steve morgan, md & scott adams, md original authors: steve morgan, md; march 2004;
DESCRIPTION
Acute Respiratory Distress Syndrome, Fat Embolism, & Thromboembolic Disease in the Orthopaedic Trauma Patient. Steve Morgan, MD & Scott Adams, MD Original Authors: Steve Morgan, MD; March 2004; New Authors: Steve Morgan, MD & Scott Adams, MD; Revised January 2007 and November 2011. Define - PowerPoint PPT PresentationTRANSCRIPT
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Acute Respiratory Distress Syndrome, Fat Embolism, &
Thromboembolic Disease in the Orthopaedic Trauma Patient
Steve Morgan, MD & Scott Adams, MD
Original Authors: Steve Morgan, MD; March 2004;
New Authors: Steve Morgan, MD & Scott Adams, MD; Revised January 2007 and November 2011
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Objectives
• Define– ARDS
– FES
– Thromboembolic Disease
• Understand Etiology & Physiology of each Condition
• Understand– Prevention
– Diagnosis
– Treatment
– Outcomes
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ARDS Acute Respiratory Distress Syndrome
• Acute respiratory failure in the post traumatic period characterized by a decreased PaO2 and a diffuse and often massive extravasations of fluid from the pulmonary vasculature to the interstitial space of the lungs.
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ARDS Clinical Definition
– Acute onset of symptoms
– Ratio of PaO2 to FIO2 of 200 mm Hg or less
– Bilateral infiltrates on CXRs
– Pulmonary arterial wedge pressure of 18 mm Hg or less or no clinical signs of left atrial hypertension
– American-European Consensus Conference (AECC) on ARDS, 94
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ARDS
• Incidence 5% – 8% after polytrauma– Much lower in isolated fracture
• Mortality up to 40%
• Uncommon in Children and the Elderly
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ARDSCommon Causes
• Trauma• Massive Transfusion• Embolism• Sepsis• Aspiration• Abdominal Distension
• Pulmonary Edema• Prolonged LOC• Cardiopulmonary
Bypass• Pancreatitis• Major Burns
MULTIFACTORAL
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ARDS Etiology
• ARDS related to MODS
• Release of inflammatory mediators results in organ dysfunction
Trauma InflammatoryMediators
OrganInjury
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ARDS PATHOPHYSIOLOGY
• Systemic Inflammatory Mediators
• Damage to Endothelial Lining
• Increased Capillary Permeability
• Fluid Extravasation
• Alveolar Collapse • Decreased Pulmonary
Compliance• Ventilation Perfusion
Abnormalities• Arteriolar Hypoxemia
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ARDS
Chest Radiograph Autopsy Specimen
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ARDS Chest CT Scan
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ARDSPrevention
• Limiting Blood Loss
• Decreasing Transfusion Requirements
• Early Stabilization Of Unstable Fractures
• Early Prophylactic Mechanical Ventilation
Temporary Ex-Fix For Stabilization
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ARDS Treatment
• Ventilator Support – Acceptable ABG’s– Avoid further alveolar damage
• Toxic FIO2
• Barotrauma
• General Organ Support• Research
– Optimal ventilator settings– Pharmalogical agents
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ARDSOutcome
• Significant Cause of Mortality
• Major Cause of Death in Patients with the Lowest ISS scores
• 30% - 40% Mortality Rate– Mortality Rate Slowly Decreasing with
Changing & Improving Therapy
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Fat Embolism Syndrome(FES)
• A condition characterized by hypoxia, confusion and petechiae presenting soon after long bone fracture and soft tissue injury.
• Diagnosis of Exclusion
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FES
• Often Placed in the Category of ARDS– May share common pathological pathways
• R/O other Causes of Hypoxia & Confusion
• Index Patient– young adult with isolated LE injury seen after long
transfer with no supporting therapy or splintage.
