Presentation is loading. Please wait.

Presentation is loading. Please wait.

TIMING OF FRACTURE FIXATION IN POLYTRAUMA PATIENTS ANAESTHESIOLOGISTS PERSPECTIVES Dr.R.Selvakumar.

Similar presentations


Presentation on theme: "TIMING OF FRACTURE FIXATION IN POLYTRAUMA PATIENTS ANAESTHESIOLOGISTS PERSPECTIVES Dr.R.Selvakumar."— Presentation transcript:

1 TIMING OF FRACTURE FIXATION IN POLYTRAUMA PATIENTS ANAESTHESIOLOGISTS PERSPECTIVES Dr.R.Selvakumar

2

3 POLYTRAUMA-NIGHTMARE FOR THE PATIENT & AS WELL AS FOR THE ANAESTHESIOLOGIST & AS WELL AS FOR THE ANAESTHESIOLOGIST KANISACON-2010

4 SURGEON & ANAESTHETIST Opposite Views having KANISACON-2010

5 Why anaesthetist wants to avoid? - prolonged hours of surgery - Unexpected response KANISACON-2010

6 Polytrauma: Hypovolemia Multiple system involvement Multiple system involvement less time for evaluation less time for evaluation missed injuries (head & abdomen) missed injuries (head & abdomen) prolonged surgery prolonged surgery massive blood transfusion massive blood transfusion difficulty in monitoring difficulty in monitoring surgical difficulties surgical difficulties KANISACON-2010

7 Unique problem increased incidence of respiratory failureincreased incidence of respiratory failure ARDSARDS KANISACON-2010

8 Why there is an increased incidence of respiratory failure? ARDS fat embolism KANISACON-2010

9 Fat embolism in polytrauma Pathophysiology in intra medullary pressure fat droplets get filtered in the pulmonary circulation in intra medullary pressure fat droplets get filtered in the pulmonary circulation minute droplets go through pulmonary circulation & get trapped in cerebral circulation minute droplets go through pulmonary circulation & get trapped in cerebral circulation alveolar lipase hydrolysis of fat alveolar lipase hydrolysis of fat release of fatty acids (palmitic, stearic, oleic) release of fatty acids (palmitic, stearic, oleic) Neutralisation by albumin Neutralisation by albumin KANISACON-2010

10 Pathophysiology of Fat Embolism - contd failure of neutralistion by albumin fatty acids + calcium intercellular septa rupture diffuse areas of haemorrhage & oedema in pulmonary interstitium & alveolar space fatty acids + calcium intercellular septa rupture diffuse areas of haemorrhage & oedema in pulmonary interstitium & alveolar space KANISACON-2010

11 Integrins CD11b & CD18 cause adherence of neutrophils & endothelium Integrins CD11b & CD18 cause adherence of neutrophils & endothelium Injured pnumocytes stop surfactant production collapse of alveoli Injured pnumocytes stop surfactant production collapse of alveoli shunt and dead space shunt and dead space Pathophysiology of Fat Embolism - contd KANISACON-2010

12 Just to relax……

13 Secondary injury: FE incidence in a polytrauma % If surgery is performed following polytrauma, If surgery is performed following polytrauma, will reaming further increase the incidence of will reaming further increase the incidence of FE? FE? KANISACON-2010

14 Will it produce a second hit ? KANISACON-2010

15 Medullary reaming & Cementation Normal I.M pressure - 30 – 50mm of Hg.Normal I.M pressure - 30 – 50mm of Hg. Violent force in the bone - I.M pressure many fold.Violent force in the bone - I.M pressure many fold. Reaming increases I.M.P up to mm of Hg.Reaming increases I.M.P up to mm of Hg. Cementation of Hg.Cementation of Hg. KANISACON-2010

16 What they did…. In 1960s: Ill development of pulmonary care Wait till FES resolves Kuntschers three recommendations KANISACON-2010

17 Kuntschers recommendations: 1. Dont nail as long as symptoms of FE are present 2. Take special precaution for patients with multiple fracture and extensive soft tissue injuries 3. Dont nail immediately, but wait a few days KANISACON-2010

