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  1. RE: "Mucormycosis complicating lower limb crash injury in a multiple traumatised patient: an unusual case"

    Dear Authors,

    I read this well presented case report with a great interest. This manuscript highlights the difficulties and challenges regarding the management of the critically ill polytrauma patients which are recognised worldwide. It also emphasises the role of the initial pre Intensive Care Unit (ICU) resuscitation, which is essential not only in reducing the physiological insult from trauma, but more importantly it influences subsequent clinical course and overall outcome for the trauma patient. Once the lethal triad (acidosis, hypothermia and coagulopathy) develops, even the best therapy in the Intensive Care Unit (ICU) cannot restore basic physiologic and immunologic functions(1,3). In addition, the delivery of prompt and definitive treatment has been directly linked with the improved survival rates after trauma all over the world.

    However, there are few points regarding the management of this case, which I would like the challenge. Firstly, I would like comment on the Diagnostic Peritoneal Lavage (DPL) and subsequently discuss the general principles of the damage control resuscitation and damage control surgery.

    I note that on arrival this haemodynamically unstable polytrauma patient undergone the DPL. The DPL is sensitive in detecting blood in the peritoneal cavity, but lacks the specificity and more importantly is unable to identify the injury to retroperitoneal structures(2). For those reasons, the DPL has been abandoned many years back in the United Kingdom when faced with trauma cases. Also one of the absolute contraindications to DPL is "an existing indication for laparotomy", which I believe was present in this case(2). The mechanism of injury provides invaluable information to the clinicians regarding the energy transfer. It allows anticipating the injuries and planning the immediate treatment. Such polytrauma scenario clearly indicates the enormous energy transfer and very likely rapid deceleration mechanism. All above suggest the possibility of any bony, visceral, soft tissue and vascular injuries. Therefore, based on this information and haemodynamic parameters either an immediate laparotomy or head to pelvis computed tomography (CT) should be performed. Currently, level one trauma centres provide a multidetecor CT (MD-CT) which allows to perform full body scan for the trauma victims within 5 seconds(4). MD-CT is for quite some time a vital part of the primary survey which allows for rapid radiological and clinical evaluation of the trauma patients regarding the decision making process: ICU admission, laparotomy/thoracotomy or interventional radiology procedures.

    Of most interest to me is the timing of the Above Knee Amputation (AKA), which was performed on day 32 of the hospitalisation. It is well recognised that following traumatic "first hit" disturbed immune and coagulation systems make trauma patients susceptible to a "second hit" insult related to surgical procedures. Aggressive and prolonged surgical interventions in such circumstances exacerbate shock induced inflammatory response leading to profound systemic and cellular complications, which causes Systemic Inflammatory Response Syndrome (SIRS), Adult Respiratory Distress Syndrome (ARDS), Multi Organ Dysfunction Syndrome (MODS) and death(5). In such scenarios the polytrauma patients benefit from the damage control concept, which can be in the form of a primary AKA. The Damage Control (DC) is based on the two principles: damage control resuscitation (DCR) and damage control surgery (DCS). The first one utilises three key concepts: permissive hypotension, early use of blood products as primary resuscitation fluids, early and rapid correction of the coagulopathy(6).

    The DCS concept is applicable to any of the major body compartments. The objectives of DCS are always the same and they aim at haemorrhage control and correction of the coagulopathy, limitation of the contamination and inflammatory response(1). It enables the salvage of critically ill trauma patients with exhausted physiology by breaking the lethal triad (hypothermia, coagulopathy, and acidosis) with aggressive resuscitation of patients on the ICU with subsequent definitive repairs at the later stage(3). Most commonly DCS is utilised in the form of Damage Control Laparotomy (DCL) and Damage Control Orthopaedics (DCO). These two procedures are performed at the same time and should take at maximum in the experienced hands about 20-30 minutes. Therefore the primary AKA would have been a perfect example of the DC principles in this case if performed at the same time as laparotomy. But the decision whether and when to amputate is not an easy one and must be a matter of clinical judgement based on each case, and it must always involve a consensus of the entire health care team and the patient. Unfortunately, the discussion with the patient very often is not possible in an acute trauma scenario. In such circumstances, the decision regarding the amputation can be delayed and made once the patient is awake. The advantages of an early amputation include quicker recovery, shorter hospitalisation and lower costs and morbidity(7). However, it's tiring being an amputee, because the energy costs needed in walking increases with the proximal level of amputation, with bilateral limb loss and age(8,9).

    It appears to me that in this case the decision was made to salvage the limb, therefore few principles should follow. In theatre, adequate debridement and lavage are crucial, because if performed inappropriately they will impact on the patient's subsequent treatment options and outcome.

