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SEFS 2019 Open fractures? Post it for the morning

SEFS 2019 Open fractures? Post it for the morning. Steven Cherney, MD. Disclosures. None. Historical 6 hour rule. Freidrich guinea pig Debridement within 6 hours = healthy. What matters most?. JOT 2015 Antibiotic prophylaxis most critical Time to coverage second. Literature support.

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SEFS 2019 Open fractures? Post it for the morning

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  1. SEFS 2019Open fractures? Post it for the morning Steven Cherney, MD

  2. Disclosures • None

  3. Historical 6 hour rule • Freidrich guinea pig • Debridement within 6 hours = healthy

  4. What matters most? JOT 2015 • Antibiotic prophylaxis most critical • Time to coverage second

  5. Literature support • Recently, largely no difference in time to debridement • Even up to 24h • Lack et al. 2015

  6. JBJS 2010 • Prognostic Level II • Earlier admission to trauma center matters but OR timing does not

  7. JBJS 2012 • Level III • No difference in infection rates

  8. Systematic review JOT 2016 • No change in infection at 6h mark

  9. JOT 2014 • Prospective, multicenter observational cohort Level I evidence

  10. Duyos et al. JAAOS 2017 • Increased infection rate debridement >24h

  11. Counterpoint • Malhotra et al. • J Trauma Acute Care Surg 2014 • Infection rate increased at 8h cutoff • Level IV

  12. Does open injury severity play a role? • Hull et a. BJJ 2014 • Increased infection rate Type II and III open tibia fractures • No time cutoff

  13. JOT 2014 • Projected increased cost of running ORs at night without obvious benefit • $4 million?

  14. Dedicated Trauma Room • Ricci et al JBJS 2009 • Lower minor complication rate in cases done during the day • Bhattacharyya et al. J Trauma 2006 • Lower complications, lower cost overruns with dedicated trauma room

  15. What about my practice? Trauma room • Staffed and available 7a-5p daily • Leave this time open • “Cold trauma” should be lowest priority in the trauma room- • Inpatients with closed injuries will get bumped • No outpatient surgery admits in the trauma room

  16. My approach • Open fractures excluding vascular injuries can wait • “Contaminated wound” not a deciding factor • Golden rule

  17. Support staff at night • Someone needs to pass instruments • Little ortho experience- (self-fulfilling?) • Poor attitudes • Someone needs to run the C-arm • Best C-arm tech is “on call”, but will then be unavailable in the AM

  18. Caveats: This may not work for you • Trauma room should be available in AM or within 24h for debridement • Trauma room may not be part of your practice • No vascular injury requiring stabilization

  19. Thank You

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