Trauma - (DCO, FES, GSW, amp, morel-lav) updated Flashcards
What is the rationale for damage control orthopedics?
- Trauma induces a sustained inflammatory reaction (2-5 days)
- Early definitive surgery can induce a ‘second hit’ resulting in exacerbation of the inflammatory response
- This may cause ARDS, SIRS, and multisystem organ dysfunction syndrome
Who should be treated with DCO?
3 types of trauma patients:
- Stable patients = Early Total Care
- Indications: [Rockwood and Green 8th ed. 2015]
- Stable hemodynamics
- No inotropes
- No hypoxemia or hypercapnia
- Lactate <2mmol/L
- Normal coagulation
- Normothermia
- Urinary output >1ml/kg/h
- Indications: [Rockwood and Green 8th ed. 2015]
- Unstable patients = DCO
- Hypotension (shock/hemorrhage)
- “Lethal triad”
- Hypothermia
- Coagulopathy
- Acidosis
- Borderline patients = require further evaluation to determine category (ETC vs. DCO)
- Parameters to treat with DCO: [Orthobullets]
- ISS >40 without thoracic trauma
- ISS >20 with thoracic trauma
- GCS of 8 or below
- Multiple injuries with severe pelvic/abdominal trauma and hemorrhagic shock
- Bilateral femoral fractures
- Pulmonary contusion noted on radiograph
- Hypothermia <35oC
- Head injury with AIS of 3 or greater
- IL-6 values above 500pg/dL
- Parameters to treat with DCO: [Orthobullets]
What are the 3 components to DCO?
[Rockwood and Green 8th ed. 2015]
- Resuscitative surgery
- Hemorrhage control
- Temporary stabilization of unstable fractures
- Ex-fix, traction or splinting
- Orthopedic injuries that should be managed at this stage include: [Miller’s, 6th ed.]
- Compartment syndrome
- Fractures associated with vascular injury
- Unreduced dislocations
- Long bone fractures
- Open fractures
- Unstable spine fractures
- Physiologic resuscitation in ICU
- Markers of adequate resuscitation: [Orthobullets]
- MAP > 60
- HR < 100
- Urine output 0.5-1.0 ml/kg/hr (30 cc/hr)
- Serum lactate levels <2.5mmol/L
- Base deficit -2 to +2
- Gastric mucosal pH >7.3
- Definitive surgical management [Miller’s, 6th ed.]
- Conversion of ex-fix to IM nail in the femur should be done within 3 weeks
- Conversion of ex-fix to IM nail in the tibia should be done within 7-10 days
- Definitive pelvis and acetabulum surgery should be done within 7-10 days
How is the Injury Severity Score calculated?
- The 3 highest AIS scores of the 6 body regions are squared and added together
- The 6 Abbreviated Injury Score (AIS) areas are:
- Head & Neck
- Face
- Chest
- Abdomen
- Extremity
- External
- Injuries for each area are graded based on severity:
- 1 – minor
- 2 – moderate
- 3 – serious
- 4 – severe
- 5 – critical
- 6 – unsurvivable
4. The ISS score takes values from 0 to 75 - If an injury is assigned an AIS of 6 (unsurvivable injury), the ISS score is automatically assigned to 75
When does the onset of Fat Embolism Syndrome (FES) occur in relation to the time of injury?
[Continuing Education in Anaesthesia Critical Care & Pain 2007;7(5):148–151]
24-72 hours after trauma
- Prevent by early (within 24 hours) stabilization of long bones
What are the major and minor criteria for diagnosis of FES (Gurd’s Criteria)?
[Continuing Education in Anaesthesia Critical Care & Pain 2007;7(5):148–151]
- Diagnosis = at least 1 major and 4 minor
- Major criteria
- Axillary or subconjunctival petechiae
- Hypoxaemia
- PaO2 <60 mm Hg; FIO2 = 0.4
- CNS depression disproportionate to hypoxaemia
- Pulmonary oedema
3. Minor criteria - Tachycardia >110 bpm
- Pyrexia >38.5°C
- Emboli present in the retina on fundoscopy
- Fat present in urine
- A sudden inexplicable drop in haematocrit or platelet values
- Increasing ESR
- Fat globules present in the sputum
What is the management of FES?
[Continuing Education in Anaesthesia Critical Care & Pain 2007;7(5):148–151]
Supportive care
- Includes:
- Maintenance of adequate oxygenation and ventilation
- Stable haemodynamics
- Blood products as clinically indicated
- Hydration
- Prophylaxis of deep venous thrombosis and stress-related gastrointestinal bleeding
- Nutrition
What defines a low velocity vs. high velocity gunshot wound?
[JAAOS 2000;8:21-36]
- <2000 ft/sec = low velocity
* Handguns, shotguns - >2000 ft/sec = high velocity
* Rifles, military weapons
Tissue damage in GSW is dependent on the resulting temporary cavity and permanent cavity - define?
[JAAOS 2000;8:21-36]
- Temporary cavity:
- Cavity formed by pressure waves perpendicular to the path of the bullet with resulting vacuum formation
- Size of temporary cavity increases with increasing velocity and energy
- Vacuum created can draw foreign material into cavity
- Permanent cavity
- Cavity remaining after temporary cavity collapses
- Follows the path of the bullet
How does range affect the classification of gunshot wounds?
