damage control orthopaedics (DCO)
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Damage Control In Orthopaedic Surgery: fad Or Fact ?
Ahmed Azmy (MSc)TEAM A-ORTHOPAEDIC DEP.
KHOULA HOSPITAL
outline
HISTORY
PATHOPHYSIOLOGY
PATIENT SELECTION
MANAGEMENT
CONCLUSION
HISTORICAL PERSPECTIVES
HISTORICAL PERSPECTIVES
“Definitive reduction of fractures in patients who
have other injuries and who may have been in
shock should be delayed until the general
condition of the patient is satisfactory.”
When was this phrase published?
“The care of fractures in the patient with multiple injuries”Compere EL. J IntCollSurg.1961 Feb;35:216-20.
RATIONALE FOR DELAYED FIXATION-THE 1960S:-
the philosophy prevailed that the polytrauma patient was ‘too sick to operate on’
The development of fat embolism syndrome and pulmonary dysfunction was feared (Bradford DS ET AL., 1970)
Definitive surgical stabilization was often delayed to 10-14 days
Cast and skeletal tractions preferred
1970S :-
Pioneering studies
showed that early
stabilization of femoral
fractures reduced
dramatically incidence of
Fat Emb.Syndrome,
pulmonary failure
(ARDS) and
postoperative
complications
RATIONALE OF EARLY FIXATION:-1980S (ETC) EARLY TOTAL CARE)
“ There is a beneficial effect of early
Stabilization of fractures on both
mortality and morbidity and length
of hospital stay.”
This new philosophy was named
Early Total Care ( ETC ). “The patient is
too sick not to be treated surgically”
Surgeries were done within 24 hrs of admission
Early 1990s Outcome after ETC increased incidence of ARDS and (M.O.F)
These complications mainly developed in patients with severe chest injuries, severe hemodynamic shock and in cases post reamed intramedullary nailing without thoracic trauma.
Early total care (CONT.):-
patients with high ISS had high mortality rate
even when treated early (Pape J Trauma 1995 - 3406
polytrauma Pts).
Early total care (CONT.):-
IN THE EARLY 1990S:-
a variety of unexpected complications related to the
early stabilisation of fractures of long bones was
described. It was suggested that the operative
procedure used to fix the bone, in most cases a reamed
intramedullary nail, could provoke rather than protect
against the development of pulmonary complications.
This led to the conclusion that the method of
stabilisation and the timing of surgery may have played
a major role in the development of such complications.
THE EVOLUTION OF DAMAGE CONTROL ORTHOPAEDICS-1990S:-
An approach to achieve rapid
skeletal stapilization of major
orthopaedic injuries to stop the
cycle of ongoing musculo -skeletal
injury and to control haemorrhage
Its purpose is to avoid worsening
of the patient's condition by the
"second hit" of a major orthopaedic
procedures
WHAT IS DAMAGE CONTROL ?
WHAT IS DAMAGE CONTROL ?
DAMAGE CONTROL IS A NAVAL
TERM:-
SAVE THE SHIP
LIMIT DAMAGE
EMERGENCY REPAIR
FINISH THE MISSION
5 TENETS OF DAMAGE CONTROL ORTHOPAEDICS:-
1. Recognize who needs
damage control.
2. Salvage operations.
3. Keep the patient
alive.
4. Accept morbidity of
the salvage
procedures.
5. Definitive repair later
PATHOPHYSIOLOGY
HYPOTHERMIACOAGULOPATH
Y
TRAUMA BLOODTRANSFUSION
BLEEDING
THE BLOODY VICIOUS CIRCLE
TRAUMA TRIAD OF DEATH
TRAUMA MORTALITY
BimodalEarly death – Blood loss
– Brain injury
Late death – Secondary brain injury
– Host defense failure -sepsis
TWO-HITS THEORY
“Hits” Induce a Host Immune Response
First Hit–Hypoxia– Hypotension– organ & soft tissue injury– fractures
Second Hit– ischemia/reperfusion injury– compartment syndrome– operative intervention– infection
INFLAMMATORY HOST RESPONSE
Local and systemic release of:
– pro-inflammatory cytokines
– arachidonic acid metabolites
– proteins of the coagulation system
– complement factors
– acute phase proteins
– hormonal mediators
Systemic
Inflammator
y
Response
Syndrome
(SIRS)
TOO MUCH
RESPONSE
SIRS• Endothelial cell damage
• Accumulation of leukocytes
• Disseminated intravascular coagulation
• Apoptosis / necrosis of parenchymal
cells
• Multiple organ dysfunction
syndrome(MODS)
• Multiple organ failure (MOF)
ANTI-INFLAMMATORY HOST RESPONSE
Local and systemically, TH2-
cells and Monocytes
/macrophages release:
–IL-4
–IL-10
–IL-13
– transforming growth factor-β
(TGF-β)
It’s a Feedback Loop:-
– Anti-inflammatory mediators (CARS):-
• Depress the activity of intracellular transcription
factors
• Depress synthesis of pro-inflammatory cytokines.
TOO MUCH
NEGATIVE
FEEDBACK
CARSINCREASE
SUSCEPTIBILI
TY TO
INFECTION
2ND HIT
Host defense response:-
Balance between SIRS and CARS
induce reparative
mechanisms
limit entry or overload of
microorganisms
avoid auto-aggressive
inflammation, with secondary
tissue damage
Avoid susceptibility to
infection
What Are We Doing?
