Mr Lee Van Rensburg Mr Alan Norrish October 2015

 ISS 57  SAH, DAI  R Haemothorax  Pelvic ring fracture  (Dissociation R hemipelvis)  # L Acetabulum  # L Femur  Compartment syndrome both lower legs and thighs

 Laparotomy  Pelvis packed, Vac dressing  C clamp and pelvic ex fix  Angiogram  Embolisation

Theatre to CT Then ICU

 Retrograde femoral nail  Fasciotomy  Both thighs both calves 8 HRS

 Angiogram  IVC filter  Repeat bleeding  Laparotomy change of packs  Bladder repair  Pubic symphysis ORIF 36 Hrs

 Angiogram  IVC filter  Repeat bleeding  Laparotomy change of packs  Bladder repair  Pubic symphysis ORIF  2 hour rewarming on table

 Removal of C clamp  Anterior plating  R Sacroiliac joint  Debridement washout closure C clamp and Ex fix wounds

 Vac dressing change 17/05/06  Closure of thigh wounds  Vac dressing change 23/05/06  Closure of L lower leg wound  Vac dressing change 28/05/06  Closure R lower leg wound

 Planned ORIF acetabulum  Wound breakdown  L iliac crest  Both thighs  Washout and vac dressings Day 6

 #BOS  #Nasal bone  APC pelvic injury  # R Supracondylar femur  # R Tibia shaft (open)  # L Tibial plateau (open)  # Bimalleolar L ankle

 Intubated through window  Pre hospital arrest  Hr 144, Systolic 60  GCS 3

 CT brain  BOS  Angiogram  Very small bleeder embolised

 External fixator  Pelvis  R leg  L leg  Debridement washout, fasciotomy and vac dressing  R thigh  R lower leg  L lower leg  Laparotomy  EVD 4 HRS

 Plating pubic symphysis  Intramedullary nail  R femur retrograde  R tibia  Change of Vacs Day 5

 ORIF L Tibial plateau  ORIF L fibula  Free Flap R tibia  Rotation flap L Tibia Day 9

 Debridement and SSG L Ankle  Medial side Day 27

 SIRS  CARS  Genes  ETO  DCO  EAP

 Condition characterised by systemic inflammation, organ dysfunction, and organ failure.  Subset of cytokine storm, abnormal regulation of various cytokines  Inflammatory response to sepsis, trauma, hypoperfusion

Threshold for fatal inflammatory response DEATH: from multiorgan failure or adult respiratory distress syndrome 1 st Hit: the trauma inflammatory response time The ‘natural’ systemic inflammatory response

 Severe trauma can result in a life threatening inflammatory response (SIRS) Threshold for fatal inflammatory response DEATH: from multiorgan failure or adult respiratory distress syndrome 1 st Hit: the trauma inflammatory response time 2 nd Hit: the surgery The exaggerated response brought about by the 2 nd hit of surgery

 Severe trauma can result in a life threatening inflammatory response (SIRS) Threshold for fatal inflammatory response DEATH: from multiorgan failure or adult respiratory distress syndrome 1 st Hit: the trauma inflammatory response time 2 nd Hit: the surgery In some individuals the lengthy surgery of early total care exacerbates the the systemic inflammatory response resulting in death

Bone RC. Sir Isaac Newton, sepsis, SIRS, and CARS. Crit Care Med. 1996;24(7):1125–8  CARS - systemic deactivation of the immune system tasked with restoring homeostasis from an inflammatory state  More than just cessation of SIRS

 Different responses to Injury

SIRS: Severe inflammation may lead to acute multi-organ failure (MOF), lung and respiratory failure (ARDS) and death CARS: An anti- inflammatory response syndrome. May result in prolonged immunosuppression leading to sepsis

 Early Total Care  Not necessarily immediate, but within first 24 hours  Often short period in ITU for resuscitation  Repair all visceral injuries as soon as possible  Definitive fixation of all long bone fractures within 24 hours  Return to ITU only when all surgical procedures finished  Often long surgical times

 Damage control  Naval Term term:  “Capacity to absorb damage while maintaining mission integrity”

 Rapid emergency surgery to save life or limb – NOT involving complex reconstructive surgery  Control bleeding  Decompress cranium, pericardium, thorax, abdomen and limbs  Decontaminate wounds and ruptured viscera  Splint fractures  Cast, traction, pelvic binder, ex-fix  Get back to ITU environment ASAP  Definitive surgery performed several days later

J Bone Joint Surg Am, 2005 Feb; 87 (2): Louisville additional criteria pH of < 7.24 Temp < 35°C Operative time > 90 minutes Coagulopathy Transfusion > ten units packed red cells

 4 groups of patients  Stable: go for Early Total Care  Borderline: ?  Unstable: go for Damage Control Surgery  Extremis: Damage Control Surgery or ITU  Borderline patients are more difficult to define

 Initial lactate:  < 2.5 mg/dL,  5.4% ( %) Mortality  2.5 mg/dL to 4.0 mg/dL,  6.4% ( %) Mortality  >=4.0 mg/dL,  18.8% ( %) Mortality Occult Hypo perfusion, raised lactate increased mortality

 Lactate easy to measure  Often high in 1 st few hours but will drop in ITU if resuscitation adequate  2.5 magic number!  > 3 DC Surgery  2.5 – Look at TREND  < 2.5 ETC

 Days 2-5 are not safe  During this period:  Marked inflammatory response ongoing  Increased capillary permeability leads to generalized oedema  Cardiac output is high  Patient is fragile  A 2 nd hit at this stage could be fatal  Pape et al: prospective study –  multiply injured patients undergoing surgery between days 2 and 4 had a significantly increased inflammatory response compared with patients operated on between days 6 and 8

Patient with multiple injuries ITU Assess clinical condition and lactate Stable Lactate <2.5 Borderline Lactate Unstable Lactate >3.0 In Extremis Attempt to resuscita te in ED or ITU Early Total Care Resuscitate Assess lactate trend Stable Uncerta in Damage Control Surgery

Trunkey DD. Trauma. Sci Am. 1983; 249:28–35

1 st mins 1 st hour 1 st few weeks Can reduce deaths only by injury prevention strategies Can reduce deaths by excellent prehospital and emergency room care Can reduce deaths by the decisions we make regarding surgical treatment. Death from MODS & ARDS

Proc (Bayl Univ Med Cent) Oct; 23(4): 349–354

Major Trauma Centre

 Early Appropriate Care  Acceptance different patients respond differently to first and second hits  Consider severity of initial injury  Consider response to resuscitation  What further surgery required  Continued re assessment and ability to change from ETO TO DCO

JTO; Volume 02 / Issue 02 / May No single physiological parameter or blood marker can as Suggested accepted level of 2.5mmol/L is too conservative patient centred approach Physiological improvement and reversal of acidosis reflected by: lactate< 4.0 mmol/L pH ≥7.25 BE above 5.5 mmol/L

 Multiply injured patients may have a profound and life-threatening inflammatory response  A ‘second hit’ of long definitive surgery can result in a fatal inflammatory response  The second hit can be avoided using early ‘damage control surgery’ followed by late ‘definitive care’  Lactate is important in identifying patients who will benefit from damage control surgery