Multiple TraumaDavid H. Masjhoer

SMF Orthopedi & TraumatologiRSU AW Syahranie/FK UNMUL

2

Biomekanik Dari Fraktur

Syndrome of multiple injuries (ISS >17) with sequential systemic traumatic reactions which may lead to dysfunction or failure of remote organs and vital systems, which had not themselves been directly injury

Fracture are more common component

definition

Wound of bone and soft tissue, giving rise to stress, pain and haemorrhage

Can cause contaminate and compartment syndromes with ischemia-reperfusion injury

Instability of fracture

Importance of fracture

Algorithm of initial assesment, life support, day-1 surgery

“Primary survey”

Basic imaging

ResuscitationOxygenation,

perfusion

Life saving surgery

ICU

Delayed primary surgery

EvaluationVital function ?

Response ?-+

? Damage control

scoring“Secondary

survey”

Stable hemodynamics

No hypoxemia, no hypercapnia

Lactate < 2 mmol/l

Normal coagulation

normothermia

Urinary output < 1 ml/kg/hour

No need for vasoactive or inotropic stimulation

End points of resuscitation

Aims and scopes for fracture management

Realized by :•Haemostasis•Debridement•Fasciotomy•Fracture fixation•Tension free wound coverage

Control of haemorrhage

Control of sources of contamination

removal of dead tissue, prevention of ischemia-reperfusion injury

Pain relief

Facilitation of intensive care

10

Priorities and Timing of Surgery Depending on Physiological Status

Physiological StatusSurgical

Intervention Timing

Response to resuscitation

Live-Saving Surgery“Damage Control”Delayed Primary Surgery

Day 1

Hyper-inflammation “Second look”, only Day 2-3

“Window of Opportunity” Scheduled definitive surgery Day 5-10

Immunosuppression No SurgeryRecovery Secondary reconstructive

SurgeryWeek 3

( -- )

( ? )

( + )

( Chris L. Colton at al., “ AO Principles of Fracture Management”, 2000 )

11

Two Hit Model

First insultModerate SIRS

Moderate Immuno-suppression

12

Two Hit Model

First insultModerate SIRS

Moderate Immuno-suppression

Severe SIRS

Severe Immuno-suppression

2nd Insult

Definitive Surgery

13

Two Hit Model

First insultModerate SIRS

Moderate Immuno-suppression

Severe SIRS

2nd Insult

Definitive Surgery

MOF

Severe Immuno-suppression

14

Two Hit Model

First insultModerate SIRS

Moderate Immuno-suppression

Severe SIRS

2nd Insult

Definitive Surgery

MOF

Infection

Severe Immuno-suppression

15

Two Hit Model

First insultModerate SIRS

Moderate Immuno-suppression

Severe SIRS

2nd Insult

Definitive Surgery

MOF

Infection

Severe Immuno-suppression

MOF

16

Two Hit Model

First insultModerate SIRS

Moderate Immuno-suppression

Severe SIRS

2nd Insult

Definitive Surgery

MOF

Infection

Severe Immuno-suppression

MOF

Definitive Surgery

Terima kasih