TIMING OF FRACTURE FIXATION IN POLYTRAUMA PATIENTS ANAESTHESIOLOGIST’S PERSPECTIVES Dr.R.Selvakumar

POLYTRAUMA-NIGHTMARE FOR THE PATIENT & AS WELL AS FOR THE ANAESTHESIOLOGIST KANISACON-2010

SURGEON & ANAESTHETIST having Opposite Views KANISACON-2010

Why anaesthetist wants to avoid? - prolonged hours of surgery - Unexpected response KANISACON-2010

Polytrauma: Hypovolemia Multiple system involvement less time for evaluation missed injuries (head & abdomen) prolonged surgery massive blood transfusion difficulty in monitoring surgical difficulties KANISACON-2010

Unique problem increased incidence of respiratory failure ARDS KANISACON-2010

Why there is an increased incidence of respiratory failure? ARDS → fat embolism KANISACON-2010

Fat embolism in polytrauma Pathophysiology ↑ in intra medullary pressure →fat droplets → get filtered in the pulmonary circulation minute droplets go through pulmonary circulation & get trapped in cerebral circulation alveolar lipase → hydrolysis of fat → release of fatty acids (palmitic, stearic, oleic) Neutralisation by albumin KANISACON-2010

Pathophysiology of Fat Embolism - contd failure of neutralistion by albumin fatty acids + calcium →intercellular septa rupture → diffuse areas of haemorrhage & oedema in pulmonary interstitium & alveolar space KANISACON-2010

Pathophysiology of Fat Embolism - contd Integrins CD11b & CD18 cause adherence of neutrophils & endothelium Injured pnumocytes stop surfactant production→ collapse of alveoli ↑ shunt and dead space KANISACON-2010

Just to relax……

Secondary injury: FE incidence in a polytrauma -30-90% If surgery is performed following polytrauma, will reaming further increase the incidence of FE? KANISACON-2010

Will it produce a second hit ? KANISACON-2010

Medullary reaming & Cementation Normal I.M pressure - 30 – 50mm of Hg. Violent force in the bone - I.M pressure ↑many fold. Reaming increases I.M.P ↑ up to 400-600 mm of Hg. Cementation → 650-1500 of Hg. KANISACON-2010

What they did…. In 1960s: Ill development of pulmonary care Wait till FES resolves Kuntscher’s three recommendations KANISACON-2010

Kuntscher’s recommendations: 1. Don’t nail as long as symptoms of FE are present 2. Take special precaution for patients with multiple fracture and extensive soft tissue injuries 3. Don’t nail immediately, but wait a few days KANISACON-2010

Negative effects of delayed fixation prolonged immobilisation pneumonia, bedsore, renal failure, inadequate nutrition, vascular abnormalities poor results KANISACON-2010

A word about hyponatraemia… old age ↓ appetite depression social conditions restlessness,disorientation etc KANISACON-2010

Drastic changes in the 1980s Early fixation better understanding of pathophysiology of trauma improvement in critical care KANISACON-2010

Changes in the 1980s….. It led to aggressive management without improving the supportive care Bad results KANISACON-2010

Damage control orthopaedics: Pack the major sources of haemorrhage Resuscitation and stabilisation of the general condition Temporary immobilisation of bone fractures KANISACON-2010

Current recommendations Classify the patients according to their physical status 1. stable grade I 2. borderline grade II 3. unstable grade II 4. In extremis grade IV KANISACON-2010

Creteria used in the physical status classification Shock – B.P, No of blood units, lactate levels,B.D,ATLS Coagulation status Temperature Soft tissue injuries KANISACON-2010

Stable patients: Do whatever you want…. KANISACON-2010

Borderline patients who respond to resuscitation…… proceed with definitive fixation limit the surgical duration within 2 hours KANISACON-2010

Remember… Grade II to IV easily….. A bad surgeon can shift the ASA KANISACON-2010

Borderline patients: Continuous reassessment Pao2/F102 should not drop below 200mm of Hg Temperature should not drop below 32C Requirement of fluids should not exceed 3L or 5units of blood Absence of significant coagulopathy If not → DCO KANISACON-2010

Unstable and patients in extremis: Life saving surgeries External fixation Resuscitation and stabilization simultaneously KANISACON-2010

Strategy in patients with head injury: Beware of the fact that cerebral auto regulation goes off following head injury Extensive sympathetic block due to regional anaesthesia may hamper CBF Severe head injury → only life saving procedures KANISACON-2010

Strategy in patients with chest injury Rib fracture or lung contusion Monitoring with pulseoximeter or ABG Incidence of ARDS Severe chest injury →only life saving procedures KANISACON-2010

What to do to prevent the incidence of FES? Avoid increase in IM pressure Medullary channel depletion Venting the medullary channel Uncemented prosthesis KANISACON-2010

summary In polytrauma, immediate fixation may lead to secondary complication Classify the patients according to their Physical status Grade I and II – Immediate surgery Grade III and IV – resuscitation,DCO, Delayed fixation KANISACON-2010

Conclusion: Pre-operative status of the patient decides the timing of the fracture fixation in the poly-trauma patients…. KANISACON-2010

THANK YOU Dr.R.SELVAKUMAR M.D.,D.A.DNB ASSOCIATE PROFESSOR COIMBATORE MEDICAL COLLEGE COIMBATORE