poly-trauma damage control orthopaedics DCO.pptx

poly-trauma damage control ortho damage control orthopaedics DCO.pptx

1. DR.K SRINIVAS REDDY PG MS[ ORTHO] Presentation by Moderators Dr. T. VENKATESHWARA RAO PROF&HOD Dr.J.VENKATESHWARLU ASSOC.PROF Dr. VENKAT SWAMY ASST.PROF Dr.PRASAD REDDY TUTOR POLYTRAUMA— CONCEPT OF DAMAGE CONTROL ORTHOPEDICS

2. Polytrauma pts are the sub group of injured pts who have sustained injuries to more than one body region and organ with atleast one of the injuries being life threatning

3. A syndrome of multiple injuries exceeding a defined severity (ISS>_17) with sequential systemic reactions that may lead to dysfunction or failure of remote organs and vital systems which have not themselves being directly injured --TRENTZ

4. Trauma scoring systems have been developed to convert the severity of injury into numeric values, allowing clinicians to communicate by means of quality assurance and quality control programs

5. Scoring Systems Glasgow Coma Scale (GCS) Revised Trauma Score (RTS) Injury Severity Score (ISS) New Injury Severity Score (NISS) * GCS<13 RTS< 11---tranported to comprehesive facilities

6. Figure 2. Revised Trauma Score (RTS). The values for the three parameters are summed to give the Triage-RTS. Weighted values are summed for the RTS. Clinical Parameter Category Score x weight Respiratory rate (Breaths per minute) 10-29 4 0.2908 >29 3 6-9 2 1-5 1 Systolic blood Pressure >89 4 0.7326 76-89 3 50-75 2 1-49 1 Glasgow Coma Scale 13-15 4 0.9368 9-12 3 6-8 2 4-5 1 3

7. AIS Score Injury 1 Minor 2 Moderate 3 Serious 4 Severe 5 Critical 6 Unsurvivable AIS Score

8. Glasgow Coma Scale Eye opening Spontaneous 4 To speech 3 To pain 2 None 1

9. Glasgow Coma Scale Motor response Obeys commands 6 Purposeful response to pain 5 Withdrawal to pain 4 Flexion response to pain 3 Extension response to pain 2 None 1

10. Glasgow Coma Scale Verbal response Oriented 5 Confused 4 Inappropriate 3 Incomprehensible 2 None 1

11. Resuscitation/Treatment Protocol Based on ATLS Guidelines 1. Primary survey and resuscitation (patient stabilization) A Airway and cervical spine B Breathing and oxygenation C Circulation and hemorrhage D Dysfunction of the CNS E Exposure and environmental 2. Consider transfer to more appropriate hospital if indicated 3. Secondary survey A Allergies M Medicines P Previous medical history/pregnancy L Last meal E Events leading to trauma 4. Definitive care (Fracture treatment) Early total care Damage control surgery 5. Tertiary survey Missed injuries

12. 12 PURPOSE OF THE INITIAL ASSESSMENT Identification of LIFE-THREATENING emergencies Assess – Change - Reassess Initiation of LIFE-SAVING measures (CPR)

13. 5 second Round Illinois EMSC 13 Pt is conscious or not Airway Ventilation Signs of massive external hemorrhage There is any deformity Skin color and temp with feeling pulse

14. Illinois EMSC 14 Primary Survey Airway/ Cervical Spine Control Breathing Circulation Disability (neurological) Expose

15. Adjuncts: BP , pulse oximetry , ABG, EKG Foley : urine output ( avoided if suspected urethral injury ) NG: decompression, decrease aspiration

16. Assessing Airway Is the airway: Clear and safe? At risk? Obstructed?

17. Airway obstruction may be a result of Midfacial fractures with obstruction of the nasopharynx Mandibular fractures with the obstruction of the pharynx by the base of the tongue Direct laryngeal or tracheal injury Blood or vomit aspiration Foreign bodies (e.g., dentures)

18. I 18 AIRWAY INTERVENTIONS Jaw thrust Vs Head tilt. Deliver Oxygen (mask with reservoir). Use Rigid suction. Secure airway.

