Early appropriate care
Resuscitation-guided timing for orthopaedic trauma surgery.
Early appropriate care (EAC) is a framework used in orthopaedic trauma surgery to identify seriously injured patients and address their most urgent fractures without increasing their physiological stress. The approach was created by Heather Vallier at MetroHealth in Cleveland, and the term first appeared in her 2013 article in the *Journal of Orthopaedic Trauma*. EAC evolved from damage control orthopaedics (DCO) but emphasizes the patient’s response to resuscitation rather than relying solely on injury severity scores.
Under EAC, definitive surgery for unstable fractures of the axial skeleton and long bones should be performed within 36 hours only if the patient shows adequate resuscitation, indicated by a pH of 7.25 or higher, lactate of 4 mmol/L or lower, and a base excess less negative than -5.5 mmol/L. Signs of coagulopathy or hypothermia—both components of the trauma triad of death—would instead call for DCO using external fixation.
The history of this field began with early total care (ETC) in the 1980s, when studies found that early definitive fixation of long bone fractures reduced secondary ARDS, fat embolism, and sepsis. Later research showed that lengthy operations in unstable patients caused a "second hit" that increased mortality. In 2000, damage control orthopaedics was proposed to prevent early death by stabilizing fractures without definitive fixation, often with external fixators. EAC built on this by focusing on resuscitation status.
- field
- Orthopaedic trauma surgery
- known_for
- System for timing of definitive fracture fixation based on resuscitation parameters
- developed_by
- Heather Vallier
- institution
- MetroHealth, Cleveland
- first_proposed
- 2013 in Journal of Orthopaedic Trauma
Lore & Background
Early appropriate care (EAC) emerged from the evolution of orthopaedic trauma philosophies. Early total care (ETC) became widespread in the 1980s, when studies showed early definitive fixation of long bone fractures led to better outcomes, with a reduction in incidence of secondary ARDS, fat embolism and sepsis. Subsequent studies showed that in the unstable patient, long operations lead to a 'second hit' which actually worsened mortality outcomes. A philosophy of damage control orthopaedics (DCO) was proposed in 2000, aiming to prevent early death in a critically wounded patient via stabilization and not definitive fixation, often with the use of external fixation systems.
Reader's Guide
EAC prescribes that definitive management of unstable axial skeleton and long bone fractures should only be undertaken within 36 hours if an adequate response to resuscitation has been demonstrated by specific laboratory values: pH ≥7.25, lactate ≤4 mmol/L, and base excess > (less negative than) -5.5 mmol/L. Other factors such as coagulopathy and hypothermia (parts of the Trauma triad of death) would also be indications for DCO with external fixation. The significance of EAC lies in its shift from using injury severity score to focusing on resuscitation status as the key determinant for surgical timing. This approach aims to reduce the 'second hit' of prolonged surgery in physiologically compromised patients while still providing timely definitive fixation for those who have adequately responded to resuscitation. EAC represents a middle ground between early total care and damage control orthopaedics, offering objective criteria to guide decision-making in orthopaedic trauma.
Did You Know?
- EAC was developed by Heather Vallier while at MetroHealth in Cleveland.
- The term 'early appropriate care' was first proposed in a 2013 Journal of Orthopaedic Trauma article.
- EAC requires pH ≥7.25, lactate ≤4 mmol/L, and base excess > -5.5 mmol/L before definitive fixation within 36 hours.
- Coagulopathy and hypothermia are indications for damage control orthopaedics with external fixation under EAC.
More in Traumatology 1-24
Spotted an error? Know more?
This is a living reference — every entry is fact-audited, and reader corrections feed straight into our audit queue. Suggest an edit · See this site's audit record