27The benefits of resuscitation Uncompensated shock gross signs of circulatory deficiency (BP, HR, UO)Compensated shock ongoing suboptimal tissue perfusionThe heart and brain are protected while the perfusion of other organs is inadequateResuscitation - tissue acidosis eliminated and aerobic metabolism restored
29Retrospective data from the 1980’s Early fracture fixation is good!
30Bone and Johnson JBJS 1989Parkland hospital – 178 patients with femur fractures randomized to before 24 hours or after 48 hoursPatients with ISS > 18 less pulmonary complications (ARDS, FE, pneumonia)Severely injured patients benefit the most!!
31Why does early fracture stabilization help the lungs?? Reduce continued marrow emboliReduce pain and narcotic requirementsEliminates traction and supine positioningLess atelectasis and decreased pulmonary venous shunting
32Primary IM femur fixation in MTP with associated lung contusion – a cause of ARDS Pape et al JT 1993 106 pts with femur fracture and ISS > 18In patients with chest trauma nailing within 24 hours led to greater ARDS (33% vs 7.7%) and mortality (21% vs 4%)
33The vast majority of patients benefit from early definitive long bone stabilization Retrospective studiesProspective Bone and Johnson 1989Early femoral fixation leads to:Less complicationsLess ICULess costBetter outcome for the limbThere is no debate!!
34IM nailing of long bones has systemic effects Robinson et al JBJS b 2001Trans esophageal echo and invasive monitoring during IM nailingIncrease in PA pressureDecrease in arterial oxygen partial pressureSystemic change in markers of coagulation
35Systemic Effects of Nailing Brundage et al JT 20021362 patients over 12 yearsFemur fixation < 24 hours - improved outcome even with severe chest and head injuries“Resuscitation and hemodynamic normalization are essential parts of our protocol”Only 65% of patients were physiologically ready within 24HHighest incidence of ARDS in group fixed between 2 and 5 days - a time of heightened inflammatory response?
36There is a systemic inflammatory response to major trauma Injury activates cell defense mechanisms, producing mediators of coagulation and inflammationProtect against infectionRemove damaged tissueInitiate repairHowever severe inflammation my lead to organ injuryGood!!Bad!!
37The pro inflammatory response is increased by primary IM nailing Pape et al JT 2003Prospective study - 35 patientsThe systemic inflammatory response measured by IL-6 was increased (55pg/ml-254pg/ml) by immediate IM nailing but not by ex fx and secondary nailingNo difference in clinical outcomes
381st hit (trauma)FESSIRS2nd hit (Surgery, infection, more FES)ARDSMODSMOFMSOF
39Occasional patients are hurt by long bone nailing Robinson et al JBJS b 20018/84 patients develop post op pulmonary compromise (7 were prophylactic for metastatic disease)
40Can we detect a patient at risk?? Injury factors - High ISS, pulmonary injury, severe abdominal injury, bilateral femur or other multiple long bone injuriesPhysiologic factors – Slow difficult resuscitation, high transfusion requirement, prolonged surgical time, hypothermia, coagulopathy
41Can we detect a patient at risk?? Genetic and biochemical markers – Currently not practical or reliableIL-6 (> 800 pg/ml) - most studied and best correlates with outcome but ….
42The optimal timing of fracture repair for all patients Is it within 48 hours or greater than five days?
44Damage Control Surgery PhilosophyStay out rather than get out of troubleRestore normal physiology at the expense of normal anatomy
45Bilateral femoral ex fix, tibial ex fix and I&D at the bedside Damage ControlBilateral femoral ex fix, tibial ex fix and I&D at the bedside
46DCO external fixation-Stabilizes orthopedic injuries while physiology improves-Avoid a “second hit” by major orthopedic procedures-Fracture stability without increased inflammatory response
47The benefits of temporary external fixation DCO - Retrospective cohort studies (Pape et al J Trauma 2002)-Significant reduction in systemic complications-No increase in local complications
48Damage Control Orthopaedics Prevent 2nd hit (MOF, MSOF, SIRS, ARDs)Hgb < 8Base Deficit > 5 mEq/lBody temperature < 33ºINR > 1.5 (2.0 – 50% mortality)Fix the femurs and the tibia within 48 hours (lung)
49L > 6hrs Group S Group M Group L p ICU stay 13.2 10.9 18.5 n.s. VentilationL > 6hrsGroup S Group M Group L pICU stay n.s.Hosp. stay n.s.Death: MOFGerman Trauma Registry
50Timing Within 24-48 hours injuries most mobile 2-5 days may be worst time to operateSoft tissue good (includes lung)Positive fluid balance
51Exchange to an IM rod safe? Bhandari et al JOT 2005-Pooled data from level 4 studies-Average infection rate 3.6%Pin drainage
52The effect of a head injury -Severity of the head injury is the greatest predictor of outcome-ICP monitoring – Keep ICP below 20-Systemic BP control – avoid hypotension-Put the two together! - CPP should be > than 70 mm hg (mean arterial minus ICP)
53Head injury and fracture fixation -No clear evidence that timing/type of fracture fixation is an important predictor of outcome-Assume full neurologic recovery will occur-Who is doing your anesthesia and judging resuscitation?