Polytrauma and the

Implementation of
Damage Control
Surgery
• Definition of Polytrauma patient
• Pathophysiology of trauma
• Management
• The role Orthopedic surgeon
• Special cases of trauma
• Polytrauma is a syndrome of multiple injuries exceeding a defined
severity (ISS ≥ 17) with sequential systemic reactions
• That may lead to dysfunction or failure of remote organs and vital
systems, which have not themselves been directly injured
 INTRODUCTION
Introduction
• over 1.2 million people die each year worldwide because of road traffic
injuries.
• only 10% in high-income countries.
• several thousand individuals survive with permanently disabling injuries
• In the United States, trauma-related Costs exceed $400 billion annually.
• The real cost is that trauma affects the youngest and most productive
members of society
 PATHOPHYSIOLOGY

• Traumatic injury leads to systemic inflammation (systemic inflammatory response

syndrome) followed by a period of recovery mediated by a counter-regulatory anti-
inflammatory response.
• Within this inflammatory process,
there is a fine balance between the
inflammation and the potential for the
process to cause and aggravate tissue injury
leading to ARDS and MODS
PATHOPHYSIOLOGY
 SCORING SYSTEMS

• Purpose of scoring systems

• Appropriate Triage And Classification Of Trauma Patients
• Predict Outcomes For Patient And Family Counseling
• Quality Assurance
• Research
-extremely useful for the study of outcomes
SCORING SYSTEMS
 SCORING SYSTEMS

SIRS Score
• Heart Rate > 90 Beats/Min
• WBC Count <4000cells/Mm³ OR >12,000 Cells/Mm³
• Respiratory Rate > 20/Min Or Paco2 > 32mm
• Temperature < 36 ° Or > 38°
Interpretation
• Score Of 2 Or More Meets Criteria For SIRS
MANAGEMENT
 MANAGEMENT

• Trauma Management Should Be Multidisciplinary Team

• Each One In The Team Plays His Role Where He Is Perfect In
 ATLS

• ‘TREAT LETHAL INJURY FIRST, THEN REASSESS AND TREAT

AGAIN
 ATLS

The steps in management are:

• Primary survey
• Resuscitation
• Secondary survey
• Definitive care
Prehospital care
• Resuscitation
• Preliminary stabilization
• Safe and fast transfer
PRIMARY SURVEY
 PRIMARY SURVEY

• Resuscitation
• ABCDE
• Fluids
• History
• Radiography (Chest, Pelvis, Spine, Abdominal U/S)
 SECONDARY SURVEY

• Does not begin until the primary survey (ABCDEs) is completed.

• Head to Toe evaluation & reassessment of all vital signs.
• A complete neurological exam is performed
 END POINT OF RESUSCITATION

• Stable Hemodynamics
• Stable Oxygen Saturation
• Lactate Level Below 2 Mmol / L
• No Coagulation Disturbance
• Normal Temp
• Urinary Output > 1ml /Kg/Hr
• No Requirement Of Inotropic Support
DEFINITIVE CARE
DEFINITIVE CARE
ORTHOPAEDIC MANAGEMENT

• Facilitating Overall Patient Care,

• Controlling Bleeding,
• Decreasing Additional Soft-tissue Injury,
• Avoiding Further Activation Of The Systemic Inflammatory Response,
• Removal Of Devitalized Tissue,
• Prevention Of Ischemia/Reperfusion Injury,
• Pain Relief
ORTHOPAEDIC MANAGEMENT
INDICATIONS FOR EARLY TOTAL CARE

• Stable Hemodynamics
• No Need For Vasoactive/Inotropic Stimulation
• No Hypoxemia, No Hypercapnia
• Lactate <2 Mmol/L
• Normal Coagulation
• Normothermia
• Urinary Output >1 Ml/Kg/H
INDICATIONS FOR “DAMAGE CONTROL”
SURGERY

1. Physiologic criteria
• Blunt trauma: hypothermia, coagulopathy, shock/blood loss, soft tissue
injury = Four vicious cycles
• Penetrating trauma: hypothermia, coagulopathy, acidosis = “Lethal Triad”
2. Complex pattern of severe injuries—
• expecting major blood loss and a prolonged reconstructive procedure in a
physiologically unstable patient
DAMAGE CONTROL AND PELVIC RING
INJURIES

• exsanguinating hemorrhage is the major cause of death in multiply injured

patients with pelvic ring disruptions.
• Concomitant bowel injury places these fractures at high risk for infection
and the need for access to the abdomen for visceral or genitourinary
system injuries may limit the treatment options .
DAMAGE CONTROL TREATMENT FOR LONG
BONES FRACTURES

