A brief approach to patient with polytrauma, physiological response of body with trauma, the trimodal mortality, golden hour, lethal triad of trauma, two hit hypothesis, inflammatory mediators, prehospital care, primary survey, secondary survey, ABCDE approach, Adjucts are included. Besides thc concept of Damage control orthopedics, trend in fracture management , evolution , principle, indication , surgical stratergies, advantage, limitation, definitive fixation and EAC and ETC are included in breif.
Damage control is a Navy term defined as “the capacity of a ship to absorb damage and maintain mission integrity". Damage Control Orthopaedics (DCO) is a relatively recent concept in orthopaedic practice it means early rapid containment & stabilization of orthopedic injuries without worsening the patient general condition. It is indicated in critically ill polytrauma patient, unfavorable surgical environment, battlefield limb injuries & mass casualties.
Damage control is a Navy term defined as “the capacity of a ship to absorb damage and maintain mission integrity". Damage Control Orthopaedics (DCO) is a relatively recent concept in orthopaedic practice it means early rapid containment & stabilization of orthopedic injuries without worsening the patient general condition. It is indicated in critically ill polytrauma patient, unfavorable surgical environment, battlefield limb injuries & mass casualties.
Can read freely here
https://sethiortho.blogspot.com/
Damage control &
Early Appropriate care in Orthopedics
ContentsEvolution of poly trauma management
Early total care
Damage control orthopedic care
Early appropriate care
Introduction
Trauma is the leading cause of death in young populatio
Immediate death – 50%- minutes
Lethal head injury
Hemorrhagic shock
Early death - 30%- hrs
Secondary brain injury
Hemorrhagic shock
Late death – 20% - days to weeks
ARDS
Pneumonia
MODS
Damage control surgery
Evolution of Polytrauma Management
Management concept - Delayed management
Splints, casts and traction
Definite surgery delayed for 10 -14 days
Prolonged bed rest and hospital stay
Damage control surgery
Decubitus ulcer
Disuse atrophy
Early definitely stabilization long bone fracture reduced incidence of fat embolism syndrome
Early Total Care
Damage control surgery
Usually within the first 24hrs
Early Total Care - Advantages
Early fixation favors skin and soft tissue healing
Prevent ongoing tissue damage
Pain relief
Improve joint function
Early mobilization
Respiratory distress
Pneumonia
Early stabilisation of hemodynamically unstable or/and had concomitant chest or head injury patients develop high mortality
mainly by ARDS and MODs
Reasons for the high mortality ?
Two hit phenomena
These findings indicated that
ETC is not appropriate for unstable poly trauma patients
Damage control surgery
Damage control is a new term first used by the US Navy during World War II to describe emergency measures for control of flooding that threatens to sink a ship.
Goal is to ensure survival of the ship until it reaches a port where definitive repairs can be safely performed.
Basic strategies of DCO -
Control of haemorrhage
Damage control surgery
Minimize the second hit
Immediate and rapid stabilization of long bone fractures - EF
Release of tight soft tissue compartments
Reductions of dislocations
Surgical debridement of open wounds
Amputation, in cases of unsalvageable extremities
Definitive fixation is later
Immediate external fixation followed by early closed intramedullary nailing is a safe treatment method for fractures of the shaft of the femur in selected polytrauma patients.
Which patient need DCO approach ?
Patients who have sustained orthopedic trauma have been divided into four groups:
Damage control surgery
Patient categorization
Limitations of DCO
Axial skeleton and femoral fractures
No external fixation
Even ex fix , patient mobilization is poor - bed ridden condition
Anatomical reduction favours pain relief, soft tissue healing and muscle function
Limitations of DCO
Classification of patient condition is not static, dynamic and changed with resuscitation
DCO recommended for those patients who are unstable or in extremis however the optimal time and type of treatment, who are in border line remain controversial
Successful management of Polytrauma must achieve the following goals, 1- Keep someone alive that would be dead without you 2- Prioritize treatment to prevent killing someone 3- Treat extremity injuries to return the patient to a functional life. The Priorities are 1- Life threatening, 2- Limb threatening, 3- Function threatening. The question about the best strategy in the management Polytrauma and the choice between an Early Total Care (ETC) vs. Damage Control Orthopedics (DCO) will be answered in this presentation.
POLYTRAUMA AND DAMAGE CONTROL ORTHOPAEDICSDr Slayer
polytrauma is Injury to 2 or more organ systems leading potentially to a life threatening condition
Damage control orthopaedics is an approach to contain and stabilize an orthopaedic injury to improve patient’s physiology which are designed to avoid worsening pt’s condition due to “second hit” phenomenon
Bone fractures are a very common orthopedic injury resulting from trauma and sudden loads or stresses applied to bones or a result from bones being weakened by certain diseases. More than 250,000 femur fracture patients are seen per year in the U.S. on average. Bone fractures are either a complete or partial break in a bone and in some cases a simple cast to immobilize the injury site is not enough to completely heal the fracture.
