1 Assessment, management and decision making in the treatment of polytrauma patients with head injury, DCO Heather A. Vallier, M.D. Professor of Orthopaedic Surgery C.L. Nash Professor of Orthopaedic Education Case Western Reserve University The MetroHealth System 2016

2 Trauma is a public health problemLeading cause of death and disability in people <45 y/o Number of injured people increases each year (more surviving) Better vehicle safety Better transport systems Better critical care Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS) 2010.

3 Trauma is a public health problem> $500B annual expenses to treat injury in US (direct + indirect costs) More costly than heart disease, cancer, cerebrovascular disease combined Centers for Disease Control and Prevention, National Center for Health Statistics (NCHS). National hospital discharge survey: 2010 summary. National health statistics reports, no. 29. Atlanta, GA: NCHS; 2010. US Department of Health and Human Services, Agency for Healthcare Research and Quality, Medical expenditures survey data, 2011.

4 Trauma centers save livesAlgorithm-based care Triage and transport patient to anticipated level of care Some regions have developed systems with multiple hospital business entities: e.g. Maryland: 1st statewide EMS system, Shock Trauma Center level 1 model e.g. Northern Ohio Trauma System: one level 1, two level 2, 13 non-trauma ctrs Mortality decreased, although # trauma centers in the area decreased Regional collaboration across hospital systems to develop and implement trauma protocols saves lives within 2 years. Claridge JA, Allen D, Patterson B, DeGrandis F, Emerman C, Bronson D, Connors A. Surgery Oct;154(4):875-82

5 Mortality after traumaImmediate: severe brain injury, transection great vessels, other major hemorrhage Early (minutes to hours): Brain injury (epidural/subdural bleed), hemo/pneumothorax, diaphragm rupture, pelvis/long bones fxs Delayed (days): sepsis, multiple organ failure

6 Trauma Deaths Immediate: Devastating injuryEarly: shock, hypoxia or head injury Delayed: sepsis, ARDS,MOF 6

7 Mortality after traumaTrauma centers mitigate early and delayed mortality Damage control tactics may improve early mortality (control hemorrhage) and delayed mortality (minimize systemic inflammation and organ failure)

8 Treat the greatest threat to life firstATLS principles Advanced Trauma Life Support Treat the greatest threat to life first Primary survey: Resuscitation simultaneously Secondary survey: Provisional and definitive care Tertiary survey ATLS Manual, 9th edition, American College of Surgeons 2012

9 Primary survey A Airway B Breathing C CirculationD Disability/neurological E Exposure/environmental

10 Potential adjuncts to primary surveyChest XR AP pelvis XR Foley catheter gastric tube FAST: Focused abdominal ultrasound

11 Lateral C spine XR is no longer included in ATLS protocolAirway Maintain C spine precautions Chin lift/jaw thrust Establish and protect airway oral, nasal, or surgical Lateral C spine XR is no longer included in ATLS protocol

12 Breathing Assess breathing and oxygenationIdentify and treat sources of reduced oxygenation: Tension pneumothorax  needle decompression Pneumothorax  chest tube insertion Perform ABG

13 Breathing Establish mechanical ventilation when pt unable to breathe adequately or unable to protect airway e.g. vomiting, seizure, combative, severe face/neck injury w/swelling and bleeding Hyperventilation for severe head injury

14 Circulation Hemorrhagic shock is most common typeAssess wounds, abdomen, pelvis stability, peripheral pulses CONTROL BLEEDING direct pressure compressive dressings tourniquets

15 Hemorrhagic shock Class 1 Class 2 Class 3 Class 4 Blood loss (mL)Class 1 Class 2 Class 3 Class 4 Blood loss (mL) Up to 750 >2000 Blood loss (% of volume) Up to 15% 15-40% 30-50% >40% Heart rate <100 >100 >129 >140 Blood pressure Normal Decreased Pulse pressure (mmHg) Respiratory rate 14-20 20-30 30-40 >35 Urine output (mL/hr) >30 5-15 Negligible Mental status Slightly anxious Mildly anxious Confused Lethargic

16 Other types of shock Cardiogenic: heart failure, acute MI, pericardial tamponade Neurogenic: spinal cord injury, closed head injury Septic (rare early in trauma)

17 Resuscitation Begins immediately, continues during primary and secondary surveys Establish 2 large bore IVs 2L lactated Ringers If no improvement in hypotension, consider transfusion

18 Disability Neurological exam Glasgow Coma Scale

19 Glasgow Coma Scale Clinical parameter Points Eye Opening (E) Spontaneous 4 To speech 3 To pain 2 None 1 Motor Response (M) Obeys commands 6 Localizes pain 5 Normal flexion (withdrawl) Abnormal flexion (decorticate) Extension (decerebrate) None (flaccid) Verbal Response (V) Fully oriented Disoriented/confused conversation Inappropriate words Incomprehensible words Glasgow Coma Scale

20 Exposure Remove clothingNormalize temperature: heating or cooling blankets, warmed fluids as indicated

21 Secondary survey Complete head to toe surveyAdditional radiography: plain XR and CT Laboratory tests

22 Tertiary survey Complete head to toe surveyImportant for orthopaedic surgeons to avoid missing injuries Repeated as needed when mental status normalizes

23 Key points for orthopaedic surgeonsPelvis fractures can be life-threatening Assess pelvic stability Assess/dress open wounds Apply sheet or binder for diastasis Perform retrograde urethrogram prior to foley catheter if blood at urethral meatus or high riding prostate Circumferential pelvic antishock sheeting: a temporary resuscitation aid. Routt ML Jr, Falicov A, Woodhouse E, Schildhauer TA. J Orthop Trauma Jan;16(1):45-8.

