POLYTRAUMA AND
DCO: RECENT
CONCEPTS
Polytrauma
 Injury to 2 or more organ systems leading
potentially to a life threatening condition
Physiological response to injury
 Inflammatory immune response
 Innate immune response (0-14 days)
 Delayed adaptive im...
Inflammatory immune response
 EARLY innate immune response
 DELAYED adaptive immune response
 LATE adaptive immune resp...
Early innate immune response
 Neutrophils (major cellular ‘player’) are drawn to
the site of injury by IL-8 and C5a (chem...
SIRS DEFINITION
 Heart rate: > 90 bpm
 WBC: <4000/mm3 or >12000/mm3 or >10%
immature PMNs
 Respiratory rate: >20/min wi...
Delayed adaptive immune
response
(immunosuppression period)
 Non-apoptotic necrotic/dead cells produce
alarmins plus Endo...
 Specific immunity mediated by ‘T’-, and ‘B’
lymphocytes operating by remembers
Ag/exogenous triggers (PAMPs=Pathogen
ass...
Interplay of SIRS and CARS (early
innate immune response)SystemicResponse
SIRS
CARS
D14D7
Adaptive Immune
Response
Innate ...
Pathological immune response
1st Hit
Moderate Injury 1st Hit
Amplification of SIRS
Delayed-onset MODS/death
Incomplete Res...
Pathological immune responseSystemicResponse
SIRS
CARS
Adaptive Immune
Response
Innate Immune
Response
Insult
Severe Injur...
Pathological immune responseSystemicResponse
SIRS
CARS
Adaptive Immune
Response
Insult
Moderate to severe injury
Pro-infla...
MODS
 Cerebral - Cerebral edema
 CVS - Hypotension and shock
 Respiratory - Acute lung injury, ARDS
 Liver - High APR ...
Overall immune responseSystemicResponse
SIRS
CARS
D14D7
Adaptive Immune
Response
Innate Immune
Response
Insult
Mild-Modera...
Polytrauma (2 hit phenomenon)
‘First Hit’ Impacts by Trauma
The Limb/Organ SystemThe Patient
Polytrauma (2 hit phenomenon)
‘Second Hit’ Impacts by Surgery and Resuscitation
The LimbThe Patient
New concept in resuscitation
First Hit Impacts
How do you decide your fluid replacement?
What is your fluid replacement re...
Class I Class II Class III Class IV
Blood loss (liter) Up to 0.75 0.75-1.5 1.5-2.0 > 2
% TBV 15% 30% 40% >40%
Pulse rate <...
Fluid resuscitation
 Bolus administration of saline?
 Colloids?
 GXM or GSH?
Fluid resuscitation
Lethal
Triad of
Death
AcidosisHypothermia
Coagulopathy
Voluminous crystalloid
● dilutes coagulation fa...
DCR Priorities Beyond ABCDE of ATLS
On-going Bleeding
Hypoperfusion
Exposure
SIRS/CARS
Resuscitation
Contamination
Balance...
Paradigm Shift in Resuscitation
From ATLS in 1980s
EARLY TOTAL CARE (ETC)
ATLS concept of Primary Survey
followed by
Secon...
Paradigm Shift in Resuscitation
To DCR in 1990s
HD Triage: Stable, Borderline, Unstable
and In Extremis
DAMAGE CONTROL RES...
HAEMODYNAMIC ‘TRIAGE’ PROTOCOL
Stable Borderline Unstable In Extremis
No clinical signs
of hypovolaemic
shock
SBP 80-100mm...
1. Fluid Replacement in Balanced Resuscitation
● Initial fluid replacement with up to 2L crystalloid
Permissive hypotensio...
3. Correction of Metabolic Derangement
● Role of THAM (Tris-hydroxmethyl-amino-methane)
● Use of NaHCO3 to correct acidosi...
Damage control orthopaedics
Damage Control Orthopaedics
 An approach to contain and stabilize an
orthopaedic injury to improve patient’s
physiology
...
DCO - evolution
1960s Delayed Surgery (‘too sick to operate on’)
Preliminary traction → delayed definitive fixation
1980s ...
Patient categorization
Parameter Stable Borderline Unstable In Extremis
Shock SBP (mmHg)
Blood unit/2h
Lactate
Base defici...
Borderline patients (ISS>18)
Bone et al. Early versus delayed stabilization of fractures. A prospective randomized study
J...
