Pathophysiology of Trauma: Influence on surgical timing and implant selection

1. Pathophysiology of Trauma:Influence on surgical timing and implant selection Piotr Blachut MD FRCSC University of British Columbia Vancouver, Canada

2. 23 yr old male • skiing accident 4 hours ago • isolated, closed injury • neurovascular normal

3. 19 yr old male • head on MVA • Head injury • GCS 6 • Multiple fractures

4. Investigations • CXR - normal • C spine - normal • Pelvis - normal • CT head • cerebral edema • hemispheric hemo. foci • SA blood • L tripod # • CT abdo • normal

6. 54 yr old male • fall from 25 ft. • no LOC • chest pain / SOB • pelvic / R ankle / L thigh pain • hypotensive • cold

8.  • What do we need to fix? • When should we fix it? • How should we fix it?

9. Priorities • Life threatening • Limb threatening • Function threatening

10. Priorities • Life threatening • Limb threatening • Function threatening - pelvic hemorrhage

11. Priorities • Life threatening • Limb threatening • Function threatening - pelvic hemorrhage -vascular injury - compartment syndrome - open fracture - irreducible dislocation

12. Priorities • Life threatening • Limb threatening • Function threatening - pelvic hemorrhage -vascular injury - compartment syndrome - open fracture - irreducible dislocation - articular fracture - distal extremity frac.

13. 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 ?

14. War experiences • Splintage • Early evacuation • Early definitive treatment Thomas splint

15. 1960’s & 1970’s System of operative fracture stabilization first applied to isolated injuries later application to polytrauma Improvement in anesthesia / critical care management

16. Eric Riska, Finland 1977 • 47 pts. • multiple trauma • all long bone fractures fixed with stable fixation • 1 death (80 y.o.)

17. 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)

18. 1980’s Early 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”

19. 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

20. 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

21. 1980’s • reamed IM nailing the standard of care for femoral shaft fractures • known marrow embolization

22. 1990’s  Three types of patients: • Isolated injuries • Multiple fractures • Multiple system Does ETC apply to all ?

23. 1990’s  Three types of patients: • Isolated injuries • Multiple fractures • Multiple system Does ETC apply to all ?

24. 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

25. 1990’s  • How show we fix it?

26. 1990’s  • CHEST INJURY

27. 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

28. 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%)

29. 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

30. 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.

31. 1990’s  • HEAD INJURY

32. Head injury • Secondary brain injury in severe head injury if exposed to: • hypotension • hypoxemia • increased ICP (intercranial pressure) • reduced CPP (cerebral perfusion pressure)

33. Head injury • Early Fracture Fixation May Be Deleterious After Head Injury Jaicks RR, Cohn SM, Moller BA, J Trauma 42(1):1-6, 1997 EarlyDelayed 19 14  fluid requirement  neuro complic.  hypoxia intra op  ICU stay  hypotension  hospital stay  GCS on discharge

34. Head injury EARLY FIXATION • Hofman 1991 • Poole 1992 • McKee 1997 • Starr 1998 • Smith 2000 • Brundage 2002 • DELAYED FIXATION • Jaicks 1997 • Townsend 1998 All retrospective studies !!!

35. Head injury • DELAYED FIXATION •  fluid requirement • hypoxia EARLY FIXATION •  length of stay •  mortality •  pulm. complic neuro outcome ? All retrospective studies !!!

36. 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.

37. Evolving concepts of pathophysiology • course after severe blunt trauma dependant on: • initial injury ( “first hit” ) • individual biologic response • type of treatment ( “second hit” )

39. Biological response • Prehospital • ER • ICU • ETC • Intermediate • Damage control Clinical outcome: ARDS, MOF, SIRS • Stable • Borderline • Unstable • In extremis 1st HIT Therapy: 2nd HIT Kellam 2003

40. 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 

41. “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

42. 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

43. 1990’s & 2000’s Damage control surgery Damage control orthopaedic surgery (DCO)

44. Damage control orthopaedic surgery Non- operative treatment ≠

45. Priorities • Life threatening • Limb threatening • Function threatening - pelvic hemorrhage -vascular injury - compartment syndrome - open fracture - irreducible dislocation - articular fracture - distal extremity frac.

46. Damage control orthopaedic surgery Avoid: • excessive fluid shifts • hypothermia • coagulopathy • pulmonary compromise • Provide stability: • pain control •  inflammatory • mediator release •  fat embolism •  mobilization

47. Damage control orthopaedic surgery • rapid external fixation • delayed definitive fixation

48. Damage control orthopaedic surgery Timing of secondary surgery • 2-4 days  multiple organ failure  inflammatory markers • 6-8 days Pape et al, 2001

49. Damage control orthopaedic surgery •  risk of local complications • infection • poorer joint reconstruction • not borne out in clinical experience (so far) • Scalea, 2000 • Nowotarski 2000

50. 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)