EditorialOptions and hazards of the early appropriate care protocol for trauma patients with major fractures: Towards safe definitive surgery
Section snippets
Issues in early fracture fixation and safe definitive surgery [1]
Recently, it has emerged that orthopaedic surgeons appear to be able to perform early definitive management of major fractures more frequently than in the past. It has also been discussed that timely resuscitation allows for early fixation of fractures in trauma. Moreover, it appears that definitive fixation is associated with a low incidence of complications. A group of orthopaedic surgeons from Cleveland, Ohio has published a set of parameters – all associated with the acid–base system – and
Dependency of acid–base changes on other factors
A normal acid–base status does not necessarily mean that the patient is in good clinical condition. Some critically ill patients have underlying pathologies that can only be identified by further analysis [9]. Moviat studied consecutive intensive care unit patients (n = 31) with metabolic acidosis, defined as a pH of <7.35 and a base excess of ≤−5 mmol/L. They recognised that various metabolites may contribute to the influence of ‘unmeasured’ anions in critically ill patients with metabolic
Dependency of acid–base changes on pre-existing medical conditions
It is well known that some diseases (such as chronic renal failure) lead to sustained changes in the acid–base system, namely lactate levels [14]. The use of the EAC protocol could be harmful in elderly patients if these medical conditions are not known at the time of admission, which is often the case with major trauma. Since many elderly patients are also treated with anticoagulants, the use of isolated parameters indicative of coagulopathy would be equally inappropriate.
Requirements for effective scoring systems: ROC values, criteria for solid parameters
Historically, grading of the patient has been attempted soon after trauma using multiple parameters [15], [16]. Some of the associated scoring systems were developed on the basis of single-centre databases, which has been subject to criticism. This obstacle was overcome when large nationwide databases became available. (National Trauma Data Bank (NTDB), the Trauma Audit and Research Network (TARN) and the German Trauma Registry (DGU) are good examples.):
The NTDB has been used to investigate
Value of ROC analyses in scoring systems
Several scoring systems have used ROC analyses to assess the accuracy and prediction of complications. Validation of recent scoring systems such as the RISC or RISC II revealed a predictive accuracy of approximately 90%. Lefering et al. analysed the most common predictive score values and determined their predictive value in a current national trauma registry. The authors concluded that the best predictors were blood pressure, pathological INR, low haemoglobin, and base deficit. The authors
Influence of the trauma system
The EAC protocol was developed in the US trauma system, which differs in some respects from other systems. In most level I centres in the USA, the admitting service for the multiply injured patient is general surgery (Fig. 1). The general surgeon also specifies the mode of resuscitation and the endpoint utilised. Most importantly, the general surgeon clears the patient for orthopaedic procedures. Orthopaedic surgeons therefore have no access until the patient is cleared or until other
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Cited by (29)
Clinical parameters and optimal candidates for early definitive fixation of extremity injury: A nationwide study
2023, Journal of Orthopaedic ScienceCitation Excerpt :The timing of definitive internal fixation for fractures of the extremities affects the duration of recumbency and inflammatory cascade, which may cause additional morbidities or increase mortality in patients particularly with severe injuries [1]. While various strategies including early total care [2–4], damage control orthopedics (DCO) [5–7], early appropriate care (EAC) [8,9], and safe definitive surgery (SDS) [10] have been developed to minimize postoperative complications in trauma patients with severe injuries in multiple organs, there is no validated consensus regarding optimal timing for definitive fixation among patients with mild to moderate injury or isolated fractures. Given that poly-trauma patients with old age, high injury severity score (ISS), or hemodynamic instability with significant acid-base changes have been reported to benefit from delayed internal fixation [5,7,12–15], general status of patients is often considered to decide the timing of definitive fixation also for isolated extremity injury.
What factors determine a “major fracture”?
2022, InjurySpine trauma management issues: Polytrauma
2022, Neural Repair and Regeneration after Spinal Cord Injury and Spine TraumaBilateral femoral shaft fracture in polytrauma patients: Can intramedullary nailing be done on an emergency basis?
2021, Orthopaedics and Traumatology: Surgery and ResearchCitation Excerpt :Also, there appears to be a difference in the critical care protocols between DCO and ETC on a global scale [29,30]. In health care systems that adopted DCO, such as Germany, the trauma surgeon is in charge of both intensive care of the polytrauma patient and of treating the fractures [31]. In hospitals that mostly use ETC, the intensive care is ensured by an anesthesiologist, who is also responsible for coordinating the specialised surgical care that the patient needs.
Bilateral femoral shaft fracture in polytrauma patients: Can intramedullary nailing be done on an emergency basis?
2021, Revue de Chirurgie Orthopedique et Traumatologique