08/01/11

POLYTRAUMA DAMAGE CONTROL IN ORTHOPAEDICS

PRESENTED BY: INTERNS 5TH BATCH DR. ADITI MISHRA DR. APARNA MISHRA DR. SASHMI MANANDHAR

A CASE PRESENTED AS
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HISTORY
PARTICULARS OF THE PATIENT: NAME: Mrs. Rekha karki AGE: 26/F RELIGION: Hindu OCCUPATION: Housewife ADDRESS: Sindhupalchowk DATE: 31 AUGUST 2010

HOPI
C/O: H/O FALL INJURY FROM HT. OF 100FT INABILITY TO MOVE LOWER LIMBS + HIP INABILITY TO MOVE LEFT HUMERUS WITH PAIN FOR 1.5 HRS.

HOPI Contnd
Fell from a ht of 100ft crashed on the drain below Taken to khadichaur immediately Bleeding from injured lt elbow+ rt big toe No h/o loc, vomiting, head injury ,bleeding from any orifices Brought to DH ER within 1.5 hrs

Past illness
H/o low BP No H/O chronic illness

GENERAL PHYSICAL EXAMINATION

GC: ILL LOOKING, WELL BUILT PALLOR + VITALS: PR: 110/ MIN BP: 84/54mm of hg RR: 25/MIN TEMP: AFEBRILE SATURATION: 94% WITHOUT O2 CVS: NORMAL

ON EXAMINATION
CHEST COMPRESSION: POSITIVE; DIFFICULTY IN BREATHING PELVIC COMPRESSION: + ROM PAINFUL, UNABLE TO MOVE LEGS & HIP NO OBVIOUS DEFORMITY, ATTITUDE OF LIMB NORMAL DNVS : INTACT

LEFTUPPER LIMB SWELLING: + TENDERNESS:+ DEFORMITY: VISIBLE-ARM & FOREARM DNVS INTACT ROM PAINFUL SO NOT ATTEMPTED NO OPEN WOUND

SPINE EXAMINATION: TENDERNESS+/ P/A:

PROVISIONAL DIAGNOSIS
POLY TRAUMA WITH IMPENDING SHOCK PELVIS #/NECK OF FEMUR #/ LT SHAFT OF HUMERUS# LT LBOW DISLOCATION/ SUPRACONDYLAR # RIBS #OF LT SIDE

INVESTIGATION
AT EMERGENCY: HB: 10.2% PCV: 32% BLOOD GRP: AB+VE SUGAR: 71mg/dl Urea: 19 mg/dl, creatinine: 1.3mg/dl Potassium: 3.5; sodium: 131mmol/lit

USG ABDOMEN+ PELVIS

LIVER: focal altered echogenicity msr4*4 cm GB: partially distended Moderate collection in abdomen & pelvishemoperitoneum Enlarged spleen with non homogenous echotexture

X-RAY
LT HUMERUS # LTELBOW DISLOCATION RIB # SPINE LT DISTAL RADIUS # PELVIS:#

Management
IMMEDIATE: ABCD Management Pain management Stabilization of hip Stabilization of humerus # CVP line opened, Foleys catheter inserted

ICU ADMISSION VITAL STABALIZATION, blood transfusion Input output monitoring.

INVESTIGATION: HB, PCV URINE FOR FAT GLOBULES: 1+ on 1/09/ 2010, RBC: 28-30 ABG: pO2, pCO2, calcium Abdominal girth: 83cm Now the pt Is in Ortho ward from surgery

BACKGROUND
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Fat embolism
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MULTIPLE FAT EMBOLI ENTER THE CIRCULATION CAUSE - PELVIC #, FEMUR #, SURGICAL PROCEDURES MORTALITY-10-20%

EMBOLI LODGE IN PULMO CAPILLARIES , THRO AV SHUNTS TO BRAIN,BLOCK THE MICROVASCULATURE CAUSING ISCHEMIC DAMAGE, INITIATING A CASCADE OF INFLAMMATION,PLATELET AGGREGATION
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C/F & T/T

