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Damage Control In

Multitrauma and Orthopaedics


dr. Bambang Widiwanto, MS, SpOT

Multitrauma
Syndrome of multiple injuries with
sequential systemic traumatic
reactions which may lead to
dysfunction or failure of remote
organs and vitals systems, which
had not themselves been directly
injured.
Fracture is the most frequent
component of multitrauma.

Pathofisiologis
Wound around fracture
inflamatory (dead tissue & hypoxic).
Inflamatory release mediators and
cytokines into circulation.
Systemic traumatic reactions produce
a whole-body inflammation or a
Systemic Inflamatory Response
Syndrome (SIRS)

Pathofisiologi
SIRS condition demanding high energy
consumption and oxygen
(Hypermetabolic condition).
Hypermetabolic condition : muscle
wasting, nitrogen loss, protein
breakdown, and raise temperature.
Depletion of immunocompetent become
critical immunosupression and sepsis
more sell death MODS & MOF

Timing and Priorities of


Surgery

Primary Objective = survive with normal


function.
First priority is resuscitation to ensure
adequate perfusion and oxygenation of
all vital organs.
If there is no response immediate
live-saving surgery.
Decompression body cavity
Control of hemorrhage

Timing and Priorities of


Surgery

If immediate definitive surgery is


needed Damage control
(control of hemorrhage and
contamination, irrigation, packing,
closure of wound and stabilization
of the physiological system) in ICU
definitive surgery after 6-12
hours.

Timing and Priorities of


Surgery
If response to resuscitation delay primary surgery.
Within the locomotors system treat with high priority:
Limb-threatening and disabling injuries (open fracture
debridement, reduction, fixation, and revascularization).
Long bone fracture, unstable pelvic fracture, highly unstable
large joints and spinal injuries temporary stabilization (EF)
definitive osteosyntesis during a window of opportunity,
between days 5-10.

Timing and Priorities of


Surgery

During window of opportunity,


definitive surgery of long bone
fracture-shaft and articular-can be
performed in relative safety.
Immunosuppression last for about 2
weeks secondary reconstruction
procedure can be planned for three
week post trauma.

General Aims and Scopes of Fracture


Management in Multitrauma
Control of hemorrhage.
Control of sources of contamination,
removal of dead tissue, prevention of
ischemia-reperfusion injury.
Pain relief.
Facilitation of intensive care.
Homeostasis, debridement, fasiotomy,
fracture fixation, and tension-free wound
coverage.

Summary
Multitrauma must be considered as
a systemic surgical disease.
Successful management :

Understanding of pathology
Complete resuscitation
Correct triage and timing
Plans of care

Damage Control Orthopaedics

Introduction :
It has long been recognized that, in
patients with severe abdominal injuries
initial management should avoid
complex operative procedures
It was believed that the polytraumatised
patient did not have the physiological
reserve to withstand prolonged
operations

Systemic impact of extremity


injury :
All extremity fractures must be
considered with the associated
haemorrhage and local soft tissue
injuries.
The injury initiates a local
inflammatory response with
increased systemic concentrations
of pro-inflammatory cytokines.

FIRST HIT INJURY

Damage control concept :


In the polytraumatized patient, this
concept of surgical treatment
intends to control but not to
definitively repair the trauma.
After restoration of normal
physiologic, definitive management
of injuries is performed

The damage control concept


consist of three components :
1. Resuscitative surgery for rapid
hemorrhage control.
2. Restoration of normal physiologic
parameter.
3. Definitive surgical management

Based on the concept of damage


control surgery, the application of
the same principles to the
management of multitrauma patient
with associated long bone fracture
& pelvic fracture

DAMAGE CONTROL
ORTHOPAEDIC

Damage Control Orthopaedics


Early stabilization of unstable
fracture, control hemorrhage,
management of soft tissue injury
Resuscitation and optimize the
patient in the ICU
Delayed definitive fracture
management if condition allowed

The practice of delaying the


definitive surgery in DCO attempts
to reduce the biological load of
surgical trauma on the already
traumatized patient.

Minimize The Second Hit Injury

Time to do a definitive surgery??


Primary procedures of greater than 6
hours duration and major surgical
procedures at day 2 to 4 should be
avoided
A prospective study has recently shown
that polytraumatized patients submitted
to secondary definitive surgery at day 2
to 4, developed a significantly increased
inflammatory response, compared to
those operated at day 6 to 8

Borderline patient type should be


considered for DCO :
1. Multitrauma with thoracic trauma
2. Multitrauma with abdominal &
pelvic trauma, shock
3. Bilateral lung contusion on x-ray

Indication for DCO


1. Unstable and laborious resuscitation.
2. Coagulation disorder, platelet count <
90.000
3. Shock, demanding more than 25 blood
units for the patients full recovery
4. GCS < 8
5. Multiple long bone fracture
6. Duration of surgical operation > 6
hours
7. Hemodynamic instability Arterial
injury