Controversies in Hemodynamically unstable Orthopaedic Trauma - PDF document

5/30/2013 Controversies in • Hemodynamically unstable Orthopaedic Trauma Surgery pelvic fractures • Damage Control Eric G. Meinberg, MD • Orthopaedics Associate Clinical Professor • Geriatric trauma UCSF/SFGH Orthopaedic Trauma Institute Low-energy Fractures • Fall from standing height Management of Hemodynamically – Simple fracture patterns Unstable Pelvic Fractures – Stable – Conservative treatment 1

5/30/2013 High-energy Fractures Lateral Compression LC-3 • Associated with significant problems • ‘Windswept pelvis’ – 75% abdominal or pelvic hemorrhage • External rotation and – 12% urogenital injury disruption of – 8% lumbosacral fracture contralateral – 60 – 80% associated fractures hemipelvis – 12-25% mortality • Rollover or crush • Unstable AP Compression AP Compression APC-1 APC-2 • <2.5 cm symphysis • >2.5 cm diastasis disruption • Opening of SI joint • Ramus fractures • Floor ligaments torn • No posterior injury • Rotationally unstable • Vertically stable • Stable 2

5/30/2013 AP Compression Vertical Shear APC-3 • >2.5 cm symphysis • Fall from height disruption • Significant vertical • Complete rupture of forces posterior ligaments • Anterior and posterior • Rotationally and vertical displacement vertically unstable • Unstable Associated Injuries Combined Mechanism AP compression • Pelvic floor disruption • • Combination of Intra-pelvic and retroperitoneal vascular injuries • Shock, sepsis, ARDS, death multiple mechanisms • 20% mortality • Significant associated Lateral compression injures • Pelvic floor is intact • Majority are LC-2 and • Decreased intra-pelvic bleeding VS • Brain and visceral injuries • Unstable • 7% mortality 3

5/30/2013 Immediate Management Technique • In the field or trauma bay • Pelvic binder or bedsheet • Apply around greater trochanters • Maintains continuous reduction until fixator applied (up to 72h safe) • May be left on in OR for other procedures Technique Technique 4

5/30/2013 Proper Placement? Pelvic Binder • Works like a sheet • Easy to place by emergency staff • Less likely to be over- tightened • Low risk of skin necrosis • Looks ‘official’ External Fixation C-Clamp • Fast and effective way of pelvic stabilization • Temporary fixation of posterior instability and • Re-establishes pelvic ring widening and decreases intrapelvic • Act as temporary SI volume screws • Applied bedside or OR • Allows access to abdomen • Decreases hemorrhage by and patient tamponade, • Only emergent method to reapproximating fracture adequately stabilize edges, decreasing motion posterior displacement 5

5/30/2013 C-Clamp Application C-Clamp Application C-Clamp Considerations Extraperitoneal Pelvic Packing • Rationale: • Not readily available – Only treatment to control bleeding from venous • Requires c-arm guidance for placement plexus – Controls arterial bleeding • Contraindicated in ilium fractures – Enables control of large vessel bleeding • May over-compress sacrum fractures – Simultaneous treatment of associated abdominal trauma • Sciatic nerve, gluteal artery injury reported • Performed after reduction of pelvic volume with fixator 6

5/30/2013 The Case for Pelvic Packing The Case for Pelvic Packing Ertal et al. JOT, 2001 Ertal et al. JOT, 2001 • 20 patients with pelvic disruption • Mean ISS 41.2 • C-clamp applied in the ER • Lactate q30 min. • Pelvic packing for persistent bleeding (non decreasing lactate) The Case for Pelvic Packing Preperitonal Pelvic Packing for Hemodynamically Unstable Ertal et al. JOT, 2001 Pelvic Fractures: A Paradigm Shift Cothren, Osborn, Moore, Morgan, Johnson, Smith, MD • Pelvic packing in 14 • 4 patients died (20%) The Journal of TRAUMA 2007 • Lactate levels predicted Transfusion requirements Pre – packing compared with subsequent 24 hrs were mortality significantly less (12 versus 6; p 0.006) 7

5/30/2013 Preperitonal Pelvic Packing for Hemodynamically Unstable Pelvic Fractures: A Paradigm Shift Cothren, Osborn, Moore, Morgan, Johnson, Smith, MD The Journal of TRAUMA 2007 25% Mortality Institutional Protocols • Biffl et al: J Orthop Trauma 2001 • Evolution of a multidisciplinary clinical pathway for the management of unstable patients with pelvic fractures Problem Reduction • Mortality 31% ->15% • Death by exsanguination 9% -> 1% • Multi-organ failure 12% -> 1% • Death within 24h 16% -> 5% 8

