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Updated: Nov 27 2023

Evaluation, Resuscitation & DCO

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  • Introduction
    • Trauma is a major public health problem with high disability, death, and societal cost
    • Three peak times of death after trauma
      • 50% within the first minutes of sustaining the injury
        • caused by massive blood loss or neurologic injury
      • 30% within hours of arrival to hospital
        • most commonly from shock, hypoxia, or neurologic injury
      • 20% within days to weeks following injury
        • multi system organ failure and infection are leading causes
    • Golden Hour
      • period of time when life threating and limb threatening injuries should be treated in order to decrease mortality
      • estimated 60% of preventable deaths can occur during this time ranging from minutes to hours
    • Use of an airbag in a head-on collision significantly decreases the rate of
      • closed head injuries
      • facial fractures
      • thoracoabdominal injuries
      • need for extraction
    • Psychological
      • 50% incidence of PTSD after traumatic event involving orthopedic injuries
        • females 4x more likely to develop PTSD
      • 33% incidence of depression
  • Evaluation
    • Primary survey
      • treat greatest threats to life first
        • pelvic fractures can be life threatening if not intervened on by orthopedic surgeons
      • brief history
      • ABCDE's
        • Airway
          • includes cervical spine control
        • Breathing and ventilation
        • Circulation
          • includes hemorrhage control and resuscitation (below)
          • pregnant women should be placed in the left lateral decubitus position to limit positional hypotension
        • Disability
        • Exposure
    • Secondary survey
      • physical examination and updated history
      • obtain indicated imaging studies
    • Tertiary survey
      • repeat physical examination and additional imaging as indicated when mental status has stabilized
      • formal tertiary survey decreases chances of missed orthopedic inury
    • Triage
      • Mass casualty events result in the local healthcare system being overwhelmed
      • Patients are sorted into categories to efficiently provide the appropriate care to the greatest number of patients (immediate, delayed, minor, expectant
  • Hemorrhagic Shock Classification & Fluid Resuscitation
      • Hemorrhagic shock classification and fluid resuscitation
      • Class
      • % Blood loss
      • HR
      • BP
      • Urine
      • pH
      • MS
      • Treatment
      • I
      • < 15% (<750ml)
      • Normal
      • Normal
      • > 30 mL/hr
      • Normal
      • Anxious
      • Fluid
      • II
      • 15% to 30 (750-1500ml)
      • > 100 bpm
      • Normal
      • 20-30 mL/hr
      • Normal
      • Confused,
      • Irritable,
      • combative
      • Fluid
      • III
      • > 120 bpm
      • Decreased
      • 5-15 mL/hr
      • Decreased
      • Lethargic,
      • irritable
      • Fluid & blood
      • IV
      • > 40% (life threatening) (>2000ml)
      • > 140 bpm
      • Decreased
      • negligible
      • Dereased
      • Lethargic, coma
      • Fluid & blood
    • Introduction
      • average adult (70 kg male) has an estimated 4.7 - 5 L of circulating blood
      • average child (2-10 years old) has an estimated 75 - 80 ml/kg of circulating blood
    • Methods of Resuscitation 
      • fluids
        • crystalloid isotonic solution
      • blood options 
        • O negative blood (universal donor)
        • Type specific blood
        • Cross-matched blood
        • transfuse in 1:1:1 ratio (red blood cells: platelets: plasma)
    • Indicators of adequate resuscitation
      • urine output 0.5-1.0 ml/kg/hr (30 cc/hr)
      • serum lactate levels
        • normal < 2.5 mmol/L, < 45 mg/dL
        • most sensitive indicator as to whether some circulatory beds remain inadequately perfused
      • gastric mucosal ph
      • base deficit
        • normal -2 to +2
    • Risk of transfusion
      • risk of viral transmission following allogenic blood transfusion
        • hepatitis B (HBV) has highest risk: 1 in 205,000 donations
        • hepatitis C (HCV): 1 in 1.8 million donations
        • human immunodeficiency virus (HIV): 1 in 1.9 million
  • Non-hemorrhagic shock
    • Cardiogenic shock
      • the heart is unable to generate sufficient cardiac output
    • Neurogenic shock
      • hypotension and relative bradycardia from loss of sympathetic tone following spinal cord inury
    • Septic shock vs. hypovolemic shock
