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Damage Control Management In The Polytrauma Patient



This book is an unparalleled source of cutting-edge information on every aspect of rescue, trauma management, and fracture care in the polytrauma/multiple injured patient. Damage control surgery is approached logically and systematically by dividing treatment into phases. The common goal of treating life-threatening conditions first, then treating major pelvic and extremity fractures, requires cooperation among all major disciplines and subspecialties involved in the care of polytrauma patients, and the book is accordingly multidisciplinary in nature. It is edited by pioneers in the field and the authors are all acclaimed experts. This second, revised and updated edition of Damage Control Management in the Polytrauma Patient will be invaluable for all clinicians who must weigh life-saving operations against limb-threatening conditions, including emergency personnel, trauma surgeons, orthopaedic traumatologists, and anesthesiologists.




Damage Control Management in the Polytrauma Patient



Hans-Christoph Pape, MD, FACS, graduated in 1988 from Hannover Medical School, where he then completed a residency in trauma surgery. He was appointed Full Professor of Trauma Surgery at the School in 2000. Between 2003 and 2005 Dr. Pape was also a Visiting Professor at Harvard Medical School and other U.S. universities. Dr. Pape is currently W. Pauwels Professor and Chairman of the Department of Orthopaedic/Trauma Surgery at the University of Aachen Medical Center, Germany. During his career, Dr. Pape has received many awards, including the Novartis Prize (2005), the Swiss AO Foundation Annual Award (2006), and the Kappa Delta Award from the American Academy of Orthopedic Surgeons (2008). He is the Editor in Chief for Open Access Emergency Medicine and a Section Editor for Injury and the European Journal of Trauma. Dr. Pape has been the lead author on 81 publications in peer-reviewed journals and co-author of a further 220. He is also the editor or author of several important books and has led many courses on polytrauma management.


Peter Giannoudis, BSc, MB, MD, FRCS, is Professor in the Academic Department of Trauma & Orthopaedic Surgery, School of Medicine, University of Leeds, UK and Honorary Consultant at Leeds General Infirmary. He specializes in the management of multiple injured patients and has major interest in reconstructive surgery and the molecular aspects of trauma. Dr. Giannoudis is a past President of the British Trauma Society and of the European Society of Pelvis and Acetabulum. He is also an Executive Board Member of the British Orthopaedic Association National Trauma committee, an instructor for the American Academy of Orthopaedic Surgeons and the British Orthopaedic Association, an executive member of the EFORT Trauma Task Force, and past Chairman of the AO polytrauma course. Dr. Giannoudis is the author of more than 450 articles in peer-reviewed journals as well as seven textbooks. He is Editor in Chief of Injury, Associate Editor of Bone & Joint Surgery (Am) and an editorial board member for various other journals.


Not all trauma patients require damage control measures. The guidelines for initiating damage control are given in Table 1. Certain conditions and complexes of injuries assessed both preoperatively and intraoperatively require damage control.


Damage control, according to Asensio et al [8], implies immediate control of life-threatening haemorrhage, hepatic packing, pancreatic drainage, temporary hollow viscus closures, rapid stapled resections, splenectomy, nephrectomy, vascular pedicle clamping in situ, and the use of intraabdominal vascular shunts. Frequently, these patients experience abdominal compartment syndrome. Therefore, the posttraumatic open abdomen with temporary abdominal wall closure is used as an extension of damage control. Specifically, for chest injuries one should repair cardiovascular injuries, perform stapled pulmonary tractotomy, pack if needed, place chest tubes, and close the skin [8].


Damage control resuscitation: This an integrated approach where DCR and DCS are undertaken simultaneously. It involves permissive hypotension and haemostatic resuscitation along with damage control surgery [9].


Background: The optimal treatment of major fractures in patients with blunt multiple injuries continues to be discussed. The aim of this study is to investigate the clinical course of polytrauma patients treated at a Level I trauma center within the last two decades regarding the effect of changes in the management of their femoral shaft fracture.


