This document discusses the management of polytrauma patients. It defines polytrauma as multiple injuries exceeding a severity threshold that can lead to organ dysfunction. Scoring systems like the Glasgow Coma Scale, Abbreviated Injury Scale, and Injury Severity Score are used to assess polytrauma patients. The physiological response to trauma involves systemic inflammatory and compensatory anti-inflammatory responses. Clinicians evaluate polytrauma patients using ATLS protocols, assess various systems, and provide resuscitation as needed. Orthopedic injuries may be managed with early total care or damage control orthopedics to minimize additional insults from surgery in unstable patients.
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 lecture prepare by three medical student in Kerbala university / college of medicine department of surgery to presented as seminar
for download as ppt
https://drive.google.com/open?id=1bc3HMEeJyhrOwag-AvTFMmPVKi12O1PU
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.
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 lecture prepare by three medical student in Kerbala university / college of medicine department of surgery to presented as seminar
for download as ppt
https://drive.google.com/open?id=1bc3HMEeJyhrOwag-AvTFMmPVKi12O1PU
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.
INITIAL ASSESSMENT OF TRAUMA PATIENTS....(INSPIRED FROM CTLS AND ATLS GUIDELI...Prerna Biswal
THIS PRESENTATION WAS MADE AT IMA HOUSE IN BHUBANESWAR,ODISHA, BY DR.NIBEDITA PANI,HOD ,DEPT. OF ANAESTHESIOLOGY AND DR.PRERNA BISWAL,PG,ANAESTHESIOLOGY,SCBMCH,CUTTACK,
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
Approach to a trauma patient - Advanced Trauma Life SupportParthasarathi Ghosh
Approach to a trauma patient from a Critical Care Medicine perspective with basics of Advanced Trauma Life Support.
References - ATLS Manual 10th Edition
INITIAL ASSESSMENT OF TRAUMA PATIENTS....(INSPIRED FROM CTLS AND ATLS GUIDELI...Prerna Biswal
THIS PRESENTATION WAS MADE AT IMA HOUSE IN BHUBANESWAR,ODISHA, BY DR.NIBEDITA PANI,HOD ,DEPT. OF ANAESTHESIOLOGY AND DR.PRERNA BISWAL,PG,ANAESTHESIOLOGY,SCBMCH,CUTTACK,
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
Approach to a trauma patient - Advanced Trauma Life SupportParthasarathi Ghosh
Approach to a trauma patient from a Critical Care Medicine perspective with basics of Advanced Trauma Life Support.
References - ATLS Manual 10th Edition
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.
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.
The presentation deals with the basics of pre anesthetic checkups, its only for the educations purpose!
Any kind of replication, modifications and republication is strictly prohibited.
All Rights reserved to the Author. 2016
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
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- 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
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Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
Title: Sense of Smell
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 primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
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?
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- 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
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
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.
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4. DEFINITION
Polytrauma is a syndrome of multiple injuries exceeding
a defined severity (ISS ≥ 17) with sequential systemic
reactions that may lead to dysfunction or failure of
remote organs and vital systems, which have not
themselves been directly injured.
5. POLYTRAUMA
World wide No.1 killer amongst the younger age group
(18-44 yrs).
Third most common cause of death in all age group.
Great economic & social loss to country.
Less than 2% of budgets for health services spend on
trauma patients.
TRAUMA- Neglected Disease of Modern Society
6. Polytrauma is not synonym of multiple fractures.
Multiple fractures are purely orthopaedic problem as
there is involvement of skeletal system alone.
While in Polytrauma there is involvement of more
than one system,Like associated head/spinal injury, chest
injury, abdominal or pelvic injury.
Polytrauma is a multi-system injury and needs
management by a team of surgeons and
physicians. Orthopaedic surgeon is one of the
team member of trauma unit.
POLYTRAUMA / MULTIPLE FRACTURES
7.
8.
9.
10. Scoring Systems
• Glasgow Coma Scale
• Abbreviated Injury Scale
• Injury Severity Score
• New Injury Severity Score
15. Abbreviated Injury Scale (AIS)
• Each area scored from 0 to 6
• Values are consensus driven
• Values found in “dictionary”
0 None
1 Minor
2 Moderate
3 Serious
4 Severe
5 Critical
6 Not survivable
20. Injury Severity Score (ISS)
• A problem with ISS… injuries within the same
anatomic system are only counted once
21. New Injury Severity Score (NISS)
• Three highest AIS values regardless of anatomic
region are utilized
• May be a better predictor of morbidity and mortality
22. • Major trauma induces an intense immuno-
inflammatory response.
• The magnitude of this response depends on
the initial trauma load, the pain stimuli, the
systemic and local release of pro-
inflammatory cytokines, age, sex as well as the
genetic make-up of the patient.