19. Treatment should prioritize removal of any airway obstruction. If the obstruction is subglottic , emergency cricothyroidotomy or tracheostomy can be lifesaving . Obstruction of the trachea in the region of the mediastinum can cause severe respiratory impairment. This can lead to severe mediastinal emphysema and perforation of the endotracheal tube

20. 5 Chest clues in the neck Wounds Distended neck veins Tracheal position Surgical emphysema Laryngeal crepitus

21. 21 CERVICAL SPINE STABILIZATION Place hands on either side of the head cervical collar.flv Maintain neck midline “manual in line stabilization”

22. Breathing and ventilation Aims Support if inadequate Eliminate any immediately life threatening thoracic condition … ..

23. Breathing and ventilation Inspection Respiratory rate Effort of breathing Symmetry Wounds & marks Palpation Tender points, equal expansion Percussion No abnormal note Auscultation All lung zones

24. I 24 BREATHING INTERVENTIONS If breathing is absent, start ventilation using: Simple Adjuvants (Airways) Bag valve mask with reservoir LMA ETT

25. Fatal Chest conditions? Tension pneumothorax Open chest trauma Cardiac tamponade Flail chest Massive hemothorax 25

26. Thoracic injury might cause acute respiratory derangement, including lung contusion, tension pneumothorax , and hemothorax . Tension pneumothorax is a life-threatening condition and should be diagnosed clinically and treated without delay. The management of pneumothorax and hemothorax should include the insertion of a chest drain to decompress the chest.

27. 27 CIRCULATORY ASSESSMENT Carotid pulse (absent or present) Capillary refill Skin color Skin temperature Sites of bleeding

28. 28 CIRCULATORY INTERVENTIONS If central pulse is absent, begin CPR Apply direct pressure to open wounds IV access (2 wide bore cannulae14/16G). Fluids (colloids Vs crystalloids) 20ml/Kg Peripheral Vs central line?

29. Hemorrhagic shock should be distinguished from other causes, such as cardiogenic and neurogenic shock . The presence of flat jugular veins might indicate the presence of hemorrhagic shock . An elevated jugular venous pressure can be diagnostic of cardiogenic shock, caused by coronary heart disease, myocardial infarction (MI), cardiac contusion, tension pneumothorax , or cardiac tamponade .

30. Neurogenic Shock Relative hypovolemia is the cause of neurogenic shock, usually due to spinal injury. Loss of the autonomic supply leads to a decrease in vascular tone with blood pooling in the periphery. This can occur without significant blood loss. The resultant increase in skin perfusion lead to warm periphery and a decrease in central blood delivery. This type of shock may be difficult to distinguish from hypovolemia .

31. CARDIOGENIC SHOCK The heart can be impaired by cardiac tamponade , tension pneumothorax , and hemothorax , or in rare cases by intra-abdominal bleeding . These pathologies may necessitate immediate surgical intervention, including placement of a chest drain, pericardiocentesis , and emergency thoracotomy

32. HYPOVOLEMIC SHOCK T he most sensitive indicator of intravascular volume is peripheral capillary blood flow, evaluated by assessing the nail beds and conjunctiva. Urine output is also a sensitive parameter that can be used for the diagnosis of shock, to determine severity and monitor the response to treatment. As a rough estimate, normal urine output should exceed 1 mL /kg/hr or 30 mL in 30 minutes

33. The general management of shock includes rapid and adequate restoration of the hemodynamic status of the patient through the use of fluid and blood concentrate replacement therapy Once volume restoration has been started, any external or internal bleeding should be identified.

34. Internal blood loss should be suspected in all patients, particularly where shock is recalcitrant . This usually occurs in one of three body regions”the thorax, abdomen, or pelvis. Differentiation of the site of internal bleeding can usually be made by using a combination of clinical judgment, thoracic and pelvic anterior-posterior radiographs and abdominal ultrasonography .

