Date: Tue, 6 May 2003 18:58:04 +0200
Subject: Unstable L2 fracture in patient with multitrauma
Need list's educated opinion.
25 year old female. On leave from psychiatric ward. Decides to drop from 5th floor onto a parked vehicle's roof, which absorbed much of the impact (depression 75 cm-car not manufactured in North America ;-)...).
On admission 30 minutes after fall. Hemodynamically stable - BP 130/85, HR 90/min, RR-22, GCS=11-(m5,v3,e3), Intubated due to agitation and inability to perform radiological evaluation. Blood from nose and echymoses of mid back. No other obvious injuries !!!
FAST- Neg for fluid, CT - (Head, C-Spine, Chest, Abdomen & Pelvis). Finally, after all tests, she has: Unstable fracture (ant + post column) of L-2, retropulsion of bone fragments (body) into spinal canal (25% of canal width). Bilateral moderate lung contusion Vs aspiration (Sats 98%, on FIO2 - 0.5, PSV 12, PEEP-5) Now in SICU, Awake enough to prove neurologicaly intact in extremities, normal rectal tone. Supine with log roll only.
What would you do at your Medical Center? Thanks for the input.
Mickey
Michael Stein MD
Director of Trauma, Attending Surgeon,
Department of Surgery,
The Rabin Medical Center, Beilinson Campus,
Petach-Tikva, 49100
Israel
From: Paul Kosmatka
Date: Tue, 6 May 2003 13:26:17 -0600
An L2 burst fracture with no neurological deficit, less than 50% canal compromise, no laterolisthesis/coronal plane deformity, AND no significant sagittal plane deformity (i.e. less than 10 degrees kyphosis)can be treated in a TLSO, and could therefore be upright/ambulatory in the brace. Upright X-rays in the brace can then be monitored for increased kyphosis or displacement.
Date: Tue, 06 May 2003 23:26:26 -0400
X-Sender: hausercj
Michael -
If the fracture is (as suggested below) truly "stable", she can be gotten up with a brace. I have some very real practical concerns however, that may make this "low-key" approach ill advised in the "real world".
1) it'll take time to get a brace made and the patients will be on logroll precautions until she's in it. That will make it hard or impossible to wake her up and extubate her in the interim. This will be doubly so if she's acutely psychotic. Loading her with antipsychotics will also make extubation problematic. A trache might weem aggressive, but might make removing her from the vent safer.
2) You're going to have a long term problem with what to do with a suicidal patient who's expected to be compliant with a TLSO. I have a feeling your "spine surgeon" may regard that as your problem and not his. Either way, it's the patient's. Moreover, I get the impression the TLSO approach is sort of a stretch on her and has a good chance of failing anyway.
You know, sometimes less is more. But sometimes more is more. So you know, a corpectomy might be safer overall. You may have to speak with the shrinks about what to expect when she wakes up.
CJH
Date: Wed, 7 May 2003 09:28:31 -0400
From: Bill Burman
>If the fracture is (as suggested below) truly "stable"
Determination of spinal "stability" remains elusive. See Alan Levine's OTA BFC lecture.
In a 138 case retrospective study J Orthop Trauma 1996;10(5):323-30, Schlegel, et al reported an association between a delay in spinal stabilization and the development of ARDS and other systemic complications if the ISS was > 18.
Group 1A - Surgery < 72 hours, ISS < 18
Group 1B - Surgery >72 hours, ISS < 18
Group 2A - Surgery < 72 hours, ISS > 18
Group 2B - Surgery > 72 hours, ISS > 18
Neurologic recovery was not related to the time of surgery. There was no difference in complications between group 1A & 1B There was significantly greater morbidity in Group 2B relative to 2A. They concluded polytrauma (ISS > 18) spine fx patients need early ORIF.
During my time at Harborview, Ted Hansen would put selected suicidal jumpers - after the acute phase - into full body spica casts after it appeared that early ORIF and skeletal stabilization sometimes facilitated repeat suicidal attempts. He called it a "portable locked ward". A number of these patients actually told me they felt "safer" in the "shell" and surprisingly it appeared to have a calming effect. I don't think Ted ever wrote up this anti-psychotic action of plaster.
