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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
- 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
- 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
- 9. Lethal Triad Of Trauma
- 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
- 14. Inflammatory mediators • Inflammatory response • Innate immune system – Macrophage – Leukcocytes – NK cells – Inflammatory cells mediated by IL 8 – C5a, C3a – ROS – Eicosanoids – Cytokines
- 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
- 19. Advanced Trauma Life Support • Delineates an order of priorities
- 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
- 25. Immediate life threatening Potentially life threatening Airway Obstruction Aortic injuries Tension Pneumothorax Tracheobronchial injuries Pericardial Tamponade Myocardial Contusion Open Pneumothorax Diaphragm Rupture Massive Hemothorax Esophageal injuries Flail Chest Pulmonary Contusion
- 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
- 27. Shock
- 28. Disability • Potential brain injury – GCS – Pupils • Spinal cord – Sensorimotor assessment – Anal tone sensation and reflexes
- 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
- 33. Reevaluation • SpO2, capnography, ABG, urine output along with vitals • Tertiary Survey – Repeated examination – Uncooperative/ Obtunded patient – Missed injuries, musculoskeletal injuries
- 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
- 48. DCO in complex injuries • Upper limb – Sling – External fixation • Below knee injuries – Splints – External fixation • Femur – Traction splint – recumbent position – External fixation
- 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
- 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
- 59. Next Presentation • Acute and Chronic Compartment Syndrome • Dr Aakash Prabhakar
Editor's Notes
- 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
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3603725/
- 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
- Contionuous ECG monitoring, capnography, ABG, Urinary catheters, EFAST, Pulse oximetry, gastric tubes, Xrays CT,
- 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.