Acute Respiratory Distress Syndrome, Fat Embolism, & Thromboembolic Disease in the Orthopaedic Traum...
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Acute Respiratory Distress Syndrome, Fat Embolism, & Thromboembolic Disease in the Orthopaedic Trauma Patient. Steve Morgan, MD & Scott Adams, MD Original Authors: Steve Morgan, MD; March 2004; New Authors: Steve Morgan, MD & Scott Adams, MD; Revised January 2007 and November 2011. Define

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Steve morgan md scott adams md original authors steve morgan md march 2004

Acute Respiratory Distress Syndrome, Fat Embolism, & Thromboembolic Disease in the Orthopaedic Trauma Patient

Steve Morgan, MD & Scott Adams, MD

Original Authors: Steve Morgan, MD; March 2004;

New Authors: Steve Morgan, MD & Scott Adams, MD; Revised January 2007 and November 2011


Objectives

Define

ARDS

FES

Thromboembolic Disease

Understand Etiology & Physiology of each Condition

Understand

Prevention

Diagnosis

Treatment

Outcomes

Objectives


Ards acute respiratory distress syndrome

ARDSAcute Respiratory Distress Syndrome

  • Acute respiratory failure in the post traumatic period characterized by a decreased PaO2 and a diffuse and often massive extravasations of fluid from the pulmonary vasculature to the interstitial space of the lungs.


Ards clinical definition

ARDS Clinical Definition

  • Acute onset of symptoms

  • Ratio of PaO2 to FIO2 of 200 mm Hg or less

  • Bilateral infiltrates on CXRs

  • Pulmonary arterial wedge pressure of 18 mm Hg or less or no clinical signs of left atrial hypertension

  • American-European Consensus Conference (AECC) on ARDS, 94


Steve morgan md scott adams md original authors steve morgan md march 2004

ARDS

  • Incidence 5% – 8% after polytrauma

    • Much lower in isolated fracture

  • Mortality up to 40%

  • Uncommon in Children and the Elderly


Ards common causes

Trauma

Massive Transfusion

Embolism

Sepsis

Aspiration

Abdominal Distension

Pulmonary Edema

Prolonged LOC

Cardiopulmonary Bypass

Pancreatitis

Major Burns

ARDSCommon Causes

MULTIFACTORAL


Ards etiology

ARDS Etiology

  • ARDS related to MODS

  • Release of inflammatory mediators results in organ dysfunction

Inflammatory

Mediators

Organ

Injury

Trauma


Ards pathophysiology

Systemic Inflammatory Mediators

Damage to Endothelial Lining

Increased Capillary Permeability

Fluid Extravasation

Alveolar Collapse

Decreased Pulmonary Compliance

Ventilation Perfusion Abnormalities

Arteriolar Hypoxemia

ARDS PATHOPHYSIOLOGY


Steve morgan md scott adams md original authors steve morgan md march 2004

ARDS

Chest Radiograph

AutopsySpecimen


Ards chest ct scan

ARDS Chest CT Scan


Ards prevention

Limiting Blood Loss

Decreasing Transfusion Requirements

Early Stabilization Of Unstable Fractures

Early Prophylactic Mechanical Ventilation

ARDSPrevention

Temporary Ex-Fix For Stabilization


Ards treatment

ARDS Treatment

  • Ventilator Support

    • Acceptable ABG’s

    • Avoid further alveolar damage

      • Toxic FIO2

      • Barotrauma

  • General Organ Support

  • Research

    • Optimal ventilator settings

    • Pharmalogical agents


Ards outcome

ARDSOutcome

  • Significant Cause of Mortality

  • Major Cause of Death in Patients with the Lowest ISS scores

  • 30% - 40% Mortality Rate

    • Mortality Rate Slowly Decreasing with Changing & Improving Therapy


Fat embolism syndrome fes

Fat Embolism Syndrome(FES)

  • A condition characterized by hypoxia, confusion and petechiae presenting soon after long bone fracture and soft tissue injury.

