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G01 mx injury assessment
- 1. Initial Assessment and Management of the Multiply Injured Patient Robert M. Harris, MD
- 2. Orthopaedic Surgery • Specialty evolved after WW I • Heritage of Orthopaedic surgery is TRAUMA • TRAUMA is the common thread of all subspecialties in Orthopaedics
- 3. Trauma in the US • Leading cause of death in < 45 age group • Blunt trauma accounts for 80% of mortality in the < 34 age group • $75 billion loss in income due to death and disability annually • Major modern epidemic
- 4. Trauma Epidemiology • Number of polytrauma patients increasing – Higher speed limits, aggressive driving – Air bags-polytrauma patients surviving • Some regional trauma centers lack adequate funding • Trauma affects all Orthopaedists regardless of subspecialty and interest
- 5. Trauma Centers • One per population of 5 million or less • Studies demonstrate a 30-40% preventable death rate due to inadequate trauma systems – West, Trunkey: Arch Surgery, 1979 – West, Cales: Arch Surgery, 1983 – Baker, et al: J Trauma, 1987
- 6. Trauma Mortality • Early phase-immediate death – severe brain injury, disruption of great vessels, cardiac disruption • Second phase-minutes to hours – subdural, epidural hematomas, hemopneumothoraces, severe abdominal injuries, multiple extremity injuries (bleeding) • Third phase-delayed – multisystem organ failure – sepsis
- 7. Multidisciplinary Trauma Team • Trauma Surgeon TEAM LEADER • Anesthesia • Musculoskeletal traumatologist • Neurosurgeon • Vascular/CT surgeon • Urology, Gynecology • Interventional radiology • Intensivist • Hospital Staff-Nursing, PT, OT, Speech, Admin. • Legal/Security • Social work • Ministry
- 8. Trauma Surgeons and Fracture Care • Europe - General Surgeon Traumatologists – treat all injuries • North America - Multidisciplinary team – Orthopaedic Traumatologist- broad knowledge of treatment of injuries involving other organ systems to coordinate care optimally with colleagues
- 9. Orthopaedic Traumatologist • General resuscitation / ICU care • Advantages / disadvantages of early stabilization of long bone fractures • Skilled sufficiently to do a procedure expeditiously with minimal risk of complications • Understands impact of treatment on multisystem injury
- 10. Polytrauma Patient • Injury Severity Score >18 • Hemodynamic instability • Coagulopathy • Closed head injury • Pulmonary injury • Abdominal injury
- 11. Principles of Resuscitation ATLS • Phases of management – Primary Survey – Resuscitation – Secondary Survey – Definitive care • Priorities in treatment – Airway – Breathing – Circulation/CNS – Digestive system – Excretory Tracts – Fractures
- 12. Airway • Establish an appropriate airway – obtain patency-jaw lift – oral or nasal airway – surgical airway • Control of the cervical spine • Lateral C-spine radiograph – not included in the initial radiographic evaluation in the revised ATLS protocol
- 13. Breathing • Assess breathing and oxygenation • Evaluation with Arterial Blood Gas (ABG) • Etiology of decreased oxygenation has to be determined – Tension pneumothorax-decompress – Open pneumothorax-seal and chest tube – Flail chest, pulmonary contusion-chest tube
- 14. Indications for Intubation • Control of airway • Prevent aspiration in unconscious patient • Hyperventilation for increased intracranial pressure • Obstruction from facial trauma and edema
- 15. Circulation • Identifiable bleeding controlled with direct pressure • Avoid blind use of vascular clamps • Tourniquets are rarely indicated except for traumatic amputations
- 16. Assessment of Blood Pressure Peripheral Perfusion Peripheral Pulse radial femoral carotid capillary refill > 2 secs Systolic Blood Pressure 80 mm Hg 70 mm Hg 60 mm Hg Hypotensive
- 17. Hemorrhage Classification Class Percent Blood Volume Blood Loss (cc) Blood pressure change Urinary output Treatment I 15 < 800 None None Crystalloid II 15-30 800-1500 Min 20-30cc/hr Crystalloid III 30-40 2000 Hypotension 10-20cc/hr Cryst/ blood IV > 40 > 2000 significant Min Blood
- 18. Resuscitation • Two peripheral large bore IVs • Two liters of Ringers Lactate – If no response then severe hemorrhage has occurred – immediate blood is needed • Monitor – Blood pressure – Urinary output – Base deficit – Initial Hematocrit/Hemoglobin -unreliable
