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.
Appraoch to patient with polytrauma and Damage control orthopedicsKaushal Kafle
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.
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
Pelvic fractures can be simple or complex and can involve any part of the bony pelvis. Pelvic fractures can be fatal, and an unstable pelvis requires immediate management.
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.
Appraoch to patient with polytrauma and Damage control orthopedicsKaushal Kafle
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.
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
Pelvic fractures can be simple or complex and can involve any part of the bony pelvis. Pelvic fractures can be fatal, and an unstable pelvis requires immediate management.
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
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.
This is a presentation which contains basics of polytrauma management,ATLS, triage, critical decision making skills, application of Glasgow coma scale and complications of different management strategies, if not applied properly.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
263778731218 Abortion Clinic /Pills In Harare ,ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group of receptionists, nurses, and physicians have worked together as a teamof receptionists, nurses, and physicians have worked together as a team wwww.lisywomensclinic.co.za/
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.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
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.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
1. Resuscitation Principles and recent advances
Polytrauma
Moderator : Dr Samarth Mittal
Co-Moderator: Dr Siva G Presenter: Dr Namith Rangaswamy
2. • ‘Significant injuries of three or more points in
two or more different anatomic AIS regions in
conjunction with one or more additional
variables from the five physiologic parameters’
• Hypotension (SBP <90 mm Hg)
• Level of consciousness (GCS < 8)
• Acidosis (base excess ≤ -6.0)
• Coagulopathy (INR≥1.4/ PT≥ 40 seconds)
• Age (>70 years)
4. • Solely the Berlin definition resulted in a patient number
reflecting clinical reality
5. INJURY SEVERITY SCORE
• Anatomic scoring
• Patient data is reduced to
number
• Degree of critical illness
• 6 body regions
• Baker SP et al, "The Injury Severity Score: a
method for describing patients with multiple
injuries and evaluating emergency care", J
Trauma 14:187-196;1974
6. ABBREVIATED INJURY SCALE
• Introduced in 1969 - updated against survival
• Ranked on a scale of 1 to 6
• Over 9 anatomic regions
Copes WS, Sacco WJ, Champion HR, Bain LW, "Progress in Characterising Anatomic Injury", In Proceedings of the 33rd Annual Meeting of the
Association for the Advancement of Automotive Medicine, Baltimore, MA, USA 205-218
7. Injury Severity Score
• Each injury is assigned an AIS and is allocated to one of six body
regions
• 3 most severely injured body regions have their score squared and
added together to produce the ISS score
• Values from 0 to 75
8. Epidemiology
• 9people die every minute from injuries or violence
• 5.8million people of all ages and economic groups die every year from
unintentional injuries and violence
• 20-50million significant injuries
• No 1 cause of death in < 40 years
* Data from ATLS Course Manual
9. INDIA
•4,13,457 deaths in 2015
•32.8 deaths per hour
•53 cases of road accidents took place every one hour during 2015,
wherein 17 persons were killed
*NCRBI, Annual Report 2015
11. Trimodal
distribution of
death in trauma
• Immediate death (50%): 0 to 1
hour
• Early death (30%): 1 to 3 hours
• Late death ( 20%): 1 to 6 weeks
12. Golden hour
• Period of time
following trauma
during which there
is the highest
likelihood that
prompt medical and
surgical treatment
will prevent death
14. ORGANISATION OF TRAUMA CENTRES
Level 1 –
Regional
Trauma Centre
Level 2 –
Community
Trauma Centre
Level 3 – Rural
Trauma Centre
15. Prehospital Phase
• Field triage
• Emphasize airway maintenance
• Control of external bleeding and
shock
• Immobilization of the patient
• Immediate transport to the closest
appropriate facility
• Page the hospital for preparation
• Oestern HJ, Garg B, Kotwal P. Trauma care in India and Germany. Clin Orthop Relat Res. 2013;471(9):2869–2877.