18 Negative effects of delayed fixation prolonged immobilisation pneumonia, bedsore, renal failure, inadequate nutrition, vascular abnormalities poor results KANISACON-2010

19 A word about hyponatraemia… old age appetite appetite depression depression social conditions social conditions restlessness,disorientation etc KANISACON-2010

20 Drastic changes in the 1980s Early fixationEarly fixation better understanding of pathophysiology of traumabetter understanding of pathophysiology of trauma improvement in critical careimprovement in critical care KANISACON-2010

21 Changes in the 1980s….. It led to aggressive management without improving the supportive careIt led to aggressive management without improving the supportive care Bad resultsBad results KANISACON-2010

22 Damage control orthopaedics: Pack the major sources of haemorrhage Resuscitation and stabilisation of the Resuscitation and stabilisation of the general condition general condition Temporary immobilisation of bone Temporary immobilisation of bone fractures fractures KANISACON-2010

23 Current recommendations Classify the patients according to their physical status 1. stable grade I 2. borderline grade II 3. unstable grade II 4. In extremis grade IV KANISACON-2010

24 Creteria used in the physical status classification Shock – B.P, No of blood units, Shock – B.P, No of blood units, lactate levels,B.D,ATLS lactate levels,B.D,ATLS Coagulation status Coagulation status Temperature Temperature Soft tissue injuries Soft tissue injuries KANISACON-2010

25 Stable patients Stable patients : Do whatever you want…. KANISACON-2010

26 Borderline patients who respond to resuscitation…… proceed with definitive fixation limit the surgical duration within 2 hours limit the surgical duration within 2 hours KANISACON-2010

27 Remember… A bad surgeon can shift the ASA Grade II to IV easily….. Grade II to IV easily….. KANISACON-2010

28 Borderline patients: Continuous reassessment Pao2/F102 should not drop below 200mm of Hg Pao2/F102 should not drop below 200mm of Hg Temperature should not drop below 32C Temperature should not drop below 32C Requirement of fluids should not exceed 3L or 5units of blood Requirement of fluids should not exceed 3L or 5units of blood Absence of significant coagulopathy Absence of significant coagulopathy If not DCO If not DCO KANISACON-2010

29 Unstable and patients in extremis: Life saving surgeries External fixation External fixation Resuscitation and stabilization simultaneously Resuscitation and stabilization simultaneously KANISACON-2010

30 Strategy in patients with head injury: Beware of the fact that cerebral auto regulation goes off following head injury Beware of the fact that cerebral auto regulation goes off following head injury Extensive sympathetic block due to regional anaesthesia may hamper CBF Extensive sympathetic block due to regional anaesthesia may hamper CBF Severe head injury only life saving procedures Severe head injury only life saving procedures KANISACON-2010

31 Strategy in patients with chest injury Rib fracture or lung contusion Monitoring with pulseoximeter or ABG Monitoring with pulseoximeter or ABG Incidence of ARDS Incidence of ARDS Severe chest injury only life saving procedures Severe chest injury only life saving procedures KANISACON-2010

32 What to do to prevent the incidence of FES? Avoid increase in IM pressure Medullary channel depletion Medullary channel depletion Venting the medullary channel Venting the medullary channel Uncemented prosthesis Uncemented prosthesis KANISACON-2010

33 summary In polytrauma, immediate fixation may lead In polytrauma, immediate fixation may lead to secondary complication Classify the patients according to their Classify the patients according to their Physical status Grade I and II – Immediate surgery Grade I and II – Immediate surgery Grade III and IV – resuscitation,DCO, Grade III and IV – resuscitation,DCO, Delayed fixation KANISACON-2010

34 Conclusion: Pre-operative status of the patient decides the timing of the fracture fixation in the poly-trauma patients…. KANISACON-2010

35 Dr.R.SELVAKUMAR M.D.,D.A.DNB ASSOCIATE PROFESSOR COIMBATORE MEDICAL COLLEGE COIMBATORE


Download ppt "TIMING OF FRACTURE FIXATION IN POLYTRAUMA PATIENTS ANAESTHESIOLOGISTS PERSPECTIVES Dr.R.Selvakumar."

Similar presentations


Ads by Google