ETC vs DCO
ETC ETC DCO DCO
OR OR OR OR ICU
Stable Borderline Unstable Extremis
Haemorrhage control and/or
Decompression in...
DCO surgery
 External fixation
 Nailing if ISS<25
 Unreamed/retrograde
 Usage of new One-step Reamer-Irrigator-
Aspira...
Application of DCO
Stage 1
Stage 3Stage 2
Definitive # fixation once
the patient is optimized
(avoid day 2-5)
Resuscitatio...
Overall immune responseSystemicResponse
SIRS
CARS
D14D7
Adaptive Immune
Response
Innate Immune
Response
Insult
Mild-Modera...
Timing of surgery
Timing Physiological Status Surgical Intervention
Day 1 Normal response to resuscitation
Early Total Car...
of 36

Polytrauma recent concepts 2014

recent concepts in managing polytrauma inclusive of physiological response to injury
Published on: Mar 4, 2016
Published in: Health & Medicine      
Source: www.slideshare.net


Transcripts - Polytrauma recent concepts 2014

  • 1. POLYTRAUMA AND DCO: RECENT CONCEPTS
  • 2. Polytrauma  Injury to 2 or more organ systems leading potentially to a life threatening condition
  • 3. Physiological response to injury  Inflammatory immune response  Innate immune response (0-14 days)  Delayed adaptive immune response (12-21 days)  Late adaptive immune response (following that)  Systemic Inflammatory Response Syndrome (SIRS)  Compensatory Anti-inflammatory Response Syndrome (CARS)  Multi Organ Dysfunction Syndrome (MODS)
  • 4. Inflammatory immune response  EARLY innate immune response  DELAYED adaptive immune response  LATE adaptive immune response Early Innate = Hyperinflammation = SIRS Adaptive = Hypoinflammation = CARS
  • 5. Early innate immune response  Neutrophils (major cellular ‘player’) are drawn to the site of injury by IL-8 and C5a (chemokines)  Priming neutrophils for defence and debridement of injured tissue, and mediating inflammation  Activation of PMN, monocytes, macrophages, NKC and endothelial cells  Release of pro-inflammatory mediators (cytokines and molecular mediators)  Considered the hyperinflammatory period
  • 6. SIRS DEFINITION  Heart rate: > 90 bpm  WBC: <4000/mm3 or >12000/mm3 or >10% immature PMNs  Respiratory rate: >20/min with PaCO2<32mmHg  Core temperature: <360C or >380C 2 of 4 parameters = SIRS
  • 7. Delayed adaptive immune response (immunosuppression period)  Non-apoptotic necrotic/dead cells produce alarmins plus Endogenous triggers (DAMPs = damage-associated molecular patterns)  CD5+ B-cells to produce natural antibody without prior exposure and subsets of T- cells to inflict self-reactivity → autoimmune tissue destruction  Considered the immunosuppression period or CARS
  • 8.  Specific immunity mediated by ‘T’-, and ‘B’ lymphocytes operating by remembers Ag/exogenous triggers (PAMPs=Pathogen associated molecular patterns) encountered before  Conventional antibodies production Late Adaptive Immune Response (Immunoproliferative period)
  • 9. Interplay of SIRS and CARS (early innate immune response)SystemicResponse SIRS CARS D14D7 Adaptive Immune Response Innate Immune Response Insult Homeostasis Mild-Moderate Injury Pro-inflammatoryAnti-inflammatory Balanced SIRS-CARS maintains homeostasis
  • 10. Pathological immune response 1st Hit Moderate Injury 1st Hit Amplification of SIRS Delayed-onset MODS/death Incomplete Resolution 2nd Hit 2nd Operation within D3-5 Sepsis Severe injury Intense CARS Early MODS/death IMBALANCE BETWEEN SIRS AND CARS
  • 11. Pathological immune responseSystemicResponse SIRS CARS Adaptive Immune Response Innate Immune Response Insult Severe Injury Pro-inflammatoryAnti-inflammatory Imbalanced CARS>SIRS leads to hypo-inflammation or early MODS
  • 12. Pathological immune responseSystemicResponse SIRS CARS Adaptive Immune Response Insult Moderate to severe injury Pro-inflammatoryAnti-inflammatory Imbalanced SIRS>CARS leads to hyper-inflammation or delayed MODS Innate Immune Response 2ndHit
  • 13. MODS  Cerebral - Cerebral edema  CVS - Hypotension and shock  Respiratory - Acute lung injury, ARDS  Liver - High APR and cytokines, hepatocytes dysfunction  GI - Increased mucosal permeability Bacterial translocation  Renal - Renal tubular necrosis, acute renal failure  Hematologic - DIVC
  • 14. Overall immune responseSystemicResponse SIRS CARS D14D7 Adaptive Immune Response Innate Immune Response Insult Mild-Moderate Injury Pro-inflammatoryAnti-inflammatory D12 Delayed adaptive immune response D21
  • 15. Polytrauma (2 hit phenomenon) ‘First Hit’ Impacts by Trauma The Limb/Organ SystemThe Patient
  • 16. Polytrauma (2 hit phenomenon) ‘Second Hit’ Impacts by Surgery and Resuscitation The LimbThe Patient
  • 17. New concept in resuscitation First Hit Impacts How do you decide your fluid replacement? What is your fluid replacement regimen?