35. Dysfunction of the CNS Aims Rapid neurological assessment Alert; Voice; Pain; Unresponsive Pupils Mini-neurological assessment GCS score Pupils Lateralising signs

36. 36

37. Exposure and environment Aims Remove clothing to allow examination of entire patient Care when removing tight trousers Prevent hypothermia Patient dignity Remove spine board

38. Don’t Forget The Back

39. Pause & check Are all immediately life-threatening injuries identified? Is all monitoring in place? Investigations ordered? Analgesia? Relatives informed? Non-essential team members disbanded?

40. The well practiced trauma team should aim to complete the primary survey in less than 10 minutes Illinois EMSC 40

41. Radiology Once the patient is stabilized the patient is sent to radiology for the survery : Cervical spine X-ray (AP and lateral view) Chest X- ray (Rib cage) Pelvis X-ray Abdomen and Pelvis U/S CT brain is ordered if there is suspicion of head trauma X-ray of extremities if fracture is suspected.

42. Traumatic Aortic Rupture These are found in victims of high-speed motor vehicle crashes and falls from great heights, and 85% of these injuries are due to blunt trauma. The majority (80-90%) of the patients die at the scene of the accident from massive blood loss. Of the patients reaching hospital alive, only 20% will survive without operation. The mortality remains high even after surgery.

43. In cases of aortic rupture, the clinical presentation depends upon the site of injury. Patients with injury to the intrapericardial portion of the ascending aorta will usually develop a cardiac tamponade. Extrapericardial ascending aortic injury produces a mediastinal haematoma and a haemothorax , usually on the right side

44. Rapid deceleration is believed to be responsible for damage to the aorta that most commonly occurs in the region of ligamentum arteriosum, just distal to the origin of left subclavian artery.

45. Patients may show transient hypotension, which responds well to fluid therapy and further clinical signs may be absent. This may delay the diagnosis with catastrophic results should the aorta rupture completely. Thus a high index of suspicion should be kept in mind.

46. Aortic disruption should always be suspected in patients with profound shock and who have no other external signs of blood loss and in whom mechanical causes of shock (tension pneumothorax and pericardial tamponade) have been excluded.

47. Symptoms (if the patient is conscious) may include: Severe retrosternal pain Pain between the scapulae Hoarseness of voice (pressure from haematoma on the recurrent laryngeal nerve) Dysphagia

48. The definitive investigation of choice is angiography or a CT angiogram of the aortic arch, the choice depending on local policy. Survival in patients who have their injury repaired surgically and who have remained haemodynamically stable during the repair is 90%.

49. MANAGEMENT OPEN PNEUMOTHORAX Ensure adequate airway 100% oxygen Seal open wound Load & Go IV access en route Notify Medical Direction Courtesy of David Effron, M.D.

50. SEALING THE OPEN WOUND Asherman chest seal is very effective

51. SEALING THE OPEN WOUND using impervious material taped on three sides

52. TENSION PNEUMOTHORAX

53. MANAGEMENT TENSION PNEUMOTHORAX Ensure adequate airway 100% oxygen Needle decompression if indicated Insertion of chest drain IV access en route

54. DEFINITION OF THE PATIENT'S CONDITION Once initial assessment and intervention is complete patients should be placed into one of four categories in order to guide the subsequent approach to their care. This is done on the basis of overall injury severity, the presence of specific injuries and current hemodynamic status STABLE—BORDERLINE ---UNSTABLE--EXTREMIS

55. Stable Stable patients have no immediately life-threatening injuries, respond to initial therapy, and are hemodynamically stable without inotropic support . There is no evidence of physiologic disturbance such as coagulopathy or respiratory distress nor ongoing occult hypoperfusion manifesting as abnormalities of acid base status . They are not hypothermic and have the physiological reserve to withstand prolonged operative intervention where this is appropriate and can be managed using an ETC approach, with reconstruction of complex injuries.

