Review Question - QID 214095

Early Appropriate Care (EAC) is the definitive treatment of major orthopaedic injuries within 36 hours in patients with an improving metabolic acidosis.

EAC is the definitive treatment of unstable fractures of the thoracolumbar spine, acetabulum, pelvis, and proximal and diaphyseal regions of the femur once the patient is adequately resuscitated. Resuscitation is assessed by an improving metabolic acidosis, indicated by at least one of the following: lactate < 4.0 mmol/L, pH ≥ 7.25, or base excess ≥ -5.5 mmol/L (base deficit ≤5.5). EAC has several advantages including a reduced number of complications. Multiply-injured patients are best managed by a multidisciplinary team that facilitates expeditious evaluation, resuscitation, and treatment.

Vallier et al. reviewed the team approach and timing of operative intervention in multiply-injured patients. The authors note that patients with multiple-system trauma are best managed by a multidisciplinary team. A team approach expedites the resuscitation and optimization of patients. Early stabilization of major fractures has been effective for mitigating complications and length of stay. They conclude that early definitive treatment of major axial and femoral fractures reduces complications, the duration of the hospital stay, and costs.

Vallier et al. also studied the system adjustment to a protocol for the management of multiply-injured patients at a level 1 trauma center. The authors defined adherence to the protocol as definitive fixation within 36 hours of injury after adequate resuscitation. They found surgeon preference was the most common reason for delayed fixation, but within 24 months only 10% of fractures were treated on a delayed basis. The authors concluded that the management of patients with multi-system trauma requires teamwork among providers from related specialties and hospital support with appropriate ancillary personnel and equipment.

O’Toole et al. studied the rate of acute respiratory distress syndrome (ARDS) in 227 patients with femoral shaft fractures and injury severity scores (ISS) >17 treated at a single center. They note their approach to treating femoral fractures in patients with multiple traumatic injuries is to perform reamed nailing after adequate resuscitation shown by normalizing lactate plus optimized ventilatory and hemodynamic parameters. Eighty-eight percent were treated with primary reamed nailing with an ARDS rate of 1.5% and a death rate of 2.0%. The authors concluded that the low rate of ARDS compared to other centers may be explained by differences in preoperative resuscitation or medical care provided to treat shock.

Figures A, B & C demonstrate a comminuted diaphyseal femur fracture.

Incorrect Answers
Answer 1: IL-6 is a parameter used to help decide when a patient should be treated with damage control orthopaedics (DCO). DCO should be considered with values > 500 pg/dL.
Answer 2: pH values ≥ 7.25 support EAC.
Answer 3: Lactate values < 4.0 mmol/L support EAC.
Answer 5: Base excess values ≥ -5.5 mmol/L support EAC.