- 19. Types of Shock • Hemorrhagic • Cardiogenic-pericardial tamponade • Neurogenic-CHI, spinal cord injury – hypotension without tachycardia – Vasoconstrictive meds not administered until volume is restored • Septic-late sequela
- 20. Blood Transfusion • Crossed Matched – 1 hour • Type Specific – 10 minutes • Type O Rh neg – immediately • Blood warmer-prevents hypothermia, arrhythmias • Blood filters-160 u macropore • Coagulation status- Platelets monitored every 10 units – Platelets < 100,000-replace • Labile factors (fibrinogen)-replace with FFP
- 21. Management of Shock Summary • Direct control of bleeding sources • Large bore IV access-Fluid replacement • Monitor-urine output, CVP, pH, lactate level • Blood replacement-indicated by clinical response
- 22. Secondary Survey • Head – skull trauma – reevaluate pupillary size and reaction – blood/fluid at tympanic membranes and nares – facial and ethmoid fractures • Cervical spine – swelling, crepitus, expanding hematoma
- 23. Neurological Exam • Glascow Coma Score- GCS • Pupil exam-intracranial pressure • Motor and Sensory - all extremities in alert patient
- 24. Secondary Survey • Chest-reevaluate for crepitus, fractures, flail segments,open wounds • Abdomen-inspect, auscultate, palpate – seat belt injury-spinal or intraabodominal injury • Pelvis-exam for tenderness, instability
- 25. Secondary Survey • Rectal exam – tone, sensory, prostate injury – if abnormal, do not pass foley-consult Urology • Extremity exam – palpate for crepitus, swelling, pain, instability, range of motion • Neurological exam-document all findings
- 26. Head Injury • Oxygenation and cerebral circulation • Loss of consciousness (LOC) > 5 mins – observation for 24 hours – potential for seizures • CT scan of head
- 27. Intracranial Hemorrhage • Meningeal • Brain tissue • Suspect in unconsciousness patient or lateralizing signs – fixed pupil
- 28. Increased Intracranial Pressure Treatment • Patient positioning • Fluid restriction • Hyperosmotic diuretics-mannitol • Deliberate hypocapnia – controlled hyperventilation – maintain pCO2 at 25-30 mm Hg • Avoidance of stimuli
- 29. Thoracic Trauma • Accounts for 50-75 % of fatalities in blunt trauma • 15% of injuries require surgical intervention • Second leading cause of death • Life saving procedures performed during the primary survey
- 30. Thoracic Trauma • Secondary survey- – pulmonary contusion, aortic disruption, airway disruption, traumatic diaphragmatic disruption, myocardial contusion • CXR-aortic disruption – widened mediastinum, fracture of 1st and 2nd ribs, sternum fracture,loss of aortic knob, trachea and esophageal deviation • Aortagram of the aortic arch
- 31. Thoracotomy Indications • Failure of resuscitation • Penetrating injury to the mediastinum • Continued thoracic hemorrhage • Failed pericardiocentesis • Tracheal, bronchial, esophageal rupture
- 32. Abdominal Trauma • Most common site for occult hemorrhage – liver, spleen, kidney, pancreas, bowel – No peritoneal signs in 40% of hemoperitoneum • NG tube to decompress gastric contents • Foley to decompress bladder – Contraindications • blood at the meatus, scrotal or perineal hematoma, high riding prostate
- 33. Peritoneal Lavage Indications • Blunt trauma when PE is not adequate to assess- altered mental status • Unexplained hypotension – pelvis, lumbar spine, lower ribs fractures • Polytrauma patient lost to continual monitoring- General Anesthesia • Contraindications-multiple abdominal operations, obvious need for operation
- 34. Peritoneal Lavage Positive Criteria • Frank blood • Fluid aspirate-unspun – > 100,000 RBC/mm3 – > 500 WBC/ mm3 – hematocrit > 2% – presence of bile, bacteria, fecal material
- 35. Other Methods of Abdominal Evaluation • Ultrasound • CT scan
- 36. Genitourinary Injuries • Seen in 15% of blunt abdominal injuries • Clinical signs – lower rib fracture, flank discoloration, lower abdominal mass, genitalia discoloration, inability to void, blood at the meatus, hematuria • Evaluation – Retrograde urethrogram- before foley is placed – Hematuria-IVP, cystogram, excretory urethrogram
