PREVENTABLE DEATH: DCO

DR THIT LWIN
SCHOOL OF MEDICINE
UMS
 Case scenario

• 16 year old male, MVA

• Pulmonary contusion
• Stable TBI
• Bilateral femoral fractures
• Hip dislocations( Right)
• 96 hours after bilateral
femoral nailing patient
develop florid ARDS
• Autopsy finding:
• It is inevitable or
preventable?
Recognition of the systemic effect of
nailing.
• Cardiopulmonary changes are the result of
releasing bone marrow into general circulation.
Gerhart küntscher
Trauma - the leading cause of death in the first four decades of life

Death from trauma has a trimodal distribution:within

-seconds to minutes

-minutes to hours
GOLDEN HOUR

-several days or
weeks
Tri-mode pattern of death due to trauma
First peak
• Within minutes of injury
• Due to major neurological or vascular injury
• Medical treatment can rarely improve outcome
Second peak
• Occurs during the 'golden hour'
• Due to intracranial haematoma, major thoracic
or abdominal injury
• Primary focus of intervention for the (ATLS)
Third peak
• Occurs after days or weeks
• Due to sepsis and multiple organ failure
management of the patient with multiple
injuriesEarly total care (ETC)

• Fix the long bones within 24 hours

• Resuscitate aggressively
• Early definitive surgery to prevent bed ridden
complications
DCO evolution
• Many trauma patients who have sustained multiple
injuries benefit from the ETC of major bone
fractures.
• However this strategy is not the best option, and
indeed might be harmful for some multiply injured
patients.
• Since going for early surgery is not the optimal
approach for those patients, the concept of damage
control Orthopaedics has evolved
Definition of DCO
• It is an approach that contains and stabilizes
orthopaedic injuries so that the patient's
overall physiology can improve.
• Its purpose is to avoid worsening of the
patient’s condition by the “second hit” of a
major orthopaedic procedure and to delay
definitive fracture repair until a time when the
overall condition of the patient is optimized.
DCO principle
• Damage control orthopaedics emphasizes the
stabilization and control of the injury, often
with use of spanning external fixation, rather
than immediate fracture repair.
• Ortho team must be resuscitator and
“stabilizer” not fixers.
• Minimally invasive surgical techniques
such as external fixation are used
initially.
• Damage control focuses on
▫ control of hemorrhage
▫ management of soft-tissue injury
▫ achievement of provisional fracture
stability while avoiding additional
insults to the patient
Pathophysiology
• Traumatic injury leads to systemic inflammation
followed by a period of recovery mediated by a
counter-regulatory anti inflammatory response
• Within this inflammatory process, there is a fine
balance between the beneficial effects of
inflammation and the potential for the process to
cause and aggravate tissue injury leading to ARDS
and multiple organ dysfunction syndrome
After trauma, there is a balance between the systemic inflammatory response
and the counter- regulatory anti-inflammatory response. Severe
inflammation can lead to acute organ failure and early death. A lesser
inflammatory response coupled with an excessive counter-regulatory anti-
inflammatory response may also induce a prolonged immunosuppressed
state that can be deleterious to the host. SIRS = systemic inflammatory
response syndrome, and CARS = counter- regulatory anti-inflammatory
response syndrome.
• The initial massive injury and shock can give rise
to an intense systemic inflammatory syndrome
with the potential to cause remote organ injury
• When the stimulus is less intense and would
normally resolve without consequence, the
patient is vulnerable to secondary inflammatory
insults that can reactivate the systemic
inflammatory response syndrome and
precipitate late multiple organ dysfunction
syndrome
PATHOPHYSIOLOGY
Two hits hypothesis
• First hits • second hits
-hypoxia, -schaemia/reperfusion
-hypotension injuries
-hypothermia -compartment $
-organ and soft tissue -operative interventions
injuries - infections)
-fractures
• host defence response is characterized by
local and systemic release of
-pro-inflammatory cytokines,
-arachidonic acid metabolites,
-proteins of the contact phase and coagulation
systems,
-complement factors and acute phase proteins,
- hormonal mediators: (SIRS),
• However, anti-inflammatory mediators are
produced (compensatory anti-inflammatory
response syndrome (CARS).
• An imbalance of these dual immune
responses seems to be responsible for organ
dysfunction and increased susceptibility to
infections.
• Hyper-stimulation of the inflammatory system,
by either single or multiple hits, is considered by
many to be the key element in the pathogenesis
of adult respiratory distress syndrome and
multiple organ dysfunction syndrome
Markers of Immune Response
• Inflammatory markers may hold the key to
identifying patients at risk for the development
of posttraumatic complications such as multiple
organ dysfunction syndrome
• It appears that, at present, only two markers, IL-
6 and HLA-DR class-II molecules,
accurately predict the clinical course and
outcome after trauma
• Def: A clinical syndrome with severe injuries
involving two or more major organ or
physiological system which will initiate an
amplified metabolic and physiological response.
Histopathological changes
• Along the endothelial wall of the vessel ,
leukocyte adhering to the endothelium and
contributing to an inflammatory response and
lysis which undermines the structural integrity
of the vessel wall and increases its permeability.
• Intravascular fluid seeps into the interstitium
causing the pulmonary tissue to become swollen
, stiff and non-compliant.
• The capillary alveolar distances increase
interfering with respiratory gas exchange.
• Initially the lung may appear healthy
and unaffected
• within 5 days to a week, the lung may take on the
appearance with a severe inflammatory response
causing stiffening interstitial edema, alveolar
collapse and ventilation perfusion imbalance.
Indications for DCO
• Unstable patients / patient in extremis
• Bilateral lung contusions / thoracic
trauma
• Abdominal / pelvic trauma and
hemorrhagic shock
• Bilateral femur fractures
• Pilon fractures (high energy, lack of
muscle)
• > 65 / geriatric patient

