Damage Control In Multitrauma and Orthopaedics

dr. Bambang Widiwanto, MS, SpOT

Multitrauma

• Syndrome of multiple injuries with sequential systemic traumatic reactions which may lead to dysfunction or failure of remote organs and vitals systems, which had not themselves been directly injured.

• Fracture is the most frequent component of multitrauma.

Pathofisiologis

• Wound around fracture inflamatory (dead tissue & hypoxic).

• Inflamatory release mediators and cytokines into circulation.

• Systemic traumatic reactions produce a whole-body inflammation or a Systemic Inflamatory Response Syndrome (SIRS)

Pathofisiologi

• SIRS condition demanding high energy consumption and oxygen (Hypermetabolic condition).

• Hypermetabolic condition : muscle wasting, nitrogen loss, protein breakdown, and raise temperature.

• Depletion of immunocompetent become critical immunosupression and sepsis more sell death MODS & MOF

Timing and Priorities of Surgery• Primary Objective = survive with normal

function.• First priority is resuscitation to ensure

adequate perfusion and oxygenation of all vital organs.

• If there is no response immediate live-saving surgery.– Decompression body cavity– Control of hemorrhage

Timing and Priorities of Surgery• If immediate definitive surgery is

needed “Damage control” (control of hemorrhage and contamination, irrigation, packing, closure of wound and stabilization of the physiological system) in ICU definitive surgery after 6-12 hours.

Timing and Priorities of Surgery

• If response to resuscitation delay primary surgery.• Within the locomotors system treat with high priority:

– Limb-threatening and disabling injuries (open fracture debridement, reduction, fixation, and revascularization).

– Long bone fracture, unstable pelvic fracture, highly unstable large joints and spinal injuries temporary stabilization (EF) definitive osteosyntesis during a window of opportunity, between days 5-10.

Timing and Priorities of Surgery• During window of opportunity,

definitive surgery of long bone fracture-shaft and articular-can be performed in relative safety.

• Immunosuppression last for about 2 weeks secondary reconstruction procedure can be planned for three week post trauma.

General Aims and Scopes of Fracture Management in Multitrauma

• Control of hemorrhage.• Control of sources of contamination,

removal of dead tissue, prevention of ischemia-reperfusion injury.

• Pain relief.• Facilitation of intensive care. Homeostasis, debridement,

fasiotomy, fracture fixation, and tension-free wound coverage.

Summary

• Multitrauma must be considered as a systemic surgical disease.

• Successful management :– Understanding of pathology– Complete resuscitation– Correct triage and timing– Plans of care

Damage Control Orthopaedics

Introduction :

• It has long been recognized that, in patients with severe abdominal injuries initial management should avoid complex operative procedures

• It was believed that the polytraumatised patient did not have the physiological reserve to withstand prolonged operations

Systemic impact of extremity injury :• All extremity fractures must be

considered with the associated haemorrhage and local soft tissue injuries.

• The injury initiates a local inflammatory response with increased systemic concentrations of pro-inflammatory cytokines.

FIRST HIT INJURY

Damage control concept :

• In the polytraumatized patient, this concept of surgical treatment intends to control but not to definitively repair the trauma.

• After restoration of normal physiologic, definitive management of injuries is performed

The damage control concept consist of three components :1. Resuscitative surgery for rapid

hemorrhage control.2. Restoration of normal physiologic

parameter.3. Definitive surgical management

• Based on the concept of damage control surgery, the application of the same principles to the management of multitrauma patient with associated long bone fracture & pelvic fracture

DAMAGE CONTROL ORTHOPAEDIC

Damage Control Orthopaedics

• Early stabilization of unstable fracture, control hemorrhage, management of soft tissue injury

• Resuscitation and optimize the patient in the ICU

• Delayed definitive fracture management if condition allowed

Minimize The Second Hit Injury

• The practice of delaying the definitive surgery in DCO attempts to reduce the biological load of surgical trauma on the already traumatized patient.

Time to do a definitive surgery??

• Primary procedures of greater than 6 hours duration and major surgical procedures at day 2 to 4 should be avoided

• A prospective study has recently shown that polytraumatized patients submitted to secondary definitive surgery at day 2 to 4, developed a significantly increased inflammatory response, compared to those operated at day 6 to 8

Borderline patient type should be considered for DCO :

1. Multitrauma with thoracic trauma2. Multitrauma with abdominal &

pelvic trauma, shock3. Bilateral lung contusion on x-ray

Indication for DCO1. Unstable and laborious resuscitation.2. Coagulation disorder, platelet count <

90.0003. Shock, demanding more than 25 blood

units for the patient’s full recovery4. GCS < 85. Multiple long bone fracture6. Duration of surgical operation > 6

hours7. Hemodynamic instability Arterial

injury