DAMAGE CONTROL

ORTHOPAEDIC OF MULTIPLE
TRAUMA

OLEH : MOCH. IMAM NUR FADLY

PEMBIMBING : DR. M. ALI HASTI, SP.OT
ADVISOR : DR. VICTOR GOZALY
 WHAT IS DAMAGE CONTROL?

 Damage control is a naval term

 -save the ship

 -limit damage
 -emergency repair
 -finish the mission
 4 TENETS OF DAMAGE CONTROL
ORTHOPAEDIC

 1. recognize who needs damage control

 2. salvage operation
 3. Keep the patient alive
 4. definitive repair later
 MULTIPLE TRAUMA

 If more than one trauma occurs simultaneously

 -head injury
 -fractures
 -chest injury
 TRAUMA MORTALITY

 Early death
- Blood loss
- Brain injury

 Late death
- Secondary brain injury
- sepsis
 2 HITS THEORY

 First hits
- hypoxia, hypotension, organ and soft tissue injury,
fractures

 Second hits
 - ischemia/reperfusion injury, compartment
syndrome, operative intervention, infecion
 INFLAMATTORY HOST RESPONSE

 Local and sistemic release of:

- Pro inflamttory cytokines
- Arachidonis acid metabolites
- Proteins of the coaagulation system
- Complement factors
- Acute phase proteins
- Hormonal mediator
 TOO Systemyc
MUCH Inflammato
ry Respose
RESPO Syndrome
NS (SIRS)
 SIRS

 Endhotelial cell damage

 Accumulation of leukocytes
 Disseminated intravaskular coagulation
 Apoptosis / necrosis of parenchymal cells
 Multiple organ dysfunction syndrome (MODS)
 Multiple organ failure (MOF)
ANTI- INFLAMMATORY HOST RESPONSE

 Local and systematically, TH2-cells and

monocytes/macophages release:
- IL-4
- IL-10
- IL-13
- Transforming growth factor-B (TGF-B)
 It’s a feedback loop
 Anti inflammatory mediators (CARS):

- depress the activity of intracellular transcription

factors
- Depress synthesis of pro-inflammatory cytokines
 CARS
TOO
MUCH INCREASE
NEGATI SUSPECTIBI
LITY TO
VE INFECTION
FEEDBA
CK 2ND
HIT
The 24-72 hour period after the initial injury appears to be the most at-risk time

DAMAGE
CONTROL EARLY
ORTHOPAEDI TOTAL CARE
CS

Decrease the chance of 2nd hit Stabilize fractures and

bleeding prior to the 24-73 hour high-
risk period
 STAGED TREATMENT DCO

 Stage 1: early temporary external fixation

stabilization of unstable fractures and the control of
hemorrhage and, if indicated, decompression of
intracranial lesion
 Stage 2: resuscitation of the patient in ICU and
optimization of his condition
 Stage 3: delayed definitive management of the
fracture
 EARLY TOTAL CARE

 Resuscitation
- stable hemodynamics
- Stable oxygen saturation
- No coagulantion disturbances
- Normal temperature
- Urinary output > 1 ml/kgBB/hour
- No isotropic support
 When to perform the secondary procedure?

It was found that a secondary procedure lasting more

than 3 hours was associated with the development of
MODS also the patients who developed complications
had their surgery performed between days 2 and 4.
whereas patients who did not go on develop MODS were
operated between days 6 and 8
 Time of secondary procedures
- Days 2 until 4 do not offer optimal conditions for
definitve surgery
- Primary procedures of greater than 6 hours
duration and major surgical procedures at days 2
until 4 should be avoided

 Intramedullary nailing
- Between 5 until 14 days