pathophysiology of trauma: influence on surgical timing and implant selection
DESCRIPTION
Pathophysiology of Trauma: Influence on surgical timing and implant selection. Piotr Blachut MD FRCSC University 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 - PowerPoint PPT PresentationTRANSCRIPT
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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
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• 23 yr old male• skiing accident 4 hours ago• isolated, closed injury• neurovascular normal
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• 19 yr old male• head on MVA
• Head injury– GCS 6
• Multiple fractures
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• Investigations– CXR - normal– C spine - normal– Pelvis - normal
– CT head• cerebral edema• hemispheric hemo. foci• SA blood• L tripod #
– CT abdo• normal
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• 54 yr old male• fall from 25 ft.• no LOC• chest pain / SOB• pelvic / R ankle / L thigh pain
• hypotensive• cold
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•WhatWhat do we need to fix?
•WhenWhen should we fix it?
•HowHow should we fix it?
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Priorities• Life threatening
• Limb threatening
• Function threatening
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Priorities• Life threatening
• Limb threatening
• Function threatening
- pelvic hemorrhage
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Priorities• Life threatening
• Limb threatening
• Function threatening
- pelvic hemorrhage
-vascular injury- compartment syndrome- open fracture- irreducible dislocation
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Priorities• Life threatening
• Limb threatening
• Function threatening
- pelvic hemorrhage
-vascular injury- compartment syndrome- open fracture- irreducible dislocation
- articular fracture- distal extremity frac.
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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 ?
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Thomas splint
War experiences•Splintage•Early evacuation•Early definitive treatment
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1960’s & 1970’s• System of operative fracture
stabilization• first applied to isolated injuries• later application to polytrauma
• Improvement in anesthesia / critical care management
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Eric Riska, Finland 1977
• 47 pts. • multiple trauma • all long bone fractures fixed with
stable fixation• 1 death (80 y.o.)
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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)
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1980’sEarly 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”
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1980’sCause of complications with delayed
stabilization
• fat embolism syndrome• supine position -> atelectasis -> sepsis narcotic use• inflammatory mediator release from
hematoma / soft tissue injurySeibel, Ann Surg 1985
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1980’sEarly 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
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1980’s•reamed IM nailing the standard of care for femoral shaft fractures
•known marrow embolization
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1990’s
Three types of patients:
• Isolated injuries• Multiple fractures• Multiple system
Does ETC apply to all ?
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1990’s
Three types of patients:
• Isolated injuries• Multiple fractures• Multiple system
Does ETC apply to all ?
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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
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1990’s
•HowHow show we fix it?
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1990’s
•CHEST INJURYCHEST INJURY
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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
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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%)
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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
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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.
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1990’s
•HEAD INJURYHEAD INJURY
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Head injury• Secondary brain injury in severe
head injury if exposed to:
– hypotension – hypoxemia– increased ICP (intercranial pressure)– reduced CPP (cerebral perfusion pressure)
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Head injury• Early Fracture Fixation May Be
Deleterious After Head InjuryJaicks 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
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Head injuryEARLY FIXATION
• Hofman 1991• Poole 1992• McKee 1997• Starr 1998• Smith 2000
• Brundage 2002
DELAYED FIXATION
•Jaicks 1997•Townsend 1998
All retrospective studies !!!
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Head injuryEARLY
FIXATION
length of stay
mortality pulm. complic
DELAYED FIXATION
fluid requirementhypoxia
All retrospective studies !!!neuro outcome ?
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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.
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Evolving concepts of pathophysiology
• course after severe blunt trauma dependant on:
– initial injury ( “first hit” )– individual biologic response– type of treatment ( “second hit” )
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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
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• 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
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“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
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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
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1990’s & 2000’s
Damage control surgery
Damage control orthopaedic surgery(DCO)
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Damage control
orthopaedic surgery
≠≠Non-
operative treatmen
t
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Priorities• Life threatening
• Limb threatening
• Function threatening
- pelvic hemorrhage
-vascular injury- compartment syndrome- open fracture- irreducible dislocation
- articular fracture- distal extremity frac.
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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
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• rapid external fixation• delayed definitive fixation
Damage control orthopaedic surgery
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Damage control orthopaedic surgery
Timing of secondary surgery
• 2-4 days multiple organ failure inflammatory markers
• 6-8 daysPape et al, 2001
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Damage control orthopaedic surgery
risk of local complications– infection–poorer joint reconstruction
• not borne out in clinical experience (so far)
–Scalea, 2000–Nowotarski 2000
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ETC versus DCOPape 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)
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What to do in 2010?Clinical status?
stable borderline unstable
resuscitate
reevaluate
ETC ?DCO
stabilized uncertain
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• 23 yr old male• skiing accident 4 hours ago• isolated, closed injury• neurovascular normal
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19 yr old MVA19 yr old MVA
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Anesthestic management critical !!!!!
Consider DCO !!!Consider DCO !!!
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54 yr old male
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Thank You
Thank You !!!!