For orthopedic surgeons and residents:
Early Total Care Philosophy & Damage Control Philosophy: Orthopedic Concepts for Polytrauma Patients
The proper treatment of multiply injured patients presents a challenging scenario for trauma teams across the country. There can be a wide variety of clinical presentations which include orthopedic conditions such as long bone fractures or pelvic ring injuries.
In these situations, a thorough understanding of orthopedic management concepts will facilitate timely and correct treatment delivery for optimal patient outcomes.
Early Total Care Philosophy
Conventional orthopedic wisdom dictates that multiple long bone fractures should be treated as early and efficiently as possible through definitive fracture fixation. This approach was called Early Total Care (ETC) and was widely adopted during the 80s until the early 90s. It involved aggressively establishing early fracture stabilization either through intramedullary nailing or plating within the first 24 hours. The goal of ETC was to aide nursing care, reduce pulmonary complications, and hasten patient recovery.
Early total care afforded many clinical and economic benefits. Researchers conducted a landmark study in the 80s evaluating the role of early surgery for fractures in multiply-injured patients. ETC was associated with fewer pulmonary complications, reduced length of stay in the intensive care unit (ICU), and the hospital in comparison to patients treated with delayed surgery.
Though many patients benefited from ETC, it would seem its application was not appropriate for all patients. In particular, unstable patients were at risk for developing pulmonary complications when treated using an ETC approach. This would set the precedent for a new treatment concept to treat a previously unrecognized subgroup of polytrauma patients.
Damage Control Philosophy
Advancements in the early 90s would allow for a deeper understanding of the pathophysiology of multiply-injured patients. Polytrauma produces a systemic inflammatory response syndrome (SIRS), which is balanced by a counter-regulatory anti-inflammatory response (CARS). The inflammatory response following trauma may trigger an excessive CARS, leading to adult respiratory distress syndrome (ARDS) or multi-organ dysfunction syndrome (MODS).
In both of these outcomes, the host is left in an immunosuppressed state in what is commonly referred to as the “first hit” phenomenon. Due to the increased morbidity and mortality associated with this, it raises important implications in the timing and extent of surgical intervention. Performing ETC surgery at this time may produce a “second hit”, predisposing patients to develop respiratory compromise. In patients with pre-existing pulmonary contusions, this can be fatal and lead to death.
Patients who are unstable and are at risk for deterioration following surgery are better suited for treatment using Damage Control Orthopedics (DCO) Philosophy. In DCO, major life-threatening injuries are treated first and initial resuscitative efforts are directed towards stabilizing the patient. Femur fractures or pelvic ring injuries are temporarily stabilized using external fixators which can be quickly applied in the operating room with minimal surgical insult and blood loss. The DCO approach defers definitive fixation surgery in favor of restoring physiologic stability and decreasing the risk of secondary pulmonary injury.
Early Total Care vs Damage Control: When and Why?
The complexity of polytrauma cases entails a multi-disciplinary approach. Following advanced trauma life support protocols, general surgeons of the receiving trauma team make the initial assessment and deliver timely resuscitation. Life-threatening conditions are addressed first while associated orthopedic injuries must be properly documented and assessed. After a comprehensive investigation of clinical parameters, laboratory and radiographic work-up, and close coordination with orthopedics and other specialists, the trauma team will need to make the quick distinction of whether early total care or damage control approach is the appropriate treatment option for the orthopedic injuries.
In general, patients are assessed through various clinical criteria looking into the hemodynamic status, coagulation profile, temperature, and associated soft tissue injuries. Based on these parameters, four classes of patients have been described: stable, borderline, unstable, and in extremis.
In the majority of cases, a patient may fall into either “stable” or “borderline” category. The ETC approach is the gold standard for treating “stable” patients and is relatively straightforward. These patients are hemodynamically stable, responsive to initial resuscitative efforts, and free of any life-threatening injuries. Achieving ETC allows early patient mobilization and decrease hospital stay.
On the other hand, patients categorized as “borderline” represent a grey area where the choice between ETC or DCO is difficult. Additional clinical criteria are available to identify parameters associated with adverse prognosis, such as radiographic evidence of pulmonary contusions or the presence of pelvic ring injury with hemodynamic shock. If any of these adverse parameters are present, DCO is the favored approach. Patients falling into "unstable" and "in extremis" are better treated using a DCO approach. In these patients, early surgery may constitute a "second hit" leading to ARDS, MODS, or even mortality.
Early total care and damage control philosophies both serve as important treatment concepts to address the wide variety of presentations seen in polytrauma patients. Early total care is the gold standard for stable trauma patients and allows early mobilization. Unstable patients with pelvic ring injuries or femoral fractures are better treated using external fixators in a damage control approach to avoid complications associated with the "second hit" phenomenon.