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. Ask the audience who these are and why they are famous in the medical world?
Picture 1 – Huw Owen Thomas: the inventor of the Thomas splint during the building of the Manchester ship canal in the 1880s for femoral fractures
Picture 2 – Sir Robert Hunt: Huw Owen Thomas’s nephew who was commander of British Medical forces in World War I (and one of the founders of the British Orthopaedic Association). Introduced his Uncle’s Thomas splint to the battle of Ypres 1916 and cut the mortality rate from a femoral fracture on the battlefield from 80% to 20% overnight.

3. Ask the audience - What did we do for next 60 years?
Not much medically, but we got much better at injuring ourselves

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

5. “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”

6. Adult 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

7. Advantages of early fracture stabilization
Reduction of ARDS
Reduction of multiple organ failure
Reduction of fat embolism
Reduction of thrombosis
Better function through early mobilization
Self explanatory
ARDS = Adult Respiratory Distress Syndrome
MOF = Multi Organ Failure

8. 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.

9. 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

10. 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

11. Systemic inflammatory response syndrome (SIRS)
Picture of Prof Peter Giannoudis from Leeds
Did not coin the term SIRS but has written more about it than most

12. SIRS—what is it? With reference to trauma:
A normal physiological response
Functional up regulation for survival

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

14. 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

15. 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

16. SIRS—is it a problem? Only if not recognized or predicted
A normal physiological response
Designed to help the patient
Not helped by you if not recognized
(and made worse)
Altered immunity – infection susceptibility
Self explanatory

17. SIRS vs sepsis Inflammation vs infection/sepsis Is there a difference?
Dulhunty et al 2008 ANZICS trial group
Sepsis presents 2 days later (5.6 days)
Central nervous system failure more likely in SIRS
Mortality similar
(Gene expression profiles different)
SIRS & sepsis are the same and have the same effect.
This nice study from Australia & New Zealand showed the effects on the patient are exactly the same – the difference is that SIRS shows those effects much earlier than sepsis

18. 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.

19. 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.

20. Ask the audience – what do these show?
Scenes from the hospital at Camp Bastion in Afghanistan
Then ask the audience – Why should we actually be grateful to the recent conflicts?
Because all massive advances in medicine have happened during wars. Debridement and evacualtion from the battlefield: Napoleonic wars by the French (Baron Laret), Early surgery and debridement + long bone fracture stabilisation: WW1, Antibiotics: WW2, very early evacuation and surgery: Vietnam, understanding the physiology of major trauma: Iraq & Afghanistan – we have learnt more in the last 12 years than in the last 5000 years.

21. 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

22. 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.

23. Why bother to recognize/predict?
SIRS and long-bone fractures (especially femur)
Pape, Smith, Giannoudis, et al: J Trauma 2003
EPOFF study group
Prospective randomized study
10 IMN vs DCO + Ex-fix then 20 IMN
Ask audience why we in orthopedic trauma should be bothered?

24. IL-6 * + + + Group I°FN Group DCO I° Ex.fix. Group DCO II° FN 400 300
0.03
0.04
Group I°FN
Group DCO
I° Ex.fix.
Group DCO
II° FN
300 + +
IL-6
200 +
EPOFF study showed that it is the instrumentation of the intramedullary canal of the femur that massively increases your IL-6
If you are severely injured this may be enough to tip you over your physiological reserve
100
Preop
7 hrs Postop
24 hrs Postop
48 hrs Postop

25. Effect of reaming on canal IL-6
But it is not reaming of the canal – it is the initial opening of the intramedullary canal with the awl/drill/guide wire that does it.
So reamed or unreamed nails makes no difference
9.6 pg/ml

26. 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

27. 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

28. 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.

29. 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

30. “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 is 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.

31. 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

32. Polytrauma / AISS > 16 ? > 6 hours needed for ETC
> 4 units over 4 hours to keep systolic > 100
Massive transfusion (25 units +)
Bilateral lung injury
“Surgical Systemic Disease”:
Injuries severe enough to affect organs/systems not directly injured
i.e. AISS > 16
“The critical 3 Cs”
Cardiovascular instability
Cold
Coagulopathy
Tell the audience that this was what was written and to ignore all this

33. “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

34. “Damage limitation” “Damage control”
“The second / real golden hour”
This is what I call “The real golden hour” in the severely injured patient

35. 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……

36. Damage control Hypotensive resuscitation
“The first clot is the best clot”
Don’t blow the clot!
Systolic pressure mm Hg
NB head injuries
Aim for this

37. 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 in 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

38. 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

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

40. Damage control orthopedics (DCO)—advantages
Attempts to limit 2nd hit
Allows definitive planning of polytrauma
Shorter overall stay in 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

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

42. 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

43. Recently re-validated in 2017

44. 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)

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

46. 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.