  • 18. Class I Class II Class III Class IV Blood loss (liter) Up to 0.75 0.75-1.5 1.5-2.0 > 2 % TBV 15% 30% 40% >40% Pulse rate < 100 > 100 >120 >140 Blood pressure Normal Normal Decreased Decreased Pulse pressure Normal or inc Decreased Decreased Decreased Respiratory rate 14-20 20-30 30-40 >35 Urine output > 30 ml/hr 20-30 5-15 Negligible Mental status Slightly anxious Mildly anxious Anxious/confused Confused/lethargic Fluid Replacement Crystalloid Crystalloid Crystalloid and blood Crystalloid and Blood Classification of Hypovolaemic Shock and Physiologic Changes What is your fluid replacement regimen?
  • 19. Fluid resuscitation  Bolus administration of saline?  Colloids?  GXM or GSH?
  • 20. Fluid resuscitation Lethal Triad of Death AcidosisHypothermia Coagulopathy Voluminous crystalloid ● dilutes coagulation factors ● causes hyperchloremic and lactate acidosis ● supplies inadequate O2 to under-perfused tissue
  • 21. DCR Priorities Beyond ABCDE of ATLS On-going Bleeding Hypoperfusion Exposure SIRS/CARS Resuscitation Contamination Balanced Resuscitation or Permissive Hypotension Haemostatic Resuscitation Damage Control Surgery
  • 22. Paradigm Shift in Resuscitation From ATLS in 1980s EARLY TOTAL CARE (ETC) ATLS concept of Primary Survey followed by Secondary Survey Timely debridement within 6-hour Early definitive fracture fixation within 24 hours (ETC) EDCBA
  • 23. Paradigm Shift in Resuscitation To DCR in 1990s HD Triage: Stable, Borderline, Unstable and In Extremis DAMAGE CONTROL RESUSCITATION Permissive hypotension and haemorrhage control Haemostatic resuscitation in ICU Damage Control Surgery Definitive fracture fixation after D5 DCBAC E
  • 24. HAEMODYNAMIC ‘TRIAGE’ PROTOCOL Stable Borderline Unstable In Extremis No clinical signs of hypovolaemic shock SBP 80-100mmHg AIS > 2 Blood transfusion 2-8/2h Absent vital signs Severe shock Uncontrolled h’hage needing mechanical resuscitation repeated CA infusion despite complete blood volume replacement within 2h (>12 blood transfusion/2h Unable to maintain SBP >90mmHg Pulse <100/min CVP>5cm H20 UO>30ml/h Despite adequate fluid resuscitation and blood transfusion over 2h
  • 25. 1. Fluid Replacement in Balanced Resuscitation ● Initial fluid replacement with up to 2L crystalloid Permissive hypotension to achieve SBP to 80- 90mmHg (radial pulse) until definitive control of bleeding is obtained ● Role of fluid challenge (250-500ml) tests to stratify responder, transient responder, non-responder 2. Haemostatic Resuscitation ● Early blood versus HBOC transfusion decreases MODS ● Packed RBC, FFP and Platelets in 1:1:1 ratio Non-surgical DCR
  • 26. 3. Correction of Metabolic Derangement ● Role of THAM (Tris-hydroxmethyl-amino-methane) ● Use of NaHCO3 to correct acidosis causes hypercapnia? 4. Hypothermia Prevention and Treatment Strategies ● Limit casualties’ exposure ● Warm IV fluids and blood products before transfusion ● Use forced air warming devices before and after surgery ● Use carbon polymer heating mattress Non-surgical DCR
  • 27. Damage control orthopaedics
  • 28. Damage Control Orthopaedics  An approach to contain and stabilize an orthopaedic injury to improve patient’s physiology  Designed to avoid worsening pt’s condition due to “second hit” phenomenon  Delay definitive surgery until pt condition is optimized  Focuses on hemorrhagic control, management of soft-tissue injury and provisional fracture stability
