1. Early total care, damage control orthopedics, and early appropriate care
Author: Nigel Rossiter
Publication date: 2018
ETC = Early Total Care, DCO = Damage Control Orthopaedics, EAC = Early Appropriate Care
Ask the audience – what is the picture of?
Picture shows the pendulum in The Partheon in Paris – largest pendulum in the world and used as an analogy for the changing priorities in Trauma care over time
AO Trauma Basic Principles Course

2. Is the patient too sick to operate on?
Is the patient too sick not to operate on?
Until 1977 this was the constant debate

3. “Early fracture fixation / early total care” the evidence:
1977 Riska 1982 Goris 1986 Meek 1985 Johnson 1989 Bone 1990 Behrman 1994 Bone 1994 van Os
From 1977 increasing evidence that early total care – early stabilisation of injuries: especially long bone and pelvic fractures was better for the patient overall.
Picture of Dr Larry Bone, author of the really seminal paper that changed the world, quoted on the slide, still working in Iraq in 2008
Bone LB, Johnson KD, Weigelt J, Scheinberg R. (J Bone Joint Surg Am 1989;71:336-40) “Early versus delayed stabilization of femoral fractures: a prospective randomized study”

4. Acute respiratory distress syndrome (ARDS) operative stabilization and ISS
What did these papers show?
That if you stabilized the fractures, especially the femur, early (under 24 hours) that the incidence of ARDS reduced.
Not only this – the worse you were injured initially the better you did with ETC

5. Duration of primary surgery
Pape and Tscherne 1999:
If 1st operation > 6 hours in patients with ISS > 25 =
Increased ventilation time
Higher mortality
Versus shorter procedures in another group
So from 1989 – 1999 we sat up all night fixing every fracture and sending the patients off to ITU, often with a Haemoglobin of 3.
However we wondered why the next day those horrible colleagues on ITU had killed our sick patients after all our hard work.
Pictures of Chris Pape & Harald Tscherne. Hannover Trauma registry. Published paper in 1999 showing the above.
We just didn’t understand at the time why this effect was being seen.

6. Optimal timing for secondary surgery in polytrauma patients
An evaluation of 4,314 serious injury cases (Pape and Tscherne 1999) “Patients with severe trauma requiring secondary operations of greater than 3 hours duration, should not be performed on post-trauma days 2-4”
Not only did they show that operating on the really severely injured patients with big operations on day 1 was bad, but, if you then operated on those patients again in the next 2-4 days they did even worse.
We did not understand why

7. Conclusions
Pulmonary and head injury complications are related to the severity of the initial trauma
The “first hit”
Initial trauma includes 10 surgery
The “second hit”
ETC facilitates early mobilization and discharge
Rigid protocols for < 24 hrs …. may not be appropriate for all
The conclusions from Pape & Tscherne’s work in 1999

8. Systemic inflammatory response syndrome (SIRS)—what is it?
With reference to trauma:
A normal physiological response
Functional up regulation for survival
Now introduce the concept of SIRS – the Systemic Inflammatory Response Syndrome
(cf = “with reference to”)

9. SIRS—stimulated by: Any of the following: Pain Blood loss Hypoxia
Acidosis
Hypothermia
Self explanatory

10. SIRS—what do you see? Altered vital signs Impaired O2 transport
Hypermetabolism
Altered protein and glucose metabolism
Altered inflammation and coagulation
Leucocytosis (usually)
Altered immunity
Self explanatory

11. SIRS definition 1992 consensus conference
4 parameters: 1 point for each, ≥ 2 = SIRS:
Temp > 38 or < 36
P > 90
RR > 20 or PaCO2 < 32
WCC > 12 or < 4
Self explanatory