Pathophysiology
26. Phases – Physiological response
[David Cuthbertson – 1930 ]
Injury
EBB FLOW RECOVERY
SHOCK CATABOLISM ANABOLISM
24-48 HRS
Hours
3-10 DAYS
Days Weeks
BREAKING DOWN
ENERGY STORES
BUILDING UP
34. Clinical Manifestations of the
Systemic Inflammatory Response
• Fever
• Tachycardia
• Hyperventilation
• Leukocytosis
35. Quantifying the Systemic
Inflammatory Response
• SIRS Score
• Four variables, each scored 0 or 1
• HR > 90
• WBC <4,000 or >12,000
• RR > 20 (or PaCO2<33mmHg)
• Temperature <36 or >38 (100.4 degrees Fahrenheit)
• Total Score= sum of four variables (0 to 4)
• Score > 2 indicative of Systemic Inflammatory Response Syndrome
41. 1. Acute “reanimation” period (1 to 3 hours)
2. Primary “stabilization” period (1 to 48 hours)
3.Secondary “regeneration” period (2 to 10
days)
4.Tertiary “reconstruction and rehabilitation”
period (weeks)
MANAGEMENT
43. Evaluation of the polytrauma patient
• ATLS
• Primary Survey
• Airway
• Breathing
• Circulation
• Disability
• Exposure/Environmental Control
• Secondary Survey
• Tertiary Survey
44. Evaluation of the polytrauma patient
• Primary Survey
• Airway
• Establishment of an airway with regard for associated
cervical spine injury
• Clinical evaluation for obstruction
• Facial fractures, mandible fractures, laryngeal or tracheal injury,
aspiration, foreign body
45. Evaluation of the polytrauma patient
• Primary Survey
• Breathing
• Clinical and radiographic (CXR) evaluation
• ABG
• Common causes of hypoxemia:
• Flail chest with contusion, tension pneumothorax, open
pneumothorax
46. Evaluation of the polytrauma patient
• Primary Survey
• Circulation
• Clinical and radiographic (CXR, pelvic X-Ray evaluation)
• Application of circumferential sheet or binder where
indicated
• Application of direct pressure to areas of obvious
hemorrhage
• Initiation of resuscitation
47. Evaluation of the polytrauma patient
• Primary Survey
• Disability
• Neuro evaluation
48. Evaluation of the polytrauma patient
• Primary Survey
• Exposure/Environmental Control
• Clinical evaluation to identify occult injuries
• Rewarming of patients
49. Evaluation of the polytrauma patient
• Must differentiate hemorrhagic shock from shock
secondary to other etiologies:
• Neurogenic
• Cardiogenic
50. Evaluation of the polytrauma patient
• Initiation of Resuscitation
• Anticipated needs based on degree (“Class”) of
hemorrhage at presentation
• Crystalloid
• 1-2 L crystalloid
• Assess response
• Rapid, transient, or minimal/none
51. Class of Hemorrhage
• Class I:
• up to 15% (750cc) blood volume loss
• Class II:
• 15-30% (750-1500cc) blood volume loss
• Class III:
• 30-40% (1500-2000cc) blood volume loss
• Class IV:
• >40% (>2000cc) blood volume loss
52. Class of Hemorrhage
Class 1 Class 2 Class 3 Class 4
Blood loss (mL) Up to 750 750-1500 1500-2000 >2000
Blood loss (% of
volume)
Up to 15% 15-30% 30-40% >40%
Heart rate <100 100-120 120-140 >140
Blood pressure Normal Normal Decreased Decreased
Pulse pressure
(mmHg)
Normal Decreased Decreased Decreased
Respiratory rate 14-20 20-30 30-40 >35
Urine output
(mL/hr)
>30 20-30 5-15 Negligible
Mental status Slightly anxious Mildly anxious Confused Lethargic
53. Blood Transfusion
• Transient or nonresponders to crystalloid (Class
III/IV hemorrhage) will require transfusion
• Cross-matched, Type-specific, or Type O blood given
based upon timing of need
54. Massive Transfusion
• Greater emphasis on more balanced product
administration
• Damage control resuscitation
• 1:1:1 ratio of pRBC:plasma:platelets
56. Patient risk stratification
Pape HC, Giannnoudis PV. Management of the Multiply Injured Patient. In Court-Brown C, Heckman JD, McQueen MM, et al (Eds.), Rockwood and Green’s Fractures in Adults, 8th Edition. 2015.
58. Evaluation of the polytrauma patient
• FAST (focused assessment with sonography for
trauma)
• Intraabdominal free fluid
• Pericardial effusion
• Solid organ injury (limited sensitivity)
Nural MS, Yardan T, Guven H, et al. Diagnostic value of ultrasound in the evaluation of blunt abdominal trauma. Diagn Interv Radiol. 2005;11:41-44.
