Damage control and definitive early stabilization in the treatment of polytrauma patient
DOI:
https://doi.org/10.1016/j.rccot.2017.11.009Keywords:
polytrauma, orthopedics, operative procedures, injury severity scoreAbstract
Background: The aim of this study is to evaluate patients with multiple trauma and pelvis or long bones fractures that were treated with definite fixation of their fractures in the first 48 hours of trauma and after 48 hours.
Methods: Retrospective cohort study that includes all polytraumatized patients with pelvis or long bones fracture, that were admitted to a first level trauma center between January 2012 and June 2016. Outcomes evaluated were mortality, infection, hospital stay length and complications. Injury severity score (ISS) and new injury severity score (NISS) were calculated for every patient.
Results: A total of 220 patients were included, with male predominance (82%). The new injury severity score had a median that was 4.5 points higher than traditional ISS (34 vs 29.5, p=0.016). Patients with early total care had shorter hospital stay lengths (p=0.008) and lower rate of complications (p=0.022).
Discussion: The traditional injury severity score might underestimate the severity of trauma because each system can only be registered once independently of how affected it is. Damage control can be reserved for the most seriously injured patients, that do not respond properly to initial reanimation, with ISS values higher than 36 points and NISS values greater than 40 points.
Evidence level: IV.
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References
Pape HC, Giannoudis PV, Krettek C, Trentz O. Timing of fixation of major fractures in blunt polytrauma: role of conventional indicators in clinical decision making. J Orthop Trauma. 2005;19:551-62. https://doi.org/10.1097/01.bot.0000161712.87129.80
D'Alleyrand JC, O'Toole RV. The evolution of damage control orthopedics: current evidence and practical applications of early appropriate care. Orthop Clin North Am. 2013;44:499-507. https://doi.org/10.1016/j.ocl.2013.06.004
Vallier HA, Wang X, Moore TA, Wilber JH, Como JJ. Timing of orthopaedic surgery in multiple trauma patients: development of a protocol for early appropriate care. J Orthop Trauma. 2013;27:543-51. https://doi.org/10.1097/BOT.0b013e31829efda1
Roberts CS, Pape HC, Jones AL, Malkani AL, Rodriguez JL, Giannoudis PV. Damage control orthopaedics: evolving concepts in the treatment of patients who have sustained orthopaedic trauma. Instr Course Lect. 2005;54:447-62. https://doi.org/10.2106/00004623-200502000-00030
Vallier HA, Super DM, Moore TA, Wilber JH. Do patients with multiple system injury benefit from early fixation of unstable axial fractures? The effects of timing of surgery on initial hospital course. J Orthop Trauma. 2013;27:405-12. https://doi.org/10.1097/BOT.0b013e3182820eba
Nahm NJ, Vallier HA. Timing of definitive treatment of femoral shaft fractures in patients with multiple injuries: a systematic review ofrandomized and nonrandomized trials. J Trauma Acute Care Surg. 2012;73:1046-63. https://doi.org/10.1097/TA.0b013e3182701ded
Martínez A. Control del dano˜ en ortopedia y traumatología. Rev Col Or Tra. 2006;20:55-64.