Immobilization from casts may not be enough to completely heal the fracture if a malunion (when both ends of the fractured bone misalign) occurs and/or if a non-union (when the fracture gap is too large and the fractured ends cannot re-attach to one another) occurs. In the case of a malunion or non-union, a possible solution to the problem is by surgically inserting an intramedullary rod into the center canal (diaphysial) region of the injured bone and fixating it into place with screws.
Tendoachilles rupture and its managementRohan Vakta
Achilles tendon is the strongest tendon of body. There are many causes of its rupture. It can be acute or chronic rupture. Management of chronic rupture by semitendinosus tendon is mentioned here.
This video explains Lumbar Disc Replacement in Detail. When degenerative disc disease begins to affect the spine this is called degenerative disc disease. This video highlights the history, epidemiology, and treatment options both conservative and surgical. If you or someone you know needs to be seen in regards to Lumbar Disc Replacement feel free to look us up online www.beverlyspine.com or www.santamonicaspine.com OR call toll free 1-8SPINECAL-1
Principles of Management of the multiply injured patientCHRIS ALUMONA
The multiply injured or polytraumatised patient is at a greater risk of morbidity and mortality than patients with isolated injuries. This risk is greater than the sum of the risks of their individual injuries. A high index of suspicion is needed to recognise immediately life threatening injuries and promptly address them. The principles of management is captured with the ATLS protocol and every trauma surgeon should be conversant with this indispensable tool.
Can read freely here
https://sethiortho.blogspot.com/
Damage control &
Early Appropriate care in Orthopedics
ContentsEvolution of poly trauma management
Early total care
Damage control orthopedic care
Early appropriate care
Introduction
Trauma is the leading cause of death in young populatio
Immediate death – 50%- minutes
Lethal head injury
Hemorrhagic shock
Early death - 30%- hrs
Secondary brain injury
Hemorrhagic shock
Late death – 20% - days to weeks
ARDS
Pneumonia
MODS
Damage control surgery
Evolution of Polytrauma Management
Management concept - Delayed management
Splints, casts and traction
Definite surgery delayed for 10 -14 days
Prolonged bed rest and hospital stay
Damage control surgery
Decubitus ulcer
Disuse atrophy
Early definitely stabilization long bone fracture reduced incidence of fat embolism syndrome
Early Total Care
Damage control surgery
Usually within the first 24hrs
Early Total Care - Advantages
Early fixation favors skin and soft tissue healing
Prevent ongoing tissue damage
Pain relief
Improve joint function
Early mobilization
Respiratory distress
Pneumonia
Early stabilisation of hemodynamically unstable or/and had concomitant chest or head injury patients develop high mortality
mainly by ARDS and MODs
Reasons for the high mortality ?
Two hit phenomena
These findings indicated that
ETC is not appropriate for unstable poly trauma patients
Damage control surgery
Damage control is a new term first used by the US Navy during World War II to describe emergency measures for control of flooding that threatens to sink a ship.
Goal is to ensure survival of the ship until it reaches a port where definitive repairs can be safely performed.
Basic strategies of DCO -
Control of haemorrhage
Damage control surgery
Minimize the second hit
Immediate and rapid stabilization of long bone fractures - EF
Release of tight soft tissue compartments
Reductions of dislocations
Surgical debridement of open wounds
Amputation, in cases of unsalvageable extremities
Definitive fixation is later
Immediate external fixation followed by early closed intramedullary nailing is a safe treatment method for fractures of the shaft of the femur in selected polytrauma patients.
Which patient need DCO approach ?
Patients who have sustained orthopedic trauma have been divided into four groups:
Damage control surgery
Patient categorization
Limitations of DCO
Axial skeleton and femoral fractures
No external fixation
Even ex fix , patient mobilization is poor - bed ridden condition
Anatomical reduction favours pain relief, soft tissue healing and muscle function
Limitations of DCO
Classification of patient condition is not static, dynamic and changed with resuscitation
DCO recommended for those patients who are unstable or in extremis however the optimal time and type of treatment, who are in border line remain controversial
Successful management of Polytrauma must achieve the following goals, 1- Keep someone alive that would be dead without you 2- Prioritize treatment to prevent killing someone 3- Treat extremity injuries to return the patient to a functional life. The Priorities are 1- Life threatening, 2- Limb threatening, 3- Function threatening. The question about the best strategy in the management Polytrauma and the choice between an Early Total Care (ETC) vs. Damage Control Orthopedics (DCO) will be answered in this presentation.