59. Evaluation of the polytrauma patient
• Secondary Survey
• Complete physical exam with updating of patient’s history
• Incorporates information from ongoing studies (FAST, CT,
extremity XRays, etc.)
• Usually within first 12-24 hours after injury
60. Evaluation of the polytrauma patient
• Tertiary Survey
• Repeat physical exam with review of any additional labs
and radiographs
• 12% of injuries in polytrauma patients are missed in first
24 hours
• Standardized tertiary survey has shown to decrease missed
injuries by 36%
Chan RN, Ainscow D, Sikorski JM. Diagnostic failures in the multiple injured. J Trauma. 1980;20:684-687.
Biffl WL, Harrington DT, Cioffi WG. Implementation of a tertiary survey decreases missed injuries. J Trauma. 2003;54:38-43.
62. Life > Limb
in the initial treatment of polytrauma
patient
• However, care of the orthopaedic injuries does impact
mortality
• Orthopaedic urgencies and emergencies must be treated
within overall context of polytraumatized patient’s condition
63. What are we trying to avoid in care
of polytrauma patient?
• MOF
• ARDS
64. Multiorgan Failure (MOF)
• Multiorgan Dysfunction Syndrome
• Affects multiple organ systems
• Many theories re: etiology
• High incidence of mortality
• May be related to imbalance between
proinflammatory and antiinflammatory
mediators
65. Acute Respiratory Distress
Syndrome
• ARDS
• Acute onset
• Bilateral infiltrates on CXR
• PaO2/FiO2 < 200
• High incidence of mortality
• May be related to imbalance between proinflammatory
and antiinflammatory mediators
67. SECONDARY SURVEY
• Does not begin until the primary survey
(ABCDEs) is completed.
• Head to Toe evaluation & reassessment of all
vital signs.
• A complete neurological exam is performed
including a GCS score.
• Special procedure is order.
MANAGEMENT
68. End point of resuscitation
• Stable hemodynamics
• Stable oxygen saturation
• Lactate level below 2 mmol / L
• No cogaulation disturbance
• Normal temp
• Urinary output > 1ml /kg/hr
• No requirement of inotropic support
MANAGEMENT
75. Indications for Early Total Care
• Stable hemodynamics
• No need for vasoactive/inotropic stimulation
• No hypoxemia, no hypercapnia
• Lactate <2 mmol/L
• Normal coagulation
• Normothermia
• Urinary output >1 mL/kg/h
Orthopaedic management
76. Indications for “Damage Control” Surgery
1. Physiologic criteria
•Blunt trauma: hypothermia,
coagulopathy, shock/blood loss, soft tissue
injury = Four vicious cycles
•Penetrating trauma: hypothermia,
coagulopathy, acidosis = “Lethal Triad”
2. Complex pattern of severe injuries—
expecting major blood
loss and a prolonged reconstructive
procedure in a physiologically unstable
patient
Orthopaedic management
78. Definition of
Damage Control Orthopaedics
• Approach to treating polytrauma patients with the goal of
minimizing the impact of the “second hit”
79. Definition of
Damage Control Orthopaedics
• Initial priorities
• Hemorrhage control
• Soft tissue management
• Provisional fracture stabilization
• Definitive treatment delayed until physiology improved
80. An approach that
1- Contains & Stabilizes Orthopaedic
Injuries so that the Patient’s Overall
Physiology can improve
2- Avoid worsening of the patient’s
condition by a major Orthopaedic
Procedure
3- Delay Definitive Fracture Repair in
borderline or unstable patient till
condition is optimized
81. Definitive open reduction & internal
fixation is delayed until the
inflammatory response and tissue
edema have decreased and the patient
is in a stable clinical condition
Applied in polytrauma patients with
pelvic and long bones fractures to avoid
the “second hit” of an extensive
definitive procedure and minimize initial
morbidity – mortality
Early rapid fracture stabilization by external fixation
Avoiding prolonged operative times
Preventing the onset of the
lethal triad ( Coagulopathy, Acidosis & Hypothermia )
Damage control orthopedics
(DCO)
82.
83. Do not kill your
Borderline patient by
(ETC)
Help him to live by
(DCO)
Give him the chance to
fight another day
84. References
• Advanced Trauma Life Support Student Course Manual. 9th Edition. American College of Surgeons
• Nural MS, Yardan T, Guven H, et al. Diagnostic value of ultrasound in the evaluation of blunt abdominal trauma. Diagn Interv Radiol. 2005;11:41-44.
• Chan RN, Ainscow D, Sikorski JM. Diagnostic failures in the multiple injured. J Trauma. 1980;20:684-687.
• Biffl WL, Harrington DT, Cioffi WG. Implementation of a tertiary survey decreases missed injuries. J Trauma. 2003;54:38-43.