      • the key variable to differentiate septic shock and hemorrhagic shock is that systemic vascular resistance is decreased with septic shock and increased with hypovolemic shock
      • Hypovolemic vs. Septic shock 
      • Hypovolemic shock
      • Septic Shock
      • Systemic Vascular Resistance
      • Increased
      • Decreased
      • Key variable to differentiate
      • Cardiac Output
      • Decreased
      • Increased
      • Pulmonary Capillary Wedge Pressure
      • Decreased
      • Decreased
      • Central Venous Pressure
      • Decreased
      • Decreased
      • Mixed Venous Oxygen
      • Decreased
      • Increased
  • Imaging
    • Delay of fracture diagnosis is most commonly caused by failure to image extremity
      • image any extremity with pain, crepitus, ecchymosis, deformity
    • AP Chest
      • mediastinal widening
      • pneumothorax
    • Lateral C-spine
      • must visualize C7 on T1
      • not commonly utilized in lieu of increased sensitivity with cervical spine CT
    • AP Pelvis
      • pelvic ring
        • further CT imaging should be delayed until preliminary pelvic stabilization has been accomplished
      • acetabulum
      • proximal femur
    • CT Scan
      • C-spine, chest, abdomen, pelvis
      • often used in initial evaluation of trauma patient to rule out life threatening injuries
  • Damage Control Orthopaedics (DCO)
    • Definition/History
      • definitive treatment delayed until physiology has improved
      • popularized in 2000
      • replaced the 1980s philosophy of Early Total Care (ETC), the concept of fixing long bone fractures as soon as possible because patients were "too sick not to operate"
        • ETC led to exacerbation of the "second-hit" in a subset of patients with hemodynamic instability, head, and/or chest injuries
    • Involves staging definitive management to avoid adding trauma to patient during vulnerable period
      • the decision to operate and surgical timing on multiple injured trauma patients remains controversial
      • intra-operative hypotension increases mortality rate in patients with head injury
    • Parameters that help decide who should be treated with DCO
      • ISS >40 (without thoracic trauma)
      • ISS >20 with thoracic trauma
      • GCS of 8 or below
      • multiple injuries with severe pelvic/abdominal trauma and hemorrhagic shock
      • bilateral femoral fractures
      • pulmonary contusion noted on radiographs
      • hypothermia <35 degrees C
      • head injury with AIS of 3 or greater
      • IL-6 values above 500pg/dL
    • Optimal time of surgery
      • patients are at increased risk of ARDS and multisystem failure during the acute inflammatory window (period from 2 to 5 days characterized by a surge in inflammatory markers)
        • therefore only potentially life-threatening injuries should be treated in this period including
          • unstable pelvic fracture
          • compartment syndrome
          • fractures with vascular injuries
          • unreduced dislocations
          • traumatic amputations
          • unstable spine fractures
          • cauda equina syndrome
          • open fractures
    • Stabilization followed by staged definitive management
      • to minimize trauma, initial stabilization should be performed and followed by staged definitive management
        • includes initial pelvic volume reduction via sheet, pelvic packing, skeletal traction, binder, or external fixation
          • if hemodynamically stable
            • proceed with further imaging including CT chest, abdomen, pelvis
          • if not hemodynamically stable
            • consider exploratory laparotomy and/or pelvic angiography and embolization
      • definitive treatment delayed for
        • 7-10 days for pelvic fractures
        • within 3 weeks for femur fractures (conversion from exfix to IMN)
        • 7-10 days for tibia fractures (conversion from external fixation to IMN)
  • Early Appropriate Care
    • Definition/history
      • identifies major trauma patients and definitively treats the most time-critical orthopaedic injuries while minimizing the secondary inflammatory response, guided by laboratory parameters of adequate resuscitation
      • popularized in 2013
      • lactate of < 4.0 mmol/L
      • pH ≥ 7.25
      • base excess ≥ -5.5 mmol/L
    • Optimal time of surgery
      • goal is to definitively treat spine, pelvis, femur, and acetabulum fractures within 36 hours of injury
    • Outcomes
      • decreased delay to surgery
      • decreased complication rates
      • increased hospital revenues
      • main reason for delay to treatment with implementation of this protocol was surgeon decision
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