Please confirm topic selection

Are you sure you want to trigger topic in your Anconeus AI algorithm?

Please confirm action

You are done for today with this topic.

Would you like to start learning session with this topic items scheduled for future?

Updated: Nov 27 2023

Evaluation, Resuscitation & DCO

Images
https://upload.orthobullets.com/topic/1005/images/dco3.jpg
https://upload.orthobullets.com/topic/1005/images/dco2.jpg
https://upload.orthobullets.com/topic/1005/images/dco3.jpg
https://upload.orthobullets.com/topic/1005/images/dco.jpg
  • 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
  • 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
Card
1 of 43
Question
1 of 60
Private Note

Attach Treatment Poll
Treatment poll is required to gain more useful feedback from members.
Please enter Question Text
Please enter at least 2 unique options
Please enter at least 2 unique options
Please enter at least 2 unique options