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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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slide1

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
slide5
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
slide9
ARDS

Chest Radiograph

AutopsySpecimen

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
slide15
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.
slide16
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

slide28
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.
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
slide37

DVT Prevention

Mechanical

Non Pharamcologic

Pneumatic

Compression

Elastic

Stockings

Vena Cava

Filter

slide38

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

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
slide46
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 spinal cord injury
Recommend Routine Thromboprophylaxis

LMWH Once Hemostasis Obtained

IPC and/or GCS

While Obtaining Hemostasis

ACCP Guidelines on SpinalCord Injury
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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