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FES
• Occurs in 0.9 – 8.5% of all fracture patients
• Up to 35% of the multiply injured
• Mortality 2.5%
• Rare in upper limb injury and children
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Etiology
• The likely pathogenetic reaction of lung tissue to shock, hypercoagulability and lipid metabolism
• Mechanical Theory
• Biochemical Theory
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Mechanical Theory
• Fracture Liberates Fat
• Intravasation - Fat Enters Venous System
• Fat Causes Mechanical Obstruction
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Mechanical Theory
• Systemic Fat Embolization
– Patent Foramen Ovale
– Pulmonary Pre-Capillary Shunts
– Skin petechiae, CNS signs
FES To Brain On MRI
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Biochemical Theory
• Neutral Fat and Chemical Mediators Released at Time of Fracture
• Neutral Fat Metabolized by Lipases releases Free Fatty Acids
• Free Fatty Acids Result in Endothelial Lung Damage
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Gurd et al
FES Diagnosis
• Major Criteria– Hypoxemia
– CNS Depression
– Petechial Rash
– Pulmonary Edema
• Minor Criteria– Tachycardia
– Pyrexia
– Retinal Emboli
– Fat in Urine
– Fat in Sputum
– Thrombocytopenia
– Decreased Hematocrit
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Gurd et al
FES Diagnosis
• Gurd & Wilson Criteria
• At least 1 Major Sign
• 4 Minor Signs
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FES Prevention
• Appropriate Splinting
• Early Fracture Stabilization
• Oxygen Therapy
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FES Prevention
• Therapies– Fluid Loading
– Hypertonic Fluid
– Alcohol
– Heparin
– Dextran
– Aspirin
• None Shown to be Effective
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FES Treatment
• Supportive
– Oxygen Therapy to maintain PaO2
– Mechanical Ventilation
– Adequate Hydration
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FES Treatment Steroids• Steroids
– Decrease endothelial damage– 30mg/kg initial dose repeated @ 4 Hours, 1gm
dose repeated @ 8 Hours: Total 3 Doses
• Complications - Frequent– Infection– GI
• Steroid Therapy Avoided Secondary To Poor Risk Benefit Ratio
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Systemic Effects of Trauma
Injury (First Hit)
24 hours 48 hours
Post InjuryInflammatoryResponse in2 Patients
Second Hit in susceptible patients
ARDSMODSThreshold
IM Nailing as a Cause of Secondary Systemic Injury
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• Early Total Care– Definitive Early
Fixation• Nail or Plate
• Damage Control– Temporary Stability
• External Fixator
– Limit Further Blood Loss
– Limit Anesthetic Time
– Delay Definitive Fracture fixation
Fracture Fixation Technique-Controversial-
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Effect of IM Nailing
• Increased IM Pressure
• Embolic Showers On Echocardiograms
• Caused by– Canal Opening– Reaming – Nail Insertion (both reamed & unreamed)
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Fracture Fixation Technique-Controversial-
• IM Nail - Reamed vs Un-Reamed – Decreased with Unreamed Technique
• Pape et al
– No Difference• Keating et al• Canadian OTS
• IM Nail Reamed vs Plate Osteosynthesis– No Difference In Pulmonary Dysfunction
• Bosse et al
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DVT Incidence
• DVT occurrence 60% if ISS >9.
• 35%-60% DVT in pelvic fracture
• PE-Most common preventable cause of death in trauma.
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Virchow Triad
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Hypercoaguability
• Tissue Thromboplastin
• Activated Procoagulants
• Decreased Fibrinolytic Activity
• Ineffective Heparin Clearance of Activated Clotting Factors
• Catecholamine Release
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Endothelial Injury
• Direct Trauma to Vein at time of Injury
• Compression of the Vein Secondary to Fracture Position
• Vein Manipulation at Time of Fracture Fixation
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Venous Stasis
• Immobilization
• Hypotension
• Venous Occlusion – Edema– Fracture Position
• Tourniquet
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DVT Prevention
Goals
• Clinically significant events– PE– Post Thrombotic syndrome
• Low Complication Rate• High Compliance Rate• Cost Effective
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MechanicalNon Pharamcologic
DVT Prevention
PneumaticCompression
Vena CavaFilter
ElasticStockings
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Pharamcologic
DVT Prevention
UnfractionatedHeparin
LMWH Heparin
ElasticStockingsWarfarin
OralAnticoagulants
Pentasacharides
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Prophylaxis
• Elastic Stockings
• Mechanical Compression Devices
• Early Mobilization
• IVC Filter (PE Prophylaxis)