Low-velocity but close range are high energy wounds and should be treated as per high velocity
What is the management of low velocity gunshot wounds?
[JAAOS 2000;8:21-36]
- Local wound care (superficial irrigation)
- Dressing
- Healing by secondary intention
- Tetanus prophylaxis as indicated
- Antibiotic prophylaxis is controversial – generally recommended
- Associated fractures – treat based on fracture pattern (nonoperative or operative)
What is the management of high velocity gunshot wounds?
[JAAOS 2000;8:21-36]
- Aggressive irrigation and debridement in OR
* Excise contaminated/devitalized tissue, explore wound tract - Associated fractures are ex-fixed or IM nail
- IV antibiotics as per open fracture management
- Tetanus prophylaxis as indicated
- Repeat I&D in 48 hours
- Closure by secondary intention, possible graft
What are indications for removal of a bullet?
[JAAOS 2017;25:169-178] [JAAOS 2000;8:21-36]
- Intra-articular
- Retained in the intervertebral disc
- Compression on the spinal cord
- Lead toxicity
- Fragment in palm or sole
What are the risk factors associated with lead toxicity following gun shot wound?
[JAAOS 2017;25:169-178]
- Length of time projectile has been retained
- Fragmentation of the projectile
- Retained in or near synovial fluid
- Retained within the intervertebral disc
- Fracture secondary to gunshot
what are the indications for L/E amp following L/E trauma
- absolue
* blunt or contaminated traumatic amputaiton
* mangled extremity in crtically injured patient in shock
*crushed extremity with arterial injury and a warm ischemia time greater than 6 hours - relative indications
* severe bone or soft tissue loss
* anatomic transection of the tibial nerve
* open tibial fracture with serious associated polytrauma or a severe ipsilateral foot injury
* prolonged predicted course to obtain soft tissue coverage and tibial reconstruction
What are the principles of managing a trauma-related amputation or traumatic amputation?
[JBJS 2010;92:2852-68]
- Initial procedure
- Control life-threatening hemorrhage
- I&D with excision of all non-viable tissue while preserving all viable muscle and fasciocutaneous tissue
- Perform a length-preserving amputation retaining as much viable tissue as possible
- Subsequent procedure
- Perform repeat I&D every 48-72h until wound is clean and all nonviable tissue removed
- Consider negative pressure wound therapy between procedures
- Definitive procedure
- Muscle management
- Ensure adequate muscle coverage over distal residual bone
- Perform a stable myodesis under physiologic muscle tension and augment with a secondary myoplasty
- Transfemoral amputation
- Adductor myodesis is critical
- Myodesis of quadriceps to biceps femoris
- Transtibial amputation
- Myodesis of the posterior flap to the anterior tibia
- Transfemoral amputation
- Nerve management
- Perform a traction neurectomy for all named nerves and identified cutaneous nerves
- Vessel management
- All major arteries and veins should be individually identified and ligated with nonabsorbable suture (silk)
- Bone management
- Bevel and smooth all bone ends
- Level of amputation
- Preserve length when possible as long as adequate soft tissue coverage is possible
Prior to performing an amputation following trauma, what should be documented in the chart?
[JAAOS 2010;18:108-117]
- Second opinion from another orthopedic surgeon, or preferably, a surgeon from another specialty (eg. plastics, vascular, trauma)
- Photographs from initial injury and debridement if available
- Discussion with patient and family
what are the outcomes of amp following L/E trauma
- LEAP study showed no difference in outcomes with amp vs limb salvage at 2 adn 7 year F/U
- patient characteristics and patient’s environment are the factors that most affect outcomes, regardless of intiial surgical treament, medical complications or the extent of residual physical limitations. LEAP study indicates that outcomes were influenced more by patient economic, social, and personal resources tahtn by the intial tx
- lifetime cost of the amp group was estimated to be about 3x higher secondary to prosthesis-related expenses
- insensate foot on presentation should not be critical indicaiton for amp, as tehre was a return of plantar sensation by 2 years in majority of cases
definition of morel lavallee lesion
- clsoed traumatic soft-tissue degloving injury characterized by sepration of the hypodermis from the underlying fascia
- results in diruption of the perforating vascular and lymphatic structures and subsequent hemolymphatic fluid colleciton between the tissue layers
what are consequences of a morel-lavallee lesion
infection, pseudocyst, cosmetic deformity
4 stages of morel-lavallee lesion evolution
- first stage - dermis is separated from the underlying fascia
- second stage - exsanguination from the lymphatics and vasculature from the injured subdermal plexus producs a fluid colleciton mixture of blood, lymph, fatty debris
- third stage - over time, these components are replaced yb serosanguinous fluid as the leion enlarges
- fourth stage - if left untreated during the acute stage, local inflammation leads to pseudocapsule formation and lesion maturation as the body attempts to sequester the fluid-filled space
what are common location for morel-lavelle lesion to occur
Gt/hip (30.4%), thigh (20.1%), pelvis (18.6%), knee (15.7%); gluteal region (6.4%), lumbosacral (3.4%), abdominal area (1.4%), calf/lower leg (1.5%), head (0.5%)
what are the management options of morel-lavallee lesions
- close observation without intervention, perc drainage, or open debridement and irrigation
- large or symptomatic lesions, esp when located in the proximity of intended surgical incision, should be addressed with debridement and irrigation through a single incison or multiple incisions