12. Can you monitor it? IL-6 Surrogate markers Temp, P, BP, RR UO GCS WCC
CRP
ESR
Base excess
Lactate
Ask the audience – How do you monitor SIRS?
Usually gets a blank.
Show then you can do it by monitoring IL-6. Show the graph. Explain why in the really seriously injured patient, ISS >26, that the IL-6 is very high – the first hit. When we do major surgery, the 2nd hit, the IL-6 level will increase – and this may be beyond the physiological reserve of that patient and so that by doing intense surgery on the severely injured it is too much for them and may hasten death. Then also show them that IL-6 levels tend to return to normal around day 3-5: hence why Pape & Tscherne observed that further surgery on the severely injured in first 4 days meant the patients did worse – the IL-6, SIRS, had not recovered and we tipped the patients over their physiological reserve.
So now ask the audience how many of them monitor IL-6?
Almost none. So then ask them: how do we monitor SIRS?
By the things we do on a daily basis and appears on the charts by the patients beds. We’ve been monitoring SIRS for years, adding those parameters together in our minds and deciding which patients were good and which bad – deciding who has SIRS and who doesn’t.

13. Can you regulate SIRS? Predict or recognize 1st and 2nd hit concept:
1st hit – trauma
2nd hit – (operative) resuscitation
So try to limit the 2nd hit
Regulate SIRS by limiting what we do to the severely injured patient, when appropriate.

14. Current concepts “Old” “New”
Trauma – resucitation – surgery (DCS) – ITU
“New”
Trauma – DCR / DCS – ITU
“Resuscitation = Physiology not Geography”
Discuss how trauma resuscitation may need to occur rapidly in the operating theater
Known in Afghanistan as: “Right turn resus” – patient came in from a helicopter with severe injuries and instead of turn left into the ER/ED/A&E, turned right and went direct into the operating theater to get hemodynamic control

15. New massive blood transfusion evidence
Blood : FFP : platelets
Malone et al: J Trauma 2006
Kirkman et al: J R Army MED Corps 2007
Gunter et al: J Trauma 2008
Duchesne et al: J Trauma 2009
Surgeon General’s policy letter 2009
All show increased survival and lower SIRS with
1:1:1
2:1:1
4:1:1
Discuss how we now know patients don’t bleed “salty water”, saline. The old “give 2 units of crystalloid” in ATLS is out.
We now replace blood with blood. British ambulance services now carry blood and will transfuse at the roadside.
In Iraq/Afghanistan it was 1 unit red cells to 1 unit plasma to 1 unit platelets.
You need to know what it is in your unit. Most UK Massive Transfusion policies have: 4 units red cells, 1 unit of FFP or cryoprecipitate, 1 unit of platelets in each “Pack” and up to three packs are given.

16. Regulation of post-traumatic inflammation
SIRS
CARS
Activation
Suppression
Ask the audience – “What is Newton’s second law?”
To every action there is an equal and opposite reaction.
Therefore if SIRS exists there must be something counter-balancing it. Who has heard of CARS?
Compensatory autoimmune response system (CARS). IL4, IL10 & IL3 all acting to counteract SIRS
TNF-a, IL-1, IL-6
IL-4, IL-10, IL-13

17. Shock, trauma, hemorrhage, surgery
Immune response
SIRS vs CARS
Hyperactive
Normal
Immunoparalysis
So we are attempting to drive down the middle.
Too far to the left = SIRS = ARDS
Too far to the right = CARS = Infections
ARDS MODS
Recovery
Infections

18. New things to help (1) Thromboelastometry (“TEG”)
Viscoelastic assessment of clot initiation, dynamics, and strength
Assesses fibrin and fibrinolysis
ROTEM machine to test
Doran et al: J Trauma 2010
TEG is a real time measure of clotting which is a real time measure of SIRS and CARS.
Ask the audience how many now use thromboelastography? Increasing numbers over last 10 years.
Explain values don’t matter – it is the shape of the readout that does. Breasts, condoms and pencils. We’re aiming for condoms.