From: carl hauser
Bill Burman wrote: Determination of spinal "stability" remains elusive. See Alan Levine's OTA BFC lecture
Bill, that was exactly my point. It's often not clear who needs fixation on a mechanical basis, and sometimes psychosocial factors may need to be considered "in the mix".
In a 138 case retrospective study J Orthop Trauma 1996;10(5):323-30, Schlegel, et al reported . . .
That's a classic cart-and-horse retrospective study for you. The observational database is probably right, but the conclusions are 180 degrees wrong.
During my time at Harborview, Ted Hansen would put selected suicidal jumpers -
after the acute phase - into full body spica casts after it appeared that early
ORIF and skeletal stabilization sometimes facilitated repeat suicidal attempts.
He called it a "portable locked ward". A number of these patients actually told
me they felt "safer" in the "shell" and surprisingly it appeared to have a
calming effect. I don't think Ted ever wrote up this anti-psychotic action of
plaster.
Did that occur before or after the Helsinki Accords ? As you can tell from my
prior post, I do appreciate the problems dealing with such 'uncooperative'
patients. But although they may not always act in their own best interests, they
still do have rights. So in the absence of clear outcomes data or a finding by
your hospital's Ethics Committee, the "portable locked ward" approach could
easily be seen by "patient advocates" (next to the JCAHO, my favorite oversight
groups) as smacking of "physician paternalism" or even as constituting false
imprisonment.
CJH
From: ecthompson
Date: Tue, 13 May 2003 14:52:15 -0500
Taking complex severely injured patients to the OR is always problematic. A 3
or 4 hour ORIF with the patient in some pulmonary unfriendly position can cause
the second hit, referring to Carl s second comment. It is my personal opinion
that anesthesia needs to be aware of this patient s status. They need to know
that this patient is sick and can get sicker without aggressive anesthesia.
Aggressive anesthesia is thinking in the ICU mode instead of the anesthesia
mode. If the patient becomes hypoxic the normal response is to turn up the O2.
This is wrong in this case. Crank up the PEEP and get a blood gas. Check the
hemoglobin.
Carl is exactly right in this case.
E
Errington C. Thompson, MD
Date: Wed, 14 May 2003 02:15:17 -0400
From: Bill Burman Carl
Bill Burman wrote:
The problem with current determinations of spinal stability is that static
studies are used in an attempt to predict abnormal motion. A bit like
trying to decide from a still picture of a vehicle whether it's stopped,
going forward, going backward or about to hit a lamp post. Punjabe and
White started to "dynamize" cervical spine stability testing with
longitudinal traction stress - but it hasn't gone much beyond that.
Controlled motion studies are needed as they are in less complex
articulations to decide instability. As in scoliosis and other corrective
spinal deformity surgery, safe and reliable methods of neurologic
monitoring can be brought to bear. I agree psychosocial factors are
important but as of yet I have not seen them biomechanically applied.
>Bill Burman wrote:
I would not single out the Journal of Orthopaedic Trauma for publishing a
retrospective study which concludes a correlation between early skeletal
stabilization and diminished rates of ARDS for patients of matched ISS. A
study by Goldstein, Phillips, Sclafani, Scalea, Duncan, Goldstein, Panetta
and Shaftan - "Early ORIF of the Disrupted Pelvic Ring" was retrospective
and uncontrolled and was permitted by the Journal of Trauma to make the
same assertion in print (26:325). Dr. John Connolly objected to the lack of
controls in the discussion of the paper at 45th AAST annual meeting but I
have found no complaints in subsequent letters about "a lack of editorial
oversight by the journal in question". Interestingly, it seems that other
studies suggesting the same sort of link between early skeletal
stabilization and the decreased incidence of ARDS e.g.:
Johnson KD, Cadambi A, Seibert GB.;Incidence of adult respiratory distress
syndrome in patients with multiple musculoskeletal injuries: effect of
early operative stabilization of fractures.J Trauma. 1985 May;25(5):375-84
Goris RJ, Gimbrere JS, van Niekerk JL, Schoots FJ, Booy LH.; Early
osteosynthesis and prophylactic mechanical ventilation in the multitrauma
patient.; J Trauma. 1982 Nov;22(11):895-903.
have also somehow been permitted to slip through the "editorial oversight"
cracks.