Methods: In a retrospective cohort study performed at a Level I trauma center, the patient's injuries and clinical outcomes were studied. Adult blunt polytrauma patients were included if a femoral shaft fracture eligible for intramedullary stabilization was stabilized (including external fixation) primarily


Haemorrhagic shock is one of the main causes of mortality in severe polytrauma patients. To increase the survival rates, a combined strategy of treatment known as Damage Control has been developed. The aims of this article are to analyse the actual concept of Damage Control Resuscitation and its three treatment levels, describe the best transfusion strategy, and approach the acute coagulopathy of the traumatic patient as an entity. The potential changes of this therapeutic strategy over the coming years are also described.


Keywords: Coagulopatía traumática; Damage control resuscitation; Hemorrhagic shock; Hiperfibrinólisis; Hyperfibrinolisis; Paciente politraumático; Polytrauma patient; Reanimación por control de daños; Shock hemorrágico; Tranexamic acid; Traumatic coagulopathy; Ácido tranexámico.


The "ideal" timing and modality of fracture fixation for unstable thoracolumbar spine fractures in multiply injured patients remains controversial. The concept of "damage control orthopedics" (DCO), which has evolved globally in the past decade, provides a safe guidance for temporary external fixation of long bone or pelvic fractures in multisystem trauma. In contrast, "damage control" concepts for unstable spine injuries have not been widely implemented, and the scarce literature in the field remains largely anecdotal. The current practice standards are reflected by two distinct positions, either (1) immediate "early total care" or (2) delayed spine fixation after recovery from associated injuries. Both concepts have inherent risks which may contribute to adverse outcome.


We propose a prospective multicenter trial on a large cohort of multiply injured patients with an associated unstable thoracolumbar fracture. Patients will be assigned to one of three distinct study arms: (1) Immediate definitive (anterior and/or posterior) fracture fixation within 24 hours of admission; (2) Delayed definitive (anterior and/or posterior) fracture fixation at > 3 days after admission; (3) "Spine damage control" procedure by posterior reduction and instrumentation within 24 hours of admission, followed by anterior 360 completion fusion at > 3 days after admission, if indicated. The primary and secondary endpoints include length of ventilator-free days, length of ICU and hospital stay, mortality, incidence of complications, neurological status and functional recovery.


However, due to the lack of high level scientific evidence from prospective randomized trials, a consensus on the "ideal" timing of spine fracture fixation in multisystem trauma has not yet been reached. Advocates of early spine fixation cite multiple intuitive advantages when managing severely injured patients with unstable spine fractures. Prolonged bed rest and the inability of adequate positioning and mobilization of polytrauma patients have been associated with severe posttraumatic complications. These include the development of pressure sores, pulmonary complications, and thromboembolic events. Multiply injured patients are at additional increased risk of sustaining such adverse events secondary to their profound immunological dysfunction, as outlined above [1, 2]. Polytrauma patients require unrestricted options of mobilization and positioning in the ICU, including the upright seated position for treatment of head injuries and prone positioning for respiratory therapy of pulmonary complications, such as the acute respiratory distress syndrome (ARDS) [15]. Last but not least, any unfixated thoracolumbar fracture may contribute to the "antigenic load" of trauma by increasing stress and pain, which will add up to the overall trauma burden to the organism and turn the physiological "host defense response" into a pathological "host defense failure disease" [1, 2]. This rationale provides a strong argument for the early clearance of bed rest and log-roll precautions in multiply injured patients and forms the basis of a "spine damage control" concept in severely injured patients [9, 16, 17].


We hypothesize that the concept of "spine damage control" will provide a safe and effective treatment modality for unstable thoracolumbar fractures in multiply injured patients, associated with less complications and improved outcomes compared to conventional treatment strategies. We define "spine damage control" as a staged procedure of immediate posterior fracture reduction and instrumentation within 24 hours ("day 1 surgery") [9, 17], followed by scheduled 360 completion fusion during a physiological "time-window of opportunity" (> 3 days after trauma), if an adjunctive anterior decompression and fusion is indicated for neurological or biomechanical reasons. This concept differs from the more common elective strategy of a staged spine fixation by initial posterior fixation and delayed anterior completion by its timeliness (posterior fixation within 24 h) and expanded applicability to all unstable thoracolumbar fractures, including pure anterior column burst fractures (AO/OTA type A3).


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