• Long Bones Fractures In A Multiply Injured Patient Are Not

Automatically Treated With Intramedullary Nailing Because Of Concerns
About The Second Hit Of Such A Procedure
• Patients With Pulmonary Injury Should Undergo Unreamed Nailing To
Avoid Increased Risk Of ARDS.
DAMAGE CONTROL TREATMENT FOR LONG
BONES FRACTURES

• Bilateral Femoral Fracture Is A Unique Scenario In Polytrauma That Is

Associated With A Higher Mortality Rate And Incidence Of ARDS Than
Is A Unilateral Femoral Fracture.
• The Use Of External Fixation As A Temporizing Measure Allows For The
Advantages Of Rigid Fixation Without The Risk Of Hypotension And
Hypoxia Associated With IMN In Seriously Injured Patients.
• 776 patients with unilateral and 118 patients with bilateral femoral shaft
fractures.
• Patients with bilateral femoral shaft fractures had Higher Injury Severity Score
(ISS) (29.5 to 25.7 points),
• Higher incidence of ARDS (34.7% vs. 20.6%) multiple organ failure (25.0% vs.
14.6%) and Higher mortality rate (16.9% vs. 9.4%).
DAMAGE CONTROL TREATMENT FOR LONG
BONES FRACTURES

• Early Fixation Of Long-bone Fractures— Especially Of The Femoral

Shaft—in Polytrauma:
• Facilitation Of Nursing Care;
• Early Mobilization With Improved Pulmonary Function;
• Shorter Time On The Ventilator;
• Reduced Morbidity And Mortality
DAMAGE CONTROL TREATMENT FOR LONG
BONES FRACTURES

• External fixation of femur-

• 35 minutes
• 90 ml blood loss
• Intramedullary nailing of femur-
• 130 minutes
• 400 ml blood loss
 CONCLUSION

• The Management Of Polytraumatized Patient Is Multidisplinary Team .

• Orthopedic Surgeon In The Striker Of The Team
• Resuscitation And Survey Is A Key For Excellent Outcome
• Timing Of Surgery Is Very Crucial
• ETC Vs. DCO Should Be Considered Carefully
CASE PRESENTATION
 HISTORY

• A 56 year old female presented to the trauma center of CMH Lahore on 12th July, 2021 with 1 day
history of multiple fractures.
• She was involved in a Car vs. Bike road traffic accident
• There was no loss of consciousness and no ear or nose bleed
• She was taken to DHQ hospital Okara 
• After initial resuscitation following ATLS protocol, her X-rays were done which
revealed bilateral Femur and bilateral Tibia fractures.
• Application of POP back slab above knee and bilateral skin traction.
• Understanding the complexity of the injuries, she was referred to CMH Lahore for further management
 EXAMINATION

• O/E, a thin-built, elderly woman with multiple

bruises on face and arms and wound of 1*5cm
on right midshaft tibia and 1*4cm wound on left
midshaft tibia.
• She was visibly distressed but vitally stable
• GCS of 15/15, conscious & oriented
• POP back slab above knee was removed and her
wounds were debrided and primarily stitched.
• Her distal neurovascular status was intact
 INITIAL MANAGEMENT

• The Patient Was Urgently Shifted To Surgical ITC. And Was Put To VSIL
List.
• She Was Resuscitated Actively With Two Pint Of Red Cell Concentrate
(RCC) And Hartmann’s Solution (R/L).
• She Was Catheterized And Noticed That She Have Adequate Urine
Output.
• Tripple Regimen Antibiotic Cover Was Given To Save Patient From
Sepsis.
• Meanwhile Her Baseline Labs And ABGS Sent.
 INITIAL WORK UP

• CBC – Hb of 10.2 gm./dl

• LFTs - normal
• RFTs - normal
• Fast Scan – unremarkable
• CT Head – unremarkable
• ABGs - normal
• X-ray pelvis with bilateral hips and X-ray lower limbs
 OPERATIVE DETAILS

• Due to the extensive nature of the

surgery, it was divided into 2 phases
• In the first phase CRIF + retrograde nails
of both femurs were done 
• Intramedullary, interlocking nails 
• Proximal and distal locking and screw
fixation was done on both sides on first
phase.
 OPERATIVE DETAILS (CONT...)

• After an interval of 72 hours, the next

phase of the surgery was performed.
• Only the right tibia was reduced using
the same principles and CRIF +
intramedullary interlocking nail was
done
• However, the left tibia was managed
conservatively following the principle
of damage control surgery
 POSTOPERATIVE CARE

• Her post op recovery was uneventful.

• Her labs were within normal limits after first and second surgery.
• She remained in hospital for almost 15 days and she was stable
• She was discharged with precations of non weight bearing and DVT
prophylaxis.
• She came to follow up last week for stitch removal and further plan
regarding her left tibia fracture management and mobilization.
THANK YOU