Pathophysiology of Pathophysiology of Trauma:Trauma:

Influence on surgical Influence on surgical timing and implant timing and implant

selectionselection

Piotr Blachut MD FRCSCUniversity of British Columbia

Vancouver, Canada

• 23 yr old male• skiing accident 4 hours ago• isolated, closed injury• neurovascular normal

• 19 yr old male• head on MVA

• Head injury– GCS 6

• Multiple fractures

• Investigations– CXR - normal– C spine - normal– Pelvis - normal

– CT head• cerebral edema• hemispheric hemo. foci• SA blood• L tripod #

– CT abdo• normal

• 54 yr old male• fall from 25 ft.• no LOC• chest pain / SOB• pelvic / R ankle / L thigh pain

• hypotensive• cold

•WhatWhat do we need to fix?

•WhenWhen should we fix it?

•HowHow should we fix it?

Priorities

• Life threatening

• Limb threatening

• Function threatening

Priorities

• Life threatening

• Limb threatening

• Function threatening

- pelvic hemorrhage

Priorities

• Life threatening

• Limb threatening

• Function threatening

- pelvic hemorrhage

-vascular injury- compartment syndrome- open fracture- irreducible dislocation

Priorities

• Life threatening

• Limb threatening

• Function threatening

- pelvic hemorrhage

-vascular injury- compartment syndrome- open fracture- irreducible dislocation

- articular fracture- distal extremity frac.

Priorities

• Life threatening

• Limb threatening

• Function threatening

- pelvic hemorrhage

-vascular injury- compartment syndrome- open fracture- irreducible dislocation

- articular fracture- distal extremity frac.

Long bone fracture ?

Thomas splint

War experiences•Splintage•Early evacuation•Early definitive treatment

1960’s & 1970’s

• System of operative fracture stabilization

• first applied to isolated injuries• later application to polytrauma

• Improvement in anesthesia / critical care management

Eric Riska, Finland 1977

• 47 pts. • multiple trauma • all long bone fractures fixed with

stable fixation• 1 death (80 y.o.)

Vivoda, Meek, 1978

• 71 pts., all multiple trauma, all ICU• two groups• no difference in AGE or ISS• Mortality

CONSERVATIVE 14/49 (28.5%)OPERATIVE …… 1/22 (4.5%)( 5:1 ratio)

1980’s

Early Total Care (ETC)fracture stabilization (especially long bone

fracture within 24 hrs)

– Riska 1982 FES – Goris 1982 stabilization - ventilation– Johnson 1985 1/5 rate of ARDS– Border 1/5 rate “pulm. septic state”

1980’s

Cause of complications with delayed stabilization

• fat embolism syndrome• supine position -> atelectasis -> sepsis narcotic use• inflammatory mediator release from

hematoma / soft tissue injury

Seibel, Ann Surg 1985

1980’s

Early Total Care (ETC)

– Bone et al., Dallas 1989•Prospective randomized studyProspective randomized study •Early vs. late femoral nailing

pulmonary complications ICU length of stay hospital costs

1980’s

•reamed IM nailing the standard of care for femoral shaft fractures

•known marrow embolization

1990’s

Three types of patients:

• Isolated injuries• Multiple fractures• Multiple system

Does ETC apply to all ?

1990’s

Three types of patients:

• Isolated injuries• Multiple fractures• Multiple system

Does ETC apply to all ?

Three types of patients:

• Isolated injuries• Multiple fractures• Multiple system

Does ETC apply to all ?

1990’s

• In severely injured patient– significant chest injury– significant head injury

• Is there a detrimental effect of added major surgery stress blood loss– fluid shifts

1990’s

•HowHow show we fix it?

1990’s

•CHEST INJURYCHEST INJURY

Pape, Hannover,1993

•pts with pulmonary contusion and early reamed femoral nail

• increase in ARDS and death

•? unreamed femoral nail / delayed nail

•? femur group sicker

Charash, 1994

• replicated Pape study

• without chest trauma pulmonary complications lower in early fixation group (10% VS 38%)

• with severe chest trauma pulmonary complications lower in early fixation group ( 16% VS 56%)

Bosse et al, 1997

• institution randomized series• early plating vs. early IM nailing • 453 patients

• no ARDS, PE, MOF, pneumonia or death

• compared to plating or chest injury alone

Dunham et al., 2001

Practice Management Guidelines for the Optimal Timing of Long-Bone Fracture Stabilization in Polytrauma Patients: The EAST Practice Management Guidelines Work Group

• There is no compelling evidence that early long-bone stabilization in patients with chest injury either enhances or worsens outcome.

