DCO or not?

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Dear Mark,

This patient in our centre would go on for ETC pathway with timely haemostatic resuscitation (no crystalloid boluses) depending the fracture pattern. This is a nonacidotic patient with borderline injuries. Bearing in mind that he could get sick very quickly. It does not matter how long the surgery takes as long as the patient is in warm OR with proper resuscitation. Certainly reassess between the two fractures (if not done simultaneously...My preference is position flat supine and do bilateral retrograde nailing) and switch from ETC to DCO.
The quality of the resuscitation and the surgical approach and the ability to switch is the key. With this approach we can prevent many DCOs and decrease ICU stay and complications.
Best Regards,

Zsolt


Professor Zsolt J. Balogh, MD, PhD, FRACS
Director of Trauma, John Hunter Hospital and Hunter New England Area Health Service
Discipline Head of Traumatology, University of Newcastle
Newcastle, NSW
AUSTRALIA
Tel: +61 2 49214259
Fax: +61 2 49214274
E-mail: zsolt.balogh at hnehealth.nsw.gov.au



-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] On Behalf Of MARK FORREST
Sent: Thursday, 12 August 2010 9:16 PM
To: Trauma & Critical Care mailing list
Subject: DCO or not?

Dear All
A case to consider and answer our debate at a recent trauma audit:

39 yr old male, motorcycle RTC, knocked off bike and then hit by a second 
vehicle:

GCS 3 on scene but improves to 11/15 in ambulance
Airway secure
Obvious chest injuries with apparent left sided flail but oxygenating well on 
FiO2 1.0 with sats of 97%
CVS - periph pulses present, BP 130/70, HR 130bpm
X-rays: chest multiple rib fractures on both sides from rib 3 downwards, 
pneumotx on L and drain inserted.
Pelvis: NAD
FAST-NAD
CT: head -NAD, Neck - NAD, Chest - rib fractures and small left pneumotx with 
drain in situ, Abdo - possible small retroperitoneal haem, small liver 
lacerations, Pelvis - NAD
Femurs- bilat comminuted shaft fractures.
One femur was compound and had a small skin wound

He dropped his pressure moderately (sys 80mmHg) twice during resus and scan and 
was given fluid boluses with good response (crystalloid then blood/FFP) but his 
lowest.

Crit care team wanted legs stabilised as quickly as possible ? external 
fixators/traction splints then ICU but ortho team insisted that femurs must be 
fixed.

As he was warm and not acidotic the Anaes team went with ortho view and BOTH 
femurs were nailed which took nearly 6 hours!! Inevitably he deteriorated and 
required significant volumes of fluid/ blood/FFP etc and subsequently a moderate 
dose of inotrope before ICU.

The question: I think that we all agree that the surgery took far too long 
BUT......in the resus room what do you all think......DCO or definitive fix?

Was immediate nailing the best call in this guy and was he stable enough to not 
warrant damage control?

Who would nail one leg and then re-consider the situation?

Many trauma cases obviously suggest DCS but certainly in our hospitals, there is 
often considerable debate on who benefits and who doesn't.

Regards
Mark F
UK
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