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