  • Diagnosis of Exclusion


Steve morgan md scott adams md original authors steve morgan md march 2004

FES

  • Often Placed in the Category of ARDS

    • May share common pathological pathways

  • R/O other Causes of Hypoxia & Confusion

  • Index Patient

    • young adult with isolated LE injury seen after long transfer with no supporting therapy or splintage.


Steve morgan md scott adams md original authors steve morgan md march 2004

FES

  • Occurs in 0.9 – 8.5% of all fracture patients

  • Up to 35% of the multiply injured

  • Mortality 2.5%

  • Rare in upper limb injury and children


Etiology

Etiology

  • The likely pathogenetic reaction of lung tissue to shock, hypercoagulability and lipid metabolism

  • Mechanical Theory

  • Biochemical Theory


Mechanical theory

Mechanical Theory

  • Fracture Liberates Fat

  • Intravasation - Fat Enters Venous System

  • Fat Causes Mechanical Obstruction


Mechanical theory1

Mechanical Theory

FES To Brain On MRI

  • Systemic Fat Embolization

    • Patent Foramen Ovale

    • Pulmonary Pre-Capillary Shunts

    • Skin petechiae, CNS signs


Biochemical theory

Biochemical Theory

  • Neutral Fat and Chemical Mediators Released at Time of Fracture

  • Neutral Fat Metabolized by Lipases releases Free Fatty Acids

  • Free Fatty Acids Result in Endothelial Lung Damage


Fes diagnosis

Major Criteria

Hypoxemia

CNS Depression

Petechial Rash

Pulmonary Edema

Minor Criteria

Tachycardia

Pyrexia

Retinal Emboli

Fat in Urine

Fat in Sputum

Thrombocytopenia

Decreased Hematocrit

FES Diagnosis

Gurd et al


Fes diagnosis1

FES Diagnosis

  • Gurd & Wilson Criteria

  • At least 1 Major Sign

  • 4 Minor Signs

Gurd et al


Fes prevention

FES Prevention

  • Appropriate Splinting

  • Early Fracture Stabilization

  • Oxygen Therapy


Fes prevention1

FES Prevention

  • Therapies

    • Fluid Loading

    • Hypertonic Fluid

    • Alcohol

    • Heparin

    • Dextran

    • Aspirin

  • None Shown to be Effective


Fes treatment

FES Treatment

  • Supportive

    • Oxygen Therapy to maintain PaO2

    • Mechanical Ventilation

    • Adequate Hydration


Fes treatment steroids

FES Treatment Steroids

  • Steroids

    • Decrease endothelial damage

    • 30mg/kg initial dose repeated @ 4 Hours, 1gm dose repeated @ 8 Hours: Total 3 Doses

  • Complications - Frequent

    • Infection

    • GI

  • Steroid Therapy Avoided Secondary To Poor Risk Benefit Ratio


Systemic effects of trauma

ARDS

MODS

Threshold

Post Injury

Inflammatory

Response in

2 Patients

Systemic Effects of Trauma

Second Hit in susceptible patients

24 hours

48 hours

Injury (First Hit)

IM Nailing as a Cause of Secondary Systemic Injury


Steve morgan md scott adams md original authors steve morgan md march 2004

Early Total Care

Definitive Early Fixation

Nail or Plate

Damage Control

Temporary Stability

External Fixator

Limit Further Blood Loss

Limit Anesthetic Time

Delay Definitive Fracture fixation

Fracture Fixation Technique-Controversial-


Effect of im nailing

Effect of IM Nailing

  • Increased IM Pressure

  • Embolic Showers On Echocardiograms

  • Caused by

    • Canal Opening

    • Reaming

    • Nail Insertion (both reamed & unreamed)


Fracture fixation technique controversial

Fracture Fixation Technique-Controversial-

  • IM Nail - Reamed vs Un-Reamed

    • Decreased with Unreamed Technique

      • Pape et al

    • No Difference

      • Keating et al

      • Canadian OTS

  • IM Nail Reamed vs Plate Osteosynthesis

    • No Difference In Pulmonary Dysfunction

      • Bosse et al


Dvt incidence

DVT Incidence

  • DVT occurrence 60% if ISS >9.