18. It is better to ‘’scoop and run’’ than ‘’stay and play’’
19. Air Ambulance
• Far from Trauma Centers
• Pitfalls : Under triage, High cost
and Crash
• 27% of US residents transported
within Golden hour
• $5000-$6000 more than ground
transport
• Expectation: 17% reduction in
mortality
23. CASE
Pt: 500183877
60year old male
Alleged history of fall from wooden ladder from
about 20 feet
No loss of consciousness
No ENT bleed
Severe pain in abdomen and pelvis
36. Definitive
airway
Inability to maintain a patent airway by
other means
Inability to maintain adequate
oxygenation
Obtundation
GCS <8
Orophalyngeal Intubation
37. Surgical Airway
• Needle Cricothyroidotomy
• Surgical Cricothyroidotomy
Edema of the glottis
Fracture of the larynx
Severe oropharyngeal hemorrhage
45. Massive Hemothorax
• Rapid accumulation of more than 1500 mL of
blood or one-third or more of the patient’s
blood volume in the chest cavity
• Volume replacement + chest decompression
46. • Accumulation of
fluid in the
pericardial sac
• Becks triad
• FAST/eFAST is a
rapid and accurate
• Emergency
thoracotomy or
sternotomy
• Subxiphoid
pericardiocentesis
47. CASE
BREATHING – Spontaneous ;RR-20/Min , SPO2-100%;
Chest – Decreased Air Entry Lt Side;
CCT- Positive
Pnemo Scan- Negative
Left sided ICD was inserted in 5th ICS under LA ,
gush of air and minimal blood with good column
movemnt
51. • Any injured patient who is cool to the touch and is
tachycardic should be considered to be in shock until
proven otherwise
• Causes
• Hypovolemic
• Cardiogenic
• Neurogenic
• Septic
52. • 90% of all trauma
patients could not be
classified according to
the ATLS1
classification of
hypovolemic shock.
• Raised critical
appraisal
54. Hypovolemic
shock
• Assess blood loss
• External or obvious
• Internal or Covert
• Chest
• Abdomen
• Limbs
• Pelvis
‘’Floor and four more’’
55. The basic management principle is to stop the bleeding and replace the
volume loss.
Controlling obvious
hemorrhage
Obtaining adequate
intravenous access
Assessing tissue
perfusion
The priority is to stop
the bleeding, not to
calculate the volume
of fluid lost
56. Fluid
replacement
Large bore cannula
Fluid warmer
Rapid infusion pump
Intraosseous access
Isotonic crystalloid solution 1 liter or
20ml/kg (in children)
‘’Permissive hypotension’’
60. Massive
Transfusion
Protocol
Designed to interrupt the lethal triad
Activated after transfusion of 4-10 units
Predefined ratio
Type O pRBCs
AB plasma
Patil V, Shetmahajan M. Massive transfusion and massive transfusion protocol. Indian J Anaesth 2014;58:590-5
63. Transient responders
• to the initial fluid bolusRespond
• if fluid/blood is slowedDeteriorate
• ongoing blood loss or inadequate resuscitationIndicate
• MTPInitiate
• rapid surgical interventionRequire
64. Non responders
Failure to
respond to
crystalloid and
blood
administration
1
Initiate MTP
2
Look for non
hemorrhagic
shock
3
Rush to OR
4
69. Exposure and
Environmental Control
• Completely undress the patient
• Cover the patient with warm blankets
• External warming device
• Warm intravenous fluid
73. • Sensitivity – 64-96%
• Specificity – 96-99%
• DPL has decreased from
9% to 1%
• Management has
changed in 32.8%
74. • FAST has excellent
diagnostic accuracy
• High negative
predictive value
99%
75. Rapid Ultrasound for Shock
and Hypotension
•Patients with
undifferentiated shock
•RUSH protocol
• The Pump
• The Tank
• The Pipes
Seif, Dina et al. “Bedside ultrasound in resuscitation and the rapid ultrasound in shock protocol.” Critical care research and practice vol. 2012 (2012): 503254.
81. CASE
CECT Torso with Cystogram
Confirmed CXR findings
Left spr & ipr #,Zone 2 sacral # left side, left L1
to L5 transverse process #, L2 to L4 spinous
process #.
Extraperitoneal bladder rupture with
extravasation of contrast in the anteroinferior
aspect of bladder, left lumbar artery muscular
branch contrast extravasation.
82.
83.
84. Hybrid OR.
Future of
Trauma
care?
• Operating Rooms with integrated Imaging
equipment
• Integration of IVR to surgical treatment
• Shorten the time-to-surgery
85. • highest mortality was from
falls >6 m.
• The ISS was 29 in survivors,
36 in non-survivors, and 54 in
the pelvic death subgroup.
