Mr Lee Van Rensburg

Mr Alan Norrish

October 2015

ISS 57ISS 57 SAH, DAISAH, DAI R HaemothoraxR Haemothorax Pelvic ring fracture Pelvic ring fracture

(Dissociation R hemipelvis)(Dissociation R hemipelvis) # L Acetabulum# L Acetabulum # L Femur# L Femur Compartment syndrome both lower legs and Compartment syndrome both lower legs and

thighsthighs

Laparotomy Laparotomy Pelvis packed, Vac dressingPelvis packed, Vac dressing

C clamp and pelvic ex fixC clamp and pelvic ex fix AngiogramAngiogram

EmbolisationEmbolisation

Theatre to CTThen ICU

Retrograde femoral nailRetrograde femoral nail FasciotomyFasciotomy

Both thighs both calvesBoth thighs both calves

8 HRS8 HRS

AngiogramAngiogram IVC filterIVC filter Repeat bleedingRepeat bleeding

Laparotomy change of packsLaparotomy change of packs Bladder repairBladder repair Pubic symphysis ORIFPubic symphysis ORIF

36 Hrs36 Hrs

AngiogramAngiogram IVC filterIVC filter Repeat bleedingRepeat bleeding

Laparotomy change of packsLaparotomy change of packs Bladder repairBladder repair Pubic symphysis ORIFPubic symphysis ORIF 2 hour rewarming on table2 hour rewarming on table

Removal of C clampRemoval of C clamp Anterior plating Anterior plating

R Sacroiliac jointR Sacroiliac joint

Debridement washout Debridement washout closure C clamp and Ex closure C clamp and Ex fix woundsfix wounds

Vac dressing change 17/05/06Vac dressing change 17/05/06 Closure of thigh woundsClosure of thigh wounds

Vac dressing change 23/05/06Vac dressing change 23/05/06 Closure of L lower leg woundClosure of L lower leg wound

Vac dressing change 28/05/06Vac dressing change 28/05/06 Closure R lower leg woundClosure R lower leg wound

Planned ORIF acetabulumPlanned ORIF acetabulum Wound breakdownWound breakdown

L iliac crestL iliac crest Both thighsBoth thighs

Washout and vac dressingsWashout and vac dressings

Day 6Day 6

#BOS#BOS #Nasal bone#Nasal bone APC pelvic injuryAPC pelvic injury # R Supracondylar femur# R Supracondylar femur # R Tibia shaft (open)# R Tibia shaft (open) # L Tibial plateau (open)# L Tibial plateau (open) # Bimalleolar L ankle# Bimalleolar L ankle

Intubated through windowIntubated through window Pre hospital arrestPre hospital arrest Hr 144, Systolic 60Hr 144, Systolic 60 GCS 3GCS 3

CT brainCT brain BOSBOS

AngiogramAngiogram Very small bleeder Very small bleeder

embolisedembolised

External fixatorExternal fixator PelvisPelvis R legR leg L legL leg

Debridement Debridement washout, fasciotomy washout, fasciotomy and vac dressingand vac dressing

R thighR thigh R lower legR lower leg L lower legL lower leg

LaparotomyLaparotomy EVDEVD

4 HRS

Plating pubic symphysisPlating pubic symphysis Intramedullary nailIntramedullary nail

R femur retrogradeR femur retrograde R tibiaR tibia

Change of VacsChange of Vacs

Day 5

ORIF L Tibial plateauORIF L Tibial plateau ORIF L fibulaORIF L fibula Free Flap R tibiaFree Flap R tibia Rotation flap L TibiaRotation flap L Tibia

Day 9

Debridement and SSG L AnkleDebridement and SSG L Ankle Medial sideMedial side

Day 27Day 27

SIRS

CARS

Genes

ETO

DCO

EAP

Condition characterised by systemic inflammation, organ dysfunction, and organ failure.