19. New things to help (2) Near infra-red spectroscopy
Optimize StO2 in DCR/DCS
10% increase in StO2 = mortality decrease x3
Sagraves et al: J Trauma 2009
Show that by increasing peripheral tissue perfusion and oxygenation will increase survival – a way of monitoring resuscitation in real time

20. “New” things to help (3) Trauma care delivery Specialist hospitals
Not a hospital of specialities
Teamwork
Leaving egos at the door
Communication and situation awareness
Explain that reorganizing trauma systems can make a massive difference.
In England all Trauma now centralized and all hospitals are accredited at certain levels. Went live in Since then the cost of caring for the trauma patient to the English population has reduced and your chance of surviving an injury giving you an ISS >25 is 40% greater in 2018 than it was in 2012 just by getting the right patient to the right place, to the right people at the right time.

21. So where were we until 2013? Isolated injuries or (A)ISS < 16:
Where I did my trauma fellowship – Parkland Memorial Hospital in Dallas, Texas, USA
The Orthopaedic Trauma Surgeons motto: you could continue to operate on the patient until someone at the top of the table told you to stop

22. “Simplistic” approach until 2013
Lactate > 2.0
Base excess > 2.0
pH < 7.3
= DCO/DCS
Do a blood gas
DCO = damage control orthopedics
DCS = damage control surgery

23. Damage limitation US Naval term World War II
Limit the spread of damage
Keep the vessel afloat
Keep the vessel functional
Where does the term come from?
Self explanatory – shut compartments down on the ship to keep it afloat and functional
General surgeons beat orthopedics to it by 10+ years……

24. Damage limitation Aim for RAPID stabilization of patient (in theater)
Guide: theater time (for Ortho/all) < 60 mins
“The real golden hour”
Transfer to ICU
Stabilize on ICU and WAIT (? hrs)
Definitive surgery when parameters normalize
In the severely injured patient only
Wait hours for the SIRS response to settle and so that you do not tip the patient over their physiological reserve

25. Rapid stabilization Hemodynamic stability
“Blood on the floor and 4 more”
Chest
Abdomen
Pelvis
Long bones
Obvious bleeding – nb scalp
Fracture stabilization not fixation
(Spine)
Remind audience we are aiming for hemodynamic stability
Look for the bleeding – remember the ATLS mnemonic; “Blood on the floor and 4 more” – chest, abdo, pelvis and long bones, but, please don’t forget the scalp
We’re aiming for rapid stabilization, not necessarily definitive fixation

26. So aiming for traction / splints / ex-fix for femur and tibia
Binder / ex-fix for the pelvis

27. Damage control orthopedics (DCO)—advantages
Attempts to limit 2nd hit
Allows definitive planning of polytrauma
Shorter overall stay on ICU
Reduces incidence of ARDS / multiple organ failure
Shorter ICU stay allows earlier rehab so better function
In patients with severe polytrauma, high (A)ISS, and/or major chest injury
The aim of DCO

28. This is what we did until Heather Vallier from Cleveland, USA, published this landmark paper in 2013

29. Early appropriate care (EAC)
ETC when the patient has been resuscitated
New parameters
Lactate </= 4.0
pH > 7.25
BE < -5.5
Within 36 hours otherwise DCO
DCO and whenever parameters reached = ETC
Heather coined the phrase: “early appropriate care”.
Perform DCO and resuscitate the patient. Did a big analysis of their registry and retrospectively + tested prospectively these new parameters for deciding from the blood gas when ETC is done and when DCO
If lactate > 4.0 etc then do DCO and wait 36 hrs and then re-test.
Prof Norbert Haas from Berlin independently also arrived at same conclusion as to parameters
But he will resuscitate and as soon as lactate < 4.0 etc he will do ETC, not wait 36 hours, and stop if during procedure lactate is > 4.0 etc and then re-resuscitate, re-assess and resume
Now good prospective evidence for this approach
Norbert Haas

30. Everything in this lecture can be read in this article on the British Orthopaedic Association website in the Journal of Trauma & Orthopaedics
If you don’t want to read it then……: (next slide)

31. You can listen to all this in a 14 minute 31 second podcast again on The British Orthopaedic Association website entitled: “The Swinging Pendulum”

32. Hopefully the audience can see how the pendulum has swung from side to side as far as management of the severely injured patient is concerned and that it is hopefully coming to rest in the middle due to better understanding of the pathophysiology.