Damage Control Management In The Polytrauma Patient
Phyllis Sterlin
Background: The optimal treatment of major fractures in patients with blunt multiple injuries continues to be discussed. The aim of this study is to investigate the clinical course of polytrauma patients treated at a Level I trauma center within the last two decades regarding the effect of changes in the management of their femoral shaft fracture.
Methods: In a retrospective cohort study performed at a Level I trauma center, the patient's injuries and clinical outcomes were studied. Adult blunt polytrauma patients were included if a femoral shaft fracture eligible for intramedullary stabilization was stabilized (including external fixation) primarily < 8 hours after primary admission. Patients were separated according to the management strategies for the femur fracture (I degrees intramedullary nailing [I degrees IMN]; I degrees external fixation [I degrees EF]; I degrees plate osteosynthesis [I degrees plate]) followed during a certain time period: (1) early total care (ETC) (January 1, 1981-December 31, 1989) and early (< 24 hours) definitive stabilization; (2) intermediate (INT) (January 1, 1990-December 31, 1992) change in the protocol; or (3) damage control orthopedic surgery (DCO) (January 1, 1993-December 31, 2000), early (< 24 hours) temporary stabilization, and secondary conversion to intramedullary nailing in patients at risk of organ failure.
Haemorrhagic shock is one of the main causes of mortality in severe polytrauma patients. To increase the survival rates, a combined strategy of treatment known as Damage Control has been developed. The aims of this article are to analyse the actual concept of Damage Control Resuscitation and its three treatment levels, describe the best transfusion strategy, and approach the acute coagulopathy of the traumatic patient as an entity. The potential changes of this therapeutic strategy over the coming years are also described.
This book is an unparalleled source of cutting-edge information on every aspect of rescue, trauma management, and fracture care in the polytrauma/multiple injured patient. Damage control surgery is approached logically and systematically by dividing treatment into phases. The common goal of treating life-threatening conditions first, then treating major pelvic and extremity fractures, requires cooperation among all major disciplines and subspecialties involved in the care of polytrauma patients, and the book is accordingly multidisciplinary in nature. It is edited by pioneers in the field and the authors are all acclaimed experts. This second, revised and updated edition of Damage Control Management in the Polytrauma Patient will be invaluable for all clinicians who must weigh life-saving operations against limb-threatening conditions, including emergency personnel, trauma surgeons, orthopaedic traumatologists, and anesthesiologists.
Hans-Christoph Pape, MD, FACS, graduated in 1988 from Hannover Medical School, where he then completed a residency in trauma surgery. He was appointed Full Professor of Trauma Surgery at the School in 2000. Between 2003 and 2005 Dr. Pape was also a Visiting Professor at Harvard Medical School and other U.S. universities. Dr. Pape is currently W. Pauwels Professor and Chairman of the Department of Orthopaedic/Trauma Surgery at the University of Aachen Medical Center, Germany. During his career, Dr. Pape has received many awards, including the Novartis Prize (2005), the Swiss AO Foundation Annual Award (2006), and the Kappa Delta Award from the American Academy of Orthopedic Surgeons (2008). He is the Editor in Chief for Open Access Emergency Medicine and a Section Editor for Injury and the European Journal of Trauma. Dr. Pape has been the lead author on 81 publications in peer-reviewed journals and co-author of a further 220. He is also the editor or author of several important books and has led many courses on polytrauma management.
Peter Giannoudis, BSc, MB, MD, FRCS, is Professor in the Academic Department of Trauma & Orthopaedic Surgery, School of Medicine, University of Leeds, UK and Honorary Consultant at Leeds General Infirmary. He specializes in the management of multiple injured patients and has major interest in reconstructive surgery and the molecular aspects of trauma. Dr. Giannoudis is a past President of the British Trauma Society and of the European Society of Pelvis and Acetabulum. He is also an Executive Board Member of the British Orthopaedic Association National Trauma committee, an instructor for the American Academy of Orthopaedic Surgeons and the British Orthopaedic Association, an executive member of the EFORT Trauma Task Force, and past Chairman of the AO polytrauma course. Dr. Giannoudis is the author of more than 450 articles in peer-reviewed journals as well as seven textbooks. He is Editor in Chief of Injury, Associate Editor of Bone & Joint Surgery (Am) and an editorial board member for various other journals.