POLYTRAUMA AND DAMAGE CONTROL ORTHOPAEDICSDr Slayer
polytrauma is Injury to 2 or more organ systems leading potentially to a life threatening condition
Damage control orthopaedics is an approach to contain and stabilize an orthopaedic injury to improve patient’s physiology which are designed to avoid worsening pt’s condition due to “second hit” phenomenon
Bone fractures are a very common orthopedic injury resulting from trauma and sudden loads or stresses applied to bones or a result from bones being weakened by certain diseases. More than 250,000 femur fracture patients are seen per year in the U.S. on average. Bone fractures are either a complete or partial break in a bone and in some cases a simple cast to immobilize the injury site is not enough to completely heal the fracture.
Immobilization from casts may not be enough to completely heal the fracture if a malunion (when both ends of the fractured bone misalign) occurs and/or if a non-union (when the fracture gap is too large and the fractured ends cannot re-attach to one another) occurs. In the case of a malunion or non-union, a possible solution to the problem is by surgically inserting an intramedullary rod into the center canal (diaphysial) region of the injured bone and fixating it into place with screws.
Tendoachilles rupture and its managementRohan Vakta
Achilles tendon is the strongest tendon of body. There are many causes of its rupture. It can be acute or chronic rupture. Management of chronic rupture by semitendinosus tendon is mentioned here.
This video explains Lumbar Disc Replacement in Detail. When degenerative disc disease begins to affect the spine this is called degenerative disc disease. This video highlights the history, epidemiology, and treatment options both conservative and surgical. If you or someone you know needs to be seen in regards to Lumbar Disc Replacement feel free to look us up online www.beverlyspine.com or www.santamonicaspine.com OR call toll free 1-8SPINECAL-1
Principles of Management of the multiply injured patientCHRIS ALUMONA
The multiply injured or polytraumatised patient is at a greater risk of morbidity and mortality than patients with isolated injuries. This risk is greater than the sum of the risks of their individual injuries. A high index of suspicion is needed to recognise immediately life threatening injuries and promptly address them. The principles of management is captured with the ATLS protocol and every trauma surgeon should be conversant with this indispensable tool.
The poly traumatized patient the role of orthopedic surgeonMohamed Abulsoud
The management of polytraumatized patient is multidisplinary team .
Orthopaedic surgeon in the striker of the team
Resuscitation and survey is a key for excellent outcome
Timing of surgery is very crucial
ETC Vs. DCO should be considered carefully
Polytrauma and multiple traumata are medical terms describing the condition of a person who has been subjected to multiple traumatic injuries. This will be more prevalent in our country
Lisfranc and Forefoot fracture in adult.pptxKaushal Kafle
Lisfranc injuries are notorious injuries easily missed and difficult to diagnose in subtle cases. Diagnosis and management is changing with changing time and fixation is the dictum. If significant injury or only ligamentous injury the newer trend is arthodesis.
Principle of Deformity Correction in lower Limb Kaushal Kafle
A brief summary about the priniciple of deformity correction in paediatrics and adults with the effects of deformity, etiology, physiological deformity, clinical and radiological assessment, measurements of various lines and angles, various terminologies, preoperative templating, acute and gradual correction , osteotomy principle and techniques, methods of fixation and stabilization.
Approach to the hip and knee joint for various procedures including the drainage of septic joint, arthroplasty, soft tissue relase and and various osteotomies around hip and knee e joints.
Proximal physeal and SOH Fractures in pediatrics can be managed conservatively irrespective of alignment and reduction as it has great remodeling potential
The younger the age more deformity is acceptable in femur fracture
Treatment Modalities in pediatric femur fracture depends on the age and fracture pattern
Proximal tibia fracture will develop valgus deformity irrespective of treatment so counselling is must
Soft tissue status in the shaft of tibia factor determines the outcome in tibia fracture
General approach to patient with genetic disorders and skeletal dysplasias. Approach to children with dwarfism and classification into various categories and further management of the cases based upon the recent knowledge of genetics and recent advances.
Congenital Pseudoarthrosis of Tibia and Blounte’s Disease.pptxKaushal Kafle
Congenital Pseudoarthrosis of Tibia and Blounte’s Disease, etiopathogenesis , cause of lowerlimb deformity and bowing in kids, treatment, prognosis and outcome, Tachdijans Padeiatric Orthopedics
Basic principle of Knee Joint arthroscopy and techniques for beginners. Basic Steps of Knee Joint Diagnostic arthroscopy and common complication following knee joint arthroscopy.
