DCO and ETC

Background

1960s

  • High complication rate with immediate surgery.
    • Due to outdated methods, poor trauma coordination, and limited ICU support.
  • Delays in treatment for up to 2 weeks with interim use of casts and traction.
    • Resulted in:
      • Pulmonary, gastrointestinal, and soft tissue complications.
      • Stiff joints, prolonged rehabilitation, and extended ICU stays.

1980s

  • Early Total Care (ETC):
    • Shift to fixing everything as early as possible.
    • Adverse outcomes:
      • Prolonged surgical times, blood loss, hypothermia, and excessive “second hit” inflammatory response.

Immune System Effects

  • Trauma induces a hyperinflammatory immune response.
    • Usually insignificant in isolated injuries.
    • Exacerbated by:
      • Hypothermia and blood loss in polytrauma patients.
      • Can lead to:
        • Coagulopathy.
        • Acute Respiratory Distress Syndrome (ARDS).
        • Renal failure.
  • Surgical considerations:
    • Surgery adds to the inflammatory response.
    • Stabilizing long bones and addressing chest/abdominal injuries help control the inflammatory cascade.

Research Studies:

  1. Morshed et al, JBJSam 2009:
    • Definitive femoral shaft fixation <12 hours post-injury led to 50% higher mortality in polytrauma patients.
  2. Pape et al, Ann Surgery 2007:
    • External Fixation (Ex Fix) followed by delayed definitive fixation reduced pulmonary complications in borderline patients.

Key Principle of DCO:

  • Stabilize injuries without causing an overwhelming “second hit” inflammatory response.

Patient Categories for DCO vs. ETC

Four Patient Groups:

  1. Stable: Suitable for ETC.
  2. Borderline: Suitable for DCO.
  3. Unstable: Suitable for DCO.
  4. In Extremis: Suitable for DCO.

Criteria for Categorizing Patient Stability

Key Parameters:

  1. Shock:
    • Blood pressure (BP), ATLS shock grades, transfusion requirements, lactate levels.
  2. Temperature:
    • Degree of hypothermia.
  3. Coagulation:
    • Platelet count, fibrinogen levels.
  4. Systemic Injuries:
    • Lung function, chest, abdominal, pelvis, and external injuries (AIS).

Markers of a Borderline Patient

  1. Mild Shock:
    • Grade 2–3 shock.
    • Blood transfusion: 6–8 liters over the last 2 hours.
    • Lactate: 2.5 mmol/L.
    • BP: 80–100 mmHg.
  2. Hypothermia:
    • Temperature < 35°C.
  3. Coagulopathy:
    • Platelets < 110,000.
  4. Other Injuries:
    • Lung function: FiO2 < 350 mmHg.
    • Thoracic trauma (e.g., rib fractures).
    • Mild pelvic and/or abdominal trauma.

Orthopaedic Treatment Principles

  1. In Extremis Patients:
    • Orthopaedic injuries take lower priority.
    • Treatment involves:
      • Debridement.
      • External fixation of long bones within 2 hours.
  2. Borderline Patients:
    • Can consider intramedullary (IM) nailing if:
      • Procedure is completed in <2 hours.
  3. Patient Monitoring:
    • Monitor during and after each procedure.
    • Proceed with the next procedure only if the patient remains stable.
    • Temporize if instability arises.
  4. Intra-Operative Markers of Instability:
    • FiO2 < 250 mmHg.
    • Temperature < 32°C.
    • Increasing fluid or blood requirement.
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