56. Borderline Borderline patients have stabilized in response to initial resuscitative attempts but have clinical features or combinations of injury, which have been associated with poor outcome and put them at risk of rapid deterioration. ISS >40 Hypothermia < 35C Multiple injuries (ISS >20) in association with thoracic trauma Multiple injuries in association with severe abdominal or pelvic injury and hemorrhagic shock at presentation (systolic BP <90 mm Hg) Radiographic evidence of pulmonary contusion Patients with bilateral femoral fracture Patients with moderate or severe head injuries This group of patients can be initially managed using an ETC approach but this should be undertaken with caution Additional invasive monitoring should be instituted and provision made for ICU admission. Conversion to a damage control approach to management at the first sign of deterioration is to be made

57. Unstable Patients who remain hemodynamically unstable despite initial intervention are at greatly increased risk of rapid deterioration, subsequent multiple organ failure and death . Treatment in these cases has evolved to use a damage control approach . This entails rapid lifesaving surgery only as absolutely necessary and timely transfer to the ICU for further stabilization and monitoring. Temporary stabilization of fractures using external fixation, hemorrhage control is advocated . Complex reconstructive procedures should be delayed until stability is achieved and the acute immunoinflammatory response to injury has subsided. This reduces the magnitude of a second hit of operative intervention or at least delay it until the patient is physiologically equipped to cope.

58. In Extremis These patients are very close to death having suffered severe injuries and 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 advocated , and only lifesaving procedures should be attempted The patients should then be transferred directly to intensive care for invasive monitoring and advanced hematological, pulmonary, and cardiovascular support. Orthopedic injuries can be stabilized rapidly in the emergency department or intensive care unit using external fixation and this should not delay other therapy. Any reconstructive surgery is again delayed and can be performed if the patient survives.

59. IN THE MULTIPLY INJURED PATIENT TIMING OF ORTHOPAEDIC INTERVENTION DAMAGE CONTROL ORTHOPAEDICS

60. Damage Control Orthopaedics An approach that contains and stabilizes orthopaedic injuries, so that the patient's overall physiology can improve . Its purpose is to avoid worsening of the patient's condition by the "second hit" of a major orthopaedic procedures

61. FIRST HIT  the initial trauma SECOND HIT  major surgery  adverse event during ICU treatment  septic stimulus

62. In severely injured patients, invasive fracture fixation surgery Stimulates a secondary inflammatory reaction (SIRS) “The second hit” detectable by an elevation of pro-inflammatory cytokines

63. Severe injury Strong systemic biological response

64. Systemic Inflammatory Response Syndrome (SIRS) Temperature >38C or <36C Heart rate > 90 beats/min Respiratory rate > 20 breaths/min or P a CO 2 < 4.3 kPa, or ventilated WBC: > 12000 cells/mm 3 or < 4000 cells/mm 3 or > 10% immature forms > 2 criteria present for 3 days Definition

65. Trauma Systemic inflammation (SIRS) Host defense response Host defense failure Organ and tissue defects Death reversible irreversible Pathophysiologic Physiologic

66. Related to: Magnitude of assault Host physiologic reserve First Hit Early ARDS Early stages of MODS Early death SIRS resulting from injury itself and resuscitation

67. Polytrauma Management Damage control Reduction of systemic trauma reaction Hallmark

68. HISTORICAL ASPECTS Until the 1950, s early definitive fracture stabilization was performed only as an exception, as it was believed that multiply injured patients were too unstable to survive surgical intervention. Complex laboratory investigations and monitoring facilities were not available. Consequently estimation of the patient's status was, on the whole, performed by clinical assessment only. Thus , complications were usually identified only in their late stages. Signs of MODS in the first posttraumatic week were similar to those caused by fat embolism syndrome, which was due to unstabilized fractures. This syndrome is characterized by hypoxia, cerebral depression (coma), coagulopathy ( petechial bleeding), and renal failure ( anuria ). Embolism was thought to be directly related to the release of fat and intramedullary content from the fracture site by fracture or early surgical treatment . It was also believed, however, that pathological movements of the fracture might be responsible for further liberation of intramedullary contents into the bloodstream.

