Sascha Halvachizadeh MD1,2, Paolo Cinelli PhD2, Florin Allemann MD1, Philipp Kobbe MD MHBA3 and Hans‐Christoph Pap MD1 1University of Zurich, Universitätsspital Zurich, Department of Trauma, Zurich, Switzerland 2University of Zurich, Universitätsspital Zurich, Research Laboratory, Division of Surgery and Harald Tscherne Laboratory, Zurich, Switzerland 3Aachen University Medical Center, Department of Orthopaedic Trauma, Aachen, Germany One of the most difficult tasks for a treating physician is to decide about clearance for surgery – and what type, depending on the patient`s condition. Previous studies have shown that early definitive surgery is beneficial in most patients, but lengthy operations, or overzealous blood loss, may trigger complications. Around the turn of the century, damage control orthopedics (DCO) was introduced to the care of the severely injured patient (level II and III).1,2 This implies the application of an external fixator to stabilize major fractures of the extremities, or the pelvis, whenever the patient’s condition is critical (borderline or worse). This technique is in contrast to early total care, where the fracture is stabilized definitively in one surgical session. The most relevant advantage of DCO is the substantial decrease of mortality3 (level III) resulting from minimal invasive surgery minimizing the second hit, a theory that indicates the surgery to be a second traumatic hit that might overwhelm the inflammatory response and lead to sepsis, multiple organ failure, and death4 (level III). However, DCO implies further surgical interventions to perform the definitive fixation and prolonged hospitalization with their associated increased risks of complications and adverse events. Table 70.1 Defining the condition of a multiple injured patient3 norm = normal range AIS = Abbreviated injury Scale TTS = Thoracic Trauma Score DCO = Damage control orthopedic ETC = Early Total Care Several studies have been performed to evaluate which is the best parameter – or combination – to describe patients at risk. For two decades, the triad of death, using indicators of shock, acidosis, and coagulopathy has been used to assess trauma patients (level III).5 One of the earliest classification method that is still in use in routine clinical practice is the Injury Severity Score (ISS), that merely describes injury severity and distribution without giving recommendations on treatment strategy (level III).6 Rotondo et al. described pathological values of acid–base, temperature, and coagulation as the triad of death that should be treated as early as possible (level III).5 Nahm et al. proposed the stratification of patients depending on only three laboratory values (all from the acid–base group) into low‐ and high‐risk patients; they postulated definitive surgery to be safe in low‐risk patients ( level III).7 A further scoring system includes the injury severity and stratifies the patient’s condition based on the mortality rate (level III).8 Based on published evidence, the clinical grading scale categorizes the severely injured patient based on parameters of shock, coagulation, temperature, and soft tissue injuries, and recommends appropriate treatment strategies based on the patient’s condition (level II).9 Overall, no level I evidence exists that clearly presents recommendations on what parameter, or which combinations of parameter, are to be used in defining the condition of the severely injured patient. Studies investigating this topic draw their conclusions mainly based on retrospective data analysis8,10,11 and one on the combination of a profound literature review and expert opinion.2 However, what most of these findings have in common are the evaluation of parameters from the same physiologic systems: shock and hemorrhage, acid–base, coagulation, temperature, and injury severity. The current literature suggests that this patient is to be graded as borderline
70
Damage Control Orthopedics
Clinical scenario
Top three questions
Question 1: In patients with multiple injuries in a borderline or unstable condition, what parameters best describe a patient in danger for complications?
Rationale
Clinical comment
Parameter
Stable (Grade 1)
Borderline (Grade 2)
Unstable (Grade 3)
In Extremis (Grade 4)
Shock
systolic Blood pressure (mmHg)
100 or more
80‐100
60‐90
<50‐60
Blood units received within 2h after admission
0‐2
2‐8
5‐15
>15
Lactate (mmol/l)
norm
<2.5
>2.5
severe acidosis
Base deficit
norm
no data
no data
> ‐18 ‐ (‐6)
ATLS Shock class
1
2‐3
3‐4
4
Urine output (ml/h)
>150
50‐150
<100
<50
Coagulation
Platelet count (mug/ml)
>110.000
90.000‐110.000
<70.000‐90.000
<70.000
Factor II/V(%)
90‐100
70‐80
50‐70
<50
Fibrinogen (g/dl)
>1
approx. 1
<1
DIC
D‐Dimer
norm
abdnormal
abdnormal
DIC
Temperature
°C
<>34
33‐35
30‐32
<30
Soft Tissue injury
Lung function (PaO2/FiO2)
>350
300
200‐300
<200
AIS Chest
1‐2
>2
>2
>3
TTS
0
1‐2
2‐3
4
Moore Abdomen
<2
<3
3
>3
AO Pelvis
A type
B or C
C
C (crush, rollover abd.)
AIS Extremities
1‐2
2‐3
ETC if stable or
3‐4
Crush, rollover
Recommended Surgical Strategy
ETC
stabilized In doubt: DCO
DCO
DCO
Available literature and quality of the evidence
Findings
Resolution of clinical scenario
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