    Of a major concern to me is the Figure 3 showing "Wound condition after surgical debridement", which is clearly inadequate. It shows malalignment of the limb with bare, exposed bone and doubtful viability of the surrounding skin. The general principles of the debridement are well described by the Nanchahal and co-authors in the "Standards for the management of open fractures of the lower limbs" and they include(10):

    1. Irrespective of the wound size careful assessment from superficial to deep tissues is essential and all non viable tissues (skin, fascia, bone, muscles) have to be excised. We should aim to be reasonably conservative with the skin and as radical as possible with the muscles.

    2. Large volumes of low pressure lavage (Normal Saline) should be used which is safe and effective in reducing the infection rate. 3. There is no doubt that broad spectrum antibiotics should be administered as soon as possible because they are the most important factor in decreasing the infection rate.

    4. External fixation is part of Damage Control Orthopaedics and is preferred when rapid stabilisation is necessary in open comminuted fractures Gustilo IIIB like in this case. Ones again application of an external fixator can be performed alongside with the laparotomy and should take no longer then 30 minutes. Conversion to internal fixation ideally should be achieved within 72 hours of primary debridement, but the surgeon is the one who is best placed to understand the best window of opportunity for the trauma patient to return to theatre for definitive surgery.

    5. Soft tissue cover can only take place when appropriate skeletal stabilisation is achieved. Extensive evidence supports the early use of soft tissue cover for the injured area, because it is associated with an increased rate of fracture union and decreased deep infection rates, flap failures and length of hospital stay(11,12). Gopal described an innovative approach to Gustilo IIIB or IIIC fractures, which includes radical debridement and soft tissue cover with muscle flap within 72 hours, but this "fix and flap" technique may not be achievable in smaller centres without 24 hour dedicated teams of plastic surgeons(13). In cases when temporary wound cover is required, Vaccum Assisted Closure dressing or antibiotic beads pouch (as part of the dressing), allow Plastic surgeon to plan for a definite bone or soft tissue cover(10). Depending on the extent of the soft tissue damage, skin grafts, local flaps or free flaps can be used. Traumatic wound, with an exposed bone which is left without soft tissue envelope is without a doubt a gate for subsequent sepsis development.

    The trauma victims represent the most vulnerable group of patients who should be looked after by a dedicated trauma surgeon who is responsible for taking the patient through all phases of the "trauma disease" pathway. Had this AKA been performed within first hours or days of admission this case may have had a very different outcome. Trauma surgeons must make quick and correct decisions, remembering that "life comes before limb" and those aggressive limb reconstruction efforts may harm patients leading to prolonged hospitalisation, rehabilitation, greater costs, as well as increased sepsis and death(7).

    References

    1. Moore EE, Burch JM, Franciose RJ, et al. Staged physiologic restoration and damage control surgery. World J Surg 1998;22:1184-1191.

    2. American College of Surgeons . ATLS manual 7th edition. Chicago: American College of Surgeons, 2004. 3. Stahel PF, Smith WR, Moore EE. Current trends in resuscitation strategy for the multiply injured patient. Injury 2009;40S4: 27-35.

    4. Chan O. Primary computed tomography survey for major trauma. Br J Surg 2009; 96: 1377-1378. 5. Moore FA, McKinley BA, Moore EE. The next generation in shock resuscitation. Lancet, 2004;12;363(9425):1988-96.

    6. Duchesne JC, McSwain NE Jr, Cotton BA, et al. Damage control resuscitation: the new face of damage control. J Trauma 2010;69(4):976-90.

    7. Busse JW, Jacobs CL, Swiontowski MF, et al. Complex Limb Salvage or Early Amputation for severe Lower-Limb Injury: A Meta-Analysis of Observational Studies. J Orthop Trauma 2007;21(1):70-76.

    8. Taghipour H, Moharamzad Y, Mafi AR, et al. Quality of Life Among Veterans with war-related unilateral lower extremity amputation: a long term survey in a prosthesis centre in Iran. J Orthop Trauma 2009;23 (7): 525-530.

    9. Dougherty PJ. Transtibial amputees from the Vietnam War. J Bone Joint Surg 2001;83-A (3):383-389.

    10. Nanchahal J, Nayagam S, Khan U, et al. Standards for the management of open fractures of the lower limb. London: Royal Society of Medicine Press Ltd, 2009.

    11. Caudle RJ, Stern PJ. Sever open fractures of tibia. J Bone Joint Surg Am 1987;69:801-7.

    12. Gopal S, Majumder S, Batchelor AGB, et al. Fix and flap: the radical orthopaedic and plastic treatment of severe open fractures of the tibia. J Bone Joint Surg 2000;82-B (7): 959-966.

    13. Gopal S, Giannoudis PV, Murray A, et al. The functional outcome of sever, open tibial fractures managed with early fixation and flap coverage. J Bone Joint Surg Br 2004;86-B (6): 861-867.

    Conflict of Interest:

    none

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