Embryological Development of Musculoskeletal system focusing on the upper limb, lower limb and spine from orthopedics point of view with clinical corelates.
Bone physiology, OSTEOPOROSIS, Pagets Disease, HyperparathyoidismKaushal Kafle
A brief introduction to bone physiology, with more focus on Osteoporosis and its recent updates. Small tail topics include hyperparathyroidism and pagets disease.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Appraoch to patient with polytrauma and Damage control orthopedics
1. Approach to Patient with
Polytrauma and Damage Control
Orthopedics
Presenter: Kaushal Raj Kafle
Moderator : Dr. Shirish Adhikari, MS
2. Content
• Defining polytrauma
• Physiological response to trauma
• Approach to patient with polytrauma patients and ATLS
protocol
• Definition and development of DCO concept
• Principles of DCO
• Indications, advantage and limitation of DCO
3.
4. AIS and ISS
• Injury Severity Score
– identify and classify injured
patients
– risk adjustment and
benchmarking using
mortality prediction model
– the ‘gold standard’ of injury
scoring
– Major trauma (MT) using
an ISS ≥ 16
5. Polytrauma
New Berlin Definition
• An Abbreviated Injury Scale score of ≥3 in ≥2 body regions
(2AIS ≥3)
• with the presence of ≥1 physiological risk factors (PRFs).
– Age (≥70)
– Glasgow Coma Scale (GCS≤8)
– Hypotension (SBP ≤60 )
– Acidosis (BE ≤-6 )
– Coagulopathy (aPPT ≥ 40s/INR ≥1.4 )
6. Trauma Mortality
• Trimodal Pattern
– Immediate (sec to min)
• Apnea secondary to Brain or
SC injury
• Catastrophic Hemorrhage
– Early (min to hours)
• Hemorrhage related
• Focus of the ATLS care
– Late
• MODS / Sepsis
• Optimal early management
7.
8. Golden Hour
• Critically injured patient receive definitive care within 60 min from
occurrence of injury
• Concept of 1970s, widely accepted and clinically plaused
• Golden hour isn’t a strictly defined time period
• Concept emphasises the urgency of care
• Still remains valid, but for some patients the ‘golden hour’ may only
be minutes, or for others, much later
• Platinum 10 minutes : No patient should have more than 10 min of
scene time stabilization
10. Physiological Response to Trauma
• Trauma : SIRS
• Recovery : CARS
• SIRS lead to MODS
• Immunosuppression leads
to Delayed MODS
• Persistent Inflammation,
Immunosuppression, and
Catabolism Syndrome
(PICS)
11. • Fine balance between the beneficial effects of inflammation
and potential to cause and aggravate tissue injury
12. Two hit hypothesis
• First Hit:
– Massive injury and shock
– Immediate aftermath of
trauma
• Immediate inflammatory
response
– IL 6,8
– L selectin
– CD11b Leucocyte
• Second Hit :
– sepsis, surgical procedures
• Cumulative inflammatory
response
• Hyperstimulation of
inflammatory system
• Potential worse outcome
compared to what was
expected out of the first
13.
14. Inflammatory mediators
• Inflammatory response
• Innate immune system
– Macrophage
– Leukcocytes
– NK cells
– Inflammatory cells
mediated by IL 8
– C5a, C3a
– ROS
– Eicosanoids
– Cytokines
15.
