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Acute Respiratory Distress Syndrome, Fat Embolism, & Thromboembolic Disease in the Orthopaedic Trauma Patient Steve Morgan, MD

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  • 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.

  • ARDSCommon Causes

    Trauma Massive Transfusion Embolism Sepsis Aspiration Abdominal Distension

    Pulmonary Edema Prolonged LOC Cardiopulmonary

    Bypass Pancreatitis Major Burns


  • ARDS Etiology

    ARDS related to MSOF

    Release of inflammatory mediators results in organ dysfunction

    Trauma InflammatoryMediators



    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

  • ARDSPrevention

    Limiting Blood Loss Decreasing Transfusion Requirements Early Fixation Of Unstable Fractures Early Prophylactic Mechanical Ventilation

  • ARDS Treatment

    Ventilator Support Goals

    Acceptable ABGs Prevent alveolar damage Facilitate healing Non-toxic FIO2 (< .60)

    Research Optimal ventilator settings

  • ARDSOutcome

    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



    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


  • 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


    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


  • Systemic Effects of Trauma

    Injury12 hours 24 hours


    Second Insult


    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


  • 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 PumpsMechanism of Action Decrease Stasis Fibrinolytic Activity

  • IVC Filter Indications

    Anticoagulation Prohibited

    High Risk Patients DVT Prior to

    Necessary Surgery PE Despite


  • 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


    Parenteral Administration


    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


    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 Homans Sign

    All Unreliable

  • Ascending Contrast Venography Sensitive for detection Invasive Dye Problems

    (allergies, renal) Injection Site Irritation Poor Pelvic Vein


    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

    ClinicalShortness of breath, agitation, confusion

    Laboratory PaO2, A-a gradient

    Diagnostic studiesV/Q scansPulmonary 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

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