Initial Management of an Orthopaedic Trauma Patient Flashcards
• Introduction • Evaluation of the polytrauma patient • Scoring Systems important to polytrauma • Urgencies and Emergencies • Complications • Physiologic responses to trauma • Definition of Damage Control Orthopaedics (DCO)
Describe the evaluation of a polytrauma patient
Well, use ATLS principles
Primary Survey
-Airway, Breathing, Circulation, Disability, Exposure/Environmental control.
Secondary Survey
- Complete physical exam with updating of patient’s history.
- Incorporates information from ongoing studies (CT, X-rays, FAST (Focused Assessment with Sonography for Trauma)).
- Usually done within the first 2-24 hours after injury.
Tertiary Survey
- Repeat the physical exam with review of any additional labs and radiographs
-It is done because 12% of injuries in polytrauma patients are missed in the first 24 hours.
- Standardized tertiary survey has shown to decrease missed injuries by 36%.
Primary Survey
Describe evaluation for Airway
describe clinical evaluation for obstruction.
- Facial fractures
- Mandible fractures
- Laryngeal or tracheal injury
- Aspiration
- Foreign body
Primary survey
Describe evaluation of breathing
-Do a clinical and radiographic(CXR) evaluation.
-ABG.
- Common causes of hypoxemia (tension pneumothorax, open pneumothorax, flail chest).
Primary survey - Evaluation of breathing
Describe the clincal signs of the common causes of hypoxemia (Tension pneumothorax, open pneumothorax and flail chest)
JUST TENSION PNEUMOTHORAX
Tension Pneumothorax
Def of Pneumothorax| A collection of air within the pleural space between the lung (visceral pleura) and the chest wall (parietal pleura).
Tension pneumothorax is a life-threatening variant of pneumothorax characterised by progressively increasing pressure within the chest and results in cardiorespiratory compromise.
Clinical features in Tension pneumothorax
1. P-THORAX- Pleuritic pain, Tracheal deviation, Hyperresonance, Onset sudden, Reduced breath sounds (and dyspnea), Absent fremitus, X-ray shows collpase).
2. They can have tachycardia, hypotension
3. Distention of jugular vein. (distended neck veins)
In every patient with pneumothorax who requires mechanical ventilation, immediate TUBE THORACOSTOMY should be performed first.
Primary survey - Evaluation of breathing
Describe the clincal signs of the common causes of hypoxemia (Tension pneumothorax, open pneumothorax and flail chest).
OPEN PNEUMOTHORAX VS CLOSED PNEUMOTHORAX (Both these are due to trauma)
Closed pneumothorax: Air enters through a hole in the lung
Open pneumothorax: Air enters through a lesion in the chest wall.
Primary survey - Evaluation of breathing
Describe the clincal signs of the common causes of hypoxemia (Tension pneumothorax, open pneumothorax and flail chest).
FLAIL CHEST
Flail chest is caused by three or more adjacent ribs fractured in two or more places. As a result, there will be paradoxical chest movements: The floating rib segment moves inward during inspiration and outward during expiration.
These patients respond very well to Positive Pressure Ventilation.
Primary survey
Describe the circulation component in the evaluation of polytrauma patient.
- Clinical and radiographic (CXR, pelvic X-ray evaluation)
- Application of circumferential sheet or binder (also known as a pelvic circumferential compression device (PCCD), is a noninvasive device used to stabilize the pelvis in patients with pelvic fractures) where indicated
- Application of direct pressure to areas of obvious haemorrhage
- Initiation of resuscitation
Primary survey
Describe the DISABILITY in the evaluation of polytrauma patient.
- Neuro evaluation
Primary survey
Describe the EXPOSURE component in the evaluation of a polytrauma patient.
- Fully expose the patient for Clinical evaluation to identify occult injuries.
- Rewarming of patients- We rewarm patients to prevent hypothermia. Hypothermia impairs clotting, increasing bleeding and leading to acidosis.
