Multiple Trauma

David H. Masjhoer
SMF Orthopedi & Traumatologi
RSU AW Syahranie/FK UNMUL

Biomekanik Dari Fraktur

definition

Syndrome of multiple injuries (ISS >17) with

sequential systemic traumatic reactions
which may lead to dysfunction or failure of
remote organs and vital systems, which had
not themselves been directly injury

Fracture are more common component

Importance of fracture
Wound of bone and soft tissue, giving rise to
stress, pain and haemorrhage
Can cause contaminate and compartment
syndromes with ischemia-reperfusion injury
Instability of fracture

Algorithm of initial assesment, life

support,
day-1 surgery
Primary
survey
Basic imaging

Secondary
survey

Resuscitation
Oxygenation,
perfusion

Evaluation
Vital function ?
Response ?

Damage
control

scoring

Life saving
surgery

ICU

Delayed
primary
surgery

End points of resuscitation

Stable

Aims and scopes for fracture

management
Control of haemorrhage
Control of sources of
contamination
removal of dead tissue,
prevention of ischemiareperfusion injury
Pain relief
Facilitation of intensive
care

Realized by :

Haemostasis
Debridement
Fasciotomy
Fracture fixation
Tension free wound
coverage

Priorities and Timing of Surgery Depending

on Physiological Status

Physiological
( -- )
Status
Response to
resuscitation

(?)

Surgical
Intervention

Hyper-inflammation
Window of Opportunity

Live-Saving Surgery
Damage Control
Delayed Primary Surgery
Second look, only
Scheduled definitive surgery

Immunosuppression

No Surgery

Recovery

Secondary reconstructive
Surgery

(+)

Timing

Day 1
Day 2-3
Day 5-10
Week 3

( Chris L. Colton at al., AO Principles of Fracture Management, 2000 )

10

Two Hit Model

First insult

Moderate SIRS
Moderate Immunosuppression

11

Two Hit Model

Severe
SIRS

First insult

Moderate SIRS
Moderate Immunosuppression
2nd
Insult

Severe
Immunosuppression

Definitive
Surgery
12

Two Hit Model

Severe
SIRS

First insult

MOF

Moderate SIRS
Moderate Immunosuppression
2nd
Insult

Severe
Immunosuppression

Definitive
Surgery
13

Two Hit Model

Severe
SIRS

First insult

MOF

Moderate SIRS
Moderate Immunosuppression
2nd
Insult

Definitive
Surgery

Severe
Immunosuppression

Infection

14

Two Hit Model

Severe
SIRS

First insult

MOF

Moderate SIRS
Moderate Immunosuppression
2nd
Insult

Definitive
Surgery
MOF

Severe
Immunosuppression

Infection

15

Two Hit Model

Severe
SIRS

MOF
Definitive Surgery

First insult

Moderate SIRS
Moderate Immunosuppression
2nd
Insult

Definitive
Surgery
MOF

Severe
Immunosuppression

Infection

16

Terima kasih