16. Genetics and trauma
• NOT all patient obey the roles set by predictive parameter
• Mutation in endonuclease restriction sites, SNP genes
• Genetically Susceptible predispose to sepsis, ARDS and MODS
• Future : Early identification of AT RISK patients
17. Approach to patient with poly trauma
• First : Synchronous Clinical Assessment
Life saving procedures
– ATLS Guidelines
– Control of massive visceral bleed
– Chest/Brain Decompression
• Second : Day 1 surgery
– Damage control interventions
– Debridement, decompression and temporary fracture
stabilization
• Finally
– Reconstructive surgery after physiological stabilization
18. Prehospital Care
• Field Triage
• Control of External hemorrhage and shock
• Airway management
• Immobilization
• Notification and immediate transfer
21. Triage
• Sorting (Prioritization) of patients based on resources
required for treatment and the resources actually available
• Priority is set by ABC principle
22. Primary Survey
• Primary Survey with simultaneous resuscitation
• Rapid identification of life threatening conditions
• ABCDE
– Airway and C spine stabilization
– Breathing and Ventilation
– Circulation with Hemostasis
– Disability/Neurological Assessment
– Exposure and Environment Control
• cABCDE
23. Airway and C spine control
• Assessment
– Able to talk
– Unconcsious
• Chin lift/ Jaw thrust
• Airway Adjuncts
– Protect excessive mobility
• Cervical Collar
24. Breathing and Ventilation
• Assessment
– Inspect, palpate, percuss and auscultation
• JVP, chest movement, tracheal deviation
• Lungs, chest wall, diaphragm
– Intact airway does not mean adequate ventilation
• High Flow Oxygen
• Adjunct : Saturation assessment
26. Circulation and Hemostasis
• Hemorrhage: most dominant preventable cause of death
• Hypotension is secondary to hemorrhage until proven
otherwise
• Assess: Consciousness, Skin , Pulse
• Monitor : BP , I/O
• Manage : Double wide bore cannula
– Fluid Resuscitation with Colloid/Crystalloid
– Blood Grouping and Cross matching
– Blood Transfusion
– Evaluate and manage for internal bleeding
29. Exposure and Environment Control
Complete Exposure of body
Back and log roll
Removal and reapplication of splints
Prevention of Hypothermia
30. Secondary Survey
• Head to toe examination
• Identification of non life threatening injuries
• AMPLE
– Allergies
– Medication
– Past medical history
– Last meal
– Event/ environment of injury
31. Physical Examination
• Head: Scalp, Vision, pupillary reflex, conjunctival hemorrhage
• Maxillofacial/ C spine and Neck
• Chest, abdomen and pelvis
• Perineum , rectum, vagina
• MSK system
• Neurology
32. Adjunct to secondary survey
• X Ray of Spine and Extremities
• CT head, Chest, Abdomen and Spine
• Contrast Urography, Angiography, bronchoscopy and
Endoscopy
34. Definitive Care
Multi Specialty Approach
Neurosurgeons
Thoracic Surgeons
Genitourinary/ GI Surgeons
Orthopedics Surgeons
Vascular Surgeons
Critical Care Physicians
Anesthesiologist
Trauma Nurse
Physiotherapist
35. Damage Control Orthopedics
• Approach that contains and stabilizes orthopedics injury so
that the patient’s overall physiology can improve.
• Focuses on
– Hemorrhage control
– Management of soft tissue injury
– Provisional stabilization of fracture
– Avoid additional insult
36. Damage Control Surgery and
Abdominal Trauma
• Sum total of all maneuvers required to ensure survival over
definitive repair
• Improved lethal triad
• Coined by Rotondo and Zonies 1993
• Systematic three phase approach
– Immediate laparotomy : hemorrhage control and containment
– Resuscitation in ICU (Hemodynamics, rewarming, coagulopathy,
ventilatory support, continued identification of injuries )
– Planned reoperation to remove packing, definitive repair,
closure and possible repair of extra abdominal injuries
37. Trends in Fracture Management
• Early Total Care
• Damage Control Orthopedics
• Safe Definitive Surgery / Early Appropriate Care
38. Early Total Care
• 1980
• Early and immediate fixation
• Early definitive surgery and aggressive
resuscitation
• Fix all fracture in single setting
• Optimal utilization of OT
setup/personnel
• Easy handling and mobilization
• Lengthy operative procedures,
associated blood loss
39. Evolution of DCO
• Benefit of early fracture stabilization
• Fear of Fat embolism syndrome
• 1990
– Challenged the accepted immediate definitive fixation
– More selective approach
– Identification of parameters associated with adverse outcome in
multiply injured patients
– Intramedullary nailing has systemic physiological effect
• Second Hit Phenomenon
• 1993 the concept of damage control was established
40. Principle of DCO
• Early Temporary Stabilization
– Rapid splinting, external fixation
– Minimize time under anesthesia
• Resuscitation and Correction of Metabolic Derangements
– Address hypovolemia, acidosis, hypothermia
– Correct coagulopathy
41. Indication of DCO
• Physiological criteria
– Blunt trauma : hypothermia, coagulopathy, shock and
blood loss, soft tissue injury = 4 vicious cycle
– Penetrating trauma : hypothermia, coagulopathy and
acidosis (lethal triad)
• Complex pattern of severe injury
– Expecting major blood loss and prolonged reconstructive
surgery in physiologically unstable patient
42. Surgical Strategies
• Minimize extensive soft tissue dissection
– Preserve vascular supply and wound coverage
– Reduce infection risk
• External fixation
– Allows for quick stabilization without extensive soft tissue handling
– Temporary stability until patient can tolerate definitive fixation
• Definitive fixation timing
– Delayed until patient's condition improves
– Consideration of physiological parameters (hemodynamics,
coagulation)
• Collaboration between orthopedic and critical care teams
43. Advantage
• Minimal systemic insult
• Helps resuscitation
• Allows better operative plan
• Reconstruction under best
circumstances
• Best team possible for
difficult task
44. Staging of Patients Physiological Status
• Stable
– No immediate life threatening
injuries
– Respond to initial therapy
– Hemodynamically stable with
out ionotrop support
– No coagulopathy, ARDS,
shock, hypothermia
• ETC
• Borderline (Patients at Risk)
– Respond to initial therapy but
risk of deterioration
• Cautious ETC
• Invasive monitoring and ICU
45. Staging of Patients Physiological status
• Unstable
– Hemodynamically unstable
despite intervention
– Rapid deterioration
• DCO
• ICU transfer and
monitoring
• In Extremies
– Close of death
– Ongoing uncontrolled
blood loss
– Severely unstable despite
ongoing resuscitative effort
• Deadly triad
• ICU with advanced
hematological, pulmonary
and CVS support
51. Definitive Fixation
• After 5 days when the level
of interleukins drop
• 5-14 days : Window of
Opportunity
• Delay beyond 15 days due
to other injuries
– Continue with Exfix
– Increased risk of pin tract
infection
.