- 37. Trauma Severity Scores • Physiologic – Trauma Index-Kirkpatrick and Youman – Glascow Coma Scale • Anatomic Damage – Abbreviated Injury Scale (AIS) – Injury Severity Score (ISS) • Biochemical Indices
- 38. Orthopaedic Surgeon • Experienced and familiar with a number of acceptable procedures • Some more demanding in terms of EBL, duration, equipment required • Potential EBL – pelvis/acetabulum - 8-10 units – IM nail femur - 2-3 units – Tibia - 1-2 units
- 39. Orthopaedic Emergencies • Open fractures • Dislocations • Compartment syndromes • Cauda equina syndrome • Extremities with neurological or vascular compromise
- 40. Orthopaedic Priorities • Reduce and stabilize dislocations • Fasciotomies in compromised limbs • Proper debridement and irrigation of open injuries • Stabilization of long bone injuries • Secure fixation of intra- articular fractures • Proper splinting of other injuries
- 41. Orthopaedic Options Equipment • Surgeon must have full knowledge of all trauma sets, implants, and where to find them • Use of power instruments-drill,tap,screw – Elliott, Injury, 1992 • External fixation-allows rapid temporary stabilization – Can be adjusted or exchanged for internal fixation as the condition dictates
- 42. Orthopaedic Options • Pelvic ring injuries • Lower extremity – long bone fractures • Fractures with vascular injuries • Complex periarticular fractures • Open fractures
- 43. Patient Stability • Adequacy of resuscitation – Vital signs of resuscitation deceptive – Laboratory parameters—base deficit, lactic acidosis • Anesthesia-agents-myocardial depressants • Coagulopathy-dilution, DIC, thrombocytopenia • As long as homeostasis is maintained no evidence of duration of the procedure alone results in pulmonary or other organ dysfunction or worsens the prognosis of the patient • Must be ready to change plan as the patient status dictates
- 44. Decision Making • General surgery, Anesthesia, Orthopaedics • Magnitude of the procedure can be tailored to the patient’s condition • Timing and extent of operative intervention based on physiologic criteria • “Too sick for an operation” not acceptable given current knowledge • May require damage control surgery as a temporizing and stabilizing measure
- 45. Reasonable Approach • Timing (when?) • Titration (how much?) • Temporization (when necessary) • Temptations (avoid)
- 46. Incomplete Resuscitation • Based on physiological assessment • ICU - monitoring, resuscitation, rewarming, correction of coagulopathy and base deficit • Once patient is warm and oxygen delivery is normalized reconsider further operative procedures
- 47. Summary • Dynamic process • Requires cooperation of entire team • Orthopaedist must: – Appreciate the interrelationships between organ system injuries to include musculoskeletal injury – Understand • options for treatment of orthopaedic injury • impact on the polytrauma patient – Provide timely and effective treatment Return to General Index
Editor's Notes
- The specialty of Orthopaedic Surgery developed in the aftermath of WWI. The heritage of Orthopaedic surgery is Trauma. Early in the 20th century much of the trauma literature came from the care of combat injuries from the major conflicts. During the second half of the century there was a shift of trauma from the battlefields to the inner cities and highways that linked the US, and with the development of trauma systems. Much of the current literature is produced from the civilian community
- Trauma is the leading cause of death in the 1-45 yr-old age group. 12% of all hospital beds are occupied by trauma patients. Trauma has become a major modern epidemic
- Speed limits in most states reach 70 mph with more aggressive driving and reported cases of road rage which contributes to the problem. Financial cutbacks from government and third party payers have forced the closure of regional trauma centers in certain areas of the US. In adults airbags have decreased the number of fatalities associated from head and thoracic impact in frontal crashes, which leads to the survival of more patients and the need for emergent Orthopaedic care. Trauma affects all subspecialties in Orthopaedics.