>Bill Burman wrote: .
Thanks for the reminder about the Helsinki
Accords
I don't think Ted Hansen had a "paternalistic" approach to patient care -
nor was he trying to get the attention of Amnesty International. I think he
was trying to prevent suicidal jumpers from hurting themselves and us as we
went out the front door after making them mobile again. I don't pretend to
be a medical ethicist. He couldn't send them to the psych ward because
there was inadequate acute monitoring capability there. The use of
restraints could badly torque the fixation. The "portable locked ward" was
not a permanent state of affairs but rather a temporary measure until their
meds had been effectively adjusted. I think he was doing a little
quarantine type thing while waiting for their meds and the plaster to have
an antipsychotic effect.
Date: Wed, 14 May 2003 02:29:02 -0400
From: Bill Burman
>Taking complex severely injured patients to the OR is always problematic.
E
I agree with this completely. At Harborview, anesthesia for early skeletal
stabilization ran (runs) in an ICU mode. After leaving there, I witnessed
deadly effects of early polytrauma ORIF without it.
Date: Wed, 14 May 2003 17:07:47 -0400
From: carl hauser
Bill Burman wrote:
Bill:
Biomechanics is a (fairly) exact science. Clinical medicine is not. It's hard
to measure patient compliance with a compass and protractor.
I would not single out the Journal of Orthopaedic Trauma for publishing a
retrospective study which concludes a correlation between early skeletal
stabilization and diminished rates of ARDS for patients of matched ISS....
- Whoa! No kidding...
"Early ORIF of the Disrupted Pelvic Ring", "Incidence of adult respiratory
distress syndrome in patients with multiple musculoskeletal injuries: effect of
early operative stabilization of fractures" and "Early osteosynthesis and
prophylactic mechanical ventilation in the multitrauma patient"
- I would agree wholehearedly that each of those papers was guilty of exactly
the same error. Journal editors often have to be responsive to the clinical
societies that "feed" them and read them. But on the other hand, the J Trauma
articles you cited were published between 1982 and 1986. The JOT paper you cited
was published in 1996. A 'sea-change' in the general understanding evidence-based
medicine had occurred in the intervening decade ....in some places, at least.
I don't think Ted Hansen had a "paternalistic" approach to patient care -
nor was he trying to get the attention of Amnesty International. I think he was
trying to prevent suicidal jumpers from hurting themselves and us as we went out
the front door after making them mobile again. I don't pretend to be a medical
ethicist. He couldn't send them to the psych ward because there was inadequate
acute monitoring capability there. The use of restraints could badly torque the
fixation. The "portable locked ward" was not a permanent state of affairs but
rather a temporary measure until their meds had been effectively adjusted. I
think he was doing a little quarantine type thing while waiting for their meds
and the plaster to have an antipsychotic effect.
- I don't have any problem with what you guys were doing. Frankly, it sounds
like Ted Hansen was trying to "do the right thing" according to the lights of his
day, and came up with a practical solution for a difficult set of circumstances.
I'm just pointing out that all that's changed. We can't do the right thing
anymore without consulting some "higher authority" consisting of nurses, lawyers,
ethicists, pathologists and retired pediatricians who think they understand what
living patients need better than we do. These passive-aggressive, quasi-clinical
parasites work 9-5, don't pay malpractice, and just happen to make a very good
living at it. Where I live, restraint orders have to be renewed on a daily basis,
and I think I could get an administrative operative consent with much less
trouble than I could get a judge to allow me to put a whole body spica on a
psychotic patient. So again, for better or worse there may be reasons to operate
that you can't measure with your protractor, and that was my point.
CJH
Date: Thu, 15 May 2003 18:06:08 -0600
From: Offner, Patrick M.D.
Although I normally just "lurk and learn" I feel compelled to put in a couple
cents worth. To suggest that only prospective randomized controlled clinical
trials be published is not only impractical--but ridiculous. To ignore the
potential importance of epidemiologic studies in terms of identifying
associations that require further focused (and more powerful)investigation
similarly seems somewhat pompous. Rather it is incumbent on all of us to read
each paper critically and recognize limitations inherent to different study
designs--thereby allowing the reader to put the same into perspective--even
perhaps allowing us design a better study to answer a particular question.