Describe the classes of haemorrhage
- Class I:
– up to 15% (750cc) blood volume loss - Class II:
– 15-30% (750-1500cc) blood volume loss
- Class II:
- Class III:
– 30-40% (1500-2000cc) blood volume loss
- Class III:
- Class IV:
– >40% (>2000cc) blood volume loss
- Class IV:
(NB) cc= millilitre.
Resuscitation is the process of restoring a patient’s physiological functions when they are acutely ill.
After you’ve ensured the patient has a pulse and is breathing, what do you give to complete the resuscitation?
- Intravenous Fluids
- Crystalloids
- Colloids
- Blood & Blood Products
What are the features of a resuscitated patient?
How do you know the patient has been fully resuscitated and stable.
- Stable hemodynamics
- No hypoxemia
- Lactate
– < 2.0 mmol/L - pH > 7.25
- Normal coagulation
- Normothermia
- Normal Urine Output (0.5 to 1ml/kg/hr)
What are the scoring systems used in Orthos?
Glasgow Coma Scale (GCS): A scale to assess consciousness, scoring 3-15 based on eye, verbal, and motor responses to stimuli.
Abbreviated Injury Scale (AIS): A system that classifies the severity of individual injuries on a scale from 1 (minor) to 6 (unsurvivable).
Injury Severity Score (ISS): A numerical score (0-75) based on AIS, used to assess the overall severity of trauma by summing the squares of the highest AIS scores in three body regions.
New Injury Severity Score (NISS): Similar to ISS, but uses the highest AIS scores from the three most severe injuries, regardless of body region.
What are Orthopaedic Emergencies?
- Unstable pelvic fractures
- Fractures or dislocations with associated vascular injuries
- Acute compartment syndrome (ACS)
- Spine injury with neurological deficit
- Joint dislocations or fracture/dislocations with neurologic or potential neurologic sequelae
- Fractures or dislocations with associated soft tissue compromise
- Open fractures
- Unstable pelvic fracture
What are we trying to avoid in polytrauma patients?
- Multiple organ
failure (MOF) - ARDS(Acute Respiratory Distress Syndrome)
- Infections
- Thromboembolism
What is Systemic Inflammatory Response Syndrome and what is it predictive of?
It’s a clinical response to a variety of conditions, including infection, trauma, or other inflammatory processes. It’s characterized by at least two of the following:
- Temperature: >38°C (100.4°F) or <36°C (96.8°F)
2.Heart rate: >90 beats per minute - Respiratory rate: >20 breaths per minute or PaCO2 <32 mmHg
- White blood cell count: >12,000 cells/μL, <4,000 cells/μL, or >10% immature (band) forms
- Predictive of:
– Acute Respiratory Distress Syndrome
– Disseminated Intravascular Coagulopathy
– Acute Renal Failure
– Shock
- Predictive of:
What is damage control orthopaedics?
- Approach to treating
polytrauma patients
with the goal of
minimizing the impact
of the “second hit” - Definitive treatment
delayed until
physiology improved
What is a second hit in orthopaedics?
- Surgery may represent
“second hit” . - May exacerbate systemic
inflammatory response - May lead to secondary lung
injury
Describe polytrauma patient risk classification.
- Stable
- Borderline
- Unstable
- In extremis
patient risk classification
Describe a borderline polytrauma patient.
- ISS>20 ( with thoracic injury)
- Multiple injuries with severe pelvic/abdominal trauma and haemorrhagic
shock - GCS of 8 or below
- ISS>40 (without thoracic trauma)
- Pulmonary contusion noted on radiographs
- Hypothermia
- Hypothermia <35 degrees C
- Bilateral femur fractures
- head injury with AIS of 3 or greater
- IL-6 values above 500pg/dL ?.
Describe Early Total Care and its requirements?
ETC refers to a trauma management strategy where a definitive surgical fixation of all fractors is done early (within 24 hours)
Requires:
1. Lactate <2.5 mmol/L = Indicates good tissue perfusion.
2. pH>7.5
3. base excess>-5.5 mmol/L, a base deficit indicates poor perfusion.