  • 29. DCO - evolution 1960s Delayed Surgery (‘too sick to operate on’) Preliminary traction → delayed definitive fixation 1980s Early Total Care within 24 hours (‘too sick not to operate on’) ATLS concepts plus Advancement in anaesthesiology and ICU care ● early fixation prevents FES ● early mobilization facilitates nursing care and ● early mobilization prevents pneumonia, sepsis, TED Patients with ISS>17 (borderline patients) are at high risk of complications 1990s Damage Control Orthopaedics
  • 30. Patient categorization Parameter Stable Borderline Unstable In Extremis Shock SBP (mmHg) Blood unit/2h Lactate Base deficit UO ml/h Class 100 or more 0-2 < 2.0 Normal >150 I 80-100 2-8 2.5 No data 50-150 II-III 60-80 5-15 >2.5 No data <100 III-IV 50-60 >15 Severe >6-18 <50 IV Coagulation Platelets Factors II/V Fibrinogen d-Dimer >110,000 90-100% >1 g/dL Normal 90-110,000 70-80% 1 g/dL Abnormal 70-90,000 50-70% <1 g/dL Abnormal <70,000 <50% DIC DIC Temperature >340C 33-350C 30-320C <300C Soft Tissue Injuries Chest AIS TTS Abd (Moore) Pelvic AO Limb AIS 2 or 2 0 <II A I-II 2 or more I-II <III B or C II-III 2 or more II-III III C III-IV 3 or more IV III or >III C Crush
  • 31. Borderline patients (ISS>18) Bone et al. Early versus delayed stabilization of fractures. A prospective randomized study J Bone Joint Surg. 1989; 71-A: 336-40 Reynold et al. Is timing of fracture fixation important for the patient with multiple trauma? Ann Surg. 1995; 222:470-81 Femoral shaft #s N=105 <24 hr 24-48 hr > 48 hr Reamed IMN ISS<18 ISS>18 Complications Complications Ecke et al. 1985 n=1127 AO Foundation
  • 32. ETC vs DCO ETC ETC DCO DCO OR OR OR OR ICU Stable Borderline Unstable Extremis Haemorrhage control and/or Decompression in the ER 20 survey (end of ER workup) ABG, FAST, I/O ratio, ABP Stable Uncertain Ext-Fix (distractor)
  • 33. DCO surgery  External fixation  Nailing if ISS<25  Unreamed/retrograde  Usage of new One-step Reamer-Irrigator- Aspirator (RIA by Synthes)
  • 34. Application of DCO Stage 1 Stage 3Stage 2 Definitive # fixation once the patient is optimized (avoid day 2-5) Resuscitation and ICU management 1.Close monitoring 2.Repletion of blood product 3.Further hemodynamic stabilization 10 rapid temporary # stabilization (in trauma room/ICU/OR) 1.Control h’hage e.g. ext-fix pelvis 2.Debridement of open wound 3.Spanning ext-fix or unreamed nailing or reamed nailing using RIA
  • 35. Overall immune responseSystemicResponse SIRS CARS D14D7 Adaptive Immune Response Innate Immune Response Insult Mild-Moderate Injury Pro-inflammatoryAnti-inflammatory D12 Delayed adaptive immune response D21
  • 36. Timing of surgery Timing Physiological Status Surgical Intervention Day 1 Normal response to resuscitation Early Total Care Day 1 Partial response to resuscitation Damage Control Surgery Day 1 No response to resuscitation Life-saving surgery Day 2-5 Hyperinflammation ‘Second-look’ only Day 6-11 Window of opportunity Definitive surgery Day 12-21 Immunosuppression No surgery Week 3+ Recovery 20 reconstructive surgery AO Philosophy

Related Documents