Pat
Date: Fri, 16 May 2003 06:51:46 -0400
From: carl hauser
Pat:
Glad to see you lurking. I'd agree in a second that there are worthwhile
retrospective analyses. We do them all the time. Sometimes that's the only
possible way to attack a problem, and as you suggest, they can guide us to more
robust analyses. But you've got to be incredibly careful with the conclusions. In
this case, the limitations of the study design clearly did not allow the
conclusions and the paper should never have been published in that form.
Sure, ultimately it's the reader's responsibility to believe or not to believe
the conclusions of any paper -caveat lector. But the vast majority of medical
readers simply don't have the time or expertise to analyze everything they read
prior to incorporating it into their knowledge base and basing patient care on
it. Never mind what happens when such dysinformation is cited for other purposes,
like litigation, or to promote drugs, devices or even individual physicians (you
know, like all those 'Our last 2000 vascular / cancer / cardiac / laparoscopic
operations without a mortality' papers). Thus an enormous responsibility must
fall to journal editors and reviewers to maintain the highest possible standards.
The concept that retrospective analysis of an administrative database
recording ISS, the hospital day of vertebral ORIF and the presence or absence of
ARDS can yield a cause and effect relationship between surgery and respiratory
failure boggles the imagination. The editors should have picked that up, but the
relationships between orthopedic procedures and systemic inflammation were
probably a little far afield from their usual expertise, and perhaps they just
didn't go outside their usual circle of reviewers to get the paper vetted. But
now it's out there in the literature, leading even sophisticated orthopedists to
cite it, and presumably to push for early vertebral ORIF's in sick patients on
that basis.
The Devil isn't in the data, it's the conclusions.
CJH
From: Michael Stein MD
Date: Fri, 16 May 2003 10:09:30 +0200
Lou, Bill, Paul, Carl, Patrick and Errington.
Thanks for the input. Now for some follow up. The patient was on mechanical
ventilationfor 3 days, and despite of the lung contusions was weaned. She was
log rolled in bed when sedated, but since she woke up (though not communicating
due to her psychiatric problem) we ordered a brace for her. However, that took
a couple of days to arrange and Xrays done as routine follow up, showed that she
deteriorated into a kyphosis of 43 degrees!! The spine surgeon is ORIFing her
today (10 days post injury). She is still, neurologically intact. Did we do
the right thing? I still wonder.
Mickey
From: Smith, Lou
Date: Fri, 16 May 2003 09:43:18 -0500
Dear Dr. Stein:
I responded initially "off-line"to your post, but I would say publicly that
if you question the response that you receive from your consultant and he really
is a conscientious professional, neither of you should be offended by obtaining
a second opinion, if it is available.
As a purely anecdotal note, I had a
similarly psychologically disturbedpatient several years ago that had a
question about a C2 fracture's stability-- while still hospitalized, he
dislocated it during a seizure...presenting symptom=death. This may have
dislocated even with ORIF, butthe incidentcertainly tempered my reluctance to
get a second opinion in a complicated case, even when the neurosurgeon is
competent and respected.
It's not like people write good literature about
these cases. If you have the gonadal fortitude to question yourself, you
should not feel bad about questioning others.
Lou
Date: Sun, 18 May 2003 12:30:56 -0400
From: Bill Burman
>Did we do the right thing? I still wonder.
Mickey
Thanks for the follow-up.
Prompted by Carl Hauser's displeasure with my selection of retrospective
references which correlate a decreased incidence of ARDS with early
operative stabilization of long bone fractures ( and it has been suggested
by some that the spine is the longest bone in the body), I took some time
to re-examine the "early ORIF" (open reduction internal fixation) belief
system.
The best reference I can find is a comprehensive interdisciplinary review
of the literature by EAST: "Optimal Timing of Long
Bone Fracture Stabilization in Polytrauma Patients" which concludes that
there is insufficient evidence to support a standard of care recommendation.