• Pentasaccharide
• Low Molecular Weight Heparin
• Heparin
• Aspirin
• Warfarin
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Mechanical Methods
• Activity• Compression
Stockings• Sequential
Compression Device• Pedal PumpsMechanism of Action• Decrease Stasis Fibrinolytic Activity
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IVC Filter Indications
• Anticoagulation Prohibited
• High Risk Patients
• DVT Prior to Necessary Surgery
• PE Despite Anticoagulation
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IVC Filter
• Prevents Major PE
• Low Morbidity – 96% Patent
– 8% Migration
– 4% PE
• Filter insertion in the ICU
• Expensive
• Invasive
• Does not treat DVT
• Venous Insufficiency
• Filter Occlusion
Advantages Disadvantage
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• No Recommendation for Vena Caval Filter
ACCP Recommendation on Vena Cava Filter
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Pentsaccharide
• Selective Inhibitor of Activated Xa– Decreased DVT rate with no change in major
bleeding rate compared to LMWH• Eriksson B I et al N Engl J Med 2001
– Increased risk of minor bleeding• Delay administration for several hours after surgery
and removal of epidural catheter
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Low Molecular Weight Heparin(LMWH)
• Potentiates Antithrombin III
• Inhibits Factor Xa & II
• Minimal effects on other Factors
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LMWH
• No Monitoring
• Increased Efficacy
• Longer 1/2 life
• Predictable Response
• Lower risk of thrombocytopenia
• Parenteral Administration
• Cost
Advantages Disadvantage
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Heparin
• Heparin Potentiates Anti-Thrombin III Activity
• Complex Inhibits
– Thrombin (IIa), IXa, Xa
• Heparin effect relative short duration
– Reversed with Protamine Sulfate
• Significant hemorrhage risk
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SQ Heparin
• Low Cost
• No Monitoring
• Convenient
• Relatively Low Incidence of Bleeding
• Insufficient Efficacy in High Risk Patients
• Unpredictable Responses
• Heparin Induced Thrombocytopenia
Advantages Disadvantage
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Aspirin
• Oral Administration• Tolerated well• In-expensive• No Monitoring
• ? Efficacy when used alone
• GI Intolerance• Prolonged anti-platelet
effect
Advantages Disadvantage
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Aspirin
• Inhibits cyclooxygenase
• Decreases Platelet Adherence
• ? Effectiveness in Musculoskeletal Trauma– Venous clots not typically found to have
Platelet aggregates
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• No Recommendation For The Use of Aspirin
• Recommend Against The Use of Aspirin For Any Indication
ACCP Recommendation on Aspirin
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Warfarin
• Blocks Vit K conversion in Liver
• Effects Vit K Dependent Factors
• Effects the Extrinsic Clotting System
• Factor VII Effected first, Short Half Life
• Monitored with Pro-Time– INR 2.0-2.5
• Reversed With Vitamin K or FFP
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Warfarin
• Effective• Oral Administration• Inexpensive
• Requires Monitoring• Difficult to Reverse• Increased Bleeding
Complications in Elderly
Advantages Disadvantage
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EAST Guidelines
• Guidelines based on qualitative review of the current scientific literature improve uniformity of opinion and prescribing practices– Watts JBJS B 05
• Risk Factors
• Level I Evidence – Major Significance– Spinal Fracture– Spinal Cord Injury
• Level II – No Major Significance– Advanced Age– ISS Score– Blood Transfusion– Long Bone, Pelvis, Head
Injury
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ACCP Guidelines
• Guidelines based on qualitative review of the current scientific literature improve uniformity of opinion and prescribing practices– Watts JBJS B 05
• Risk Factors
• Level I Evidence – Major Significance– Spinal Cord Injury– Major Trauma– Hip Fractures– Complex Lower-extremity
Fracture– Pelvic Fracture– Prolonged Immobility– Delay in Commencement Of
Thromboprophylaxis
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• Recommend Routine Thromboprophylaxis
• Fondaparinux• LMWH• Warfarin (INR 2.5)• LDUH
ACCP Guidelines on Hip Fractures
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• Recommend Routine Thromboprophylaxis
• LMWH Once Hemostasis Obtained
• IPC and/or GCS– While Obtaining
Hemostasis
ACCP Guidelines on Spinal Cord Injury
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• No Routine Thromboprophylaxis
ACCP Guidelines on Isolated Injuries Distal To The Knee
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Duration of Prophylaxis
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• 10 to 35 Days
• Agents– LMWH
– Fondaparinux
– Warfarin