52. Limitations of DCO
• Developed under the studies of femoral fractures
• Unstable pelvic and acetabulum fractures
• Thoracolumbar spine fractures
• Need of further surgery
• Additional Implants and cost
• Lack of rigorous prospective designs
• Confounding effects of associated head, chest, abdomen
injury and its severity have not been accounted
53. Staging of management period
1. Acute “reanimation” period (1 to 3 hours)
– Control of acute life threatening conditions
– ATLS with secondary survey
2. Primary “stabilization” period (1 to 48 hours)
– Fracture with vascular injuries
– Acute compartment syndrome
– Temporarily stabilized with external fixation
3. Secondary “regeneration” period (2 to 10 days)
– Re-evaluate the constantly evolving clinical picture
4. Tertiary “reconstruction and rehabilitation” period (weeks)
– Complex surgical procedures
54.
55. Early Appropriate Care
• 2013
• Aka Safe Definitive Surgery
• Offers benefit of ETC and Safety of DCO
• Unstable fracture of axial skeleton and long bones
– Definitive fixation within 36 hours
– Demonstrable response to resuscitation
• reversal of acidosis: serum lactate <4 mmol/L, pH ≥7.25
or base excess more than 5.5 mmol/L
• Best suited for borderline patients
• Team based Case to case decision
56. • Chest injury is identified as Strongest independent predictor
of pulmonary complication regardless of MSK injury and type
of fixation
• Patient’s physiological status measured by acidosis seems to
be predictive of complications
– Admission pH and Base excess proportional to magnitude
of resuscitation and prognostic of mortality and morbidity
– No improvement in Acidosis over 24hrs with resuscitation
progressed to pneumonia, ARDS or pulmonary
complications
• Early reamed nails is safe provided they have been adequately
resuscitated
57. Conclusion
• Trauma is a surgical disease, and surgery is a carefully
choreographed trauma.
• Individually adjusted surgical “damage control” and “immune
control” are important interactive concepts in polytrauma
management.
• ATLS is life-saving strategy with standardised process and care
of patient.
• DCO is staged and adaptable approach to treating unstable
polytrauma patient to minimize complication and optimize
outcomes.
58. References
• Rockwood and Greens Fracture in adults, 8e
• Apleys Textbook of Orthopedics.
• ATLS 10e, 2016
• Various Articles
Trauma is wound/hurt/ defeat in Greek Bailey and Love: Physical force exerted on a person leading to physical injury
Common forces being mechanical, along with chemical thermal ionizing
Majority of causes: RTAs, Accidental falls, and Phyiscal violence
RTA being the most documented ones.
disproportionate impact on the young, working age population.
Though the data is more on the causation of the injury, it can high light the gravity of problem on public health, the increasing number of injuries, the proportionate number of lives that can be saved with proper intervention at various level.
World Bank 2020 report on delivering road safety in Nepal https://openknowledge.worldbank.org/server/api/core/bitstreams/ae34a0d8-c59c-51c5-82bd-7d8ef13b17ff/content
AIS is an anatomically based, consensus derived, global severity scoring system that classifies an individual injury by body region according to its relative severity on a 6 point scale (1=minor and 6=maximal).
