SCCM Resource Library-Damage Control: Orthopedics

Video Transcription

Good afternoon. It's a real pleasure to be here speaking to you all. Wish it was in person. Wish  we were in Puerto Rico. But I really want to thank the program committee for the invitation to speak  to you all today. My name is Deb Stein. I am a surgical intensivist and trauma surgeon at the Arden's Kellogg Shock Trauma Center at the University of Maryland School of Medicine.  And I am thrilled to be talking today about damage control orthopedics. I think that is one of those things that we often relegate a lot of the decision making about some of our  polytrauma patients to some of our subspecialists. And I think particularly as intensivists,  understanding why our orthopedic surgeons are doing what they're doing, what they're doing,  first of all, and why they're doing it. And then how can we as intensivists really help to maximize  our patients' outcome by improving their physiology and really understanding the principles behind  damage control orthopedics. I think it's really important. So I'm thrilled to be part of this  session and speaking to you all today. So let's talk about the what and the why of damage control  orthopedics and start with a little bit of history. As always, we know that polytrauma occurs very  frequently. This is an actual patient of mine. It can be life-threatening and obviously requires a  multidisciplinary and specialized approach. And we know that the management of these patients  with fractures has changed dramatically over the last decades, just as it has changed as Dr. Moore  has just spoken to you about with respect to abdominal injuries. And Dr. Duchesne is going  to talk to you about with respect to vascular injuries. But we don't do what we did back 40,  50 years ago. In the early 70s, for those of us with gray hair who can remember back that far,  if our friend broke their leg skiing, what happened? They got put in bed in the cast or in traction for X number of weeks, and they immobilized. Well, we don't do that anymore  because we know that that was associated with numerous complications, including pulmonary infections, atrophy of the musculature, and thromboembolic complications due to prolonged  immobilization, as well as just the inconvenience of leaving people lying flat on their back in  traction for days and weeks on end. And then that concept of how we took care of fractures in the 70s was really challenged by this landmark study. Prospective randomized study  included 178 multiply injured, i.e., ISS greater than 18 patients to compare the clinical outcome  after early, less than 24-hour versus delayed, greater than 48-hour femoral fracture fixation.  And this publication demonstrated that early total care, or ETC, was associated with fewer pulmonary complications, reduced ICU and hospital length of stay, as well as lower cost.  Similarly, a few other studies demonstrated benefits of early fracture fixation with respect to early mobilization, avoidance of nutritional depletion, and reduced wound  infections. Therefore, early total care became a standard approach for polytrauma in the 80s  and in the early 90s. And why is early orthopedic care so important? Why is it so important to fix  fractures? Well, this is just a very pictorial way of looking at this. These are rats. The upper left  hand side there is going to be your control animal, and the frames B and C, upper right and  bottom left, are after a femur fracture, and one day and three days after injury. And what you're  looking at here is pulmonary tissue. And what you're seeing here is a dramatic increase in  congestion, pulmonary edema, polymorphonuclear and mononuclear cell infiltrates, damage to the  alveoli, just purely by the nature of these animals having a fracture. A fracture is an  immunologically active organ, and it induces significant systemic complications and inflammation.  So fixing fractures is really important systemically for the patient, not just for functional outcomes,  not just for early mobilization, but the unfixed fracture can make the patient really sick.  Well, similarly, unfortunately, fixing fractures does kind of the same thing. So is early total  care good for all patients? Well, we know that the fracture fixation may lead to the development of  an additional secondary potentially life-threatening inflammatory response reaction, which can cause an excessive inflammatory reaction known as the second hit. And early total care  in unstable polytraumatized patients may significantly increase the severity of systemic inflammatory response, may lead to the development of ARDS and multiple organ failure,  and a high incidence of morbidity and mortality. And this is just some biochemical as well as  clinical data to support that supposition. We know that at the top there, while patients were getting femoral nails, the levels of serum IL-6 and elastase rose significantly,  indicating a measurable second hit. That figure on the bottom right, excuse me, on the bottom left  there, that red line is kind of that excessive inflammatory secondary hit. You see the first,  the dark gray there is going to be the patient's fracture. And then those two lighter gray lines,  one is early care, where you can see that that secondary hit really goes over and exceeds what  a patient can tolerate. Whereas if you wait a little bit and do a stage surgical intervention,  you lessen that secondary hit. And over there on the right-hand side, it's going to be the clinical correlate to that. This is another landmark study where they stratified patients  as stable versus borderline, and they either got early external fixation, i.e. damage control versus  intramedullary nailing. And you can see over on the right-hand side there, those patients who  had borderline condition did much worse from a respiratory perspective when they had early  internal medullary nailing, as opposed to the patients who were in, quote unquote, stable condition, they did just fine no matter what strategy you used.  Therefore, we know definitive stabilization of all fractures in all severely injured patients  is not appropriate. It's been widely accepted that one should differentiate between those patients who can tolerate prolonged surgical procedures and for those for whom it is not  advisable. The damage control orthopedic strategy is widely accepted now in the treatment of  unstable severely injured patients. The basic principles of damage control orthopedics include initial stabilization of life-threatening conditions related to the injury, fixation  of long bone fractures using modular minimally invasive external frames, and proceeding with  the definitive management of the fracture fixation only after the patient has had metabolic and  respiratory recovery. So who are these people who should get damage control surgery? Well, this is one list of criteria, ISS of greater than 40 without thoracic trauma,  an ISS of greater than 20 with thoracic trauma, a Glasgow coma scale score of eight or below,  those patients who have multiple injuries with severe pelvic and abdominal trauma and hemorrhagic  shock, those patients who have bilateral femoral fractures, those patients with pulmonary contusions,  patients who are hypothermic, those patients who have a head injury with an IAS of three or greater,  and those patients, if you're able to measure them, who have IL-6 values above 500.  