24 Key points for orthopaedic surgeonsMultiple long bone fractures generate massive hemorrhage Femur fx: cc Tibia fx: cc Open fractures will bleed more and may have had large blood loss prior to arrival Risk of mortality: the relationship with associated injuries and fracture treatment methods in patients with unilateral or bilateral femoral shaft fractures. Willett K, Al-Khateeb H, Kotnis R, Bouamra O, Lecky F. J Trauma Aug;69(2):405-10

25 Orthopaedic emergenciesDysvascular extremity  reduce fx/disloc and reassess, emergent provisional stability and revascularization Compartment syndrome  fasciotomy Cauda equina syndrome  decompression Open fractures  iv abx <6hr, debridement Dislocations  reduction (open if closed reduction not possible) Type III open tibia fractures: immediate antibiotic prophylaxis minimizes infection. Lack WD, Karunakar MA, Angerame MR, Seymour RB, Sims S, Kellam JF, Bosse MJ. J Orthop Trauma Jan;29(1):1-6.

26 Basic management of injuries to other systemsHead injury Chest injury Abdominal injury

27 Head injury Keep brain perfused and oxygenatedReverse Trendelenberg position Maintain cerebral perfusion pressure > 70mmHg and ICP < 20mmHg (CPP = MAP – ICP) - iv mannitol - hyperventilation - fluid restriction Flierl MA, Stoneback JW, Beauchamp KM, et al. Femur shaft fracture fixation in head-injured patients: When is the right time? J Orthop Trauma 2010;24:   Scalea TM, Scott JD, Brumback RJ, et al. Early fracture fixation may be "just fine" after head injury: no difference in central nervous system outcomes. J Trauma 1999;46: Wang MC, Temkin NR, Deyo RA, et al. Timing of surgery after multisystem injury with traumatic brain injury: Effect on neuropsychological and functional outcome. J Trauma 2007;62:

28 Chest injury Most chest injuries are minor Some are life-threatening:Tension pneumothorax Hemo/pneumothorax Pericardial tamponade Aortic injury Diaphragm rupture Tracheal rupture

29 Abdominal injury Most common site of occult hemorrhageExploratory laparotomy indicated for penetrating trauma or uncontrolled hemorrhage after blunt trauma In presence of pubic diastasis, perform pelvic ex fix prior to exploratory laparotomy to prevent further diastasis The effect of laparotomy and external fixator stabilization on pelvic volume in an unstable pelvic injury. Ghanayem AJ, Wilber JH, Lieberman JM, Motta AO. J Trauma Mar;38(3):

30 Timing of axial and femoral fracture fixationThese injuries have associated bleeding (reduction and fixation will control) These injuries require recumbency and bedrest until stabilized (associated pulmonary and thrombotic risks) These injuries produce more pain/narcotic requirements until stabilized The impact of open reduction internal fixation on acute pain management in unstable pelvic ring injuries. Barei DP, Shafer BL, Beingessner DM, Gardner MJ, Nork SE, Routt ML. J Trauma Apr;68(4):

31 Early definitive fixation may be considered standard of care in stable patientsBone LB, Johnson KD, Weigelt J, Scheinberg R: Early versus delayed stabilization of femoral fractures. A prospective randomized study. J Bone Joint Surg Am Lefaivre KA, Starr AJ, Stahel PF, Elliott AC, Smith WR. Prediction of pulmonary morbidity and mortality in patients with femur fracture. J Trauma 2010;69: ;71: Harvin JA, Harvin WH, Camp EC, et al. Early femur fracture fixation is associated with a reduction in pulmonary complications and hospital charges: a decade of experience with 1376 diaphyseal femur fractures. J Trauma 2012;73: Vallier HA, Super DM, Moore TA, Wilber JH. Do patients with multiple system injury benefit from early fixation of unstable axial fractures? The effects of timing of surgery on initial hospital course, J Orthop Trauma 2013;27:

32 Early total care Stabilization of all fracturesDefinitive, not provisional Can be dangerous in under-resuscitated patients Early Total Care can be dangerous to the systemic status of pts who are underresuscitated. It can also be deleterious to compromised soft tissues associated with periartiuclar fxs when definitive fixation is performed too early.

