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 • 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 • What do we need to fix? • When should we fix it? • How should we fix it? Priorities • Life threatening • Limb threatening • Function threatening Priorities • Life threatening • Limb threatening • Function threatening - pelvic hemorrhage Priorities • Life threatening - pelvic hemorrhage • Limb threatening -vascular injury - compartment syndrome - open fracture - irreducible dislocation • Function threatening Priorities • Life threatening - pelvic hemorrhage • Limb threatening -vascular injury - compartment syndrome - open fracture - irreducible dislocation - articular fracture • Function threatening - distal extremity frac. Priorities • Life threatening - pelvic hemorrhage • Limb threatening -vascular injury - compartment syndrome Long fracture ? - openbone fracture - irreducible dislocation - articular fracture • Function threatening - distal extremity frac. War experiences •Splintage •Early evacuation •Early definitive treatment Thomas splint 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 Goris 1982 Johnson 1985 Border FES stabilization - ventilation 1/5 rate of ARDS 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 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 ? 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 • How show we fix it? 1990’s • CHEST 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 longbone stabilization in patients with chest injury either enhances or worsens outcome. 1990’s • HEAD 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 19 fluid requirement hypoxia intra op hypotension GCS on discharge Delayed 14 neuro complic. ICU stay hospital stay Head injury EARLY FIXATION DELAYED FIXATION • Hofman 1991 • Poole 1992 • McKee 1997 • Starr 1998 • Smith 2000 • Brundage 2002 •Jaicks 1997 •Townsend 1998 All retrospective studies !!! Head injury EARLY FIXATION DELAYED FIXATION • length of stay • fluid requirement • mortality •hypoxia • pulm. complic neuro outcome ? All retrospective studies !!! 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” ) •Stable 1st HIT •Borderline •Unstable •In extremis Biological response Therapy: 2nd HIT •Prehospital •ER •ICU •ETC •Intermediate •Damage control Clinical outcome: ARDS, MOF, SIRS Kellam 2003 2 nd 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 “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 ≠ Nonoperative treatment Priorities • Life threatening - pelvic hemorrhage • Limb threatening -vascular injury - compartment syndrome - open fracture - irreducible dislocation - articular fracture • Function threatening - distal extremity frac. Damage control orthopaedic surgery Avoid: • excessive fluid shifts • hypothermia • coagulopathy • pulmonary compromise Provide stability: • pain control • inflammatory • mediator release • fat embolism • mobilization Damage control orthopaedic surgery • rapid external fixation • delayed definitive fixation Damage control orthopaedic surgery Timing of secondary surgery • 2-4 days • 6-8 days multiple organ failure inflammatory markers Pape 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 stabilized ETC uncertain ?DCO • • • • 23 yr old male skiing accident 4 hours ago isolated, closed injury neurovascular normal 19 yr old MVA Anesthestic management critical !!!!! Consider DCO !!! 54 yr old male