What is the best course of treatment for a patient with volvulus (twisting of the intestine) and a femur fracture after a traumatic fall, who also has a recent diagnosis of heart failure?

From the Guidelines

The best course of treatment for this complex case requires immediate surgical intervention for the volvulus, followed by orthopedic management of the femur fracture, all while carefully managing the patient's heart failure, as recommended by the latest guidelines 1. The volvulus represents the most urgent threat to life and requires emergency exploratory laparotomy to untwist the intestine and assess bowel viability. If necrosis is present, bowel resection with primary anastomosis or temporary stoma may be necessary. Following volvulus management, the femur fracture should be stabilized, preferably with intramedullary nailing or less invasive fixation methods to minimize cardiovascular stress. Throughout treatment, heart failure management is critical, including careful fluid balance (targeting euvolemia), continuation of heart failure medications (ACE inhibitors, beta-blockers, and diuretics as appropriate), and close hemodynamic monitoring, as suggested by the European Heart Journal guidelines 1. Pain control should utilize multimodal analgesia with cautious opioid use, supplemented by acetaminophen and possibly regional anesthesia techniques. Prophylactic antibiotics (such as cefazolin 2g IV for surgical prophylaxis) and DVT prophylaxis (with mechanical methods and possibly low-dose anticoagulation once bleeding risk decreases) are essential. This approach prioritizes life-threatening conditions while minimizing cardiac stress, as the combination of trauma, surgery, and heart failure significantly increases perioperative risk and requires multidisciplinary care involving surgery, orthopedics, cardiology, and critical care, as highlighted in the World Journal of Emergency Surgery guidelines 1. Additionally, the latest guidelines from the Anaesthesia journal recommend a multidisciplinary approach, including anaesthesiologists/intensivists, surgeons, and cardiologists, to manage patients with heart failure undergoing non-cardiac surgery 1. The management of pharmacological cardiovascular treatments in AHF patients before non-cardiac surgery should be carefully considered, with recommendations including the continuation of beta-blockers, statins, and renin-angiotensin-aldosterone system inhibitors, as outlined in Table 1 of the Anaesthesia journal guidelines 1. Overall, the treatment plan should focus on minimizing morbidity, mortality, and improving the patient's quality of life, as emphasized by the Circulation journal guidelines 1.

Some key points to consider in the treatment plan include:

• The importance of early palliative care consultation in geriatric trauma patients, as recommended by the World Journal of Emergency Surgery guidelines 1
• The need for careful fluid balance and hemodynamic monitoring in patients with heart failure, as suggested by the European Heart Journal guidelines 1
• The use of multimodal analgesia and cautious opioid use for pain control, as recommended by the Anaesthesia journal guidelines 1
• The importance of prophylactic antibiotics and DVT prophylaxis in preventing postoperative complications, as emphasized by the Circulation journal guidelines 1

From the Research

Treatment Approach for Volvulus and Femur Fracture with Recent Heart Failure Diagnosis

• The patient's condition involves multiple complex issues: volvulus (twisting of the intestine), a femur fracture, and a recent diagnosis of heart failure.
• For intestinal volvulus, most patients require some form of surgical intervention 2. The decision between emergent versus elective surgery is crucial as it influences morbidity and mortality.
• In the context of heart failure, angiotensin-converting enzyme (ACE) inhibitors are a cornerstone of treatment, offering benefits in reducing morbidity and mortality 3, 4.
• The management of heart failure with reduced ejection fraction (HFrEF) typically involves a combination of ACE inhibitors/angiotensin receptor-neprilysin inhibitor (ARNI), beta-blockers, mineralocorticoid receptor antagonists (MRA), and SGLT2 inhibitors 4.
• For the femur fracture, surgical intervention is often necessary to stabilize the fracture and allow for proper healing.
• The presence of a recent heart failure diagnosis complicates the treatment approach, as it necessitates careful consideration of the patient's cardiovascular status and the potential impact of surgical interventions on heart function.
• The combination of beta-blockers and ACE inhibitors may be beneficial across the spectrum of cardiovascular diseases, including heart failure, due to their complementary actions on the sympathetic nervous system and renin-angiotensin-aldosterone system 5.

Considerations for Surgical Intervention

• Prompt recognition and surgical correction of sigmoid volvulus are critical to mitigate further morbidity and mortality, especially in cases where it occurs after trauma 6.
• The surgical approach for volvulus and femur fracture must be carefully planned, considering the patient's overall condition, including heart failure.
• The use of ACE inhibitors and other heart failure medications should be optimized pre-operatively and post-operatively to minimize cardiovascular risk.

Multidisciplinary Care

• Given the complexity of the patient's condition, a multidisciplinary approach involving surgeons, cardiologists, and other specialists is essential for optimal management.
• Close monitoring of the patient's cardiovascular status, as well as their orthopedic and gastrointestinal conditions, is necessary to ensure the best possible outcomes.