• Kobbe P, Micansky F, Lichte P et al. Increased morbidity and mortality after bilateral femoral shaft fractures: myth or reality in the era of damage control? Injury. 2013;44:221-225.
• Cannada LK, Taghizadeh S, Murali J, et al. Retrograde intramedullary nailing in treatment of bilateral femur fractures. J Orthop Trauma. 2008;22:530-534.
• Lane MK, Nahm NJ, Vallier HA. Morbidity and mortality of bilateral femur fractures. Orthopedics. 2015;38:588-592.
• Manson T, O’Toole RV, Whitney A, et al. Young-Burgess classification of pelvic ring fractures: does it predict mortality, transfusion requirements, and non-orthopaedic injuries? J
Orthop Trauma. 2010;24:603-609
• Weinlein, J. Fractures and Dislocations in Adults: Hip. In S. Canale & James H. Beaty (Eds.), Campbell’s Operative Orthopaedics, 12th Edition. 2013.
• Lack WD, Karunakar MA, Angerame MR, et al. Type III open tibia fractures: immediate antibiotic prophylaxis minimizes infection. J Orthop Trauma. 2015;29:1-6.
• Bosse MJ, Kellam JF. Damage Control Orthopaedic Surgery: A Strategy for the Orthopaedic Care of the Critically Injured Patient. In Browner BD, Jupiter JB, Levine AM et al. (Eds.),
Skeletal Trauma, 4th Edition. 2009.
• Pape HC, Giannnoudis PV. Management of the Multiply Injured Patient. In Court-Brown C, Heckman JD, McQueen MM, et al (Eds.), Rockwood and Green’s Fractures in Adults, 8th
Edition. 2015.
• Bone LB, Johnson KD, Weigelt J, et al. Early versus delayed stabilization of femoral fractures. A prospective randomized study. J Bone Joint Surg Am. 1989;71:336-340.
• Pape HC, Aufm’Kolk M, Paffrath T, et al. J Trauma. 1993;34:540-547.
• Pape HC, Hildebrand F, Pertschy S, et al. Changes in the management of femoral shaft fractures in polytrauma patients: from early total care to damage control orthopedic surgery. J
Trauma;200253:452-462.
• Sears BW, Stover MD, Callaci J. J Am Acad Orthop Surg. 2009; 17:255-265.
85. References (cont.)
• Morshed S, Miclau T, Bembom O, et al. J Bone Joint Surg Am. 2009;91:3-13.
• Pape HC, Rixen D, Husebye EE, et al. Ann Surg. 2007;246:491-499.
• Weinlein JC, Deaderick S, Murphy, R. Morbid obesity increases risk for systemic complications in patients with femur fractures. J Orthop Trauma. 2015;29:91-95.
• Canadian Orthopaedic Trauma Society. Reamed versus unreamed intramedullary nailing of the femur: comparison of the rate of ARDS in multiple injured patients. J Trauma.
2006;20:384-387.
• Crowl AC, Young JS, Kahler DM, et al. Occult hypoperfusion is associated with increased morbidity in patients undergoing early femur fracture fixation. J Trauma. 2000;48:260-267.
• Morshed A, Corrales LA, Lin K, et al. Femoral nailing during serum bicarbonate-defined hypo-perfusion predicts pulmonary organ dysfunction in multi-system trauma patients. Injury.
2011;42:643-649.
• Vallier HA, Wang X, Moore TA et al. Timing of orthopaedic surgery in multiple trauma patients: development of a protocol for early appropriate care. J Orthop Trauma. 2013; 27:543-
551.
• Nahm NJ, Moore TA, Vallier HA. Use of two grading systems in determining risks associated with timing of fracture fixation. J Trauma Acute Care Surg. 2014; 77:268-279
• Vallier HA, Moore TA, et al. Complications are reduced with a protocol to standardize timing of fixation based on response to resuscitation. J Orthop Surg Res. 2015;10:155.
• O’Toole RV, O’Brien M, Scalea T, et al. Resuscitation before stabilization of femoral fractures limits acute respiratory distress syndrome in patients with multiple traumatic injuries
despite low use of damage control orthopedics. J Trauma. 2009;67:1013-1021.
• Scannell BP, Waldrop NE, Sasser HC, et al. Skeletal traction versus external fixation in the initial temporization of femoral shaft fractures in severely injured patients. J Trauma.
2010;68:633-640.
• Pape HC, van Griensven M, Rice J, et al. Major secondary surgery in blunt trauma patients and perioperative cytokine liberation: determination of the clinical relevance of biochemical
markers. J Trauma. 2001;50:989-1000.
• Harwood JH, Giannoudis PV, van Griensven M, et al. Alterations in the systemic inflammatory response after early total care and damage control procedures for femoral shaft fracture
in severely injured patients. J Trauma. 2005;58:446-454.