Dr. Fathi Neana, MDChief of Orthopaedics

Dr. Fakhry & Alrajhy HospitalSaudi Arabia

December, 2 – 2016

DAMAGE CONTROL IN POLYTRAUMA

DAMAGE CONTROL ORTHOPAEDICS

(DCO)

Damage control is a Navy term defined as “the capacity of a ship to absorb damage and

maintain mission integrity

This sequence is followed by immediate transfer to the intensive care unit (ICU) with subsequent

rewarming, correction of coagulopathy and hemodynamic stabilization.

Return to the operating theatre is then pursued 6–48 hours later for a planned re-exploration that includes definitive repair and primary

fascial closure if possible.

When applied to surgery and critically ill patients

Damage control surgery (DCS) incorporates fundamental

tenets: arresting surgical hemorrhage,

containing gastrointestinal spillage, inserting surgical

sponges and applying a temporary abdominal closure

Damage control is a Navy term defined as “the capacity of a ship to absorb damage and maintain mission integrity

Damage control resuscitation (DCR)

represents the natural evolution of the initial

concept of damage control surgery (DCS). This concept

also applies to severe injuries within anatomical transition zones as well as

extremities (DCO).

Although the adaption of the term “damage control” to the field of traumatology can be credited to Schwab and

colleagues2 in 1993, its dominant principles are more accurately rooted in the 1976 address by Lucas and

Ledgerwood3

 Hospital ships, the USNS Mercy and the USNS Comfort. ... Mercy was on line in

1986 and Comfort launched in 1987 .

In summary, DCR is a structured, mobile intervention that can be

delivered to a critically ill patient in any location (emergency department, interventional radiology suite, operating

theatre and/or ICU). Basic principles include arresting hemorrhage;

restoring blood volume; and correcting Coagulopathy,

Acidosis and Hypothermia.

Early rapid Containment& Stabilization of Orthopedic

injuries without worsening the patient general condition

DAMAGE CONTROL ORTHOPAEDICS (DCO)Relatively recent concept in Orthopaedic

practice

IndicationsCritically ill polytrauma patient

Unfavorable surgical environment

Battlefield limb injuries & mass casualties

Remember that Orthopedics is a Reconstructive

Surgery

Orthopedics

is a

Reconstructive Surgery

Damage Control 0rthopedics Definition

An approach that1- Contains & Stabilizes Orthopaedic Injuries

so that the Patient’s Overall Physiology can improve

2- Avoid worsening of the patient’s condition by a major Orthopaedic Procedure

3- Delay Definitive Fracture Repair in borderline or unstable patient till

condition is optimized

Definitive open reduction & internal fixation is delayed until the inflammatory response and tissue edema have decreased and the

patient is in a stable clinical condition 

Applied in polytrauma patients with pelvic and long bones fractures to avoid the “second hit” of an extensive definitive

procedure and minimize initial morbidity – mortality

Early rapid fracture stabilization by external fixation Avoiding prolonged operative timesPreventing the onset of the

lethal triad ( Coagulopathy, Acidosis & Hypothermia )

Damage control orthopedics (DCO)

Polytrauma Patient

Polytrauma is a Syndrome of Multiple Injuries exceeding a defined Injury

Severity Score ISS > = 17

Sequential Post traumatic Systemic Inflammatory Reactions

(SIRS)

Dysfunction or failure of Remote Systems or Organs which are not

injured (MODS – MOF)

• Specialty evolved after WW I

• Trauma is the Heritage of Orthopaedic surgery

• Trauma is the common thread of all Orthopaedic

Subspecialties

Evolution of Orthopaedic Surgery

Evolution of Fracture Management

Before 1950’s(Unstable External fixation)mal union – nonunion - stiffness

1950–> 1990(Mechanical Rigid internal

fixation)infection – delayed union -

metal failure

After 1990(Biological Elastic fixation)

Surg. Technique – implant contact (ext.fix. – int.

fixators locked plate …)

Wilheim Roentgen

(1845-1923)

Alexander Fleming(1881-1955)

DAMAGE CONTROL ORTHOPAEDICS (DCO)

Early total care of major bone fractures in polytrauma pts was questioned

Are we doing good or more harm to the patient ?

