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TIMING OF FRACTURE FIXATION IN POLYTRAUMA PATIENTS

TIMING OF FRACTURE FIXATION IN POLYTRAUMA PATIENTS. ANAESTHESIOLOGIST’S PERSPECTIVES. Dr.R.Selvakumar. POLYTRAUMA-NIGHTMARE FOR THE PATIENT & AS WELL AS FOR THE ANAESTHESIOLOGIST. KANISACON-2010. SURGEON & ANAESTHETIST. Opposite Views. having. KANISACON-2010.

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TIMING OF FRACTURE FIXATION IN POLYTRAUMA PATIENTS

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  1. TIMING OF FRACTURE FIXATION IN POLYTRAUMA PATIENTS ANAESTHESIOLOGIST’S PERSPECTIVES Dr.R.Selvakumar

  2. POLYTRAUMA-NIGHTMARE FOR THE PATIENT & AS WELL AS FOR THE ANAESTHESIOLOGIST KANISACON-2010

  3. SURGEON & ANAESTHETIST Opposite Views having KANISACON-2010

  4. Why anaesthetist wants to avoid? - prolonged hours of surgery - Unexpected response KANISACON-2010

  5. Polytrauma: • Hypovolemia • Multiple system involvement • less time for evaluation • missed injuries (head & abdomen) • prolonged surgery • massive blood transfusion • difficulty in monitoring • surgical difficulties KANISACON-2010

  6. Unique problem • increased incidence of respiratory failure • ARDS KANISACON-2010

  7. Why there is an increased incidence of respiratory failure? ARDS → fat embolism KANISACON-2010

  8. Fat embolism in polytrauma Pathophysiology • ↑ in intra medullary pressure →fat droplets → get filtered in the pulmonary circulation • minute droplets go through pulmonary circulation & get trapped in cerebral circulation • alveolar lipase → hydrolysis of fat → release of fatty acids (palmitic, stearic, oleic) • Neutralisation by albumin KANISACON-2010

  9. Pathophysiology of Fat Embolism - contd • failure of neutralistion by albumin • fatty acids + calcium →intercellular septa rupture → diffuse areas of haemorrhage & oedema in pulmonary interstitium & alveolar space KANISACON-2010

  10. Pathophysiology of Fat Embolism - contd • Integrins CD11b & CD18 cause adherence of neutrophils & endothelium • Injured pnumocytes stop surfactant production→ collapse of alveoli • ↑ shunt and dead space KANISACON-2010

  11. Just to relax……

  12. Secondary injury: • FE incidence in a polytrauma -30-90% • If surgery is performed following polytrauma, will reaming further increase the incidence of FE? KANISACON-2010

  13. Will it produce a second hit ? KANISACON-2010

  14. Medullary reaming & Cementation • Normal I.M pressure - 30 – 50mm of Hg. • Violent force in the bone - I.M pressure ↑many fold. • Reaming increases I.M.P ↑ up to 400-600 mm of Hg. • Cementation → 650-1500 of Hg. KANISACON-2010

  15. What they did…. In 1960s: • Ill development of pulmonary care • Wait till FES resolves • Kuntscher’s three recommendations KANISACON-2010

  16. Kuntscher’s recommendations: 1. Don’t nail as long as symptoms of FE are present 2. Take special precaution for patients with multiple fracture and extensive soft tissue injuries 3. Don’t nail immediately, but wait a few days KANISACON-2010

  17. Negative effects of delayed fixation • prolonged immobilisation • pneumonia, bedsore, renal failure, inadequate nutrition, vascular abnormalities • poor results KANISACON-2010

  18. A word about hyponatraemia… • old age • ↓ appetite • depression • social conditions restlessness,disorientation etc KANISACON-2010

  19. Drastic changes in the 1980s • Early fixation • better understanding of pathophysiology of trauma • improvement in critical care KANISACON-2010

  20. Changes in the 1980s….. • It led to aggressive management without improving the supportive care • Bad results KANISACON-2010

  21. Damage control orthopaedics: • Pack the major sources of haemorrhage • Resuscitation and stabilisation of the general condition • Temporary immobilisation of bone fractures KANISACON-2010

  22. Current recommendations Classify the patients according to their physical status 1. stable grade I 2. borderline grade II 3. unstable grade II 4. In extremis grade IV KANISACON-2010

  23. Creteria used in the physical status classification • Shock – B.P, No of blood units, lactate levels,B.D,ATLS • Coagulation status • Temperature • Soft tissue injuries KANISACON-2010

  24. Stable patients: • Do whatever you want…. KANISACON-2010

  25. Borderline patients who respond to resuscitation…… • proceed with definitive fixation • limit the surgical duration within 2 hours KANISACON-2010

  26. Remember… • A bad surgeon can shift the ASA Grade II to IV easily….. KANISACON-2010

  27. Borderline patients: • Continuous reassessment • Pao2/F102 should not drop below 200mm of Hg • Temperature should not drop below 32C • Requirement of fluids should not exceed 3L or 5units of blood • Absence of significant coagulopathy • If not → DCO KANISACON-2010

  28. Unstable and patients in extremis: • Life saving surgeries • External fixation • Resuscitation and stabilization simultaneously KANISACON-2010

  29. Strategy in patients with head injury: • Beware of the fact that cerebral auto regulation goes off following head injury • Extensive sympathetic block due to regional anaesthesia may hamper CBF • Severe head injury → only life saving procedures KANISACON-2010

  30. Strategy in patients with chest injury • Rib fracture or lung contusion • Monitoring with pulseoximeter or ABG • Incidence of ARDS • Severe chest injury →only life saving procedures KANISACON-2010

  31. What to do to prevent the incidence of FES? • Avoid increase in IM pressure • Medullary channel depletion • Venting the medullary channel • Uncemented prosthesis KANISACON-2010

  32. summary • In polytrauma, immediate fixation may lead • to secondary complication • Classify the patients according to their • Physical status • Grade I and II – Immediate surgery • Grade III and IV – resuscitation,DCO, • Delayed fixation KANISACON-2010

  33. Conclusion: Pre-operative status of the patient decides the timing of the fracture fixation in the poly-trauma patients…. KANISACON-2010

  34. THANK YOU Dr.R.SELVAKUMAR M.D.,D.A.DNB ASSOCIATE PROFESSOR COIMBATORE MEDICAL COLLEGE COIMBATORE

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