That's a little bit of a separate but similar definition. This is the Berlin definition of  polytrauma, patients who have two injuries that are greater than or equal to three on the IAS,  as well as one or more additional pathological conditions, being hypotension defined as a stock blood pressure of less than or equal to 90, unconsciousness or altered mental status  with a GCS score of less than or equal to eight, patients who are acidotic or a base deficit of  less than or equal to negative six or a lactate of greater than 2.5, those patients who are  coagulopathic, as defined by a PTT of greater than or equal to 40 or an INR of greater than  equal to 1.4, and those patients who are over the age of 69. Additionally, you can also classify  patients by their clinical status, which might help you to determine the appropriate treatment  strategy. Stable patients and those patients who are borderline, who can improve with resuscitation  measures, can typically safely undergo definitive treatment with a major fracture.  Unstable patients and those in extremis should not undergo a prolonged surgical procedure.  Patients who are unstable should undergo damage control procedures, and those patients who are in extremis should only undergo life-saving procedures that absolutely are necessary.  Those types of potentially life-threatening injuries that should be addressed in your patient extremis are going to be your unstable pelvic fracture, compartment syndrome,  fractures, vascular injuries, your unreduced dislocations, traumatic amputations, unstable spine fractures, cauda equina syndrome, and open fractures with significant contamination.  So, for example, you have this patient here who has a significant, as everybody can see,  open book pelvic fracture there on the left-hand side, probably is at least unstable if not in extremis, should absolutely unequivocally undergo only life-saving interventions with  a damage control approach, as opposed to that patient on the right-hand side there who simply has a fifth metacarpal fracture, can probably undergo a whole lot of nothing.  So what do we do? What are these damage control approaches? And I picked out a couple of  different injury types that we could talk about. The first one is going to be pelvic fractures.  This is the one for whom we really what runs the huge range of in extremis going to die  at any moment now versus doing pretty well and can do some definitive fixation. First principle here is obviously stopping the bleeding and avoiding trauma-induced coagulopathy.  Absolutely unequivocally, that's got to be your first-line therapy. But taking care of a patient  with a bad pelvic fracture is really truly a multidisciplinary effort. And so oftentimes,  stopping that bleeding and avoiding trauma-induced coagulopathy, it goes with some degree of  stabilization. The initial life-saving maneuver here is placement of a binder. You can see up  there on the left-hand side of the binder, you can see that widening of the pubic symphysis there.  That's pre-binder and then post-binder. And you can see the same patient dramatic reduction in  the pelvic elements. It is a great temporizing measure, and it can stay on the patient for a  while. We used to think we had to get them off quickly because we were worried about tissue necrosis. But oftentimes now, our orthopedic colleagues are preferring to leave patients  in binder rather than do external fixation for a wide variety of reasons. The real limiting factor  of the binder is your inability to access the groins. If the patient needs a laparotomy, it can be troublesome. And external fixtures do provide better probably bony stabilization,  but they're morbid and they are associated with a not zero risk of complications.  C-clamps were in favor back in the 80s and 90s. They're kind of coming back in favor now. There  are some newer devices. They can be placed at the bedside percutaneously by experienced personnel, and they do provide very good reduction, particularly at the posterior elements.  And then obviously those patients who are doing okay who don't require a damage control approach  can undergo definitive fixation. More and more now, we're being asked by our orthopedic colleagues  that the patient's not an extremist but ill. They're really getting pretty good at putting  in these SI screws. And so oftentimes that can be a component of their damage control approach with very little tissue disruption and very little additional physiologic compromise.  What about patients with femur fractures? These fractures, these are like the classic damage control patients. We know that the femur can bleed a whole lot, right? I mean,  just in and of itself, femoral bone fractures, in addition to the systemic inflammatory response it  can induce, it also can provoke acute life-threatening bleeding. We know that approaching these patients who are systemically ill or probably traumatized with a damage control  approach, including an external fixture, can achieve better overall outcomes, fewer surgical interventions, fewer blood transfusions, and overall a shorter hospital stay. However,  the patient's an extremist may not be appropriate even for an X-fix. Those patients should have  non-compressive garments or skeletal traction, at least as a purely temporizing measure.  Again, similar to our interest in doing early SI screws or percutaneous pinning in some of  these pelvic fracture patients, there are some authors that are advocating now early IM nailing, which can reduce the need for mechanical ventilation, decrease treatment costs.  