Evolved in 1990’sResearch at a cellular level

Pathophysiology of multiply injured pt

Systemic inflammatory response to trauma. (SIRS)

“Second hit” phenomenon

Priorities & Way of thinking changed & became very clear

The aim is to Save lives not just fixing a fracture in a limb

Orthopedic team become a resuscitators & stabilizers not just a fixers

Early Skeletal fixation (DCO)is appropriate by external fixator

As Early Total Care may be very risky in Hemodynamic instability

Pulmonary instabilitySever head injury

Lethal triad (Coagulopathy, Hypothermia & Acidosis)

DAMAGE CONTROL ORTHOPAEDICS (DCO)

Damage Control OrthopaedicsWay of thinking

Evidence Based Medicine

The 24-72 hour period after the initial injury appears to be the most at risk time

DAMAGE CONTROL ORTHOPAEDICS DCO

Decrease the chance of a Second hit

EARLY TOTAL CAREStabilize Fractures & Bleeding prior

to the 24-72

Inflammatory mediators (SIRS ) Systemic inflammatory response syndromeAnti-inflammatory mediators (CARS) Compensatory anti-inflammatory

response syndrome

Imbalance between the two immune responses (SIRS vs CARS) => (MODS -MOF)

Multi organ (Dysfunction -Failure ) Syndrome (Parenchymal cell Necrosis (Apoptosis & Necrosis)

TraumaTissue inj.

ToxinsOxidantsInfection

Inflammatory Mediators ReleaseOrganInjury

Common Pathophysiological Pathways

SIRS

CARS

Anti-inflammatory mediators (Immune System)

Cytokine STORm

Cytokine storm (pro inflammatory mediators)imbalance between the two immune responses (SIRS vs CARS)

MODS (Multi organ Dysfunction Syndrome)MOF (Multi organ Failure Syndrome)

Physiological base of Damage Control Orthopaedics(DCO)

2- 4 Days 6-8 Days

24 –

48 H

.

Systemic Effects of Trauma & surgery

Injury (First Hit)

24 hours

48 hours

Post InjuryInflammatory

ResponseIn 2 Patients

Second Hit in susceptible patients

ARDS, MODS Threshold

IM Nailing as a Cause of Secondary Systemic Injury

2-4 days 6-8 days

Damage Control Orthopaedics - GoalLimit ongoing hemorrhage,

hypotension, & release of inflammatory factors

Limit stress on injured brain

Initial surgery < 1-2 hrs

limit surgical trauma and blood loss

Hemorrhage.Soft-tissue injury.

Provisional Fracture stability.

Focus

Damage Control OrthopaedicsMethods

Initial focus on Stabilization External fixation▪ Limited debridement

▪ Limited or no internal fixation or definitive care

Delayed definitive fixation (5-7 days)

What to do ? - Clinical status

Stabilized Uncertain

Stable Unstable or

In extremis

Borderline

ResuscitateReevaluate

? DCOOP - ICU

ETC

THE BORDERLINE PATIENT

Polytrauma + ISS >20 + Thoracic trauma

Polytrauma + Abdominal/Pelvic trauma + Hemorrhagic shock BP <90

ISS >40 in the absence of thoracic injury

X-ray : bilateral Lung contusionInitial mean Pulmonary arterial

pressure >24mm HgIncrease of >6mm Hg in pulmonary arterial pressure during IM Nailing

Clinical parameters used in Hannover Germany to define the Borderline Patient for Whom DCO is often

preferred

COAGULOPATHIC

HYPOTHERMIA (T <32)

ACIDOSIS

SHOCK

TIME > 6H

ARTERIAL INJURY AND HAEMODYNAMIC

INSTABILITY

EXAGGERATED INFLAMMATORY

RESPONSE

Orthopaedic injury complexes

Femoral fractures in a multiply injured

Pelvic ring injuries with shock

Polytrauma in a geriatric patient

Long bone fractures with chest or head injuries

Mangled extremities

Long Bone Fracture in Chest injuryTwo schools of thought - (Early fixation)

Early fixation is safe and beneficial

Bone et al : Early vs delayed stabilization of femoral

Fractures.J B JS. 1989;71:336-40.

