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 unstable, under resuscitated patients increases complications
• But, stabilizing long bones early in adequately resuscitated patients has major benefits
First Hit, Second Hit
First Hit
• The trauma itself
– Massive inflammatory response
– Ongoing blood loss
– Pain
Second hit
• What we do with surgery
– Increased blood loss
– Hypotension
– 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 take them if we are not actively resuscitating”
• Books:
– Improving acidosis
– 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