We’re limiting the 2nd hit.
SO..WHAT WE ARE DOING?
WE ARE LIMITING THE 2ND HIT
PATIENT SELECTION
PATIENT SELECTIONPATIENT ASSESSMENT:-
PATIENT CLINICALLY ASSESSED ABOUT THEIR PHYSICAL STATUS AND CLASSIFIED AS:-
I. STABLE: GRADE 1
II. BORDERLINE: GRADE2
III. UNSTABLE: GRADE 3
IV. EXTREMIS: GRADE 4
BORDER LINE PATIENTS (PAPE HC 2001) :-
COAGULOPATHIC
HYPOTHERMIA (T <32)
ACIDOSIS
SHOCK
PERSUMED OR TIME > 6H
ARTERIAL INJURY AND HAEMODYNAMIC
INSTABILITY
EXAGGERATED INFLAMMATORY RESPONSE
MANAGMENT
DCO: PRINCIPLES
Do reconstruction under best circumstances
More time for planning is usually better
Best team possible for difficult work
APPLICATION OF DCO STRATEGY
Multiply injured patient
Physiologically unstable
Severe chest injury
Severe hemorrhge
Mass casualty situation
Damage control in orthopedic surgery
Stage 1: early temporary External Fixation Stabilization of unstable fractures and the control of hemorrhage and, if indicated, decompression of intracranial lesion.
Stage 2: resuscitation of the patient in ICU and optimization of his condition.
Stage 3: delayed definitive management of the fracture
STATGED TREATMENT
OT
OT
ICU
MINIMALLY INVASIVE OPERATIONS
External fixation of femur- 35 minutes 90 ml blood loss
Intramedullary nailing of femur-130 minutes 400 ml blood loss
Scales et al., “ External fixation as a bridge to intramedullary nailing for patients with multiple injuries and with femur fractures: damage control orthopaedics”, J.Trauma 2000; 48: 613-23
Reamed Intramedullary nailing Has been associated with development of “second hit” phenomena (Pape 1993).
Primary external fixation has not stimulated any inflammatory reaction“second hit”
REAMED IMN VS. EX. FIX
SKELETAL TRACTION VS. EXTERNAL FIXATION
External fixation of femur fractures in severely injured
patients offers no significant advantages compared
with skeletal traction. The use of ST as a temporization
method remains a practical option.
(SCANELL,BRIAN P. ,2010: JOURNAL OF TRAUMA –INJURY INFECTION AND CRITICAL CARE-VOLUME 68- ISSUE 3-PP) 633-640)
SECONDARY PROCEDURE FOR WHOME ?
&WHEN?
RESUSCITATION:-
• Stable hemodynamics
• Stable oxygen saturation
• Lactat level < 2 mmol/l
• No coagulation
disturbances
• Normal temperature
• Urinary output > 1
ml/kg/hour
• No isotropic support
E.T.CDEFINITIVE OPERATION
When to perform the secondary procedure?
One of the most important decisions to be made in designing a DCO protocol is the timing of secondary surgical proceduresIn a retrospective analysis of 4314 patients, it was found that a secondary procedure lasting more than 3 h was associated with the development of MODS Also the patients who developed complications had their surgery performed between days 2 and 4, whereas patients who did not go on to develop MODS were operated between days 6 and 8 (PAPE HC 1999)OPERATE BETWEEN DAYS
6 & 8
DCO IN CHEST INJURY
Bosse and Associates studied the method of fixation used to manage femoral shaft fractures. They compared early reamed intramedullary nailing to open reduction and internal fixation. No difference was noted between the plating and nailing groups in terms of mortality, the occurrence of ARDS, pulmonary embolism or pneumonia. In their study, the incidence of ARDS was only 2% (bosse et al., 1997)
In a retrospective review of 138 patients with multiple injuries, the patients with significant pulmonary injuries had a 56% complication rate when fixation was delayed compared with a 16% complication rate for those who had earlyStabilization (Charash WE et al., 1994)
There is no evidence in basic physiology research to suggest that reamed intramedullary nailing would have a significant negative effect on pulmonary function in the clinical setting (beter j. et al., 2003)
DCO IN HEAD INJURY (Hofman and Goris,1991) in their retrospective review of head injured patients with long-bone fracture found that mortality was more than 3 times higher in patients with delayed or no fracture fixation and that the neurologic outcome, based on the glasgow outcome score, was better in patients who had early fracture stabilization.
(Townsend and colleagues, 1998) retrospectively reviewed 61 patients with severe or moderate closed head injury and femoral fracture. They demonstrated an 8-fold increase in the risk of intraoperative hypotension if the operation was carried out within 2 hours of admission to hospital and a 2-fold increase if the operation was carried out within 24 hours of admission. They found that the risk of low intraoperative cerebral perfusion pressure lasted even longer than 24 hours
DCO IN MANGLED EXTREMITY
A DCO approach to save the limb:-
Spanning ex. Fix.
Antibiotic bead pouches
Vacuum assisted wound closure
CONCLUSION
DCO: Principles in polytrauma
Ortho team must be resuscitators and stabilizers: not “fixers”
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