiogram
 Very small bleeder
embolised

17.  External fixator
 Pelvis
 R leg
 L leg
 Debridement
washout, fasciotomy
and vac dressing
 R thigh
 R lower leg
 L lower leg
 Laparotomy
 EVD
4 HRS

19.  Plating pubic symphysis
 Intramedullary nail
 R femur retrograde
 R tibia
 Change of Vacs
Day 5

20.  ORIF L Tibial plateau
 ORIF L fibula
 Free Flap R tibia
 Rotation flap L Tibia
Day 9

21.  Debridement and SSG L Ankle
 Medial side
Day 27

24.  SIRS
 CARS
 Genes
 ETO
 DCO
 EAP

25.  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

26. 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

27.  Severe trauma can result in a life threatening
inflammatory response (SIRS)
Threshold for
fatal
inflammatory
response
DEATH: from multiorgan failure or adult
respiratory distress syndrome
1st Hit: the trauma
inflammatory
response
time
2nd Hit: the surgery
The exaggerated
response brought
about by the 2nd hit of
surgery

28.  Severe trauma can result in a life threatening
inflammatory response (SIRS)
Threshold for
fatal
inflammatory
response
DEATH: from multiorgan failure or adult
respiratory distress syndrome
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

29. Bone RC. Sir Isaac Newton, sepsis, SIRS, and CARS. Crit Care Med. 1996;24(7):1125–8
 CARS - systemic deactivation of the immune system
tasked with restoring homeostasis from an
inflammatory state
 More than just cessation of SIRS

30.  Different responses to Injury

31. SIRS: Severe
inflammation may lead to
acute multi-organ failure
(MOF), lung and
respiratory failure (ARDS)
and death
CARS: An anti-
inflammatory response
syndrome. May result in
prolonged
immunosuppression
leading to sepsis

32.  Early Total Care
 Not necessarily immediate, but within first 24 hours
 Often short period in ITU for resuscitation
 Repair all visceral injuries as soon as possible
 Definitive fixation of all long bone fractures within 24
hours
 Return to ITU only when all surgical procedures
finished
 Often long surgical times

33.  Damage control
 Naval Term term:
 “Capacity to absorb damage while maintaining
mission integrity”

34.  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

35. J Bone Joint Surg Am, 2005 Feb; 87 (2): 434 -449
Louisville additional criteria
pH of < 7.24
Temp < 35°C
Operative time > 90 minutes
Coagulopathy
Transfusion > ten units packed red
cells

36.  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

37.  Initial lactate:
 < 2.5 mg/dL,
 5.4% (4.5-6.2%) Mortality
 2.5 mg/dL to 4.0 mg/dL,
 6.4% (5.1-7.8%) Mortality
 >=4.0 mg/dL,
 18.8% (15.7-21.9%) Mortality
Occult Hypo perfusion, raised lactate increased mortality

38.  Lactate easy to measure
 Often high in 1st few hours but will drop in ITU if
resuscitation adequate
 2.5 magic number!
 > 3 DC Surgery
 2.5 – Look at TREND
 < 2.5 ETC

39.  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. Patient with multiple injuries
ITU
Assess clinical condition and lactate
Stable
Lactate <2.5
Borderline
Lactate 2.5-3.0
Unstable
Lactate
>3.0
In
Extremis
Attempt
to
resuscita
te in ED
or ITU
Early
Total
Care
Resuscitate
Assess lactate
trend
Stable
Uncerta
in
Damage
Control
Surgery

41. Trunkey DD. Trauma. Sci Am. 1983; 249:28–35

42. 1st mins 1st hour 1st few weeks
Can reduce deaths only by injury prevention strategies
Can reduce deaths by
excellent prehospital and
emergency room care
Can reduce deaths by
the decisions we make
regarding surgical
treatment.
Death from MODS &
ARDS

43. Proc (Bayl Univ Med Cent). 2010 Oct; 23(4): 349–354

44. Major Trauma Centre

45.  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

46. JTO; Volume 02 / Issue 02 / May 2014
2013 No single physiological parameter or blood marker can as
Suggested accepted level of 2.5mmol/L is too conservative
patient centred approach
Physiological improvement and reversal of acidosis reflected by:
lactate< 4.0 mmol/L
pH ≥7.25
BE above 5.5 mmol/L

47.  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’
 Lactate is important in identifying patients who will
benefit from damage control surgery