1974
identify and classify injured patients within trauma systems,
component of risk adjustment and benchmarking using mortality prediction
Anatomic : ISS AIS NISS OIS Physiological RTS < GCS, APACHE Combined : TRISS ASCOT
An international consensus meeting in
polytrauma by combining the concept of injuries in different body regions
parameters of physiological response
swift transport is beneficial for patients suffering neurotrauma and the haemodynamically unstable penetratingly injured patient. For haemodynamically stable undifferentiated trauma patients, increased on-scene-time and total prehospital time does not increase odds of mortality. For undifferentiated trauma patients, focus should be on the type of care delivered prehospital and not on rapid transport.
https://sci-hub.ee/10.1016/j.injury.2015.01.008
period of time when life threating and limb threatening injuries should be treated in order to decrease mortality
estimated 60% of preventable deaths can occur during this time ranging from minutes to hours
era characterised by a lack of an organised trauma system and inadequate prehospital care.
the preference for a ‘scoop and run’ approach to prehospital care rather than “stay and play”
share a complex relationship; each factor can compound the others,
high mortality if this positive feedback loop continues uninterrupted
Hypothermia: blood loss, exposure, decreased metabolic activity Coaguloapthy : blood loss, impaired metabolic activity of shock
Acidosis: hypoperfusion mediated lactic acid built up interferes with normal cellular process and leads to organ dysfunction
Local and systemic inflammatory response: increased catecholamines and adrenocorticoids : General Adaptation syndrome : HR RR fever
Simulatenous immune system activation : hemostasis, prevention of infection and initiation of tissue repair
Compensatory anti-inflammatory response syndrome
Bodys attempt to balance overwhelming proinflammatory response with anti-inflammatory response to prevent excessive tissue damage.
Cascade of events following systemic trauma, generalized hypoxemia,
Two hit Hypothesis of SIRS
The combined levels of inflammatory mediators are high enough to cause generalised tissue damage and lead to MODS
Secondary insult can have disproportionately severe impact on the patients overall outcome potentially leading to worse outcome compared to what was expected out of the first
PICS long term physical cognitive and psychological effect that persists following a prolonged ICU stay for critical illness or injury resulting from critical illness, inflammatory response, prolonged mechanical ventilation, sedation, immobilization
…. Physical respiratory impairment, muscle weakness, neuropathies, cognitive Delirium, psychological PTSD anxiety depression
IL-6 is a reliable marker as it has a strong correlation with the magnitude of the injury, and levels in excess of 200 pcg/L are associated with poorer outcomes
Genetic constitution causes Biological variations
Single Neucleotide polymorphism
Relationship between different polymorphic variants and risk of development of post traumatic complications have been well studied.
However the studied genes are just epiphenomenon
Goal Directed therapy, use of low dose steriods, Blood glucose control and activated C protein appeared have improved outcomes in Sepsis and similar acheivements in patient with acute trauma
Speed with which lethal process is identified and halted makes difference in the survival and recovery of patient
The change of survival and extent of recovery is highly dependent on medical care
Identification and stoppage of lethal processes makes difference
Nebraska : orthopedic surgeon following airplane crash 1978
Standardised the process and care of patient
Effective initial assessment and good initial management
• Manpower: • trauma team • trained staffs • Materials: • properly functioning instruments, • medicines, fluids • Resuscitation area • Preparedness for mass casualties and disasters
an organized team approach
Rule out facial fractures, tonugue fall back, foreign body , secretions inside mouth
Adjuncts : Guedel airway, nasopharyngeal oropharyngeal airway , LMA
GCS < 8 definitive airway : tracheostomy and intubation
Breathing, adequate ventilation and oxygenation
Sites for needle thoracotomy
(once Tension Pneumothorax is ruled out)
Carotid : 60mm Hg femoral 70 radial 90 DPA 100
EFAST : Extended Focused Assessment of sonography in trauma
Maintain IV Volume, oxygen carrying capacity and preserve the coagulation cascade
Avoid provoking a severe inflammatory response
Sufficient enough to prevent further damage and possibilty of development of compartment syndrome
Allowing patient for easy mobilization for test and improved general care
1940s 1950s Griswold, kentucky, Penetrating injury if abdomen
1980 Feliciano 9/10 hepatic packing survived for exanguinating hemorrhage survived
Damage control in trauma surgery, Hirsgberg A
1993
n 2000 Scalea introduced the term “Damage Control Orthopaedics (DCO)
https://journals.lww.com/jbjsjournal/abstract/1989/71030/early_versus_delayed_stabilization_of_femoral.4.aspx
Fix long bones with in 24 hours
Resusicate aggressively
Based on principle that it decreases late complications.
However some patients are too unstable to undergo lengthy operative procedures, tolerate assosciated blood loss
80-90 ETC was promising
1990 Border et all evaluated the patients with blunt trauma
These physiological effects were Later descirbed as second hit phenomenon
Nailing a femur is a systemic insult and large enough to fill the role of second hit . Any major operative intervention carried out when the level of mediators are high has significant likelihood of serving as Second hit
IL6-IL8 remains high for atleast 5 days
DCO
Head injury with orthopedic injur : second hit : Increase mediators> systemic BP drops > Hypoperfusion of brain > more swellling and raised ICP
Local soft tissue damage :
In centres where resources (personnel, facilities, experience ) to manage polytraumais limited, restricts ETC in stable or boderline patient, DCO becomes the best option before transfering patient to appropriate institution.