• Exaggerated inflammatory response

• - IL 6 > 800 ug/ml
Injury Severity Score
• Based on Injury Scale / AIS
- 9 body regions
- head / face / neck / chest / spine /
abdomen / UL / LL / external
- rated in severity 1 - 6
- max of 75
- minor / moderate / serious / severe /
critical / untreatable
- a score of 6 in any region indicates futility
of medial care
• ISS
- 6 body regions
- head and neck / face / thorax / abdomen /
extremity / external
- top 3 scores in any region are squared
- major trauma > 15
Clinical Parameters Associated with Adverse
Outcomes in Multiply Injured Patients
• Acidotic: pH < 7.24, lactate > 2.5 mmol/l
▫ Coagulopathy (platelet count <90,000)
▫ Hypothermia (<32°C)
▫ Shock and >25 units of blood needed
▫ Bilateral lung contusion on first plain radiograph
▫ Arterial injury and hemodynamic instability
(blood pressure <90 mm Hg)
▫ Exaggerated inflammatory response (e.g., IL-6
>800 pg/mL)
▫ Operation time >90minutes
• Interleukin 6 is a reliable, subclinical parameter which
reflects the systemic inflammatory response to trauma.
• CRP, TNF, IL 1 and 8 no correlation to injury severity
JBJS vol 87-A no.2 February 2005
• Clinical Parameters of the “Borderline” Patient
1.Multiple injuries with (ISS) >20 with additional
thoracic trauma AIS >2.
• 2.Multiple injuries with abdominal/pelvic trauma
(>Moore grade 3) and haemorrhagic shock (initial
systolic BP <90 mmHg).
• 3.ISS >40
• 4.Radiographic (CXR or CT) evidence of bilateral
pulmonary contusion.
• 5.Initial mean pulmonary arterial pressure >24
mmHg.
(.Pulmonary artery pressure increase during
intramedullary nailing >6 mmHg)
End point for resuscitation
• Stable haemodynamics
• Stable oxygen saturation
• Lactate level <2 mmol/l
• No coagulation disturbances
• Normal temperature
• Urine out put > 1ml/kg/hr
• No requirement for inotropic support
JBJS vol 85-B No.4 May 2003
• the management of the "borderline patient"
should be control of hemorrhage and shock, tube
thoracostomies as needed for chest
decompression, FAST or other evaluation for
hemoperitoneum and other ATLS protocol
diagnostic and resuscitative measures.
• Shortly thereafter a second ATLS type re-
evaluation is performed.
• This includes repetition of arterial blood
pressure and blood gas monitoring, a second
FAST and a measure of urine output as well as
inflammatory factors (such as IL-6).
Patient with multiple
injuries in unstable or in
extremis

Stage1: OT temporary
stabilisation of
fractures with EF

Stage2: ICU;Resuscitation-
correction of hypothermia
&coagulation disturbances-
ICP monitoring

Sequence of damage Stage3:OT (after 4days)

definitive stabilisation of
control orthopaedics fracture
Post operative local complication during three
period