- Regionalizaton of trauma care has improved the outcome for trauma patients. In Orange Co Calif , West et al noted a dramatic change in non-CNS deaths secondary to MVC. In two separate studies they noted a decline in non-CNS preventable deaths form 73 and 71% to 9% in regional trauma centers, while the rate at non-trauma center hospitals was 67%. Baker et al study validated the policy of bypassing the nearest hospital to treat the trauma patient at a regional trauma center with better outcomes.
- First phase is immediate death or shortly thereafter due to severe brain injury, or disruption of the heart, aorta, or great vessels. Second phase: Death occurs minutes to a few hours. Deaths are due to lifethreating injuries such as subdural, epidural hematomas, hemopneumothoraces, severe abdominal injuries, long bone fractures, multiple injuries associated with blood loss. This is the group that with rapid evacuation , resuscitation and proper early management can be given the best chance for survival and improved outcomes. Third phase: Patients die days to weeks from multiple system organ failure and sepsis. Specialized centers with their expertise and experience can reduce mortality in the second and third phases
- The Multidisciplinary Trauma Team is comprised of many subspecialties with the Trauma surgeon as the team leader. This individual needs constant input from the other members about timing and management of multisystem injuries. Orthopaedics play a major role in restoring stabilization of pelvic injuries, long bone fractures, and other emergency care of extremity trauma. The team has expertise in many areas of medical, legal administrative and rehabilitation to provide the optimal outcome for the trauma patient.
- The majority of Trauma in European systems are performed by General surgeon traumatologists who also care for orthopaedic injuries. Dr Tscherne is a world class example of this type of Traumatologist. In North America our system utilizes a multidisciplinary team approach, however the Orthopaedic surgeon must have a broad base of knowledge of injuries of other organ systems to better interact with other team members for optimal care of the trauma patient.
- All Orthopaedic surgeons that care for trauma patients should have a good background in resuscitation and ICU management to discuss the care of these patients with other members of the team based on current academic literature. The Orthopaedic surgeon is member of the team who should be able to convey the advantages of long bone stabilization and possess the skills to do so in a timely fashion with minimal risk of complications.
- In general these criteria, injuries and complications define the nature of polytrauma patients.
- The central theme of system management during resuscitation is simultaneous rather that sequential. The Orthopaedic surgeon is an integral part of the ATLS protocol and participates in the primary survey to assess and temporarily stabilize pelvic ring injuries
- A patent airway is the most urgent priority with complete assessment of the respiratory system 15% of unresponsive patients may have and unstable cervical injury therefore C-spine precautions and stabilization should be initiated at the scene of the accident and maintained until properly cleared. In the new revised ATLS protocol the C-spine radiograph is not included. Experience has shown this may not be appropriate in the primary survey of ATLS but can be done with later assessments and studies.
- ABG should be drawn and analyzed immediately to determine the adequacy of oxygenation. The three most common traumatic conditions compromising ventilation are Tension pneumothorax, Open pneumothorax, and Flail chest with pulmonary contusion. Visual inspection palpation and auscultation PE findings combined with vital signs can help diagnose the cause of the respiratory compromise and the appropriate treatment.
- Emergency Surgical airways are performed when Intubation is prevented by edema of the glottis, larynx fracture, or severe otopharyngeal bleeding. Needle cricothyroidotomy is an acceptable alternative to surgical airways and is preferred in children under 12 years.
- Indications for intubation include for the unconscious patient control of the airway to prevent aspiration or to hyperventilate. Early intubation for trauma to the head and neck region to avoid obstruction from edema, bleeding or secretions
- Sterile dressings should be applied to control identifiable bleeding, while avoiding the blind use of clamps in the emergency setting. The use of a tourniquet is indicated in a traumatic amputation
- In the severely injured patient time may not permit blood pressure measurements on the initial survey. This chart provides general guidelines to assess the BP by palpation of the peripheral pulses. Hypotension is suggested by a delayed capillary refill of more than 2 secs
- The 70 Kg male holds approximately 5 liters of blood or equivalent of 25 units of PRBC. The above classification is based on the percent of blood loss and provides some parameters to estimate the amount of blood loss as a means of fluid replacement.