Although polytrauma patients represent a major therapeutic challenge, improved results can be achieved in dedicated institutions with efficient triage and focused trauma specialist care. The treatment of polytrauma patients noted a significant development as a result of better understanding of the physiopathological mechanisms of injury, development of a network of prehospital trauma management, institution of multispecialist integrated groups, and improved intensive care resuscitation.
The poor prognosis of pelvic fractures is related to the high incidence of hemorrhagic shock, due to the anatomical proximity of arteries and veins. Fracture and vascular injury can cause the formation of hematoma in the pelvis and retroperitoneum. This space can hold up to 4 liters of blood before the pressure within the hematoma dabs further hemorrhage [45]. In most of the cases (90%), the bleeding originates from venous disruption or from cancellous bone, while bleeding is due to an arterial injury in only 10% of cases. The mortality of polytrauma patients with pelvic fracture and unstable hemodynamics has been reported to be as high as 50% in one series [46]. Early mortality is usually secondary to uncontrolled hemorrhage, whereas late mortality is due to associated injuries and sepsis-induced MODS. With advances in resuscitation, the mortality directly related to pelvic trauma is most likely closer to 7% [44].
In the absence of a clear extrapelvic bleeding (that could explain the hemodynamic instability), the orthopedic surgeon should assume that the cause of the shock is a retroperitoneal hematoma related to the pelvic fracture. At this point, every effort should be aimed at stabilization of the fracture in order to reduce the volume of the open pelvic ring and to dab the venous bleeding. A method that has proved useful over the years is wrapping of the pelvis. This method consists in binding the pelvis with a commercial device, such as the TPOD, or with a sheet, which allows to reduce pelvic volume. This application is rapidly accomplished, is free from side effects, and is usually able to effectively staunch vein bleeding [49]; these patients can then be safely subjected to total-body CT scan. Pelvic binders have largely replaced external fixation and pelvic C-clamp as the best initial means of controlling the hemorrhage associated with unstable fractures of pelvis [50]. In spite of the fact that pelvic external fixation can be rapidly applied, reduces the pelvic volume, and provides temporary fracture stabilization, this fixation is located in front of the patient, while pelvic ring instability is predominantly posterior. By compressing the front, external fixation may widen the posterior pelvis and worsen the problem [51]. The pelvic C-clamp also allows rapid reduction and stabilization of the posterior pelvic ring, through the positioning of two nails in the coccyx and sacroiliac joint. This device does not prevent operators' access to the abdomen but can be burdened with neurological complications, particularly in the presence of sacral fractures [48].
Algorithm representing the management of the pelvic fracture in polytrauma patient. Abbreviations: EFAST: extended focused assessment sonography for trauma; CT Scan: computerized tomography; Ex-Fix: external fixation.
The algorithm for treatment of major fractures, based on patient's clinical categories (data from [26]). Abbreviations: OR: operating room; ICU: intensive care unit; ETC: early total care; DCO: damage control orthopedic; ABG: arterial blood gas; SBP: systolic blood pressure; EFAST: focused assessment with sonography in trauma; UO: urine output.
processing.... Drugs & Diseases > Clinical Procedures The Polytraumatized Patient Updated: Dec 26, 2018
- Author: Chat V Dang, MD; Chief Editor: Murali Poduval, MBBS, MS, DNB more...
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- Sections The Polytraumatized Patient Overview Primary Survey Shock In The Polytraumatized Patient Secondary Survey Immediate Management Of Musculoskeletal Injuries Special Patient Populations Risk Management: Missed Injuries Show All Media Gallery Tables References