Again, that has to be weighed against the patient's physiology and the concept of that  second hit phenomenon that we already discussed. The other situation, in addition to the long bone  blunt classic polytrauma patient, is the patient who has concomitant bony injury with a femoral around the knee joint, tibial plateau, et cetera, oftentimes from penetrating injury  with significant concomitant vascular injury. Dr. Duchesne is going to talk to you about damage control vascular injury, so I'm not going to go into a lot of detail on this,  but these are like the stereotypical patients for whom you really want to be working with  your orthopedic surgeons. You want to reestablish blood flow with the use of a shunt, let them get  the leg out to length, put a rigid frame on it with an external fixator, and then go in and do  your definitive vascular repair. The reason you want it out to length before you do your repair  is you don't want them pulling it out to length after you do your repair and find out that your  graft or whatever you did with respect to definitive fixation is too short. Shunts and external fixers are great temporary conduits to save somebody's life and get them out of the  operating room, get them up to the ICU, get them resuscitated, and take them back to fight another  day. Spinal fractures, I get asked about this a lot. What do we do about patients who have  spinal fractures? When do we fix their spine? Well, when we are able, early fixation is preferred. It  is safe. It decreases the incidence of pulmonary complications and neurologic damage. It reduces  the duration of intensive care. It lowers morbidity. It enhances survival and neurologic recovery.  You can do damage control of the spine. It's a little bit different than damage control looks elsewhere, but it's really a stage procedure of immediate posterior fracture reduction  instrumentation within the first 24 hours, and then completing the fusion, if possible, with typically an anterior approach is then carried out at a later stage as further blood  loss in a second hit with extensive soft tissue exposure can aggravate the patient's condition if  it's done too soon. When sufficient closed reduction is feasible, posterior less invasive  stabilization systems are typically preferred, but oftentimes when there is neurologic injury,  a speedy open decompression just may be what you need to do in order to get the pressure off the  spinal cord. I want to talk briefly about upper extremity fractures because I think that we  tend to give our orthopedic surgeons a little bit more leeway, so to speak, with upper extremity  injuries and the rationale being that obviously function is hugely, hugely important in upper  extremity injuries. The mainstay of therapy is to provide an appropriate base on which to stabilize  the fractures. Sometimes you need to do some significant soft tissue cleaning, extraction  of any foreign bodies, and occasionally you'll need radical debridement just to get rid of the  dead or devitalized soft tissue that's going to make the patient sick if you leave it there.  That principle is true for the lower extremity as well. For forearm bone fractures, either external  fixator or rapidly placed plates can be used in a damage control approach, but the key thing in the  upper extremity, it's also true in the lower extremity, but obviously in the upper extremity from a functional perspective, super, super important to preserve longitudinal vascular  nerve and tendon function and viable structures. So again, we tend to give our upper extremity  surgeons a little bit more leeway, let them do a little bit more just in the sake of trying to  maintain as much function as we possibly can of that upper extremity. Definitive coverage obviously  is then going to be done with skin and muscle flaps undertaken when the patient's general state  allows. So what about in 2022? What do we do with damage control orthopedics? Although DCO  is currently applied worldwide, the concept has not been validated in well-designed prospective  studies, and there is significant controversy about whether the indiscriminate application may be harmful and incur substantial unnecessary expense. Two studies, one out of Germany,  the Polytrauma Study Group of the German Trauma Society, they reviewed 63 controlled trials of damage control orthopedics, but really found no generalized management strategy.  Similarly, a study that was conducted in the United States reported that damage control orthopedic implementation rates in high volume, high quality reputed institutions  range from a low of 12% to a high of 57%, indicating that there's a huge amount of variability in how  these principles are applied. And so now we've kind of shifted a little bit to this concept of early appropriate care. This is really the principle identifying major trauma patients  and definitively treating the most time critical orthopedic injuries while minimizing the secondary  inflammatory response. And what we want to try to do as much as possible is be guided by laboratory parameters or at least objective measures of adequate resuscitation, such as  a lactate of less than four, pH of greater than or equal to 7.25, and a base deficit greater than  or equal to negative 5.5. As a general rule using this approach, the optimal timing of definitive surgery is going to be to treat the spine, pelvis, femur, or acetab, those fracture  patterns, particularly within 36 hours of injury. And that's kind of where this damage control approach is shifting towards, to really use objective data to guide our decision  making and getting the patients resuscitated and definitively fixed as soon as possible.  Well, what can we do as intensivists to help in all of this? Well, first of all, understanding and  understanding why they're doing what they're doing, understand the rationale behind it, understand the patient selection criteria. But then the key thing is after they do the damage  control or the pure temporizing measure, getting the patient up to the ICU and then letting us  go to go to work is really what's going to help make the patient well and get them well enough  to get their definitive fixation to maximize functional outcome. We need to be correcting their metabolic disturbances. We need to be correcting their coagulopathy. We need to be  normalizing temperature, not too hot, not too cold. We need to be normalizing their blood sugar, right? We don't want them hypoglycemic. We definitely don't want them hypoglycemic.  We want to be mobilizing them as early as possible. We want to be providing good pulmonary hygiene.  We want to be providing good VTE prophylaxis. Absolutely unequivocally, we want to be providing  nutrition. We want to be doing the best we can with respect to hospital-acquired infection prevention. We want to be good antibiotic stewards. We do not want to be giving patients  unnecessary antibiotics that are only going to induce resistance and have harmful side effects. We have to be good antibiotic stewards, particularly in the setting up orthopedic  injuries that are not definitively fixed and knowing what the recommendations are with respect to antibiotic management is very important. And then lastly, but certainly not  least, we want to obviously prevent delirium in these patients to maximize their outcomes  ultimately. So I will leave it at that. I thank you very much for your attention. Again, I'm so  sorry we're not in person. I hope I have made things clearer and not more confusing for you, but I am happy at any time. If people have questions for me, please feel free to reach  out to me. I'm readily available by email. Thank you again.

