Initial Assessment and Management of the Multiply

Injured Patient

Robert M. Harris, MD

Orthopaedic Surgery

• Specialty evolved after WW I

• Heritage of Orthopaedic surgery is TRAUMA

• TRAUMA is the common thread of all subspecialties in Orthopaedics

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

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

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

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

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

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

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

Polytrauma Patient

• Injury Severity Score >18

• Hemodynamic instability

• Coagulopathy

• Closed head injury

• Pulmonary injury

• Abdominal injury

Principles of ResuscitationATLS

• Phases of management– Primary Survey– Resuscitation

– Secondary Survey– Definitive care

• Priorities in treatment– Airway– Breathing

– Circulation/CNS– Digestive system– Excretory Tracts– Fractures

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

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

Indications for Intubation

• Control of airway

• Prevent aspiration in unconscious patient

• Hyperventilation for increased intracranial pressure

• Obstruction from facial trauma and edema

Circulation

• Identifiable bleeding controlled with direct pressure

• Avoid blind use of vascular clamps

• Tourniquets are rarely indicated except for traumatic amputations

Assessment of Blood PressurePeripheral Perfusion

Peripheral Pulse

radial

femoral

carotid

capillary refill > 2 secs

Systolic Blood Pressure

80 mm Hg

70 mm Hg

60 mm Hg

Hypotensive

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

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

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

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

Management of ShockSummary

• Direct control of bleeding sources

• Large bore IV access-Fluid replacement

• Monitor-urine output, CVP, pH, lactate level

• Blood replacement-indicated by clinical response

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

Neurological Exam

• Glascow Coma Score-GCS

• Pupil exam-intracranial pressure• Motor and Sensory - all extremities in alert patient

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

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

Head Injury

• Oxygenation and cerebral circulation

• Loss of consciousness (LOC) > 5 mins– observation for 24 hours– potential for seizures

• CT scan of head

Intracranial Hemorrhage

• Meningeal

• Brain tissue

• Suspect in unconsciousness patient or lateralizing signs– fixed pupil

Increased Intracranial PressureTreatment

• Patient positioning

• Fluid restriction

• Hyperosmotic diuretics-mannitol

• Deliberate hypocapnia– controlled hyperventilation

– maintain pCO2 at 25-30 mm Hg

• Avoidance of stimuli

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

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

Thoracotomy Indications

• Failure of resuscitation

• Penetrating injury to the mediastinum

• Continued thoracic hemorrhage

• Failed pericardiocentesis

• Tracheal, bronchial, esophageal rupture

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

Peritoneal LavageIndications

• 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

Peritoneal Lavage Positive Criteria

• Frank blood

• Fluid aspirate-unspun– > 100,000 RBC/mm3

– > 500 WBC/ mm3

– hematocrit > 2%

– presence of bile, bacteria, fecal material

Other Methods of Abdominal Evaluation

• Ultrasound

• CT scan

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

Trauma Severity Scores

• Physiologic– Trauma Index-Kirkpatrick

and Youman

– Glascow Coma Scale

• Anatomic Damage– Abbreviated Injury Scale

(AIS)

– Injury Severity Score (ISS)

• Biochemical Indices

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

Orthopaedic Emergencies

• Open fractures • Dislocations• Compartment syndromes• Cauda equina syndrome• Extremities with neurological or vascular compromise

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

Orthopaedic OptionsEquipment

• 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

Orthopaedic Options

• Pelvic ring injuries• Lower extremity – long bone fractures• Fractures with vascular injuries• Complex periarticular fractures• Open fractures

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

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

Reasonable Approach

• Timing (when?)

• Titration (how much?)

• Temporization

(when necessary)

• Temptations (avoid)

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

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 treatmentReturn to

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