G05 ards, fes, dvt, pe

G05 ards, fes, dvt, pe
Acute Respiratory Distress Syndrome, Fat Embolism, & Thromboembolic Disease in the Orthopaedic Trauma Patient Steve Morgan, MD
Objectives • Define – ARDS – FES – Thromboembolic Disease • Understand Etiology & Physiology of each Condition • Understand – Prevention – Diagnosis – Treatment – Outcomes
ARDS • Acute respiratory failure in the post traumatic period characterized by a decreased PaO2 and a diffuse and often massive extravasation of fluid from the pulmonary vasculature to the interstitial space of the lungs.
ARDS Common Causes • Trauma • Massive Transfusion • Embolism • Sepsis • Aspiration • Abdominal Distension • Pulmonary Edema • Prolonged LOC • Cardiopulmonary Bypass • Pancreatitis • Major Burns MULTIFACTORAL
ARDS Etiology • ARDS related to MSOF • Release of inflammatory mediators results in organ dysfunction Trauma Inflammatory Mediators Organ Injury
ARDS PATHOPHYSIOLOGY • Systemic Inflammatory Mediators • Damage to Endothelial Lining • Increased Capillary Permeability • Fluid Extravasation • Alveolar Collapse • Decreased Pulmonary Compliance • Ventilation Perfusion Abnormalities • Arteriolar Hypoxemia
ARDS Chest Radiograph
ARDS Chest CT Scan
ARDS Prevention • Limiting Blood Loss • Decreasing Transfusion Requirements • Early Fixation Of Unstable Fractures • Early Prophylactic Mechanical Ventilation
ARDS Treatment • Ventilator Support • Goals – Acceptable ABG’s – Prevent alveolar damage – Facilitate healing – Non-toxic FIO2 (< .60) • Research – Optimal ventilator settings
ARDS Outcome • Significant Cause of Mortality • Major Cause of Death in Patients with the Lowest ISS scores • 40% - 50% Mortality Rate – Mortality Rate Slowly Decreasing with Changing & Improving Therapy
Fat Embolism Syndrome (FES) • A Causative Factor In ARDS • Occurs Following A Long Bone Fracture • Characterized by: – Hypoxia – Mental Confusion – Petechial Rash
FES • Unanticipated Respiratory Distress • Diagnosis of Exclusion • Often Placed in The Category of ARDS • R/O other Causes of Hypoxia – Pulmonary Contusion – ARDS – Pneumonia
Etiology • Mechanical • Biochemical • No simple etiology
Mechanical Etiology • Fracture Liberates Fat • Intravasation - Fat Enters Venous System • Fat Causes Mechanical Obstruction
Mechanical Etiology • Systemic Fat Embolization – Patent Foramen Ovale – Pulmonary Pre- Capillary Shunts FES To Brain On MRI
Biochemical Etiology • Chemical Mediators Released @ time of Fracture • Fat Released at Time of Fracture • Fat Metabolism by Lipase releases Free Fatty Acids • Free Fatty Acids Result in Endothelial Lung Damage
Gurd et al FES Diagnosis • Major Criteria – Hypoxemia – CNS Depression – Petechial Rash – Pulmonary Edema • Minor Criteria – Tachycardia – Pyrexia – Retinal Emboli – Fat in Urine – Fat in Sputum – Thrombocytopenia – Decreased Hematocrit
Gurd et al FES Diagnosis • 1 Major Criteria • 4 Minor Criteria
FES Treatment • Supportive • Oxygen Therapy to maintain PaO2 • Mechanical Ventilation
FES Treatment • Steroids – Decrease endothelial damage – 30mg/kg initial dose repeated @ 4 Hours, 1gm dose repeated @ 8 Hours: Total 3 Doses • Complications - Frequent – Infection – GI • Steroid Therapy Avoided Secondary To Poor Risk Benefit Ratio
FES Prevention • Therapies – Fluid Loading – Hypertonic Fluid – Alcohol – Heparin – Dextran – Aspirin • Not Shown to be Effective
FES Prevention • Appropriate Splinting • Early Fracture Stabilization • Oxygen Therapy
Timing of Fracture Fixation • Early Fracture Fixation Optimal • Decreases Pulmonary Complications • Delayed Fracture Fixation – Increased Pulmonary Dysfunction
Type of Fracture Fixation -Controversial- • IM Nail - Reamed vs Un-Reamed – Increased Pulmonary Dysfunction With Reamed technique – Decreased with Unreamed Technique – Pape et al • IM Nail Reamed vs Plate Osteosynthesis – No Difference In Pulmonary Dysfunction • Bosse et al
Effect of IM Nailing • Canal Opening • Reaming • Nail Insertion • Unreamed Nail Insertion • All Cause Increased IM Pressure • All Cause Embolic Showers On Echocardiograms
Systemic Effects of Trauma Injury 12 hours 24 hours Postinjury Inflammatory Response Second Insult MOF IM Nailing As A cause of Secondary Systemic Injury
DVT Incidence • DVT occurance 60% if ISS >9. • 35%-60% DVT in pelvic fracture • PE-Most common preventable cause of death in trauma.
