Mr Lee Van Rensburg Mr Alan Norrish October 2015.
Transcript of Mr Lee Van Rensburg Mr Alan Norrish October 2015.
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Mr Lee Van Rensburg
Mr Alan Norrish
October 2015
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ISS 57ISS 57 SAH, DAISAH, DAI R HaemothoraxR Haemothorax Pelvic ring fracture Pelvic ring fracture
(Dissociation R hemipelvis)(Dissociation R hemipelvis) # L Acetabulum# L Acetabulum # L Femur# L Femur Compartment syndrome both lower legs and Compartment syndrome both lower legs and
thighsthighs
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Laparotomy Laparotomy Pelvis packed, Vac dressingPelvis packed, Vac dressing
C clamp and pelvic ex fixC clamp and pelvic ex fix AngiogramAngiogram
EmbolisationEmbolisation
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Theatre to CTThen ICU
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Retrograde femoral nailRetrograde femoral nail FasciotomyFasciotomy
Both thighs both calvesBoth thighs both calves
8 HRS8 HRS
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AngiogramAngiogram IVC filterIVC filter Repeat bleedingRepeat bleeding
Laparotomy change of packsLaparotomy change of packs Bladder repairBladder repair Pubic symphysis ORIFPubic symphysis ORIF
36 Hrs36 Hrs
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AngiogramAngiogram IVC filterIVC filter Repeat bleedingRepeat bleeding
Laparotomy change of packsLaparotomy change of packs Bladder repairBladder repair Pubic symphysis ORIFPubic symphysis ORIF 2 hour rewarming on table2 hour rewarming on table
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Removal of C clampRemoval of C clamp Anterior plating Anterior plating
R Sacroiliac jointR Sacroiliac joint
Debridement washout Debridement washout closure C clamp and Ex closure C clamp and Ex fix woundsfix wounds
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Vac dressing change 17/05/06Vac dressing change 17/05/06 Closure of thigh woundsClosure of thigh wounds
Vac dressing change 23/05/06Vac dressing change 23/05/06 Closure of L lower leg woundClosure of L lower leg wound
Vac dressing change 28/05/06Vac dressing change 28/05/06 Closure R lower leg woundClosure R lower leg wound
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Planned ORIF acetabulumPlanned ORIF acetabulum Wound breakdownWound breakdown
L iliac crestL iliac crest Both thighsBoth thighs
Washout and vac dressingsWashout and vac dressings
Day 6Day 6
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#BOS#BOS #Nasal bone#Nasal bone APC pelvic injuryAPC pelvic injury # R Supracondylar femur# R Supracondylar femur # R Tibia shaft (open)# R Tibia shaft (open) # L Tibial plateau (open)# L Tibial plateau (open) # Bimalleolar L ankle# Bimalleolar L ankle
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Intubated through windowIntubated through window Pre hospital arrestPre hospital arrest Hr 144, Systolic 60Hr 144, Systolic 60 GCS 3GCS 3
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CT brainCT brain BOSBOS
AngiogramAngiogram Very small bleeder Very small bleeder
embolisedembolised
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External fixatorExternal fixator PelvisPelvis R legR leg L legL leg
Debridement Debridement washout, fasciotomy washout, fasciotomy and vac dressingand vac dressing
R thighR thigh R lower legR lower leg L lower legL lower leg
LaparotomyLaparotomy EVDEVD
4 HRS
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Plating pubic symphysisPlating pubic symphysis Intramedullary nailIntramedullary nail
R femur retrogradeR femur retrograde R tibiaR tibia
Change of VacsChange of Vacs
Day 5
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ORIF L Tibial plateauORIF L Tibial plateau ORIF L fibulaORIF L fibula Free Flap R tibiaFree Flap R tibia Rotation flap L TibiaRotation flap L Tibia
Day 9
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Debridement and SSG L AnkleDebridement and SSG L Ankle Medial sideMedial side
Day 27Day 27
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SIRS
CARS
Genes
ETO
DCO
EAP
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Condition characterised by systemic inflammation, organ dysfunction, and organ failure.