The EAST analysis could find no Class I (randomized, prospective) data to
support early ORIF even though one of the studies listed in the
bibliography (by Bone, Johnson, Weigelt and Scheinberg JBJS 71A:336 1989)
was a randomized, prospective study of 178 patients. I am no statistician.
Perhaps the sample size was inadequate.
Similar to a recent retrospective study from Harborview (Brundage, McGhan,
Jurkovich, Mack, Maier; J Trauma 52:299 2001) which found that early (< 24
hr) ORIF was associated with diminished pulmonary complications, ICU stay
and cost - even in head and chest polytrauma patients - there were no
significant differences in mortality between those patients fixed early and
those left to lie on their fractures.
This J Trauma article has the editorial oversight by David Dries which Carl
Hauser calls for. Dr. Dries suggests that data, gleaned from relatively
non-specific ICD9 administrative-type databases, is flawed in terms of
differentiating ARDS from pneumonia.
Bob Keller, recent past chair of the AAOS Committee on Outcomes has stated
(SPINE 20 384 1995):
"It has become increasingly clear that much of the clinical research that
has long been published and on which we base much of our education and
practice activity is, in fact, severely flawed."
And so we probably need to return to the advice of Hill, NEJM 248:995 1953:
"One must go seek more facts, paying less attention to technique of
handling the data and far more to the development and perfection of the
method for obtaining them."
before we can really determine "the right thing".
In the meantime, it would be interesting to talk to the critical care staff
who were pushing for early ORIF and patient mobilization. Maybe they know
something we don't.
From: Errington Thompson
Date: Sun, 18 May 2003 15:15:25 -0500
I'm not sure that Carl's tastes were the issue. I think that he correctly
pointed out some of the weaknesses in that paper. I agreed with his
analysis didn't you?
I believe that there is more and more evidence to support early fixation
just as you pointed out.
E
Errington C. Thompson, MD
From: William SLyons MD
Date: Sun, 18 May 2003 21:41:12 -0400
CJH BB ECT & Pat O,
it hardly boggles the imagination to see the connection between ARDS and
delayed ORIF when the saline load during the delay is factored in. Unfortunately
orthopedic papers are usually lacking this important data. In seeking more
facts, a la Hill, this should not be overlooked. Restating the obvious, ARDS is
more frequent in delayed ORIF in that the patient receives inadequately
monitored and excessive saline during the delay. Then at surgery anesthesia adds
to it at rates of 500 - 1000 cc per hour. Little wonder the incidence of ARDS
is related to length of the delay or is minimized by prompt surgery. More data
is needed on pre, intra and post-op saline.
BILL LYONS
Date: Mon, 19 May 2003 09:49:27 -0400 From: carl hauser Bill: My displeasure was with the papers, not at all with your quoting them.
I'm overjoyed when anyone shows an awareness that this controversy is out
there and needs to be addressed. Most people read one paper (or worse still,
one "comprehensive interdisciplinary review" or meta-analysis)
and think the issue's settled. As I see it, the real problem with assessing the systemic effects of
early fracture fixation is that the definition of the term "early"
is so variable. If you look back at Border's original article (Seibel and
LaDuca, Blunt multiple trauma (ISS 36), femur traction, and
the pulmonary failure-septic state. Ann Surg, 1985) that initiated the concern
for early vs late fracture fixation, it found that pulmonary 'sepsis' was
higher in patients placed in traction for 2 weeks than in
patients undergoing "immediate" fixation, ie in less than 2 weeks.
In retrospect, the "pulmonary failure-septic state" they saw
was probably in part what we'd now call "ARDS" or "ALI",
but along with immunosuppression and nosocomial pneumonia, PE's from prolonged
immobility, atelectasis etc. But our concern now is
whether the fractures in very sick polytrauma patients should be fixated
in <12 hours, 12-24 hours, <48h, >48h etc. And if you look at the
"early fracture fixation vs ARDS literature", the definition of
"early" is all over the map. This is a truly critical issue, because if you're going to look at the
immune / inflammatory sequellae of fracture fixation, you need to understand
the underlying physiology. Both systemic immunocyte activation status and
the mediator content of fractures change radically over the first week.