1990’s

•HEAD INJURYHEAD INJURY

Head injury

• Secondary brain injury in severe head injury if exposed to:

– hypotension – hypoxemia– increased ICP (intercranial pressure)

– reduced CPP (cerebral perfusion pressure)

Head injury

• Early Fracture Fixation May Be Deleterious After Head Injury

Jaicks RR, Cohn SM, Moller BA, J Trauma 42(1):1-6, 1997

Early Delayed 19 14 fluid requirement neuro complic. hypoxia intra op ICU stay hypotension hospital stay GCS on discharge

Head injury

EARLY FIXATION

• Hofman 1991• Poole 1992• McKee 1997• Starr 1998• Smith 2000

• Brundage 2002

DELAYED FIXATION

•Jaicks 1997•Townsend 1998

All retrospective studies !!!All retrospective studies !!!

Head injury

EARLY FIXATION

length of stay

mortality pulm. complic

DELAYED FIXATION

fluid requirementhypoxia

All retrospective studies !!!All retrospective studies !!!

neuro outcome ?

Dunham, 2001

Practice Management Guidelines for the Optimal Timing of Long-Bone Fracture Stabilization in Polytrauma Patients: The EAST Practice Management Guidelines Work Group

• There is no compelling evidence that early long-bone stabilization in mild, moderate, or severe brain injured patients either enhances or worsens outcome.

Evolving concepts of pathophysiology

• course after severe blunt trauma dependant on:

– initial injury ( “first hit” )– individual biologic response– type of treatment ( “second hit” )

Biological response

Therapy: 2nd HIT

•Stable

•Borderline

•Unstable

•In extremis

Clinical outcome: ARDS, MOF, SIRS

•ETC

•Intermediate

•Damage control

•Prehospital

•ER

•ICU

Kellam 2003

1st HIT

• Second hit from the management of

skeletal injuries is under the control of the surgeon

• Determine the patients ability to withstand a second hit from trauma surgery

• How to minimize the second hit

2 nd HIT

“Borderline Patient”

• Polytrauma +ISS>20 + thoracic trauma (AIS>2)

• Polytrauma + abdominal/pelvic trauma and hemodynamic shock (initial BP< 90 mmHg)

• ISS >40

• Bilateral lung contusions on x-ray

• Initial mean pulmonary arterial pressure >24mmHg

• Pulmonary artery pressure increase during IM nailing > 6mmHG

Factors associated with BAD outcome

• Unstable difficult resuscitation

• Coagulopathy (platelets<90,000)

• Hypothermia (<32°C)

• Shock + 25 units blood

• Head Injury: GCS < 8, bleeding, edema

1990’s & 2000’s

Damage control surgery

Damage control orthopaedic surgery(DCO)

Damage control

orthopaedic surgery

≠≠Non-

operative treatmen

t

Priorities

• Life threatening

• Limb threatening

• Function threatening

- pelvic hemorrhage

-vascular injury- compartment syndrome- open fracture- irreducible dislocation

- articular fracture- distal extremity frac.

Damage control orthopaedic surgery

Avoid:Avoid: • excessive fluid shifts• hypothermia• coagulopathy• pulmonary compromise

Provide stability:Provide stability:• pain control• inflammatory• mediator release• fat embolism• mobilization

• rapid external fixation• delayed definitive fixation

Damage control orthopaedic surgery

Damage control orthopaedic surgery

Timing of secondary surgery

• 2-4 days

multiple organ failure inflammatory markers multiple organ failure inflammatory markers

• 6-8 days• 6-8 daysPape et al, 2001

Damage control orthopaedic surgery

risk of local complications– infection–poorer joint reconstruction

• not borne out in clinical experience (so far)

–Scalea, 2000–Nowotarski 2000

ETC versus DCO

Pape et al., J Trauma, 2002

• prospective randomized multicentre series• 17 versus 18 patients

• early IM nailing -> sustained inflammatory response ( IL-6)

• no clinical difference (complication rate / LOS)

What to do in 2010?

Clinical status?

stable borderline unstable

resuscitate

reevaluate

ETC ?DCO

stabilized uncertain

• 23 yr old male• skiing accident 4 hours ago• isolated, closed injury• neurovascular normal

19 yr old MVA19 yr old MVA

Anesthestic management critical !!!!!

Consider DCO !!!Consider DCO !!!

54 yr old male

Thank You

Thank You !!!!