- Initial management of the the trauma patient in shock is a 2L bolus of RL in the adult (30ml/kg in pediatric patient). The patient s response to this challenge will indicate the severity of the blood loss an if blood products should be obtained. Urinary output is the best indicator of volume status.(ant.) Hct/Hg are unreliable and inappropiate diagnostic tools. The Orthopaedic surgeon can provide valuable insight to the Trauma Team when dealing with severe pelvic ring injuries and/or long bone fractures and the potential for blood loss associated with each.
- In the trauma patient shock is hemorrhagic until proven otherwise and treatment directed at restoring cellular and organ perfusion with adequate oxygen delivery to the tissues. Listed are the differential diagnosis of shock. Cardiogenic shock can occur secondary to myocardial dysfunction form tamponade, arrhythmias,or myocardial damage. Beck’s Triad-distended neck veins, muffled heart sounds, and hypotension may indicate the need for pericardiocentesis. Arrhythmias may be due to infarction or contusion and treated with appropriate antiarrhythmic medications. Neurogenic shock may present with hypotension without tachycardia and considered in a head or spinal cord injuried patient. Vasoactive drugs should not be administered until volume is restored. Septic shock does not occur in the initial trauma setting, however may occur in patients with gangrene, missed open injuries, and contaminated wounds closed primarily.
- In patients who require blood, this chart gives the surgeon some reference to the type of blood available and the time for processing when dealing with the trauma patient. Special procedures should be used in patient who require significant transfusions. For low platelets (&lt;100,000) platelet packs should be given. Labile clotting factors (Factor VII, fibrinogen) should be checked and if low replaced with fresh frozen plasma.
- The initial management of the patient in shock involves the above steps. The goal is rapid reversal of hypovolemia with adequate perfusion and oxygenation of the cell. Prolonged shock is a contributing factor to later complications such as fat emboli syndrome, hepatic dysfunction, gut-origin septic state and multisystem organ failure
- Starting at the head , one should evaluate all lacerations,palpate for crepitus, examine all orifices. The face should be examined for potential airway compromise from fractures or edema.The palate and midface should be examined for ethmoid fractures which would require the NG tube to be placed through the mouth rather than the nose. Cervical spine precautions should be observed in an unresponsive patients or with maxillofacial trauma.
- The GCS should be performed for the initial evaluation of the level of consciousness and for subsequent exams. Intracranial pressure can be assessed by exam of the pupils. A careful neurological and vascular exam should be performed and documented in the cooperative awake patient.
- The chest should be inspected for flail segments, fractures or open wounds. Exam of the abdomen may reveal marking s form the seat belts which may indicate intraabominal or spinal injury. The pelvis should be palpated for fractures and gently stressed to determine instability. (Aggressive manipulation may cause rebleeding)
- A rectal exam is mandatory to determine rectal tone, sensation, and prostate injury. Blood at the rectum may indicate a pelvic injury, blood at the meatus or high riding prostate may indicate an urethral injury. Females with pelvic fractures should have a vaginal speculum exam performed by OB/GYN to rule out any possibility of an open pelvic fracture. A complete exam of all four extremities and documentation of the neurological exam should be completed at this time.
- In suspected head injury the first step in management is proper oxygenation and circulation to restore oxygen to the brain. If LOC has occurred for &gt; 5min hospital admission is warranted to observe for potential complications-retrograde amnesia, emesis, and high potential for seizures. In patients with a cerebral contusion with prolonged LOC and alteration in focal neurological signs will need a CT and close observation. Intracranial hemorrhage is also evaluated by CT
- The following are clinical findings associated with certain types of intracranial injuries. Meningeal Hemorrhage Epidural-associated with skull fracture LOC followed by lucid interval then subsequent severe LOC Contralateral hemiparesis, fixed pupil Subdural-life threatening slower to occur, needs decompression Subarachnoid-not life threatening produces meningeal irritation Brain Hemorrhage Intraventricular/Intracerebral high mortality rate Laceration penetrating objects or missiles Neurosurgeon services needed immediately
- Cerebral edema can cause increased intracranial pressure. This is managed with fluid restriction, diuretics (hyperosmolar), deliberate hypocapnia. Hyperventilation to maintain pCO2 at 25-30 mm Hg may decrease ICP but may deleteriously affect brain oxygenation. Used if other measures fail.
- Thoracic trauma occurs in the majority of blunt trauma fatalities, however on only 15 % require surgical intervention. Thoracic injuries are the 2nd leading cause of death –after head injuries in trauma patients. Life saving procedures (intubation, cricothyroidotomy, chest tubes, pericardiocentesis and thoracotomy) should have been done in the primary survey.