The patient's neutrophils are "hot" for the first 12 hours or
so after injury. After that, they are primed but hyporesponsive at selected
receptors. That seems to resolve within a week or so, excluding "second
hits". Likewise, fracture hematomas appear to be 'bland' for the first
6-12 hours or so, but mature and contain huge amounts of PMN inflammatory
cytokines like IL-8, and well as IL-6 and factors that suppress innate immunity
by 24-48 hours. These mediators may be differentially mobilized by various
operative fracture-fixation techniques. And yes, the differential distribution
of the various fluids used for resuscitation and volume support during anesthesia
and their effects on immune cell function will vary over time. Now, how all these lab findings may go on to interact and produce post-fracture
fixation pulmonary dysfunction is wildly speculative, but there's no doubt
that all the pathophysiologic changes are phasic. Thus the
use of any single time cut-point analysis (especially when it represents
the structures of administrative databases) probably will not only cancel
out and hide, but may frankly misrepresent the phasic changes that occur
over time. Using meta-analyses may actually decrease the power
of the data if the timelines of the papers selcted for meta-analysis used
are not identical. The only answer will come from multicenter studies by trauma surgeons
and orthopedists willing (and able) to subject both the timing and techniques
of fracture fixation in their sick patients to rigorous prospective analysis.
These are not easy studies to do, and no pharmaceutical house will support
them. But eventually they have to be done. CJH
Date: Tue, 20 May 2003 1:30 AM EST
From: Bill Burman
Carl Thank you for the information on fracture hematoma immunobiology and
the reference to John Border's 1985 Ann Surg paper. I believe the abstract
says the "early" group was treated with skeletal fixation within
30 hours. John Border was a frequent visiting professor at Harborview when I was
there. He gave us (in the orthopaedic department) intriguing talks on the
beneficial aspects of "fresh air" and "chicken soup"
which could be delivered to the polytrauma patient by means of early operative
fixation of fractures. Admittedly, with less than a complete understanding
of the intricacies involved, I found myself eager to be an advocate for
these ingredients - but an underlying, gnawing uncertainty caused me to
write to him for further clarification. John Border very courteously and promptly wrote back: "Immediate internal fixation drastically shortens the duration
and magnitude of the pulmonary failure septic state. The question is why the septic state? The answer is that the tracheal
intubation prevents the patient from eating and defecating and that secondary
to these things, the patient gets gut origin septic states of endotoxin
and bacteria that do not respond to antibiotics and are probably made worse
by antibiotics. The correct therapy is to feed them enterally to support
the normal gut mucosa antibacterial antitoxin penetration mechanisms. Thus
immediate internal fixation works not only on the pulmonary failure but
also by getting them extubated and fed to prevent gut origin septic states.
This , of course, is a more sophisticated version of the chicken soup
story which was clearly correct in principal if not in magnitude." So after consideration of Dr. Dries' call for better specification of
the pulmonary infiltrates, Dr. Lyon's concerns for how much they get to
drink, Dr. Border's concerns for how much they get to eat, Dr. E's concern
about the level of anesthesia "ICU mode", your concerns about better
delineation of the treatment timetables and how that relates to the immunobiology
and inflammatory cascade of the fracture hematomas - it does appear (as
you suggest) that the studies need to be redone - if we are to raise the
discourse from a state of haranguing evangelism to that of proper ecumenical
scholars. I therefore request the permission of all those involved in this thread
for its web publication at: http://www.hwbf.org/hwb/conf/stein1/lsfx.htm This is presently an unlinked, non-indexed web page, which can be taken
down if there are objections. Otherwise, perhaps it can serve as a starting
point for further AAST-OTA discussion and investigation. Date: Tue, 20 May 2003 08:30:12 -0400
From: david livingston
One other thought on this whole controversy is the that there also may
be differences in the way the fractures are handled that play into this
as well. In the 80's when Border's paper was written, more often than
not, ORIF meant OPEN the fracture. let out the evil humors that Carl has
described and plate/screw/etc it. Today, ORIF usually means, keep the
fracture closed, manipulate it into alignment and nail it.