Barei DP, Shafer BL, Beingessner DM, Gardner MJ, Nork SE, Routt ML. The impact of open reduction internal fixation on acute pain management in unstable pelvic ring injuries. J Trauma. 2010;68:949-53. https://doi.org/10.1097/TA.0b013e3181af69be
White TO, Jenkins PJ, Smith RD, Cartlidge CW, Robinson CM. The epidemiology of posttraumatic adult respiratory distress syndrome. J Bone Joint Surg Am. 2004;86-A:2366-76. https://doi.org/10.2106/00004623-200411000-00002
Harwood PJ, Giannoudis PV, Probst C, Krettek C, Pape HC. The risk of local infective complications after damage control procedures for femoral shaft fracture. J Orthop Trauma. 2006;20:181-9. https://doi.org/10.1097/00005131-200603000-00004
Lefaivre KA, Starr AJ, Stahel PF, Elliott AC, Smith WR. Prediction of pulmonary morbidity and mortality in patients with femur fracture. J Trauma. 2010;69:1527-35. https://doi.org/10.1097/TA.0b013e3181f8fa3b
Pape HC, Rixen D, Morley J, Husebye EE, Mueller M, Dumont C, et al., EPOFF Study Group. Impact of the method of initial stabilization for femoral shaft fractures in patients with multiple injuries at risk for complications (borderline patients). Ann Surg. 2007;246:491-9. https://doi.org/10.1097/SLA.0b013e3181485750
Pape HC, Regel G, Dwenger A, Sturm JA, Tscherne H. Influence of thoracic trauma and primary femoral intramedullary nailing on the incidence of ARDS in multiple trauma patients. Injury. 1993;24 Supl 3:S82-103. https://doi.org/10.1016/0020-1383(93)90012-U
Hildebrand F, van Griensven M, Huber-Lang M, Flohe SB, Andruszkow H, Marzi I, et al. Is there an impact of concomitant injuries and timing of fixation of major fractures on fracture healing? A focused review of clinical and experimental evidence. J Orthop Trauma. 2016;30:104-12. https://doi.org/10.1097/BOT.0000000000000489
Balogh ZJ, Reumann MK, Gruen RL, Mayer-Kuckuk P, Schuetz MA, Harris IA, et al. Advances and future directions for management of trauma patients with musculoskeletal injuries. Lancet. 2012;380:1109-19. https://doi.org/10.1016/S0140-6736(12)60991-X
Baker SP, O'Neill B. The injury severity score: an update. J Trauma. 1976;16:882-5. https://doi.org/10.1097/00005373-197611000-00006
Wong TH, Krishnaswamy G, Nadkarni NV, Nguyen HV, Lim GH, Bautista DC, et al. Combining the new injury severity score with an anatomical polytrauma injury variable predicts mortality better than the new injury severity score and the injury severity score: a retrospective cohort study. Scand J Trauma Resusc Emerg Med. 2016;24:25. https://doi.org/10.1186/s13049-016-0215-6
Deng Q, Tang B, Xue C, Liu Y, Liu X, Lv Y, et al. Comparison of the ability to predict mortality between the injury severity score and the new injury severity score: A metaanalysis. Int J Environ Res Public Health. 2016;13(8.):E825, https://doi.org/10.3390/ijerph13080825
Rapsang AG, Shyam DC. Scoring systems of severity in patients with multiple trauma. Cir Esp. 2015;93:213-21. https://doi.org/10.1016/j.cireng.2013.12.031
Osler T, Baker SP, Long W. A modification of the injury severity score that both improves accuracy and simplifies scoring. J Trauma. 1997;43:922-5. https://doi.org/10.1097/00005373-199712000-00009
Pape HC, Lefering R, Butcher N, Peitzman A, Leenen L, Marzi I, et al. The Definition of polytrauma revisited: An international consensus process and proposal of the new 'Berlin definition'. J Trauma Acute Care Surg. 2014;77: 780-6. https://doi.org/10.1097/TA.0000000000000453
Metsemakers WJ, Handojo K, Reynders P, Sermon A, Vanderschot P, Nijs S. Individual risk factors for deep infection and compromised fracture healing after intramedullary nailing of tibial . shaft fractures: a single centre experience of 480 patients. Injury. 2015;46:740-5. https://doi.org/10.1016/j.injury.2014.12.018
Crist BD, Ferguson T, Murtha YM, Lee MA. Surgical timing of treating injured extremities: an evolving concept of urgency. Instr Course Lect. 2013;62:17-28.
Illescas Fernandez GJ. Escalas e índices de severidad en trauma. Trauma. 2003;6:88-94.
Bone LB, Giannoudis P. Femoral shaft fracture fixation and chest injury after polytrauma. J Bone Joint Surg Am. 2011;93:311-7. https://doi.org/10.2106/JBJS.J.00334
Johnson KD, Cadambi A, Seibert GB. Incidence of adult respiratory distress syndrome in patients with multiple musculoskeletal injuries: effect of early operative stabilization of fractures. J Trauma. 1985;25:375-84. https://doi.org/10.1097/00005373-198505000-00001
Gandhi RR, Overton TL, Haut ER, Lau B, Vallier HA, Rohs T, et al. Optimal timing of femur fracture stabilization in polytrauma patients: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2014;77:787-95. https://doi.org/10.1097/TA.0000000000000434
