Definition
Approach that contains and stabilises orthopaedic injuries
- so that the patient's overall physiology can improve
Aim to avoid second hit of a major orthopaedic procedure
- delay definitive fracture repair until a time when the overall condition of the patient is optimised
History
Damage control began in general surgery
Phase 1
- control bleeding with packs
Phase 2
- resuscitate patient
Phase 3
- definitive surgery
Pathogenesis
One hit
- initial massive injury and shock
- intense systemic inflammatory syndrome
- macrophages, leucocytes, NK cells, interleukin, complement
- can precipitate multiorgan damage and failure
- i.e. increase endothelial permeability in lungs and predispose to ARDS / MODS
Second hit
- restimulates / hyperstimulates inflammatory system
- i.e. prolonged surgical procedures
Injury severity markers
IL6
- correlates well with degree of injury
- now routine in large trauma centres
CRP, TNF, IL 1 and 8
- no correlation to injury severity
Genetic predisposition
- DLA-DRII
Indications for DCO
Unstable patients / patient in extremis
Bilateral lung contusions / thoracic trauma
Abdominal / pelvic trauma and hemorrhagic shock
Bilateral femur fractures
Parameters
1. Acidotic: pH < 7.24, lactate > 2.5 mmol/l
2. Hypothermia: temperature < 35
3. Transfusion: > 10 units of blood
4. Coagulopathy: platelets < 90 000
4. Long operative times > 90 minutes
5. > 65 / geriatric patient
Exaggerated inflammatory response
- IL 6 > 800 ug/ml
Injury Severity Score / ISS
- > 20 with chest trauma
- > 40
Injury Severity Score
Based on Injury Scale / AIS
- 9 body regions
- head / face / neck / chest / spine / abdomen / UL / LL / external
- rated in severity 1 - 6
- max of 75
- minor / moderate / serious / severe / critical / untreatable
- a score of 6 in any region indicates futility of medial care
ISS
- 6 body regions
- head and neck / face / thorax / abdomen / extremity / external
- top 3 scores in any region are squared
- major trauma > 15
Timing of secondary Orthopaedic Procedures
Inflammatory response not diminished until day 6
Probably once patient stable