DHL
Date: Tue, 20 May 2003 10:59:25 -0400 From: carl hauser Bill: >Bill Burman wrote: Thank you for the information on fracture hematoma
immunobiology and the reference to John Border's 1985 Ann Surg paper. I
believe the abstract says the "early"
group was treated with skeletal fixation within 30 hours. Well, actually as I understood Border's study, the groups were discontinuous.
To quote the abstract: "Group I (N = 20) had immediate internal fixation, postoperative
ventilatory support, and was sitting up at 30 hours. Group II (N = 20)
had 10 days of femur traction and postoperative ventilatory support. Group
III (N = 9) was immediately extubated after surgery and had 30 days of
femur traction." So there wasn't a cut point analysis per se. But my point was that if
you look at the "early fracture fixation literature", you'll see
that the definitions of early - as opposed to 'elective' or 'routine' -
fracture fixation were vastly different in the commonly cited papers. >Bill Burman wrote: John Border was a frequent visiting professor
at Harborview when I was there . . . I never had the chance to hear John Border lecture, but there is much
in what he says. There is much in what he observed 20 years ago that has
stood the test of time and some that has not. The "gut septic state"
is an idea that Border picked up from the work of Jake Fine 20 years earlier,
and described in a similar paper in Ann Surg a year or two later. Our evolving
knowledge suggests that this is probably a misnomer, and that the "gut
septic state" is probably more of a "gut-inflammatory state".
Gut inflammation appears to be partly due to gut hypoperfusion and excess
nitric oxide effect. The data suggests that gut flora does play a role in
gut-origin inflammation, although not as a traditional septic or invasive
process. Either way, enteral feedings do seem to ameliorate the effect.
But we feed polytrauma patients enterally far more aggressively now than
we did in 1985. So hopefully in the context of cutting-edge trauma care
that shouldn't be as much of an issue as it was. Keeping patients intubated and ventilated is much more of a current problem
in terms of pulmonary sepsis. The presence of tubes in the airway clearly
leads to slow, continuous microaspiration of nosocomial, multi-drug resistant
oropharyngeal flora. Also, being mechanically ventilated per se contributes
to acute lung injury. So if early fracture stabilization in any location
can contribute anything to earlier independence from the ventilator, it
is likely to be an incremental plus in terms of systemic morbidity and mortality
on that basis alone. All this is over and above those considerations related
to the direct effects of fracture wounds and their management on systemic
immunity. >Bill Burman wrote: So after consideration of Dr. Dries' call for
better specification of the pulmonary infiltrates, Dr. Lyon's concerns for
how much they get to drink, Dr. Border's concerns for how much they get
to eat, Dr. E's concern about the level of anesthesia "ICU mode",
your concerns about better delineation of the treatment timetables and how
that relates to the immunobiology and inflammatory cascade of the fracture
hematomas - it does appear (as you suggest) that the studies need to be
redone - if we are to raise the discourse from a state of haranguing evangelism
to that of proper ecumenical scholars. Right on. >Bill Burman wrote: I therefore request the permission of all those
involved in this thread for its web publication . . . OK by me. CJH
Trauma Surgeon
Trinity Mother Frances
Tyler, Tx
Determination of spinal "stability" remains elusive. See Alan
Levine's OTA BFC
lecture
> CJH wrote:
>that was exactly my point. It's often not clear who needs fixation on a
>mechanical basis, and sometimes psychosocial factors may need to be
>considered "in the mix".
In a 138 case retrospective study J Orthop Trauma 1996;10(5):323-30,
Schlegel, et al reported . . .
>CJH wrote:
>That's a classic cart-and-horse retrospective study for you . . .
Publishing papers like this suggests a lack of editorial oversight
by the journal in question.
>During my time at Harborview, Ted Hansen would put selected suicidal
>jumpers - after the acute phase - into full body spica casts . . .
> CJH wrote:
>Did that occur before or after the Helsinki Accords ? . . .
. . . Aggressive anesthesia is thinking in the ICU mode instead of the anesthesia mode.
I agree psychosocial factors are important but as of yet I have not seen them
biomechanically applied.
Trauma Surgeon
Trinity Mother Frances
Tyler, Tx