- Secondary survey looks for signs of pulmonary contusion, aortic disruption, airway disruption, esophageal disruption, traumatic diaphragmatic herniation and myocardial contusion. CXR can aid in the diagnosis of pulmonary contusion, and signs of traumatic aortic disruption which is confirmed with arch arteriography. Distal airway injuries may present with free air on the CXR
- These are indications for thoracotomy and are performed in the Primary survey
- Most common site for occult bleeding in the trauma patient with the above organs the most often involved. A high index of suspicion must be maintained since up to 40% will not have peritoneal signs. Ng tube is placed to relieve gastric dilatation and prevent potential aspiration. A foley is needed for bladder decompression, UA, and to follow urinary output. Contraindications are listed and placement of a suprapubic catheter by Urology is needed. If anterior pelvic ring requires ORIF, suprabubic catheter may be contraindicated
- Indications for Peritoneal Lavage for inadequate PE in unresponsive patient (head injuries, drugs, ETOH, spinal cord trauma), unexplained hypotension, patient that will be lost to continued monitoring such as those undergoing GA for other procedures. Contraindications-multiple abdominal operations, obvious need for operation-Ex-Lap
- The above criteria are indicators of a positive Peritoneal lavage. CT is being used more frequently to help in diagnosing intraabodominal pathology.
- Ultrasound is highly operator dependent but increasing in popularity. Capable of detecting free fluid in the abdomen but does not otherwise characterize solid organ injury. CT scanning provides details of solid organ injury and demonstrates intraperitoneal free fluid but may be time consuming (less so with modern trispiral scanners).
- Fifteen percent of abdominal trauma results in GU injuries. Injuries occur form direct blows, rib fractures, improperly worn seat belts, pelvis injuries. A history of blunt trauma to the abdomen, lower chest, flank , or genitalia/perineum should alert the surgeon to possible GU injuries. Clinical signs are listed. If an urethral injury is suspected a retrograde urethrogram should be performed before a foley is passed. When hematuria is present an excretory urethrogram, cystogram, and IVP should be performed
- Many forms of Trauma scores have developed for retrospective reviews of outcomes. Some are more predictive of mortality and some outcome. This slides presents a general summary of the three types of scoring categories. Physiologic: The body responds to injury with physiologic changes. These changes from normal parameters of vital signs and level of consciousness can be correlated to mortality, response to therapy and predicting outcome. Kirkpatrick and Youman’s Trauma Index was an early attempt to develop a system based on vital signs-A numerical system that was easy to use and predict the need for hospitalization but is less predictive of morbidity an d mortality. GCS widely used index that reliably assesses the degree of coma in patients with craniocerebral injuries. It is based on 3 behavioral responses 1. Eye opening, 2. Best verbal response and 3. Best motor response. Scores range from 3-15 and has been correlated with mortality. I t has been incorporated into the Trauma Score and Revised Trauma score. AIS-work began in 1969 and is a list of several hundred injuries which are assigned a score (1-minor to 6-fatal). Several revisions have occurred AIS-90 includes more details on injuries to the head chest and abdomen, including vascular injuries to the head and brain. Wounds are quantified. The system has been used in medical discharge coding. Because the AIS assigns severities to individual injuries summary scores are needed to characterize the trauma patient. ISS-is a summary score for multiple traumatic injuries . Values range fro 1-75. The ISS is calculated by summing the squares of the three highest AIS scores for injuries to 5 different body regions: head and neck; face; thorax; abdomen and pelvic contents; pelvic ring and extremities; and skin. ISS correlates with mortality but has limitations in that it only considers the highest AIS score from any body region, and considers injuries with equal AIS scores to be of equal value regardless of body region. Therefore it is a poor predictor of outcome in cohorts of patients with heterogeneous injury combinations Biochemical Indices have been used to measure injury severity as well. Kapsh found that plasminogen concentrations were initially depressed in patients after trauma but there was an greater increase in fibrinolytic activity. Other researchers have evaluated plasma cathecholinamine levels which has no prognostic significance, Kenney evaluated correlation coefficients for serum glucose , osmolality and cortisol were useful in patients with major occult injury
- The Orthopaedic surgeon must be trained and familiar with a number of acceptable procedures to stabilize the patients bony injuries. Awareness of the potential blood loss, time of certain procedures and equipment needed will help guide the care provided initially and subsequent procedures based on the stability of the patient.