• Type C fracture was a
predictor of mortality
• Pelvic death subgroup
received a mean of 10.7 units
of blood
86. • No improvement
in shock after
implementation
of MTP in pelvic
fracture patients
90. • Results in a shorter time
to intervention
• Lower mortality
compared to AE
Preperitoneal packing
91. • Successful outcome
• Justified surgery
• Efficient
hemorrhage control
• Can be definitive
fixation in some
cases
92. Resuscitative Endovascular Balloon Occlusion
of Aorta
• SBP increased from
60(35-75)mmHg to
115(91-128)mmHg
• Non invasive
• Balloon inflation in
zone 3
93. • Initial response to
resuscitation with
ANGIO is 73%.
• Also identifies arterial
injury
Angio Embolization
94. Spine / SCI
• Level
• Severity of neurological deficit
• Spinal cord syndrome
• Always consider spine injury to be
unstable unless proved
96. National Emergency X-Radiography Utilization
Study (NEXUS) Criteria
• No posterior midline cervical-spine tenderness
• No evidence of intoxication
• A normal level of alertness
• No focal neurologic deficit
• No painful distracting injuries
NO NO X-RAY
Meets ALL low-risk criteria?
98. Open fracture
• Tourniquet if
bleeding is ongoing
• Wound wash
• Antibiotics
• Assess vascular and
Neurological status
• Splinting
99.
100. Blunt Trauma Abdomen
• Direct blow/ Shearing injuries
• Spleen (40% to 55%), liver (35% to 45%),
and small bowel
• FAST or DPL
• Laparotomy – surgical judgement to
determine timing of surgery
101.
102. Damage control orthopedics
• Limited early surgical intervention
• Limit ongoing hemorrhage and soft-tissue
injury , reduce contamination
• External fixation of long bone/pelvis
fractures
• Debridement of open fractures
• Prevent second hit – and development of
lethal triad
103. Whom?
• Polytrauma + ISS of >20 points and additional thoracic trauma
• Polytrauma with abdominal/pelvic trauma and hemorrhagic shock
• ISS of ≥40 points in the absence of additional thoracic injury
• Radiographic findings of bilateral lung contusion
• Initial mean pulmonary arterial pressure of >24 mm Hg
• >6 mm Hg in pulmonary arterial pressure during intramedullary
nailing
104.
105. CASE
Admitted under Trauma Surgery for
observation
Continuous vitals monitoring
Continuous urinary bladder irrigation
Pelvic binder with Supracondylar femoral
skeletal traction with 8 kg weight
107. • Nearly 4.4 lakh
deaths due to
preventable medical
error
• Patient safety –
priority
• Learn from errors
108. Q1. A 5-year-old boy is struck by an automobile and brought to the
emergency department. He is lethargic, but withdraws purposefully
from painful stimuli. His blood pressure is 90 mm Hg systolic, heart rate
is 140 beats per minute, and his respiratory rate is 36 breaths per
minute. The preferred route of venous access in this patient is
Percutaneous femoral vein cannulation
Cutdown on the saphenous vein at the ankle
Intraosseous catheter placement in the proximal tibia
Percutaneous peripheral veins in the upper extremities
Central venous access via the subclavian or internal jugular vein
109. Q2. A 32 year old man’s right leg is trapped beneath his overturned car
for nearly 2 hours before he is extricated. On arrival in the ER, his right
lower extremity is cool, mottled, insensate and motionless. Pulses cannot
be palpated below femoral vessels. During initial management of this
patient, which of the following is most likely to improve the chances for
limb salvage?
Applying skeletal traction
Anticoagulant therapy
Thrombolytic therapy
Right lower limb fasciotomy
Immediately transfer patient to Trauma Centre
118. Massive Blood Transfusion
• Replacement of one entire blood volume within 24 h
• Transfusion of >10 units of packed red blood cells (PRBCs) in 24 h
• Transfusion of >20 units of PRBCs in 24 h
• Transfusion of >4 units of PRBCs in 1 h when on-going need is
foreseeable
• Replacement of 50% of total blood volume (TBV) within 3 h
119. NEW INJURY
SEVERITY
SCORE
• Sum of the squares of the top three scores
regardless of body region
• Statistically outperform the traditional ISS score
120. EXPONENTIAL
INJURY
SEVERITY
SCORE
• Kuo SCH, Kuo PJ, Chen YC, Chien PC, Hsieh HY, et al.
