Damage Control

Orthopaedics

AOA Outreach, Bali

2015
Importance
This will not necessarily get
you through your exams

This will make you a better

Doctor

This will make you a better

Clinician

This will make you a better

Trauma Surgeon
DCO Definition
• An approach to the multiply injured
patient that contains and stabilises
orthopaedic injuries to allow the
patients overall physiology to
improve.

• Avoid the 2nd Hit

History
• Early C-19th
• Avoid any manipulation  Fat embolism
• 1938 – Hoffmann Ex-fix
• Roger Anderson – Castless ambulatory
fixation (banned in WW2)
• 1950 - AAOS Ex-fix XS complications
• 1950 – Gavril Ibramovich Ilizarov
AO?
AO
• Early restoration of function
• Each injury in isolation
• “Aggressive traumatolgy”
• Patient “too sick” not to operate

• Internal fixation developed at a

faster rate than external fixation
Progress
• 1980’s
• Early Total Care (Bone et al)

• 1990’s
• More selective fixation
(Border et al)
• Greater physiological
understanding
Progress
• 1993 – first literature reporting
successful use of temporary ex-fix

• Late 1990’s – DCO

Gen Surgery Damage Control

• 1940’s 
• Phase 1 – Laporotomy stop bleeding
• Phase 2 – Resuscitate
• Phase 3 – Definitive surgery + closure
Gen Surgery Damage Control

• 1940’s 
• Phase 1 – Laporotomy stop bleeding
• Phase 2 – Resuscitate
• Phase 3 – Definitive surgery + closure
SIRS – systemic inflammatory response syndrome
CARS – counter reg’ anti-inflam’ response syn’
MODS – Multiple organ dysfunction syndrome
ARDS – Adult respiratory distress syndrome
First Hit
• Initial massive injury and shock
• Systemic Inflammatory Syndrome
• MØ, LØ, NK Cells, IL’s, Complement
•  Endothelial permeability lungs
• ARDS, MODS/MOF
ARDS
What’s wrong with IL-9!
Second Hit
• Restimulate / Hyperstimulate
inflammatory system

• Prolonged surgical procedure…….

……….”it’ll only take half an hour!”
Injury Severity Markers
• IL-6 (>800ug/ml)

• CRP, TNF, IL-1, IL-8  of no benefit

• Genetic predisposition - DLA-DRII!!

Genetic Predisposition?
Indications
Indications
• Unstable Patient

• Bilateral lung contusion / Thoracic Trauma

• Abdo / Pelvic Trauma

• Shock

• Bilateral femur fractures

Parameters
• Acidosis
• Hypothermia
• Massive transfusion (>10units)
• Coagulopathy (Plt<90)
• Long operative time >90 mins
• Age >65
Adverse Outcomes
Timing of 2° procedures
• Inflammatory response diminished
approx day 6.

• Once patient stable –

communication with ICU / Anaes!
Questions?
Injury Severity Score (1974)
6 Body Regions

• Head/neck
• Face
• Chest
• Abdo
• Extremity
• External
Injury Severity Score
Abreviated Injury Scale (threat to life)

• Minor 1
• Moderate 2
• Serious 3
• Severe 4
• Critical 5
• Unsurvivable 6
Injury Severity Score
• Highest AIS for each region
• Top 3 used
• Scores squared and added
• Out of 75
• Major Trauma ISS>15
• Any region scoring 6 = ISS 75
Injury Severity Score
• Correlates with Mortality, morbidity, LOS

• LD50 (Bull 1975)

• 15-44 ISS 40
• 45-64 ISS 29
• 65 - ISS 20