Damage Control Orthopaedics - Everything You Need To Know - Dr. Nabil Ebraheim

Dr. Ebraheim’s educational animated video describes information associated with damage control orthopaedics.

In damage control orthopaedics; what do you focus on, what are the priorities? How do you determine adequacy of resuscitation? When do you do definitive care?
In damage control orthopaedics, we use an approach to treat the multiple trauma patient by staging the definitive management. We do this to limit the cumulative trauma effect.
Trauma is associated with a surge in the inflammatory mediators. The peak is usually about 2.5 days post-trauma (first hit). We delay the definitive management until the acute inflammatory window is closed. We avoid and minimize the second hit!
We avoid provoking a severe inflammatory response and at the same time, provide sufficient stabilization of fractures and prevent tissue damage. We will stop the hemorrhage, restore the circulation or perfusion, and eliminate contamination of the wounds. By adopting this damage control, we will decrease the impact of the second hit and avoid adding more trauma to the vulnerable patient. Definitive care is delayed until the patient’s condition improves. In this case you will use external fixation for the femur and the tibia, and splints for the forearm and the humerus.
You can leave external fixation in the femur for up to 3 weeks and in the tibia, external fixation can be left for up to 10 days. In the tibia, if treatment is delayed or if there is pin tract infection, then you have to do stage conversion.
With the pelvis, look for the word “binder” if you need a pelvic binder. In multiple trauma, you will delay the surgery on the pelvis for 7-10 days.
We use damage control when the patient cannot be adequately resuscitated. The patient is acidotic, hypotensive, hypoxic, hypothermic, patient has coagulopathy, and you are going to use an external fixation. The leukocytes are primed by the initial, primary trauma.
The early total care in a sick patient may not be appropriate and actually may bring severe complications to the patient, such as ARDs and multiple organ failure.
What are the parameters that will help us to decide which patient should be treated with damage control orthopaedics?
• Injury severity score (ISS) more than 40 without thoracic trauma
• Injury severity score (ISS) more than 20 with thoracic trauma
• Glasgow coma scale of 8 or below
• Bilateral femur fractures
• Pulmonary contusion as seen on x-rays
• Multiple injuries with severe abdominal and pelvic trauma
• Hemorrhagic shock
• Hypothermia less than 35 degrees
• Patients with severe head injuries are at risk of hypothermia
• If the international normalized ration (INR) is more than 1.5, then the patient could be disseminated intravascular coagulation (DIC). In head injury patients, the drop in the systemic blood pressure may lower the cerebral perfusion and compromise the brain function.
These groups of patients will have damage control orthopaedics. They find reduction in the rate of ARDS and multiple organ failure with the use of damage control orthopaedics.
First Hit:
• Trauma
o Systemic inflammatory response
o Cytokines and primed leukocytes
o If the surgeon is doing an early total care, especially with IM rods (reaming is bad, has systemic effects), in this case you will have a long surgery with blood loss, fluid loss, ore cytokines, and more activation of the coagulation system.
• Second Hit
o Surgical blood loss
o Surgery will exacerbate the systemic inflammatory response.
The primed immune system of the patient has a huge ability for response with primed leukocytes that will cause tissue and lung injury (avoid this by damage control). We control the situation now! We say yes or no to surgery. Yes to small surgery and no to big surgery. We stage the treatment with damage control. This acute inflammatory response window is considered to occur between 2-5 days. This is the period when most of the surge in the inflammatory markers occurs. Only potential or limb threatening injuries can be treated during this time (compartment syndrome, fractures with vascular injury, unreduced dislocations, open fractures, long bone fractures or an unstable spine). If timing of surgical intervention is not appropriate, you can get the second hit with acute tissue and lung injury. If the patient is stable, they will go to the operating room. If the patient is not stable, then the case will be delayed. This borderline patient will probably benefit from a delay in surgery.

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