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1-3 DAYS AFTER INJURY RESP- TACHYPNEA, HYPOXEMIA NEURO- AGITATION,DELIRIUM, COMA HAEM- ANEMIA, LOW PLATELETS DERMA- PETECHIAL RASH

MAINTAINANCE OF INTRAVASCULAR VOLUME, NUTRITION OXYGEN,BLOOD PDTS, STABLE HEMODYNAMICS, GI BLEED, STEROIDS,EARLY STABILIZATION

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ARDS-DEFINITION
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PaO2/FIO2 <200 B/L PULMONARY INFILTRATES PCWP<18 MM HG EXCLUSION OF CARDIAC CONDITIONS

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CAUSES &C/F
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TRAUMA, SEPSIS, PANCREATITIS, BLOOD TRANSFUSION,BURNS,ASPIRATION, DRUG ABUSE

ACUTE ONSET OF SOB 1-2 DAYS OF INJURY HYPOXEMIA NEURO- CONFUSION,STUPOR,COMA

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PATHOLOGY
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DIFFUSE INFLAMMATION INCREASED PERMEABILITY TYPE 2 PNEUMOCYTE DAMAGE DECREASED SURFACTANT & EXUDATES

3 PHASES EXUDATIVE, PROLIFERATIVE, FIBROTIC

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DIAGNOSIS & T/T

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LOW SATURATION ABG- RESP ACIDOSIS CXR

MECHANICAL VENTILATION FLUID MANAGEMENT ANTIBIOTICS STEROID, NO, SURFACTANT????

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DAMAGE CONTROL ORTHOPEDICS

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APPROACH - STABILIZES ORTHOPEDIC INJURIES TILL OVERALL PHYSIOLOGY IMPROVES AVOIDS SECOND HIT OF A MAJOR PROCEDURE FOCUS- MANAGEMENT OF HEMORRAGE, SOFT TISSUE INJURY, PROVISIONAL # STABILITY USE OF EXTERNAL FIXATORS

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PHYSIOLOGY
08/01/11

TRAUMA SECOND HIT

INFLAM RESPONSE o RESOLUTION MODS/ARDS

o BALANCE BETWEEN INFLAMMATORY & ANTI INFLAMMATORY RESPONSE

o o o

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PHYSIOLOGY
08/01/11

INNATE IMMUNITY ACTIVATED MEDIATED BY- IL-1, IL-6, IL-8, IL-10, TNF , CRP, ELASTASE, LOW PLATELET INCREASED PERMEABILITY OF PULMONARY CAPILLARIES AND ARDS

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GENETIC PREDIPOSITION
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POLYMORPHISM IN GENES FOR TNF , IL-6, Ig RECEPTOR, IFN-GAMMA

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PATIENT SELECTION
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STABLE, BORDERLINE, UNSTABLE , IN EXTREMIS PH<7.24,T<35 LAST 3 BEST TREATED WITH DCO,OPERATIVE TIME =90 MINS, COAGULOPATHY,MASSSIVE BLOOD TRANSFUSIONS, FEMORAL #, PELVIC # WITH EXSANGUINATING HEMORAGE

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AND THE JOURNALS SAY

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Evolving trends in the care of polytrauma patients

08/01/11

Injury, International Journal of Care of the Injured Before 1970s:

Non-operative treatment Too ill to withstand surgery High rates of complications as a result of prolonged recumbency Fracture fixation techniques developing rapidly Early fracture stabilisation of multiply injured patients, known as early total care Early stabilisation of skeletal injuries produced poor results. Introduction of the concept of damage control surgery

1980s:

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Fat embolism: special situations B/L femoral # and pathologic femoral #

08/01/11

Injury, International Journal of Care of the Injured B/L femoral #:

29.5% of the total femoral #, high energy trauma and multitrauma patients

Fat embolism: 4.87.5% Reason: Intramedullary nailingsystemic inflammatory response burden to pulmonary function Fat embolism during treatmentintramedullary nails: 010%. Femur common site of metastatic bone disease, treatment of impending and actual pathological fractures complicated by increased rates of lung damage

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Respiratory complication after early vs. late stabilization of femoral shaft #

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IJMS, Emami et all

150

patients, 2 groups Single # and polytrauma; within and after 48 hrs ABG and CXR Conclusion: Early fixation complications

Cases Early OT Resp compli Late OT Resp compli

Group I 123 63 3.3%

Group II 27 14 7.1% 13 76.5%

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Systemic effects of b/l tibial vs. b/l femoral #

Acta Orthopedica et Traumatologica Hellenica Study of difference in IMIL in B/L tibial and femoral #, Retrospective analysis

08/01/11

TF Cases 12 Incidence 3.8% ISS 13 Mean 4.2 lit resuscitation req 1 Mortality ARDS 2 Sepsis 4 Amputation 3

FF 14 4.6% 16 10.6 lit 2 6 1 1

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Conclusion:
Lower

incidence in

ISS ARDS Sepsis Amputation Mortality

Due

to:

Anatomic difference Volume of liberated intravascular marrow fat Organization of intravascular fat
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Do corticosteroids reduce the risk of fat embolism syndrome in patients with longbone fractures?
08/01/11

Canadian Journal of Surgery, 2008

Meta

analysis of published results, 2 groups steroid (+) and steroid (-) 389 patients FES by 78%, only 8 pt developed FES risk of hypoxia Conclusion:
Steroids beneficial for prevention of FES and hypoxia No risk of infection

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Damage Control Nailing

08/01/11

Higgins, Thomas F MD; Horwitz, Daniel S MD; Journal of Orthopaedic Trauma

Temporary

external fixation Alternative: Rapidly executed small-diameter unreamed retrograde nailing of the femur

Advantage: Rapid stabilization under uncontrolled circumstances

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Damage control in cases of severe polytrauma mainly sustaining orthopaedic trauma

08/01/11

Chinese Journal of Traumatology

53 cases Retrospective analysis 53 patients saved 38 patients returned to their former work Conclusions:
Primary

minimally-invasive external # stabilization for extremities and pelvis to avoid additional surgical trauma Definitive secondary fracture care after medical stabilization in intensive care unit (ICU).

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Effects of changing strategies of fracture fixation on immunologic changes and systemic complications after multiple trauma
08/01/11

Journal of Orthopaedic Research, 2008

Long surgical procedures early after trauma risk of ARDS, esp after femoral shaft # stabilization IL: inflammatory response to injury, magnitude of surgery and the systemic impact induced

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The Effects of Intraoperative Positioning on Patients Undergoing Early Definitive Care for Femoral Shaft Fractures
08/01/11

Journal of Orthopaedic Trauma, 2009

988 patients, retrospective study Femoral shaft # undergoing early definitive care with intramedullary (IM) nails in the supine vs the lateral position Surgical stabilization using IM nails inserted with reaming of the femoral canal in the lateral position not associated with an increased risk of mortality or ICU admission

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ATLS and damage control in spine trauma

08/01/11

World Journal of Emergency Surgery

Traumatic brain and acute lung injury: Implants for quick stabilization + elective surgical approaches Similar approach for spinal trauma Spinal injury adressed only secondarily in the broadly used ATLS polytrauma algorithm

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Damage control orthopaedics' in patients with delayed referral to a tertiary care center
08/01/11

Journal of Trauma Manangement and Outcome Study of damage control modality, retrospective analysis of 1 year
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cases Cases referred after 24 hours 62 fractures, 3 still under treatment, others united Radiological and functional scoring: 20 excellent, 29 good, 5 fair and 5 poor results, no mortality Conclusion:

In situations of delayed referral in areas where composite trauma centers do not exist the damage control modality provides an acceptable method of treatment in the management of polytrauma cases

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THANK YOU

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