  • 35%-60% DVT in pelvic fracture

  • PE-Most common preventable cause of death in trauma.


Virchow triad

Virchow Triad


Hypercoaguability

Hypercoaguability

  • Tissue Thromboplastin

  • Activated Procoagulants

  • Decreased Fibrinolytic Activity

  • Ineffective Heparin Clearance of Activated Clotting Factors

  • Catecholamine Release


Endothelial injury

Endothelial Injury

  • Direct Trauma to Vein at time of Injury

  • Compression of the Vein Secondary to Fracture Position

  • Vein Manipulation at Time of Fracture Fixation


Venous stasis

Venous Stasis

  • Immobilization

  • Hypotension

  • Venous Occlusion

    • Edema

    • Fracture Position

  • Tourniquet


Dvt prevention

DVT Prevention

Goals

  • Clinically significant events

    • PE

    • Post Thrombotic syndrome

  • Low Complication Rate

  • High Compliance Rate

  • Cost Effective


Steve morgan md scott adams md original authors steve morgan md march 2004

DVT Prevention

Mechanical

Non Pharamcologic

Pneumatic

Compression

Elastic

Stockings

Vena Cava

Filter


Steve morgan md scott adams md original authors steve morgan md march 2004

DVT Prevention

Pharamcologic

Pentasacharides

Unfractionated

Heparin

Elastic

Stockings

LMWH

Heparin

Warfarin

Oral

Anticoagulants


Prophylaxis

Elastic Stockings

Mechanical Compression Devices

Early Mobilization

IVC Filter (PE Prophylaxis)

Pentasaccharide

Low Molecular Weight Heparin

Heparin

Aspirin

Warfarin

Prophylaxis


Mechanical methods

Mechanical Methods

  • Activity

  • Compression Stockings

  • Sequential Compression Device

  • Pedal Pumps

    Mechanism of Action

  • Decrease Stasis

  •  Fibrinolytic Activity


Ivc filter indications

IVC Filter Indications

  • Anticoagulation Prohibited

  • High Risk Patients

  • DVT Prior to Necessary Surgery

  • PE Despite Anticoagulation


Ivc filter

Prevents Major PE

Low Morbidity

96% Patent

8% Migration

4% PE

Filter insertion in the ICU

Expensive

Invasive

Does not treat DVT

Venous Insufficiency

Filter Occlusion

IVC Filter

Advantages

Disadvantage


Accp recommendation on vena cava filter

No Recommendation for Vena Caval Filter

ACCP Recommendation on Vena Cava Filter


Pentsaccharide

Pentsaccharide

  • Selective Inhibitor of Activated Xa

    • Decreased DVT rate with no change in major bleeding rate compared to LMWH

      • Eriksson B I et al N Engl J Med 2001

    • Increased risk of minor bleeding

      • Delay administration for several hours after surgery and removal of epidural catheter


Low molecular weight heparin lmwh

Low Molecular Weight Heparin(LMWH)

