Early Total Care

Dave Laverty MD Case

• 24 yo female • MVC • Bilateral femur fractures • Left monteggia fracture • Right midfoot fracture dislocation • Nonoperative spleen injury • Initial Hgb 8.9 Background

• Damage Control Orthopedics – External fixation, traction, splints • Early Total Care – Intramedullary nails, plates and screws • Early Appropriate Care – Physiology based treatment Background

• History – 1960’s • Immediate stabilization of long-bones in polytrauma was common • Retrospective data showed unacceptably high mortality rate • Major concern was fat emboli / cardiopulmonary dysfunction • Due to this, surgery was delayed… 10-14 days • Patient’s were treated with casts, splints, and traction – Delays led to… • Immobilization / Bedrest • Pneumonia • Persistent pain • Decubitus ulcers • Psychological disturbances • Disuse atrophy (leading to later difficulty with therapy/mobilizing) • GI disorders, leading to aspiration • Longer ICU stays

Backgrouond

• History – 1980’s • Studies showed a link between delayed long-bone fixation in polytrauma patients and acute respiratory distress syndrome (ARDS) • Better outcomes when femur fracture treated in 1st few days after admission • Bone et al published landmark research showing decreased incidence of ARDS and mortality with early fixation • Due to this, time spent in traction decreased from 9- days to 2-days

Backgound

• History – Term “damage control” was 1st used by U.S. Navy to describe tactics needed to keep a ship afloat when compromised – Adopted by general surgery trauma for certain techniques, such as packing to stop hemorrhage (rather than lengthy immediate repair) • Allowing for physiology to improve before definitive treatment • Leading to improved survival rates – Next, adopted by ORS for DC orthopaedics

Background

• History – Studies • Scalea et al – 43 polytrauma patients – 46% had head injuries, 65% had HD instability – DCO had minimal complications, improved survival • Taeger et al • Pape et al

• Morshed et al – Retrospective review of 3,069 patients – Definitive stabilization done within 12hrs = high mortality – Waiting >12hrs decreased mortality by 50%

DCO

• So it seems Damage Control is the way to go! But wait……

• Need to compare apples to apples

• Not all trauma patients are the same • No doubt operating on • But, stabilizing long unstable, under bones early in resuscitated patients adequately resuscitated increases complications patients has major benefits First Hit, Second Hit

First Hit Second hit

• The trauma itself • What we do with – Massive inflammatory surgery response – Increased blood loss – Ongoing blood loss – Hypotension – Pain – Potential for fat emboli – Inflammatory process “tipped over the edge” We need a talented, smart leader to help us win! When is the right time to stabilize fractures?? • Coopwood: “you can • Books: take them if we are not – Improving acidosis actively resuscitating” – pH >7.25 – Base excess of -5.5 – Lactate <4.0 • Considerations: – Head injury – Other active medical issues (CVA/AMI) Early Appropriate Care

• If we hit our resuscitation indicators: – Definitive fixation of pelvis, acetabulum, femur and +/- spine fractures within 36 hours Head Injury

• Severe – Depends on ICP, CPP • ICP <20 = definitive surgery • CPP >70 = definitive surgery • If neither = DCO

Chest Injury

• Massive = consider DCO • Compensated and resuscitated = definitive fixation – Decreased pain – Upright posture – Promotes mobilization Abdominal Injury

• Collaborative effort with trauma team

• Life threatening injuries first

• Determines DCO versus ETC/EAC So how it really works….

• Life saving measures by trauma team • Assess mitigating factors (head injury, soft tissue injury, medical issues) • Evaluate level of resuscitation If “not actively resuscitating”

• Femur fracture = IMN • Tibia fracture = IMN • Humerus fracture = ORIF • Forearm fracture = ORIF • Pelvis fracture = binder/traction • Hand/wrist = splint • Ankle = ex fix, possible ORIF • Foot – splint • Other peri-articular – ex fix, planned staged management

If actively resuscitating

• External fixation – In OR or ICU • Femoral traction • Pelvic binder • Splinting • Wound VAC

Case

• Bilateral femur fracture – IMN • Midfoot fracture dislocation – ORIF • Monteggia fracture – ORIF Conclusion

• Truly collaborative effort • Need to have all resources readily available • Match the treatment to the patient Thank You