Trauma-adjusted surgical techniques are crucial to limit the systemic response known to put remote organs at risk.
Stable. These patients have the physiologic reserve to withstand prolonged operative intervention where this is appropriate and they can be managed using an early total care (ETC) approach, with reconstruction of complex injuries.
Borderline (Patients at Risk) Borderline patients have stabilized in response to the initial resuscitative attempts but they have clinical features or combinations of injury, which are often associated with poor outcome and put them at risk of rapid deterioration. These have been defined as follows. • ISS >40 • Hypothermia below 35ºC • Initial mean pulmonary arterial pressure >24 mm Hg or a >6 mm Hg rise in pulmonary artery pressure during intramedullary nailing or other operative intervention • Multiple injuries (ISS >20) in association with thoracic trauma (AIS >2) • Multiple injuries in association with severe abdominal or pelvic injury and hemorrhagic shock at presentation (systolic BP
Unstable Patients who remain hemodynamically unstable, despite initial intervention, are at a greatly increased risk of rapid deterioration, subsequent multiple organ failure, and death. Treatment in these cases has evolved to utilize a “damage control” approach. This entails rapid, essential lifesaving surgery and timely transfer to the ICU for further stabilization and monitoring. Temporary stabilization of fractures using external fixation, hemorrhagecontrol, and exteriorization of gastrointestinal injuries where possible is advocated. Complex reconstructive procedures should be delayed until stability is achieved and the acute immunoinflammatory response to injury has subsided. This rationale is intended to reduce the magnitude of the “second hit” of operative intervention or at least delay it until the patient is physiologically equipped to cope.
In Extremis These patients are very close to death having suffered severe injuries and they often have ongoing uncontrolled blood loss. They remain severely unstable despite ongoing resuscitative efforts and are usually suffering the effects of a “deadly triad” of hypothermia, acidosis, and coagulopathy. A damage control approach is certainly advocated. Only absolutely lifesaving procedures are attempted in order to avoid exhaustion of their biologic reserve. The patients should then be transferred directly to intensive care for invasive monitoring and advanced hematologic, pulmonary, and cardiovascular support. Orthopedic injuries can be stabilized rapidly in the emergency department or ICU using external fixation and this should not delay other therapy. Any reconstructive surgery is again delayed and can be performed if the patient survives.
Ex fix of femoral fracture is rapid
Involves little blood loss
Not invasive enough to trigger second hit
external fixation (whether supra acetabular or iliac crest) predominantly controls and stabilizes the anterior pelvic ring
iliac crest external fixator is problematic in obese patients.
AIIS Supraacetabular 10-20 carnial and 20-30 medial
Ilaic crest : anterior 1/3 sparing the 1.5cm of ASIS Gluteus medius pillar
Lateral cutenous femoral nerve
Delay in fixation increases risk of infection
Poor soft tissue condition : open fractures, crush injuries, and significant wounds, the condition of soft tissues dictates the ideal time for definitive fracture fixation. 10-21 days is optimal
The majority of previous studies lack the rigor of a randomized prospective design and have limitations of small group size and variable definitions of “early” fixation timing.
severe chest injury is a risk factor for pulmonary complications,
Surgical management principles of polytraumatized patients for the first 10 days based on main pathophysiological mechanisms. The upper part of the diagram pictures the main pathophysiological changes in relation to the time elapsed after the injury. The lower part describes the surgical principles adjusted to the individual injury pattern and the systemic inflammatory response (SIRS).
Vallier HA, 2013 Timing of orthopaedic surgery in multiple trauma patients:Development of a protocol for early appropriate care. J Orthop Trauma.
adults with pelvis (n = 291), acetabulum (n = 399), spine (n = 102), and/or proximal or diaphyseal femur (n = 851) fractures
Prognostic Level II
The purposes of this project were to define which injuries or clinical parameters warrant delay of definitive fracture management, with particular respect to the course of resuscitation and to determine what time interval for fracture fixation promotes optimal patient outcome, provided the patient has been adequately resuscitated.
early reamed femoral nailing is safe in patients with ISS .17 provided they have been adequately resuscitated, as defined by significant improvement in serum lactate, with ARDS occurring in only 1.5%.
a correction of a pH to >7.25 within eight hours, base excess equal to or above 5.5 mmol/L and a lactate
Surgical diease its enhancing effect is not limited to the inflicted site but has a generalized character, which can be reduced by using gentle techniques and materials.