Virchow Triad
Hypercoaguability • Tissue Thromboplastin • Activated Procoagulants • Decreased Fibrinolytic Activity • Ineffective Heparin Clearance of Activated Clotting Factors • Catecholamine Release
Endothelial Injury • Direct Trauma to Vein @ time of Injury • Compression of the Vein Secondary to Fracture Position • Vein Manipulation @ Time of Fracture Fixation
Venous Stasis • Immobilization • Hypotension • Venous Occlusion – Edema – Fracture Position
DVT Prevention Goals • Clinically significant events – PE – Post Thrombotic syndrome • Low Complication Rate • High Compliance Rate • Cost Effective
DVT Prevention
Prophylaxis • Elastic Stockings • Mechanical Compression Devices • Inferior Vena Cava Filter (IVC) • Heparin • Warfarin • Low Molecular Weight Heparin • Aspirin
Mechanical Methods • Activity • Compression Stockings • Sequential Compression Device • Pedal Pumps Mechanism of Action • Decrease Stasis ∀ ↑ Fibrinolytic Activity
IVC Filter Indications • Anticoagulation Prohibited • High Risk Patients • DVT Prior to Necessary Surgery • PE Despite Anticoagulation
IVC Filter • Prevents Major PE • Low Morbidity – 96% Patent – 8% Migration – 4% PE • Filter insertion in the ICU • Expensive • Invasive • Does not treat DVT • Venous Insufficiency • Filter Occlusion • Permanent Advantages Disadvantage
Heparin • Heparin Potentiates Anti-Thrombin III Activity • Complex Inhibits – Thrombin (IIa), IXa, Xa • Heparin effect relative short duration – Reversed with Protamine Sulfate • Significant hemorrhage risk
SQ Heparin • Low Cost • No Monitoring • Convenient • Relatively Low Incidence of Bleeding • Insufficient Efficacy in High Risk Patients • Unpredictable Responses • Heparin Induced Thrombocytopenia Advantages Disadvantage
Low Molecular Weight Heparin (LMWH) • Potentiates Antithrombin III • Specific for Factor Xa • Minimal effects on other Factors
LMWH • No Monitoring • Increased Efficacy • Longer 1/2 life • Predictable Response • Lower risk of thrombocytopenia • Parenteral Administration • Cost Advantages Disadvantage
Aspirin • Inhibits cyclooxygenase • Decreases Platelet Adherence • ? Effectiveness in Musculoskeletal Trauma – Venous clots not typically found to have Platelet aggregates
Aspirin • Oral Administration • Tolerated well • In-expensive • No Monitoring • ? Efficacy when used alone • GI Intolerance • Prolonged anti-platelet effect Advantages Disadvantage
Warfarin • Blocks Vit K conversion in Liver • Effects Vit K Dependent Factors • Effects the Extrinsic Clotting System • Factor VII Effected first, Short Half Life • Monitored with Pro-Time – INR 2.0-2.5 • Reversed With Vitamin K or FFP
Warfarin • Effective • Oral Administration • Inexpensive • Requires Monitoring • Difficult to Reverse • Increased Bleeding Complications in Elderly Advantages Disadvantage
DVT screening • Physical Exam • Ascending venography • Duplex Ultrasonography • Magnetic Resonance Venography
Physical Examination • Calf Swelling • Palpable Venous Cords • Calf Pain • Homan’s Sign • All Unreliable
Ascending Contrast Venography • Sensitive for detection • Invasive • Dye Problems (allergies, renal) • Injection Site Irritation • Poor Pelvic Vein Evaluation • Gold Standard *Invasiveness,expense make ACV a poor screening tool
Doppler/Duplex Ultrasound • Comparable to Venogram • Non Invasive • No Morbidity • Poor Axial (i.e Pelvic) Vein Evaluation • Operator Dependent • Good Screening Tool – Noninvasive, reproducible
Magnetic Resonance Venography • Non Invasive • Good Visualization of Pelvic Veins • Difficult in Polytrauma Patient • Excellent specificity and sensitivity for suspected DVT • Controversial for screening
Pulmonary Embolism Clinical Shortness of breath, agitation, confusion Laboratory ↓ PaO2, ↑ A-a gradient Diagnostic studies V/Q scans Pulmonary Angiogram
Ventilation Perfusion Scan • Ventilation Perfusion mismatch • Results – Low probabiltity • 15% False Negative – Medium • Need Angiogram – High probability • 15% False Positive • Screening Tool
Pulmonary Angiogram • Angiographic Evaluation of pulmonary vascular tree • Allows Placement of IVC Filter in same setting if indicated • Sensitive - Standard in PE Detection. Diagnostic
Treatment PE • Anticoagulation • Filter for recurrent event despite anticoagulation • Thrombectomy – Serious Acute PE – Patient in extremous – Large identifiable PE
Treatment DVT/PE • Heparin – Bolus 10-15K units – Continuous Infusion • 1000Units/Hr – Goal → PTT 2x Control • Prevent Clot propagation and recurrent PE – Discontinue when Therapeutic on Wafarin • Warfarin – INR 2.0-3.0 – 3-6 Month Duration – Contraindicated in: • Pregnancy • Liver insufficieny • Poor Compliance – Prolonged Therapy may decrease recurrence rates (6 mos)
DVT/PE Outcome • No Diagnosis and Treatment – 30% Mortality • Correct Diagnosis and Therapy – 11% Mortality in First Hour – 8% Mortality After First Hour
DVT/PE Outcome • Post Thrombotic Syndrome – Valvular Incompetence – Venous Stasis – Edema – Cutaneous Atrophy • Recurrent DVT – 20% of Patients Return to General Index

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