Review Question - QID 219188

This polytraumatized patient is hemodynamically stable following resuscitation and requires stabilization of his orthopaedic injuries. A base excess of -6.5 mmol/L (same as a base deficit of 6.5) is indicative of inadequate resuscitation, and early definitive orthopaedic care will place the patient at risk for complications secondary to inflammatory cascade (Answer 1). As a result, the patient should be stabilized following the tenets of damage control orthopaedic (DCO), with the application of a pelvic external fixator, irrigation and debridement and external fixation of his femur, and closed reduction and splinting of his elbow.

Polytraumatized patients represent a challenging clinical scenario, and inappropriate management of these patients can lead to a litany of complications including acute respiratory distress syndrome (ARDS) and multi-organ failure (MOF). The management of these patients has undergone multiple paradigm shifts over the past 40 years. In the 1980s, the philosophy of early total care (ETC) was most dominant, as surgeons believed that these patients were "too sick not to operate". Unfortunately, many patients experienced a marked "second-hit" phenomenon and succumbed to systemic complications. The early 2000s brought to light the concept of damage control orthopaedics (DCO), a strategy characterized by staging definitive management to avoid the additive effects of additional trauma to these patients during a time of extreme vulnerability. Recently, there has been a focus on the concept of early appropriate care (EAC), which sought to identify major trauma patients and definitively treat the most time-critical orthopaedic injuries while still minimizing the secondary inflammatory response. This strategy was popularized in 2013, and characterized by the goal of definitively treating spine, pelvis, femur, and acetabular fractures within 36 hours of injury.

The tenets of EAC are based upon three laboratory parameters (lactate < 4.0 mmol/L, pH ≥ 7.25, and base excess ≥ -5.5 mmol/L), which allow surgeons to identify adequately resuscitated patients fit for definitive orthopaedic stabilization. The outcomes of EAC are promising, with patients experiencing decreased length of hospital stay and time to definitive surgery with decreased complication rates. Despite ample evidence supporting this strategy, surgeons' unwillingness to follow these guidelines continues to delay the time to definitive treatment.

Vallier et al. provide a seminal study on EAC. This retrospective study included 1443 adult patients with 291 pelvis fractures, 399 acetabulum fractures, 102 spine fractures, and 851 femur fractures. The authors concluded that acidosis on presentation was associated with an increased complication rate, and found that correction of patient pH to > 7.25 within 8 hours of injury was associated with fewer pulmonary complications. Furthermore, the authors found that lactate was the most specific predictor of complications, and correction of lactate to < 4.0 mmol/L was associated with a markedly reduced risk of subsequent pulmonary complications.

Volpin et al. provide a current concepts review of DCO in polytraumatized patients. The authors note that the historic goal of ETC was associated with patients experiencing a "second hit", characterized by ARDS and MOF. The authors highlight that while DCO serves to minimize secondary complications, there may be a subset of patients who may meet the criteria for EAC, and note that the application of EAC requires repeat assessment of clinical parameters to ensure that patients are appropriately indicated for this strategy.

Nahm and Vallier performed a systematic review to investigate the optimal timing for the definitive treatment of polytraumatized patients with femoral shaft fractures. Their study pooled data from 38 studies that compared either early versus delayed treatment or early versus DCO. Overall, the authors conclude that EAC may be used safely for most patients with multiple injuries, but highlight the importance of clinical assessment, as there exists a subgroup of patients who may benefit from the application of DCO principles.

Incorrect Answers:
Answer 2: lactate values < 4.0 mmol/L indicate appropriate resuscitation.
Answer 3: patients with IL-6 values above 500 pg/dL are best managed with DCO principles.
Answer 4: a pH of 7.28 indicates reversal of acidosis, and suggests that the patient is fit for EAC.
Answer 5: the patient's base excess indicates inadequate resuscitation and ongoing acidosis. He should be managed best on the DCO principles.