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Matej Cimerman
University Clinical Centre Ljubljana
Slovenia
Treatment algorithms for the polytrauma patient
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Objectives
• To understand politrauma and “two hit” model
• To understand DC concept
• A short owerview of resuscitation phase
• Clarify what is stable, borderline and unstable patient
• Set the priorities of fracture treatment
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Polytrauma
• Syndrome of multiple injuries (ISS > 17) with sequential systemic
traumatic reactions which may lead to dysfunction or failure of remote
organs and vital systems, which have not been directly injured (Trentz
2000)
• No1 cause of death in 18 – 40y age group
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First hit
• Organ injury
• Skeletal inury
• Soft tissue injury
• Hipotension
• Hipoxemia
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Second hit
• Sepsis
• Prolonged hipotension
• Invasive surgery
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Pathophysiology of
6
Multiple Organ Dysfunction Syndrome (MODS)
Host Defense Response- reversible -
„Two Hit“ – Model Keel, Trentz. Injury 2005;36:691
Moore et al. J Trauma 1996;40:501
First Hits
- Hypoxia- Hypotension- Organ injuries- Soft tissue injuries- Fractures
Systemic Inflammatory Response Syndrome (SIRS)
-Temperature- Pulse- Breathing- Leukocytes
Crit Care Med 1992;20:864
Multiple Organ Failure (MOF)
Host Defense Failure Disease - irreversible -+Bacteria
Sepsis
Second Hits
Endogenic (antigenic):- Hypoxia- Hypotension, Azidosis- Ischemia/Reperfusion- Cellular detritus- Contamination/Infection
Exogenic (interventional):- Surgery with blood loss, Tissue
damage, Hypothermia- Neglected Trauma- Missed Injuries- Massive transfusions
Courtesy M Keel
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Damage control concept (from US Navy)
“…keeping afloat a badly damaged ship by procedures to limit flooding,
stabilize the vessel, isolate fires and explosions and avoid their
spreading…definitive repair where logistically possible”
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8
History of DC surgical procedures
• Pringle-maneuver Pringle. Ann Surg. 1908; 48:541
• Intra-abdominal packing Feliciano, et al. J Trauma. 1981; 21:285
• Damage Control as approach Rotondo, et al. J Trauma. 1993; 35:375
• Early packing – Outcome Garrison, et al. J Trauma. 1996; 40:923
• Timing of fracture treatment – DCO (Damage Control
Orthopaedic Surgery) Pape, et al. Am J Surg. 2002; 183:622
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What is orthopedic damage control surgery?
• Simple Safe Short fracture fixation: external fixation
• Debridement and necrectomy
• Decompression of compartments: fasciotomy
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1. primary survey
2. resuscitation phase
3. secondary survey
4. definitive care
Treatment of polytraumatised patient
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Resuscitation (ATLS protocol)
Airway with C spine protect
Breathing /ventilation/ oxygenation
Circulation: stop the bleeding
Disability: neuro status
Expose, environment, body temperature
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Resuscitation (ATLS protocol)
Airway with C spine protect
Breathing /ventilation/ oxygenation
Circulation: stop the bleeding
Disability: neuro status
Expose, environment, body temperature
Role of the surgeon?
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Endotracheal intubation
• Indications...
Surgical cricotomy
• Maxillofacial trauma
• Neck trauma
• Laryngeal trauma
Airway
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• Inadequate delivery of oxygenated blood to the brain is the
quickest killer of the injured
• Pneumothorax (open, tension)
• Haematothorax
• Chest tubes
Breathing
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SHOCK
• Inadequate tissue perfusion and oxygenation
• Hemorrhagic
• Nonhemorrhagic (cardiogenic, tension pneumothorax,
neurogenic)
C: Surgical task
Circulation
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Hemoragic shock: close the taps
laparothomy pelvic stabilization
thoracotomy
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After resuciation phase...
Stable patient: stable hemodynamics, no inotropic support, stable
coagulation, urinary output, normotermic, lactate >2... ETC
Borderline: BP 80-100, lactate 2.5, slightly impaired coagulation, BT 33-
35, ISS >20 with chest trauma, ISS>40 without chest trauma....DC
Unstable and in extremis: BP 60, severe acidosis, coagolopathy,
severe risk of deterioration....DC or life saving surgery
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Fracture management
• What needs to be done?
• When needs to be done?
• How much can be done safely?
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What needs to be done
• Stabilization of hemodinamic unstable pelvis
• Fractures with vascular injuries
• Compartment sindrome
• Early stabilization of long bones
• Debridement and stabilzation of open fractures
• Unstable spine injuries with neurological deficit
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When needs to be done?
• In resuscitation phase (bleeding)
Stabilization of hemodynamically unstable pelvic
fracture
• After the patient is stabilized
Compartment syndrome IN 1 - 2 h
Fr. with vascular injuries
Early stabilization of long bones IN 6 - 8
Excision and stabilization of open fractures
Unstable spine injury with neurologic def.
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When needs to be done?
PHYSIOLOGICAL STATUS
SURGICAL INTERVENTION TIMING
Resuscitation response
- “life – saving” OP
? “damage control” OP
+ early OP
Day 1
hyperinflamation second look onlyDay
2. – 3.
“window of oportunity” definitive delayed OPDay
5. – 10.
immunosupression NO SURGERYDay
10. – 21.
recovery secundary reconstructive OPAfter week
3
Trentz, 2000
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How much can be done sefely?
Stable patient: stable hemodynamics, no inotropic support, stable
coagulation, urinary output, normotermic, lactate >2... ETC
Borderline: BP 80-100, lactate 2.5, slightly impaired coagulation, BT 33-
35, ISS >20 with chest trauma, ISS>40 without chest trauma....DC
Unstable and in extremis: BP 60, severe acidosis, coagolopathy,
severe risk of deterioration....DC or life saving surgery
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You are on duty...
• 18 y old male, conscious, told that he sustained a collision with the
bus as a motor bike driver, pain in pelvic and abdominal region
• Affected with pains
• SBP 80, pulse 100
• Anestesiologist intubated him and started with fluid support
• SBP after 10 minutes 90, pulse 100
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Emergeny room: scout film of thorax: 3 ribs fractured
left, FAST OK, emergency x ray of pelvis:
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After resusciation phase
• BP 90
• Pulse 100
• Lactate 3.0 mmol/l
Stable?
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After resusciation phase
• BP 90
• Pulse 100
• Lactate 3.0 mmol/l
Stable?
Borderline.
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After resusciation phase
• BP 90
• Pulse 100
• Lactate 3.0 mmol/l
Stable?
Borderline.
What to do?
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After resusciation phase
• BP 90
• Pulse 100
• Lactate 3.0 mmol/l
Stable?
Borderline.
What to do?
Stabilize hemodinamically unstable pelvis (close the taps!)
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Suttures of rectum, Hartmann procedure
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ICU for 10 days, intraabdominal abscess, 2 X
drained, after 20 days conversion to ORIF (only
anterior)
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After 6 months, EMG of pelvic floor: reinervation
of levator any improved, reconstruction of rectum,
closing of colostomy
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Functional result (sfincter function recovered
completely)
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• Politrauma is systemic surgical emergeny
• Rsusciation phase: treat first what kills first
• Shock: close the taps
• Stable, borderline, unstable, in extremis
• Two hit concept: extensive surgery can be a second hit
• Consider DCO vs. ETC: STAY ON THE SAFE SIDE
Take home message