  • Potentiates Antithrombin III

  • Inhibits Factor Xa & II

  • Minimal effects on other Factors


Steve morgan md scott adams md original authors steve morgan md march 2004

No Monitoring

Increased Efficacy

Longer 1/2 life

Predictable Response

Lower risk of thrombocytopenia

Parenteral Administration

Cost

LMWH

Advantages

Disadvantage


Heparin

Heparin

  • Heparin Potentiates Anti-Thrombin III Activity

  • Complex Inhibits

    • Thrombin (IIa), IXa, Xa

  • Heparin effect relative short duration

    • Reversed with Protamine Sulfate

  • Significant hemorrhage risk


Sq heparin

Low Cost

No Monitoring

Convenient

Relatively Low Incidence of Bleeding

Insufficient Efficacy in High Risk Patients

Unpredictable Responses

Heparin Induced Thrombocytopenia

SQ Heparin

Advantages

Disadvantage


Aspirin

Oral Administration

Tolerated well

In-expensive

No Monitoring

? Efficacy when used alone

GI Intolerance

Prolonged anti-platelet effect

Aspirin

Advantages

Disadvantage


Aspirin1

Aspirin

  • Inhibits cyclooxygenase

  • Decreases Platelet Adherence

  • ? Effectiveness in Musculoskeletal Trauma

    • Venous clots not typically found to have Platelet aggregates


Accp recommendation on aspirin

No Recommendation For The Use of Aspirin

Recommend Against The Use of Aspirin For Any Indication

ACCP Recommendation on Aspirin


Warfarin

Warfarin

  • Blocks Vit K conversion in Liver

  • Effects Vit K Dependent Factors

  • Effects the Extrinsic Clotting System

  • Factor VII Effected first, Short Half Life

  • Monitored with Pro-Time

    • INR 2.0-2.5

  • Reversed With Vitamin K or FFP


Warfarin1

Effective

Oral Administration

Inexpensive

Requires Monitoring

Difficult to Reverse

Increased Bleeding Complications in Elderly

Warfarin

Advantages

Disadvantage


East guidelines

Guidelines based on qualitative review of the current scientific literature improve uniformity of opinion and prescribing practices

Watts JBJS B 05

Risk Factors

Level I Evidence – Major Significance

Spinal Fracture

Spinal Cord Injury

Level II – No Major Significance

Advanced Age

ISS Score

Blood Transfusion

Long Bone, Pelvis, Head Injury

EAST Guidelines


Accp guidelines

Guidelines based on qualitative review of the current scientific literature improve uniformity of opinion and prescribing practices

Watts JBJS B 05

Risk Factors

Level I Evidence – Major Significance

Spinal Cord Injury

Major Trauma

Hip Fractures

Complex Lower-extremity Fracture

Pelvic Fracture

Prolonged Immobility

Delay in Commencement Of Thromboprophylaxis

ACCP Guidelines


Accp guidelines on hip fractures

Recommend Routine Thromboprophylaxis

Fondaparinux

LMWH

Warfarin (INR 2.5)

LDUH

ACCP Guidelines on Hip Fractures


Accp guidelines on spinal cord injury

Recommend Routine Thromboprophylaxis

LMWH Once Hemostasis Obtained

IPC and/or GCS

While Obtaining Hemostasis

ACCP Guidelines on SpinalCord Injury


Accp guidelines on isolated injuries distal to the knee

No Routine Thromboprophylaxis

ACCP Guidelines on Isolated Injuries Distal To The Knee


Duration of prophylaxis

Duration of Prophylaxis


Accp guidelines duration of therapy hip fractures

10 to 35 Days

Agents

LMWH

Fondaparinux

Warfarin

ACCP Guidelines Duration of Therapy Hip Fractures


Accp guidelines on duration of therapy for trauma patients

Up to Hospital Discharge

Agents

LMWH

Fondaparinux

Warfarin

ACCP Guidelines on Duration of Therapy for Trauma Patients


Accp guidelines length of prophylaxis trauma population

Exception

Impaired mobility who undergo inpatient rehabilitation

Thromboprophylaxis

LMWH

Warafarin INR, 2.5

ACCP Guidelines Length of ProphylaxisTrauma Population


Dvt screening

DVT screening

  • Physical Exam

  • Ascending venography

  • Duplex Ultrasonography

  • Magnetic Resonance Venography


Physical examination

Physical Examination

  • Calf Swelling

  • Palpable Venous Cords

  • Calf Pain

  • Homan’s Sign

  • All Unreliable


Ascending contrast venography

Ascending Contrast Venography

  • Sensitive for detection

  • Invasive

  • Dye Problems (allergies, renal)