Subset of cytokine storm, abnormal regulation of various cytokines

Inflammatory response to sepsis, trauma, hypoperfusion

Threshold for fatal

inflammatory response

DEATH: from multiorgan failure or adult respiratory distress syndrome

1st Hit: the trauma

infla

mm

ator

y re

spon

se

time

The ‘natural’ systemic inflammatory response

Severe trauma can result in a life threatening inflammatory response (SIRS)

Threshold for fatal

inflammatory response

DEATH: from multiorgan failure or adult respiratory distress syndrome

1st Hit: the trauma

infla

mm

ator

y re

spon

se

time2nd Hit: the surgery

The exaggerated response brought about by the 2nd hit of surgery

Severe trauma can result in a life threatening inflammatory response (SIRS)

Threshold for fatal

inflammatory response

DEATH: from multiorgan failure or adult respiratory distress syndrome

1st Hit: the trauma

infla

mm

ator

y re

spon

se

time2nd Hit: the surgery

In some individuals the lengthy surgery of early total care exacerbates the the systemic inflammatory response resulting in death

Bone RC. Sir Isaac Newton, sepsis, SIRS, and CARS. Crit Care Med. 1996;24(7):1125–8

CARS - systemic deactivation of the immune system tasked with restoring homeostasis from an inflammatory state

More than just cessation of SIRS

Different responses to Injury

SIRS: Severe inflammation may lead

to acute multi-organ failure (MOF), lung and

respiratory failure (ARDS) and death

CARS: An anti-inflammatory

response syndrome. May result in

prolonged immunosuppression

leading to sepsis

Early Total Care Not necessarily immediate, but within first 24 hours Often short period in ITU for resuscitation Repair all visceral injuries as soon as possible Definitive fixation of all long bone fractures within 24

hours Return to ITU only when all surgical procedures

finished Often long surgical times

Damage control Naval Term term:

“Capacity to absorb damage while maintaining mission integrity”

Rapid emergency surgery to save life or limb – NOT involving complex reconstructive surgery Control bleeding Decompress cranium, pericardium, thorax,

abdomen and limbs Decontaminate wounds and ruptured viscera Splint fractures

Cast, traction, pelvic binder, ex-fix Get back to ITU environment ASAP Definitive surgery performed several days later

J Bone Joint Surg Am, 2005 Feb; 87 (2): 434 -449

Louisville additional criteriapH of < 7.24Temp < 35°COperative time > 90 minutesCoagulopathyTransfusion > ten units

packed red cells

4 groups of patients Stable: go for Early Total Care Borderline: ? Unstable: go for Damage Control Surgery Extremis: Damage Control Surgery or ITU

Borderline patients are more difficult to define

Initial lactate: < 2.5 mg/dL,

5.4% (4.5-6.2%) Mortality

2.5 mg/dL to 4.0 mg/dL, 6.4% (5.1-7.8%) Mortality

>=4.0 mg/dL, 18.8% (15.7-21.9%) Mortality

Occult Hypo perfusion, raised lactate increased mortality

Lactate easy to measure Often high in 1st few hours but will drop in ITU if

resuscitation adequate

2.5 magic number! > 3 DC Surgery 2.5 – Look at TREND < 2.5 ETC

Days 2-5 are not safe During this period:

Marked inflammatory response ongoing Increased capillary permeability leads to generalized

oedema Cardiac output is high Patient is fragile A 2nd hit at this stage could be fatal

Pape et al: prospective study – multiply injured patients undergoing surgery between days

2 and 4 had a significantly increased inflammatory response compared with patients operated on between days 6 and 8

Patient with multiple injuries

ITU

Assess clinical condition and lactate

StableLactate <2.5

BorderlineLactate 2.5-3.0

Unstable Lactate

>3.0

In ExtremisAttempt

to resuscitate in ED or ITU

Early Total Care

ResuscitateAssess lactate

trend

StableUncertain

Damage Control Surgery

Trunkey DD. Trauma. Sci Am. 1983; 249:28–35

1st mins 1st hour 1st few weeks

Can reduce deaths only by injury prevention strategies

Can reduce deaths by excellent prehospital and emergency room care

Can reduce deaths by the decisions we make regarding surgical treatment.Death from MODS & ARDS

Proc (Bayl Univ Med Cent). 2010 Oct; 23(4): 349–354

Major Trauma Centre

Early Appropriate Care Acceptance different patients respond differently to

first and second hits Consider severity of initial injury Consider response to resuscitation What further surgery required Continued re assessment and ability to change from

ETO TO DCO

JTO; Volume 02 / Issue 02 / May 2014

2013 No single physiological parameter or blood marker can asSuggested accepted level of 2.5mmol/L is too conservativepatient centred approachPhysiological improvement and reversal of acidosis reflected by:

lactate< 4.0 mmol/LpH ≥7.25BE above 5.5 mmol/L

Multiply injured patients may have a profound and life-threatening inflammatory response

A ‘second hit’ of long definitive surgery can result in a fatal inflammatory response

The second hit can be avoided using early ‘damage control surgery’ followed by late ‘definitive care’

Lactate is important in identifying patients who will benefit from damage control surgery