(2017) Comparison of the new Exponential Injury Severity Score
with the Injury Severity Score and the New Injury Severity Score
in trauma patients: A cross-sectional study. PLOS ONE 12(11):
e0187871.
121.
122. REVISED TRAUMA SCORE
• Physiologic scoring
• range 0 to 7.8408
Champion HR et al, "A Revision of the Trauma Score", J Trauma 29:623-629,1989
125. • How are the numerical identifiers structured ?
ex: 851814.3
• 8 = Body Region: Lower Extremity
• 5 =Type of Anatomic Structure: Skeletal
• 18 =Specific Anatomic Structure: Femur
• 14= Level of injury: Shaft
• .3 = AIS: Severity score
126.
127. INTERNATIONAL CLASSIFICATION OF DISEASES
INJURY SEVERITY SCORE (ICISS)
• Utilizes the ICD-9 codes assigned to each patient
• Measured survival risk ratios are assigned to all ICD-9 trauma codes
• Simple product of all such ratios
• ICISS = (SRR)injury1 x (SRR)injury2 x (SRR)injury3 X (SRR)injury4…
• Can be calculated from existing hospital information without the need
for a dedicated trauma registrar
• Even non-clinical hospital coders are able to accurately interpret and
document the injuries sustained
number of definitions of polytrauma have been reported in the literature generally referring to trauma patients whose injuries involve multiple body regions and in whom the combination of injuries would cause a life-threatening condition
To objectify
New definition proposed in 2014 in Berlin with consensus of various international trauma associations
Various Definitions put to test by Frenzel, they found that
To understand the definition better it is necessary to know ISS
One of very few scoring system according to consider anatomic region
Which is a process by which complex and variable patient data is reduced to a single number
And indicate degree of critical illness
Injuries are ranked on a scale of 1 to 6, with 1 being minor, 5 severe, and 6 a nonsurvivable injury
The AIS is monitored by a scaling committee of the Association for the Advancement of Automotive Medicine
If an injury is assigned an AIS of 6 (unsurvivable injury), the ISS score is automatically assigned to 75
drawback of the ISS is that it only considers one injury in each body region
The ISS score is virtually the only anatomical scoring system in use and correlates linearly with mortality, morbidity, hospital stay and other measures of severity
Its weaknesses are that any error in AIS scoring increases the ISS error
Global stats, ATLS MANUAL
In India,
NCRBI, ANUUAL REPORT 2015
Death in trauma can be divided into three time periods
The first peak occurs within seconds to minutes of injury
During this immediate period, deaths generally result from apnea due to severe brain or high spinal cord injury or rupture of the heart, aorta, or other large blood vessels. Very few of these patients can be saved because of the severity of their injuries. Only prevention can significantly reduce this peak of trauma-related deaths
second peak occurs within minutes to several hours
Deaths that occur during this period are usually due to subdural and epidural hematomas, hemopneumothorax, ruptured spleen, lacerations of the liver, pelvic fractures, and/or multiple other injuries associated with significant blood loss
third peak, which occurs several days to weeks after the initial injury
often due to sepsis and multiple organ system dysfunctions
Generally considered to be 1st hour
Causes of death during that period is stoppage of heart, disturbed airway followed by hemorrhage. Needs care in that sequence
ATLS – American College of surgeon
ETC – European Resuscitation council
JATEC- Japanese Association for the surgery in trauma
Only 56% of the ambulances have one or more paramedics
To cut short such crisis, CATS was started in New Delhi
Smith published a study in Injury Journal comparing two strategies of Prehospital care and found it is always better to scoop and run than stay and play
2014 Apr 25, annals of emergency medicine
Delgado in his study found that
ZPS is intended to interrogate and manage AND
optimize non-clinical processes before and during a resuscitation
Look
Inspect
feel
One person always stabilizes spine while the other expands the helmet to remove it
Indicated when there is
Inability to maintain a patent airway by other means, with impending or potential airway compromise (e.g., following inhalation injury, facial fractures, or retropharyngeal hematoma
Inability to maintain adequate oxygenation by facemask oxygen supplementation, or the presence of apnea
Obtundation or combativeness resulting from cerebral hypoperfusion
(Glasgow Coma Scale [GCS] score of 8 or less
Principle of management is to
Promptly close the defect with a sterile occlusive dressing that is large enough to overlap the wound’s edges. Tape it securely on three sides to provide a flutter-valve effect.