69. Embolic Fat In Lung Originates In Marrow: First Hit Magnitude of injury

70. Then, second insult: “ Sustained Hit ” Pulmonary embolization of fat and marrow contents associated with reaming Effects of femoral nailing

71. Parameters Associated with Adverse Outcome in Multiple Injured Patient 1. Unstable condition or difficult resuscitation 2. Coagulopathy (platelet count < 90,000) 3. Hypothermia (<32 c) 4. Shock and > 25 units of blood replacement 5. Bilateral lung contusions on initial radiographs 6. Multiple long bones plus truncal injury AIS > 2 7. Probable operating time > 6 hr 8. Arterial injury and hemodynamic instability (BP< 90) 9. Exaggerated inflammatory response (IL-6 > 800 pg/ml)

72. Conditions in Which Damage Control Surgery Should Be Considered 1. Polytrauma + ISS > 20 and thoracic trauma (AIS >2) 2. Polytrauma with severe abdominal/pelvic trauma and hemodynamic shock (BP <90 mm Hg) 3. ISS > 40 4. Bilateral lung contusions 5. Initial mean pulmonary arterial pressure > 24 mmHg 6. Pulmonary artery pressure increase >6 mmHg during long bone intramedullary nailing

73. DCO In the polytraumatized patient, this concept of surgical treatment intends to control but not to definitively repair the trauma-induced injuries early after trauma . After restoration of normal physiology (core temperature, coagulation, hemodynamics , respiratory status), definitive management of injuries is performed

74. DAMAGE CONTROL ORTHOPAEDICS Initial Rapid External Fixation

75. External fixation is an expedient and minimally invasive method of providing stabilization and can be used efficiently to accomplish early fracture stabilization but postpone the additional biological stresses posed by prolonged surgical procedures . The delayed definite procedure to stabilize long bone fractures, and in particular femur fractures, is most frequently intramedullary nailing and is carried out when the condition of the patient allows.

76. The practice of delaying the definitive surgery in DCO attempts to reduce the biological load of surgical trauma on the already traumatized patient. This hypothesis was assessed by many prospective randomized studies by means of measuring proinflammatory cytokines A sustained inflammatory response (higher levels of IL-6) was measured after primary (<24 hours) intramedullary femoral instrumentation, but not after initial external fixation or after secondary conversion to an intramedullary implant

77. The ideal time to perform the secondary definitive surgery It has been shown that days 2 to 4 do not offer optimal conditions for definitive surgery . In general during this period, marked immune reactions are ongoing and enhanced generalized edema is observed . These patients represent a highly diverse group and individual clinical judgment is more reliable, especially when combined with information from the newer laboratory tests.

78. The measurement of inflammatory mediators has been shown to be sensitive in gauging the ongoing response in recovering patients . Prospective studies show that polytraumatized patients submitted to secondary definitive surgery at day 2 to 4, developed a significantly increased inflammatory response, compared to those operated at day 6 to 8 . Primary procedures of greater than 6 hours duration and major surgical procedures at day 2 to 4 should be avoided Conversion of the external fixator to a nail should be done in the first 2 weeks, thus minimizing the risk of developing deep sepsis

79. Staged Intramedullary Nailing After Physiologic Stabilization

80. Thigh and leg compartment syndromes, tibia fracture open. Temp 35.5 C ;; CT Head shows contusion + hemorrhage

81. Rapid fasciotomies + Ex-Fix prior to physiologic stabilization

82. Delayed, elective femoral nailing after physiologic stabilization

83. Delayed tibial nailing after physiologic stabilization

84. Who Is A Candidate For Damage Control Orthopaedics? Multiply injured patient, unstable Severe chest injury (pulmonary insufficiency) Severe head injury (hemorrhage or elevated ICP) Coagulopathy , hypothermia Prior to transfer (intra or inter-institutional) Patient in extremis

85. Indications For Rapid Ex Fix Patient in extremis Massive open injury Vascular repair mass casualties External Fixation as a resuscitative device Eliminate the timing controversy

86. Patient In Extremis Experienced neurosurgeons Experienced anesthesia Monitor ICP Work with patient sitting May fix fractures in ER ICP often goes down External Fixation Massive head injury

87. External Fixation Patient In Extremis Benefits of rapid fracture fixation Lung, mediator release, hemorrhage Speed of application

88. THANK YOU