ETC period Intermediate DCO period P value

period
Pin tract 2/39 2/21 4/86 NS
infection
Wound 5/235 2/88 3/191 NS
infection
osteomyelitis 2/235 0/88 1/191 NS

Numbers of patient with complication/total number of patients NS= not

significant

JBJS vol 87-A no.2 February 2005

• Certain specific orthopaedic injury complexes
appear to be more amenable to damage control
orthopaedics; these include-
▫ femoral fractures in a multiply injured patient,
▫ pelvic ring injuries with exsanguinating
hemorrhage
▫ polytrauma in a geriatric patient.
Femoral Fractures-
• Femoral fractures in a multiply injured
patient are not automatically treated with
intramedullary nailing because of
concerns about the second hit of such a
procedure.

• In addition to the second hit, embolic fat

from use of instrumentation in the
medullary canal will worsen the
pulmonary status.

• Patients with a chest injury are most

prone to deterioration after an
intramedullary nailing procedure
• There are some consistent findings associated with a
higher likelihood of hemorrhage
▫ Posterior pelvic ring injuries are associated with a two
to threefold increase in blood replacement requirements
compared with anterior injuries
▫ Anterior-posterior compression type-III injuries and
lateral compression injuries are associated with a high
prevalence of vascular injury (22% and 23%,
respectively)
▫ Pelvic fractures in patients over 55 years old are more
likely to produce hemorrhage and require angiography
• Damage control orthopaedics for a pelvic ring
injury with exsanguinating hemorrhage
involves
▫ rapid clinical decision-making
▫ multiple teams for resuscitation
▫ minimally invasive pelvic stabilization (e.g.,
with a pelvicbinder, external fixator, pelvic
c-clamp, or pelvic stabilizer).
• Patients who do not respond to these measures should
be considered for angiography and embolization if
they are likely to survive the trip to the angiography

• otherwise, they should be considered for pelvic

packing once any underlying coagulopathy has been
corrected
Geriatric Trauma
• Elderly trauma patients require special evaluation and
treatment because of their higher mortality rate
following trauma
• This increased mortality wasdue to–
▫ lower Glasgow coma score
▫ greater transfusion requirements
▫ greater fluid infusion requirements
As compare to younger population
• These differences highlight the importance of
considering damage control orthopaedics for elderly
patients.
• In addition, treatment should be directed toward
measures that enhance immediate mobilization and
the avoidance of prolonged bed rest in this patient
population.
• A selective approach should be used
for patients with long-bone fractures
and a chest injury
• Clinical parameters may be helpful in
determining the appropriateness of
early long-bone stabilization:
▫ severity of pulmonary dysfunction
▫ Hemodynamic status
▫ estimated operative time
▫ Estimated blood loss
▫ fracture status (open or closed)
Head Injuries
• The initial management of a patient with a head
injury should be similar to that of other trauma
patients, with a focus on the rapid control of
hemorrhage and restoration of vital signs and tissue
perfusion.
• A brain injury can be made worse if resuscitation is
inadequate or if operative intervention such as long-
bone fixation decreases mean arterial pressure or
increases intracranial pressure.
• The treatment protocol for unstable patients should
be based on the individual clinical assessment and
treatment requirements rather than on mandatory
policies with respect to the timing of fixation of long-
bone fractures.
• Aggressive management of intracranial pressure
appears to be related to an improved outcome
• Intracranial pressure monitoring should be utilized in
the intensive care unit as well as during surgical
procedures in the operating room.
• Maintenance of cerebral perfusion pressure at >70
mm Hg and intracranial pressure at <20 mm Hg
should be mandatory before, during, and after
surgical procedures
Mangled Extremities
• A damage control orthopaedics
approach to saving the limb may
make it possible to improve surgeon-
controlled variables that appear to be
related to better outcome
• E.g. The use of spanning external
fixation, antibiotic bead pouches and
the vacuum-assisted wound closure
technique may provide a bridge to
staged osseous reconstruction and soft
tissue coverage procedures.
Isolated Complex Lower-Extremity Trauma
• Indication for a limited form of damage control
orthopaedics
• Specific injuries that are amenable to this approach
include
▫ complex proximal tibial articular and metaphyseal
fractures
▫ distal tibial pilon fractures.
Advantages of DCO

• Minimal systemic effect

• Help resuscitation e.g. bleeding control
• Allow better operative plan.(more time for planning)
• Less argument with colleagues.(“prudently
aggressive”)
• Reconstruction under best circumstances.
• Best team possible for difficult work.
•THANK YOU

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