Video Summary

The speaker, Deb Stein, is a surgical intensivist and trauma surgeon who discusses the concept of damage control orthopedics. Damage control orthopedics involves the initial stabilization and management of fractures in polytrauma patients, followed by subsequent definitive surgical interventions once the patient's physiology has improved. The speaker emphasizes the importance of understanding the principles behind damage control orthopedics and explains that fixing fractures not only improves functional outcomes, but also has systemic implications. The traditional approach of immobilizing fractures has been replaced by early total care, which has been shown to have better outcomes and lower costs. However, the speaker cautions that early total care may lead to an excessive inflammatory response in some patients, particularly those who are unstable or in extremis. Hence, the speaker advocates for a selective approach to damage control orthopedics based on patient criteria such as coagulopathy, physiological stability, and severity of injuries. The speaker also discusses specific damage control approaches for different types of fractures, such as pelvic fractures, femur fractures, spinal fractures, and upper extremity fractures. Finally, the speaker acknowledges the lack of consensus and ongoing debate regarding the optimal application of damage control orthopedics and highlights the importance of collaborative management involving intensivists and orthopedic surgeons to maximize patient outcomes.

Asset Subtitle

Trauma, Resuscitation, 2022

Asset Caption

Damage control in trauma has become a critical component of care in the trauma patient. Learning Objectives: -Summarize damage control techniques for the critical care management of the trauma patient -Relate how damage control is extended into the ICU resuscitation -Illustrate how to prepare the trauma patient in the middle of damage control to return to the OR

Meta Tag

Content Type Presentation

Knowledge Area Trauma

Knowledge Area Resuscitation

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Tag Trauma

Tag Hemorrhage

Tag Resuscitation

Year 2022

Keywords

damage control orthopedics

fracture stabilization

polytrauma patients

early total care

selective approach

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