Yg dibahas cmn slide 6,7,11

Damage Control In
Multitrauma and Orthopaedics

dr. Bambang Widiwanto, MS, SpOT

 Baca sendiri

Multitrauma
• Syndrome of multiple injuries with
sequential systemic traumatic
reactions which may lead to
dysfunction or failure of remote
organs and vitals systems, which
had not themselves been directly
injured.
• Fracture is the most frequent
component of multitrauma.
 Baca sendiri

Pathofisiologis
• Wound around fracture 
inflamatory (dead tissue & hypoxic).
• Inflamatory release mediators and
cytokines into circulation.
• Systemic traumatic reactions produce
a whole-body inflammation or a
Systemic Inflamatory Response
Syndrome (SIRS)
 Baca sendiri

Pathofisiologi
• SIRS condition demanding high energy
consumption and oxygen
(Hypermetabolic condition).
• Hypermetabolic condition : muscle
wasting, nitrogen loss, protein
breakdown, and raise temperature.
• Depletion of immunocompetent become
critical immunosupression and sepsis 
more sell death  MODS & MOF
Timing and Priorities of Baca sendiri

Surgery
• Primary Objective = survive with normal
function.
• First priority is resuscitation to ensure
adequate perfusion and oxygenation of
all vital organs.
• If there is no response  immediate
live-saving surgery.
– Decompression body cavity
– Control of hemorrhage
 SOAL!!

Tidak mencapai titik

optimum yg diinginkan
(respon tdk adekuat)
Ex: respon stelah
resusitasi baik  tapi
abis itu turun lagi

Pasien datang dengan multiple trauma  resusitasi  tdk brhasil  life saving surgery
SOAL!!
Timing and Priorities of asdf

Surgery
• If immediate definitive surgery is
needed  “Damage control”
(control of hemorrhage and
contamination, irrigation, packing,
closure of wound and stabilization
of the physiological system) in ICU
 definitive surgery after 6-12
hours.
 Timing and Priorities of Baca sendiri

Surgery

• If response to resuscitation  delay primary surgery.

• Within the locomotors system treat with high priority:
– Limb-threatening and disabling injuries (open fracture 
debridement, reduction, fixation, and revascularization).
– Long bone fracture, unstable pelvic fracture, highly unstable
large joints and spinal injuries  temporary stabilization (EF)
 definitive osteosyntesis during a window of opportunity,
between days 5-10.
Timing and Priorities of Baca sendiri

Surgery
• During window of opportunity,
definitive surgery of long bone
fracture-shaft and articular-can be
performed in relative safety.
• Immunosuppression last for about 2
weeks secondary reconstruction
procedure can be planned for three
week post trauma.
SOAL!
General Aims and Scopes of Fracture
Management in Multitrauma
• Control of hemorrhage.
• Control of sources of contamination,
removal of dead tissue, prevention of
ischemia-reperfusion injury.
• Pain relief.
• Facilitation of intensive care.
 Homeostasis, debridement,
fasiotomy, fracture fixation, and tension-
free wound coverage.
Summary
• Multitrauma must be considered as
a systemic surgical disease.
• Successful management :
– Understanding of pathology
– Complete resuscitation
– Correct triage and timing
– Plans of care
Damage Control Orthopaedics
Introduction :
• It has long been recognized that, in
patients with severe abdominal injuries
initial management should avoid
complex operative procedures

• It was believed that the polytraumatised

patient did not have the physiological
reserve to withstand prolonged
operations
Systemic impact of extremity
injury :
• All extremity fractures must be
considered with the associated
haemorrhage and local soft tissue
injuries.
• The injury initiates a local
inflammatory response with
increased systemic concentrations
of pro-inflammatory cytokines.

FIRST HIT INJURY

Damage control concept :
• In the polytraumatized patient, this
concept of surgical treatment
intends to control but not to
definitively repair the trauma.
• After restoration of normal
physiologic, definitive management
of injuries is performed
The damage control concept
consist of three components :
1. Resuscitative surgery for rapid
hemorrhage control.
2. Restoration of normal physiologic
parameter.
3. Definitive surgical management
• Based on the concept of damage
control surgery, the application of
the same principles to the
management of multitrauma
patient with associated long bone
fracture & pelvic fracture

DAMAGE CONTROL
ORTHOPAEDIC
Damage Control Orthopaedics
• Early stabilization of unstable
fracture, control hemorrhage,
management of soft tissue injury
• Resuscitation and optimize the
patient in the ICU
• Delayed definitive fracture
management if condition allowed
• The practice of delaying the
definitive surgery in DCO attempts
to reduce the biological load of
surgical trauma on the already
traumatized patient.

Minimize The Second Hit Injury

Time to do a definitive surgery??
• Primary procedures of greater than 6
hours duration and major surgical
procedures at day 2 to 4 should be
avoided
• A prospective study has recently shown
that polytraumatized patients submitted
to secondary definitive surgery at day 2
to 4, developed a significantly increased
inflammatory response, compared to
those operated at day 6 to 8
Borderline patient type should be
considered for DCO :

1. Multitrauma with thoracic trauma

2. Multitrauma with abdominal &
pelvic trauma, shock
3. Bilateral lung contusion on x-ray
Indication for DCO
1. Unstable and laborious resuscitation.
2. Coagulation disorder, platelet count <
90.000
3. Shock, demanding more than 25 blood
units for the patient’s full recovery
4. GCS < 8
5. Multiple long bone fracture
6. Duration of surgical operation > 6
hours
7. Hemodynamic instability Arterial
injury