  • Injection Site Irritation

  • Poor Pelvic Vein Evaluation

  • Gold Standard

*Invasiveness,expense make ACV a poor screening tool


Doppler duplex ultrasound

Doppler/Duplex Ultrasound

  • Comparable to Venogram

  • Non Invasive

  • No Morbidity

  • Poor Axial (i.e Pelvic) Vein Evaluation

  • Operator Dependent

  • Good Screening Tool

    • Noninvasive, reproducible


Magnetic resonance venography

Magnetic Resonance Venography

  • Non Invasive

  • Good Visualization of Pelvic Veins

  • Difficult in Polytrauma Patient

  • Excellent specificity and sensitivity for suspected DVT

  • Controversial for screening


Pulmonary embolism

Pulmonary Embolism

Clinical

Shortness of breath, agitation, confusion

Laboratory

 PaO2,  A-a gradient

Diagnostic studies

V/Q scans

Pulmonary Angiogram, CT PA


Ventilation perfusion scan

Ventilation Perfusion Scan

  • Ventilation Perfusion mismatch

  • Results

    • Low probabiltity

      • 15% False Negative

    • Medium

      • Need Angiogram

    • High probability

      • 15% False Positive

  • Screening Tool


Pulmonary angiogram

Pulmonary Angiogram

  • Angiographic Evaluation of pulmonary vascular tree

  • Allows Placement of IVC Filter in same setting if indicated

  • Sensitive - Standard in PE Detection. Diagnostic


Treatment pe

Treatment PE

  • Anticoagulation

  • Filter for recurrent event despite anticoagulation

  • Thrombectomy

    • Serious Acute PE

    • Patient in extremous

    • Large identifiable PE


Treatment dvt pe

Heparin

Bolus 10-15K units

Continuous Infusion

1000Units/Hr

Goal  PTT 2x Control

Prevent Clot propagation and recurrent PE

Discontinue when Therapeutic on Warfarin

LMWH / Pentasaccharide

Mass related dose SQ inj

Single daily dose

No monitoring necessary

Discontinue when Therapeutic on Warfarin

Treatment DVT/PE


Treatment dvt pe1

Warfarin

INR 2.0-3.0

3-6 Month Duration

Contraindicated in:

Pregnancy

Liver insufficiency

Poor Compliance

Prolonged Therapy may decrease recurrence rates

Treatment DVT/PE


Dvt pe outcome

DVT/PE Outcome

  • No Diagnosis and Treatment

    • 30% Mortality

  • Correct Diagnosis and Therapy

    • 11% Mortality in First Hour

    • 8% Mortality After First Hour


Dvt pe outcome1

DVT/PE Outcome

  • Post Thrombotic Syndrome

    • Valvular Incompetence

    • Venous Stasis

    • Edema

    • Cutaneous Atrophy

  • Recurrent DVT

    • 20% of Patients


Bibliography fes ards

Bibliography FES/ARDS

  • Gurd AR, Wilson RI Fat-embolism syndrome Lancet. 1972 Jul 29;2(7770):231-2

  • Giannoudis PV, Pape HC, Cohen AP, Krettek C, Smith RM. Review: systemic effects of femoral nailing: from Küntscher to the immune reactivity era. Clin Orthop Relat Res. 2002 Nov;(404):378-86

  • Bosse MJ, MacKenzie EJ, Riemer BL, Brumback RJ, McCarthy ML, Burgess AR, Gens DR, Yasui Y. Adult respiratory distress syndrome, pneumonia, and mortality following thoracic injury and a femoral fracture treated either with intramedullary nailing with reaming or with a plate. A comparative study. J Bone Joint Surg Am. 1997 Jun;79(6):799-809

  • Canadian Orthopaedic Trauma Society.Reamed versus unreamed intramedullary nailing of the femur: comparison of the rate of ARDS in multiple injured patients. J Orthop Trauma. 2006 Jul;20(6):384-7


Bibliography dvt pe

Bibliography DVT/PE

  • Geerts WH, Bergqvist D, Pineo GF, Heit JA, Samama CM, Lassen MR, Colwell CW; American College of Chest Physicians Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008 Jun;133(6 Suppl):381S-453S

  • Rogers FB, Cipolle MD, Velmahos G, Rozycki G, Luchette FA Practice management guidelines for the prevention of venous thromboembolism in trauma patients: the EAST practice management guidelines work group. J Trauma. 2002 Jul;53(1):142-64

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