- After initial life saving procedures are performed, the Orthopaedic surgeon must closely evaluate for potential surgical emergencies. All dislocations should be identified and relocated ASAP in the appropriate setting. Open fractures, compartment syndrome and neuro vascular compromise must be identified and approximately treated within certain time frames to decrease the morbidity associated with these injuries.
- This is a relative list of priorities which must be accomplished during the initial intervention. Working concurrently with the trauma surgeons(when possible) in the OR can allow for simultaneous procedures to occur in caring for the trauma patient. Many studies have demonstrated the benefits of early long bone stabilization. The condition of the patient may not permit intramedullary nailing of the femur, and the Orthopaedic surgeon should have the means to rapidly stabilize long bone fractures with external fixation instead of femoral pin traction. If time permits anatomic reduction and fixation of displaced intraarticular fractures is easier to perform earlier before the effects of multiple organ system injuries prevents timely return to the OR for these procedures
- It is the treating surgeons responsibility to have full working knowledge of all sets , implants, and their location in the hospital for cases at any time of the night. The surgeon has to check all the needed equipment and implants and insure the proper equipment is available and have a back up plan such as temporary Ex-Fix available in the room or in the sterile hallway in case the patients condition becomes unstable. The use of power equipment for implant or pin insertion can lessen the operative time. Elliott et al demonstrated no difference in screws placed in cortical bone by traditional AO techniques and with power instruments. In emergency situations long bone fractures can rapidly be stabilized with self drilling and tapping half pins to for bridging knee frames. A recent study out of Shock Trauma has demonstrated no increased risk of complications with conversion to and intramedullary nail when the patient is stable and can tolerate the procedure.
- The Orthopaedic surgeon must know the current treatment options (based on the literature) for each of these situations that challenge us at all hours day and night and be able to prioritize for that particular patient. He must also be willing to change the plan as the situation dictates These are covered in detail in other talks in this series.
- The Orthopaedic surgeon must have a basic understanding and be able to evaluate the adequacy of resuscitation based on physiological parameters and continual interaction with the trauma surgeon. Anesthesia must be aware of the potential effects of certain agents. Resuscitation, consisting of correction of hypothermia, base deficit and coagulation problems, is essential to the outcome of the polytrauma patient. Once homeostasis is achieved more complex procedures (longer OR time) can be performed without increasing the morbidity to the patient
- With input from all subspecialists involved in the care of the trauma patient, a knowledgeable estimate of the EBL, length of the procedure, equipment availably, the Orthopaedic surgeon can make an informed decision on the timing and extent of procedures that can be performed at the initial setting. The old phrase Too sick for an operation from the most junior member of the trauma surgery team should not be accepted but a rational discussion based on the physiologic parameters and stability of the patient and the benefits of early and appropriate Orthopaedic care is in the best interest of the patients care.
- The Orthopaedic surgeon should consider all elements in the decision making process for stabilization of extremity trauma in the polytrauma patient. Studies have demonstrated the benefit of early long bone stabilization and mobilization. Stabilization does not always mean definitive fixation but temporary fixation (Ex-fix) followed by resuscitation in the ICU and the definitive procedure is performed in a timely fashion with all equipment and personnel available to minimize the operative time and complications. Avoid the Superman complex of trying to do every definitive procedure at the initial setting which may place the patient at undue risk of becoming unstable while also introducing the element of fatigue to the operative team.
- Certain patients will require more extensive resuscitation or observation before definitive stabilization of fractures can be safely performed. The ICU is used to monitor the progress of the resuscitation efforts. Once the patient is stabilized consideration for further operative procedures may be possible within a 12 hours window. Further Orthopaedic care does not always happen in a timely fashion in the real world. Reasons such as: weekend schedule, workload of OR staff, failure of other specialist to realize benefit of early bone stabilization, are not valid when caring for the polytrauma patient where delays in treatment may affect morbidity and mortality. We must work to provide the best academic input to our multispecialty trauma service and perform the surgery when indicated, not when it is convenient.