33 Damage control orthopedicsProvisional fixation of fractures to allow for improved physiology Provide stability and minimal soft tissue damage with little surgical bleeding Avoid “second hit” of major orthopedic procedure until patient is resuscitated Scalea TM, Boswell SA, Scott JD, et al. External fixation as a bridge to intramedullary nailing for patients with multiple injuries and with femur fractures: damage control orthopedics. J Trauma 2000;48: Tuttle MS, Smith WR, Williams AE, et al. Safety and efficacy of damage control external fixation versus early definitive stabilization for femoral shaft fractures in the multiple-injured patient. J Trauma 2009;67:

34 Inflammation Cytokines and inflammatory mediators cause tissue hypoxia and PMN activation PMN activation generates endothelial damage and vascular permeability Coupled with hemorrhage from injury (hypo-volemia and hypoxia) can be life-threatening Systemic inflammatory response syndrome (SIRS) SIRS: criteria 2 or more: T<36 or >38; HR>90; RR>20; WBC<4 or >12, immature neutrophils >10% Pape HC, Giannoudis PV, Krettek C, Trentz O. Timing of fixation of major fractures in blunt polytrauma. Role of conventional indicators in clinical decision making. J Orthop Trauma 1991;19: Pape HC, Schmidt RE, Rice J, et al. Biochemical changes after trauma and skeletal surgery of the lower extremity: quantification of the operative burden. J Crit Care Med 2000;28: Harwood PJ, Giannoudis PV, van Griensven M, Krettek C, Pape HC. Alterations in the systemic inflammatory response after early total care and damage control procedures for femoral shaft fracture in severely injured patients. J Trauma 2005;58:

35 Surgery creates additional trauma while treating the injury!Early definitive care Systemic inflammation Delayed definitive care Time Surgery creates additional trauma while treating the injury!

36 Damage Control Systemic inflammation Time DCO minimizes inflammation to prevent exceeding a threshold level for SIRS and organ failure

37 Unresolved issues with DCOWhat about injuries other than the femur? Spine, pelvis, acetabulum Some fractures are not amenable to external fixation When to use DCO? Which parameters? Problems w/inflammatory markers Which injury types are predictive? When to use DCO: what parameters or injury types Inflammatory markers are nonspecific, unavailable, expensive to measure, take several days, and MAY indicate established inflammation, not pts at risk Consider non-femur fxs and fxs not amenable to ex fix (including some femur fxs) Most axial and femoral fxs are safely stabilized acutely and THIS IS MORE COST-EFFECTIVE DCO: adds expenses of materials, OR time, extra days in hospital, increased infection risk from pins When is DCO cost effective?

38 Unresolved issues with DCOWhat to do when ex fix is not an option? Which injury types warrant delay?

39 Indications for DCO Persistent hemodynamic instabilityPersistent metabolic acidosis Severe head injury with CPP <70 mmHg; ICP >20 mmHg Spinal cord injury with evolving neuro deficit (reduction/fixation of spine may be higher priority) Cardiac dysfunction Nicholas B, Toth L, van Eessem K, et al. Borderline femur fracture patients: early total care or damage control orthopaedics? ANZ J Surg 2011;81: Pape HC, Rixen D, Morley J, et al; EPOFF Study Group. Impact of the method of initial stabilization for femoral shaft fractures in patients with multiple injuries at risk for complications (borderline patients). Ann Surg 2007;246: Nahm NJ, Moore TA, Vallier HA. Use of two grading systems in determining risks associated with timing of fracture fixation. J Trauma Acute Care Surg 2014;77:

40 Indications for definitive fixationAdequate resuscitation lactate <4.0, base excess ≥-5.5, pH ≥7.25 Coagulopathy corrected Early definitive fixation (within 36 hours) of axial (pelvis/spine), femoral shaft, proximal femur, and acetabulum fractures in stable patients reduces complications, length of stay and costs O’Toole RV, O’Brien M, Scalea TM, et al. Resuscitation before stabilization of femoral fractures limits acute respiratory distress syndrome in patients with multiple traumatic injuries despite low use of damage control orthopaedics. J Trauma 2009;67: Stahel PF, VanderHeiden T, Flierl MA, et al. The impact of a standardized “spine damage-control” protocol for unstable thoracic and lumbar spine fractures in severely injured patients. J Trauma 2013;74: Vallier HA, Wang X, Moore TA, Wilber JH, Como JJ. Timing of orthopaedic surgery in multiply-injured patients: Development of a protocol for Early Appropriate Care, J Orthop Trauma 2013;27: Complications are reduced with a protocol to standardize timing of fixation based on response to resuscitation. Vallier HA, Moore TA, Como JJ, Wilczewski PA, Steinmetz MP, Wagner KG, Smith CE, Wang XF, Dolenc AJ. J Orthop Surg Res Oct 1;10:155.

41 Summary Trauma care is algorithm-based, follows ATLS guidelines, and requires continuous reassessment of pt Ortho emergencies: massive hemorrhage from fxs (pelvis, multiple long bones), dysvascular limb, compartment syndrome, open fxs, dislocations

42 Summary Early definitive fixation of axial and femoral fxs (within 36 hr) is safe and advantageous in stable pts (lactate <4.0) DCO indications: head injury with CPP <70mmHg, myocardial demise, persistent metabolic acidosis/hemodynamic instability