Subset of cytokine storm, abnormal regulation of various cytokines
Inflammatory response to sepsis, trauma, hypoperfusion
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Threshold for fatal
inflammatory response
DEATH: from multiorgan failure or adult respiratory distress syndrome
1st Hit: the trauma
infla
mm
ator
y re
spon
se
time
The ‘natural’ systemic inflammatory response
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Severe trauma can result in a life threatening inflammatory response (SIRS)
Threshold for fatal
inflammatory response
DEATH: from multiorgan failure or adult respiratory distress syndrome
1st Hit: the trauma
infla
mm
ator
y re
spon
se
time2nd Hit: the surgery
The exaggerated response brought about by the 2nd hit of surgery
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Severe trauma can result in a life threatening inflammatory response (SIRS)
Threshold for fatal
inflammatory response
DEATH: from multiorgan failure or adult respiratory distress syndrome
1st Hit: the trauma
infla
mm
ator
y re
spon
se
time2nd Hit: the surgery
In some individuals the lengthy surgery of early total care exacerbates the the systemic inflammatory response resulting in death
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Bone RC. Sir Isaac Newton, sepsis, SIRS, and CARS. Crit Care Med. 1996;24(7):1125–8
CARS - systemic deactivation of the immune system tasked with restoring homeostasis from an inflammatory state
More than just cessation of SIRS
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Different responses to Injury
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SIRS: Severe inflammation may lead
to acute multi-organ failure (MOF), lung and
respiratory failure (ARDS) and death
CARS: An anti-inflammatory
response syndrome. May result in
prolonged immunosuppression
leading to sepsis
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Early Total Care Not necessarily immediate, but within first 24 hours Often short period in ITU for resuscitation Repair all visceral injuries as soon as possible Definitive fixation of all long bone fractures within 24
hours Return to ITU only when all surgical procedures
finished Often long surgical times
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Damage control Naval Term term:
“Capacity to absorb damage while maintaining mission integrity”
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Rapid emergency surgery to save life or limb – NOT involving complex reconstructive surgery Control bleeding Decompress cranium, pericardium, thorax,
abdomen and limbs Decontaminate wounds and ruptured viscera Splint fractures
Cast, traction, pelvic binder, ex-fix Get back to ITU environment ASAP Definitive surgery performed several days later
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J Bone Joint Surg Am, 2005 Feb; 87 (2): 434 -449
Louisville additional criteriapH of < 7.24Temp < 35°COperative time > 90 minutesCoagulopathyTransfusion > ten units
packed red cells
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4 groups of patients Stable: go for Early Total Care Borderline: ? Unstable: go for Damage Control Surgery Extremis: Damage Control Surgery or ITU
Borderline patients are more difficult to define
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Initial lactate: < 2.5 mg/dL,
5.4% (4.5-6.2%) Mortality
2.5 mg/dL to 4.0 mg/dL, 6.4% (5.1-7.8%) Mortality
>=4.0 mg/dL, 18.8% (15.7-21.9%) Mortality
Occult Hypo perfusion, raised lactate increased mortality
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Lactate easy to measure Often high in 1st few hours but will drop in ITU if
resuscitation adequate
2.5 magic number! > 3 DC Surgery 2.5 – Look at TREND < 2.5 ETC
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Days 2-5 are not safe During this period:
Marked inflammatory response ongoing Increased capillary permeability leads to generalized
oedema Cardiac output is high Patient is fragile A 2nd hit at this stage could be fatal
Pape et al: prospective study – multiply injured patients undergoing surgery between days
2 and 4 had a significantly increased inflammatory response compared with patients operated on between days 6 and 8
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Patient with multiple injuries
ITU
Assess clinical condition and lactate
StableLactate <2.5
BorderlineLactate 2.5-3.0
Unstable Lactate
>3.0
In ExtremisAttempt
to resuscitate in ED or ITU
Early Total Care
ResuscitateAssess lactate
trend
StableUncertain
Damage Control Surgery
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Trunkey DD. Trauma. Sci Am. 1983; 249:28–35
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1st mins 1st hour 1st few weeks
Can reduce deaths only by injury prevention strategies
Can reduce deaths by excellent prehospital and emergency room care
Can reduce deaths by the decisions we make regarding surgical treatment.Death from MODS & ARDS
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Proc (Bayl Univ Med Cent). 2010 Oct; 23(4): 349–354
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Major Trauma Centre
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Early Appropriate Care Acceptance different patients respond differently to
first and second hits Consider severity of initial injury Consider response to resuscitation What further surgery required Continued re assessment and ability to change from
ETO TO DCO
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JTO; Volume 02 / Issue 02 / May 2014
2013 No single physiological parameter or blood marker can asSuggested accepted level of 2.5mmol/L is too conservativepatient centred approachPhysiological improvement and reversal of acidosis reflected by:
lactate< 4.0 mmol/LpH ≥7.25BE above 5.5 mmol/L
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Multiply injured patients may have a profound and life-threatening inflammatory response
A ‘second hit’ of long definitive surgery can result in a fatal inflammatory response
The second hit can be avoided using early ‘damage control surgery’ followed by late ‘definitive care’
Lactate is important in identifying patients who will benefit from damage control surgery
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