This document discusses acute respiratory distress syndrome (ARDS), fat embolism syndrome (FES), and thromboembolic disease which are common complications in orthopaedic trauma patients. It defines each condition and covers their etiology, pathophysiology, diagnosis, treatment, prevention and outcomes. ARDS is an acute respiratory failure caused by lung inflammation from trauma or other insults. FES occurs after long bone fractures and causes hypoxia, confusion and rash. Thromboembolic disease risks include immobility and hypercoagulability from injury. The document outlines ways to prevent these conditions through early fracture fixation, prophylactic measures and screening protocols.
3. 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.
11. 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
12. Fat Embolism Syndrome
(FES)
• A Causative Factor In ARDS
• Occurs Following A Long Bone Fracture
• Characterized by:
– Hypoxia
– Mental Confusion
– Petechial Rash
13. FES
• Unanticipated Respiratory Distress
• Diagnosis of Exclusion
• Often Placed in The Category of ARDS
• R/O other Causes of Hypoxia
– Pulmonary Contusion
– ARDS
– Pneumonia
17. 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
18. 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
19. Gurd et al
FES Diagnosis
• 1 Major Criteria
• 4 Minor Criteria
25. 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
26. Effect of IM Nailing
• Canal Opening
• Reaming
• Nail Insertion
• Unreamed Nail Insertion
• All Cause Increased IM Pressure
• All Cause Embolic Showers On
Echocardiograms
27. Systemic Effects of Trauma
Injury
12 hours 24 hours
Postinjury
Inflammatory
Response
Second Insult
MOF
IM Nailing As A cause of Secondary Systemic Injury
28. DVT Incidence
• DVT occurance
60% if ISS >9.
• 35%-60% DVT in
pelvic fracture
• PE-Most common
preventable cause of
death in trauma.
31. Endothelial Injury
• Direct Trauma to Vein @ time of Injury
• Compression of the Vein Secondary to
Fracture Position
• Vein Manipulation @ Time of Fracture
Fixation
37. IVC Filter Indications
• Anticoagulation
Prohibited
• High Risk Patients
• DVT Prior to
Necessary Surgery
• PE Despite
Anticoagulation
38. 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
39. 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
40. 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
41. Low Molecular Weight Heparin
(LMWH)
• Potentiates Antithrombin III
• Specific for Factor Xa
• Minimal effects on other Factors
42. LMWH
• No Monitoring
• Increased Efficacy
• Longer 1/2 life
• Predictable
Response
• Lower risk of
thrombocytopenia
• Parenteral
Administration
• Cost
Advantages Disadvantage
43. Aspirin
• Inhibits cyclooxygenase
• Decreases Platelet Adherence
• ? Effectiveness in Musculoskeletal Trauma
– Venous clots not typically found to have
Platelet aggregates
44. Aspirin
• Oral Administration
• Tolerated well
• In-expensive
• No Monitoring
• ? Efficacy when used
alone
• GI Intolerance
• Prolonged anti-platelet
effect
Advantages Disadvantage
45. 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
49. 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
50. Doppler/Duplex Ultrasound
• Comparable to Venogram
• Non Invasive
• No Morbidity
• Poor Axial (i.e Pelvic)
Vein Evaluation
• Operator Dependent
• Good Screening Tool
– Noninvasive, reproducible
51. Magnetic Resonance Venography
• Non Invasive
• Good Visualization of
Pelvic Veins
• Difficult in Polytrauma
Patient
• Excellent specificity and
sensitivity for suspected
DVT
• Controversial for screening
53. Ventilation Perfusion Scan
• Ventilation Perfusion mismatch
• Results
– Low probabiltity
• 15% False Negative
– Medium
• Need Angiogram
– High probability
• 15% False Positive
• Screening Tool
54. Pulmonary Angiogram
• Angiographic Evaluation of
pulmonary vascular tree
• Allows Placement of IVC
Filter in same setting if
indicated
• Sensitive - Standard in PE
Detection. Diagnostic
55. Treatment PE
• Anticoagulation
• Filter for recurrent
event despite
anticoagulation
• Thrombectomy
– Serious Acute PE
– Patient in extremous
– Large identifiable PE
56. 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)
57. DVT/PE Outcome
• No Diagnosis and Treatment
– 30% Mortality
• Correct Diagnosis and Therapy
– 11% Mortality in First Hour
– 8% Mortality After First Hour
58. DVT/PE Outcome
• Post Thrombotic Syndrome
– Valvular Incompetence
– Venous Stasis
– Edema
– Cutaneous Atrophy
• Recurrent DVT
– 20% of Patients
Return to
General Index