FAST is 90–95% accurate in identifying the presence of pericardial fluid for the experienced operator
Emergency thoracotomy or sternotomy
Subxiphoid pericardiocentesis
The second step in managing shock is to identify the probable cause of shock and adjust treatment accordingly
Look for
Mutschler published a study in INJURY where he criticized the earlier classification given by ATLS of Hypovolaemic shock.
Blood loss of <15, 15-30, 31-40 and over 40 percent for class I,II,III and IV respectively
Mutschler added Base deficit and GCS in this newer classification
Richard Buckley
General Principles of Fracture Care
Canadian Orthopaedic Association, Orthopaedic Trauma Association
Earlier recommendation for to use upto 2L of crystalloid, However newer studies and so ATLS currently recommends 1 liter of crystalloid
Permissive hypotension – organ perfusion and tissue oxygenation with the avoidance of rebleeding by accepting a lower-than-normal blood pressure
Also called as “controlled resuscitation,” “balanced resuscitation,” “hypotensive resuscitation
• Obtain surgical consultation for definitive hemorrhage control.
table
PRBC, plasma and platelets given in ratio 1:1:1
Restore the oxygen-carrying capacity of the intravascular volume
complete crossmatching process requires approximately 1 hour
type O pRBCs (Rh negative preferred in female)
AB plasma
MTP describes the process of management of blood transfusion requirements in major bleeding episodes, assisting the interactions of the treating clinicians and the blood bank and ensuring judicious use of blood and blood components
Main aim is to interrupt the lethal triad
Generally this is activated after transfusion of 4-10 units. MTPs have a predefined ratio of RBCs, FFP/cryoprecipitate and platelets units (random donor platelets) in each pack
Once the patient is in the protocol, the blood bank ensures rapid and timely delivery of all blood components together to facilitate resuscitation
Sterile collection of blood from body cavities and processing it through anticoagulants and cell saver system where the packed cells are prepared to preset hematocrit.
The GCS is a quick, simple, and objective method of determining the level of consciousness
Prevention of secondary brain injury by maintaining adequate oxygenation and perfusion are the main goals of initial manage ment
After completing the assessment, cover the patient with warm blankets or an external warming device to prevent him or her from developing hypothermia in the trauma receiving area
bedside ultrasound in patients with undifferentiated shock allows for rapid evaluation of reversible causes of shock
Pump: pericardial effusion, ventricular sizes, contractility
Tank: reserve- venecava, leakiness-fast/thoracic, compromise – pneumothorax
Pipe: leak-aneurysm,rupture /obstruction-dvt
Trauma CT protocol – Vertex to coccyx, preferred than selective CT
They save the time needed to transfer patients, who are medically unstable, from the operating room to the angiography suite
All though evidence are limited to case reports this could be future of integrated trauma care
One such case report was published international journal of em medicine by Japanese medical experts where they saved almost 1 hour of acute care time with such integration
Coming to importance of pelvic fractures, study by palmcrantz showed that
And hence need for definite control of bleeding
World society of emergency surgery has very recently given guidelines and classification of pelvic trauma severity
Study by clay cothren burlew showed that preperitoneal packing lowers mortality compared to AE and is time saving
Prospective study
Study comparing Exfix with angio and determined that initial response to resuscitation with angio was 73% .
Determine the level and severity of neurological deficit
Identify cord syndromes
Presence of high risk or absence of low risk of if patient is voluntarily able to rotate neck 45degree
judicious use of a tourniquet can be lifesaving and/or limb-saving in the presence of ongoing hemorrhage
Instructional course material was put together by American academy of Orthopaedic Surgeons and published in JBJS
RECENTLY INTRODUCED, 2004
The EISS was computed as the simple change in AIS values by raising each AIS severity score (1–6) by 3 taking a power of AIS minus 2, and then summing the three most severe scores (i.e., highest AIS values), regardless of body regions. If
utilizes the ICD-9 codes assigned to each patient
Measured survival risk ratios are assigned to all ICD-9 trauma codes
The simple product of all such ratios for an individual patient's injuries have been found to predict outcome more accurately than ISS
ICISS = (SRR)injury1 x (SRR)injury2 x (SRR)injury3 X (SRR)injury4…
ICISS is promoted as being able to be calculated from existing hospital information without the need for a dedicated trauma registrar.
This assumes, however, that the non-clinical hospital coders are able to accurately interpret and document the injuries sustained.