5/30/2013 Institutional Protocols Who should get angiography? • ATLS - identify pelvis as source • Temporary pelvic volume reduction • Concerns: • Acute external fixation +/- – Venous and fracture (cancellous bone) bleeding traction • Laparotomy +/- pelvic account for >90% packing – Arterial bleeding accounts for <10% • Pelvic angiography & embolization Case 1 • 30 year old male • 1 hour after motorcycle accident 2 Patients…. • initial vital signs: • blood pressure 100/60 • heart rate 100 • respiratory rate 40 • Acute abdomen, and….. 9

5/30/2013 Emergent laparatomy, ex fix, packing Ongoing ‘Shock’ Classic Indication • Persistent shock despite treatment embolization angiography packing External fixator 10

5/30/2013 Case 2 • 70 year old female • Struck by car • Initial responder but ongoing low blood pressure • Only injury….……. Classic Indications Initial treatment • No need for • Persistent shock binder despite treatment • Skeletal traction leg • Shock with normal • Transfusion 4 pelvic volume units packed cells and 6L crystalloid first 4hrs 11

5/30/2013 ‘Clues’ re: need for angio Ongoing hypotension • transfusion requirements • contrast extravasation (CE) 9 hours post injury: • age > 60 • Successful angiographic embolization of obturator • bladder displacement artery – ‘pelvic hemorrhage volume’ ‘Clues’ re: need for angio Extravasation • transfusion requirements • Identification of • contrast extravasation (CE) ‘extravasation’ on • age > 60 contrast CT that • bladder displacement correlated with angiographic findings – ‘pelvic hemorrhage volume’ 12

5/30/2013 Age ‘Clues’ re: need for angio • transfusion requirements Kimbrell et al: Arch Surg 2004 • angio 92 patients -> 55 (60%) embolization • contrast extravasation (CE) • age > 60: 94% embolization (vs 50%) • age > 60 • 2/3 patients > 60 yo = normal BP @ admission • bladder displacement • embolization -> 100% efficacy – ‘pelvic hemorrhage volume’ Velmahos J Trauma 2002 Case - acetabular fracture Successful embolization of SGA 13

5/30/2013 Angiography/ embolization • Should be used in a protocol – Frequency ≈10% Damage Control Orthopaedics • Indications (DCO) • ‘clues’ • Avoid bilateral internal iliac a. embolization • Associated risks: – acute renal failure – gluteal muscle necrosis – deep infection 60 ’s to 80’ s 80 ’s to the 90’ s “The patient is too sick to have surgery” “Patient is too sick NOT to have surgery” • Riska 1976 • Goris 1982 • Meek 1986 • Bone 1989 14

5/30/2013 Orthopedic Damage Origins of “damage control” Control “… temporary stabilization of fractures soon after injury, minimizing the operative time, and preventing heat and blood loss.” • In severely injured patients, initial orthopaedic surgery should not be definitive treatment • Definitive treatment delayed until after patients overall physiology improves Scalea et al J Trauma 48(4), 2000. Damage Control Decision Making Must Focus on the • Decompression of body cavities Patient as a “Whole” • Bleeding control • Repair of hollow viscus injuries • Stabilization of central fractures – Pelvis – Femur 15

5/30/2013 ARDS and Multiple Organ Failure Orthopaedic Damage Control • Avoid worsening the patients condition by a major Cascade of inflammatory reactions orthopaedic procedure (“2 nd Hit”)  Exaggerated systemic inflammatory response syndrome (SIRS)  ARDS and Multiple Organ Failure (MOF) ARDS and Multiple Organ Failure No Severe Pulmonary Injury • 20 years of data at the Hannover Trauma Center suggest that patients who • In patients without severe chest trauma underwent a major (> 3 hour) operation – Early IM nailing reduced the length of ICU stay on PTD 3 – 5 had increased mortality (7.3 days vs. 18.0 days) • Secondary surgical procedure acted as a – Reduced the length of intubation (5.5 days vs. “second hit” , exacerbating the primed 11.0 days) systemic inflammatory response • In the absence of severe chest trauma primary IM femoral nailing is beneficial Pape HC, et al. J. Trauma. 34: 540 – 657, 1993. 16

5/30/2013 Treatment Protocol Severe Pulmonary Injury • In patients with severe chest trauma when IM nailing was performed in the first 24 hours – Higher incidence of posttraumatic ARDS (33% vs. 7.7%) – Higher mortality (21% vs. 4%) Pape HC, et al. J. Trauma. 34: 540 – 657, 1993. Temporary External Fixation Temporary External Fixation Mean Mean OR time blood loss • External fixation 35 min. 90 cc • Reamed femoral nail 135 min. 400 cc • 1.7 % infection rate • One stage conversion considered safe – Ex fix on for short time (< 2 weeks) – No signs of pin site or systemic infection – No loosening of pins Nowatarski PJ et al. J Bone Joint Surg. 82A: 781, 2000. Scalea et al J Trauma 48(4), 2000. 17