ACCP Guidelines Duration of Therapy Hip Fractures
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• Up to Hospital Discharge
• Agents– LMWH
– Fondaparinux
– Warfarin
ACCP Guidelines on Duration of Therapy for Trauma Patients
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ACCP Guidelines Length of Prophylaxis
Trauma Population• Exception
– Impaired mobility who undergo inpatient rehabilitation
– Thromboprophylaxis
– LMWH
– Warafarin INR, 2.5
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DVT screening
• Physical Exam
• Ascending venography
• Duplex Ultrasonography
• Magnetic Resonance Venography
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Physical Examination
• Calf Swelling
• Palpable Venous Cords
• Calf Pain
• Homan’s Sign
• All Unreliable
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Ascending Contrast Venography
• Sensitive for detection• Invasive• Dye Problems
(allergies, renal)• Injection Site Irritation• Poor Pelvic Vein
Evaluation
• Gold Standard
*Invasiveness,expense make ACV a poor screening tool
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Doppler/Duplex Ultrasound
• Comparable to Venogram• Non Invasive• No Morbidity• Poor Axial (i.e Pelvic)
Vein Evaluation• Operator Dependent• Good Screening Tool
– Noninvasive, reproducible
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Magnetic Resonance Venography
• Non Invasive• Good Visualization of
Pelvic Veins• Difficult in Polytrauma
Patient• Excellent specificity and
sensitivity for suspected DVT
• Controversial for screening
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Pulmonary Embolism
Clinical
Shortness of breath, agitation, confusion
Laboratory
PaO2, A-a gradient
Diagnostic studies
V/Q scans
Pulmonary Angiogram, CT PA
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Ventilation Perfusion Scan
• Ventilation Perfusion mismatch• Results
– Low probabiltity• 15% False Negative
– Medium• Need Angiogram
– High probability• 15% False Positive
• Screening Tool
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Pulmonary Angiogram
• Angiographic Evaluation of pulmonary vascular tree
• Allows Placement of IVC Filter in same setting if indicated
• Sensitive - Standard in PE Detection. Diagnostic
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Treatment PE
• Anticoagulation
• Filter for recurrent event despite anticoagulation
• Thrombectomy– Serious Acute PE– Patient in extremous– Large identifiable PE
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Treatment DVT/PE
• Heparin– Bolus 10-15K units– Continuous Infusion
• 1000Units/Hr– Goal PTT 2x Control
• Prevent Clot propagation and recurrent PE
– Discontinue when Therapeutic on Warfarin
• LMWH / Pentasaccharide– Mass related dose SQ inj
– Single daily dose
– No monitoring necessary
– Discontinue when Therapeutic on Warfarin
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Treatment DVT/PE
• Warfarin– INR 2.0-3.0
– 3-6 Month Duration
– Contraindicated in:• Pregnancy
• Liver insufficiency
• Poor Compliance
– Prolonged Therapy may decrease recurrence rates
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DVT/PE Outcome
• No Diagnosis and Treatment – 30% Mortality
• Correct Diagnosis and Therapy– 11% Mortality in First Hour– 8% Mortality After First Hour
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DVT/PE Outcome• Post Thrombotic Syndrome
– Valvular Incompetence– Venous Stasis– Edema– Cutaneous Atrophy
• Recurrent DVT– 20% of Patients
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Bibliography FES/ARDS
• Gurd AR, Wilson RI Fat-embolism syndrome Lancet. 1972 Jul 29;2(7770):231-2
• Giannoudis PV, Pape HC, Cohen AP, Krettek C, Smith RM. Review: systemic effects of femoral nailing: from Küntscher to the immune reactivity era. Clin Orthop Relat Res. 2002 Nov;(404):378-86
• Bosse MJ, MacKenzie EJ, Riemer BL, Brumback RJ, McCarthy ML, Burgess AR, Gens DR, Yasui Y. Adult respiratory distress syndrome, pneumonia, and mortality following thoracic injury and a femoral fracture treated either with intramedullary nailing with reaming or with a plate. A comparative study. J Bone Joint Surg Am. 1997 Jun;79(6):799-809
• Canadian Orthopaedic Trauma Society.Reamed versus unreamed intramedullary nailing of the femur: comparison of the rate of ARDS in multiple injured patients. J Orthop Trauma. 2006 Jul;20(6):384-7
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Bibliography DVT/PE
• Geerts WH, Bergqvist D, Pineo GF, Heit JA, Samama CM, Lassen MR, Colwell CW; American College of Chest Physicians Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008 Jun;133(6 Suppl):381S-453S
• Rogers FB, Cipolle MD, Velmahos G, Rozycki G, Luchette FA Practice management guidelines for the prevention of venous thromboembolism in trauma patients: the EAST practice management guidelines work group. J Trauma. 2002 Jul;53(1):142-64
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