Thoracic trauma and early intramedullary nailing

of femur fractures : are we doing harm?

J Trauma. 1997;43:24-8.

No increase in morbidity or mortality in

association with early intramedullary nailing

(within twenty-four hours) of femoral

fractures in patients who had sustained blunt

thoracic trauma.

Delayed Internal Fixation of Femoral Shaft Fracture

Reduces Mortality Among Patients with Multisystem

Trauma

JBJS 2009FOUR TIME ZONES

By delaying fixation beyond 12 hrs-

Allowed time for resuscitation

reduces mortality by approximately 50%.

Abdominal trauma pts had max benefit

Only exception time zone 24-48 hrs

Long Bone Fracture in Chest injury Two schools of thought - (Delayed fixation)

Long Bone Fracture in Head Injury

Goal - limit ongoing hemorrhage

and hypotension

pelvic ring injury-- external fixation reduced

mortality from 43% to 7% (Reimer, J Trauma, ‘93)

open injury--limit bleeding

long bone fracture -- controversial

Early fixation (<24 hours) well accepted in the polytrauma patient

Eearly fixation may cause Hypotension – elevated ICP - blood loss – coagulopathy

– hypoxia

Advocates of early and delayed treatment

Long Bone Fracture in Head InjuryEarly Osteosynthesis

. Kalb (Surgery ‘98): 123 patients, head AIS > 2, 84 early, 39 late fixation

early group had increased fluid requirement but no other difference in mortality or complication . emphasized the role of appropriate monitoring

Scalea (J Trauma ‘99): 171 patients, mean GCS 9, 147 early, 24 late fixation

early fixation no effect on length of stay, mortality, CNS complications

Early stabilization does not enhance or worsen the outcome in pts with head injury.

Individualize Rx Cerebral perfusion pressure at >70 mm Hg

Intracranial pressure at <20 mm Hg

. Reynolds (Annals of Surg ‘95): Mortality 2/105 patients, both early rodding (<24 hrs)

one due to neurologic and the other pulmonary deterioration

Jaicks (J Trauma ‘97): 33 patients with head AIS > 2; 19 early fixation 14 late

early group required more fluid in 48 hrs (14 vs 8.7 l); more intraoperative hypotension (16% vs 7%); lower discharge GCS (13.5 vs

15)

Townsend (J Trauma ‘98): 61 patients with GCS < 8;

hypotension 8 X more likely if operated < 2 hrs and 2 X more likely when operated within 24 hrs

no difference noted in GOS

Long Bone Fracture in Head InjuryDelayed Osteosynthesis

Algorithm in Fracture care in Head injury

Severe Head injury (GCS <9) or unstable pt

Damage control surgeryConvert to definitive at 5+ days

Mild head injury (GCS 13 -15); stable ptEarly total care

Intermediate head injuryPatient stability vs. Complexity of surgery

MANGLED EXTREMITIESAmputation vs Reconstruction

Amputation group have a better functional outcome than

reconstructionRapid return to work

Reconstruction groupHigher complication rate

More surgeriesMore hospital admissions6.4% risk of amputation

(DCO) IN MANGLED EXTREMITIES

Leap studyIncreasing trend towards limb salvage rather than immediate

amputation in complex open lower limb injuries

A DCO approach

Spanning external fixator

Antibiotic pead pouches

Vacuum assisted wound closure

Control Bleeding

Manage Soft tissues

Spanning Ex. Fixator

Antibiotic Pouch

Vacuum Dressings

Steps of Damage Control Orthopaedics

Control Bleeding Manage Soft tissues

Spanning External Fixator

Antibiotic PouchVacuum Dressings

Do not kill your Borderline patient by

(ETC)

Help him to live by (DCO)

Give him the chance to fight another day

THANKYOU