Trauma - Nonspecific (Complete) Flashcards

1
Q

What is the rationale for damage control orthopedics?

A
  1. Trauma induces a sustained inflammatory reaction (2-5 days)
  2. Early definitive surgery can induce a ‘second hit’ resulting in exacerbation of the inflammatory response
  3. This may cause ARDS, SIRS, and multisystem organ dysfunction syndrome
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2
Q

Who should be treated with DCO?

A

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
  • 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
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3
Q

What are the 3 components to DCO?

[Rockwood and Green 8th ed. 2015]

A
  1. 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
      1. 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
      1. 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
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4
Q

How is the Injury Severity Score calculated?

A
  1. The 3 highest AIS scores of the 6 body regions are squared and added together
  2. The 6 Abbreviated Injury Score (AIS) areas are:
  • Head & Neck
  • Face
  • Chest
  • Abdomen
  • Extremity
  • External
  1. 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
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6
Q

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]

A

24-72 hours after trauma

  • Prevent by early (within 24 hours) stabilization of long bones
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7
Q

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]

A
  1. Diagnosis = at least 1 major and 4 minor
  2. 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
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8
Q

What is the management of FES?

[Continuing Education in Anaesthesia Critical Care & Pain 2007;7(5):148–151]

A

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
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9
Q

What defines a low velocity vs. high velocity gunshot wound?

[JAAOS 2000;8:21-36]

A
  1. <2000 ft/sec = low velocity
    * Handguns, shotguns
  2. >2000 ft/sec = high velocity
    * Rifles, military weapons
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10
Q

Tissue damage in GSW is dependent on the resulting temporary cavity and permanent cavity - define?

[JAAOS 2000;8:21-36]

A
  1. 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
  1. Permanent cavity
  • Cavity remaining after temporary cavity collapses
  • Follows the path of the bullet
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11
Q

How does range affect the classification of gunshot wounds?

A

Low-velocity but close range are high energy wounds and should be treated as per high velocity

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13
Q

What is the management of low velocity gunshot wounds?

[JAAOS 2000;8:21-36]

A
  1. Local wound care (superficial irrigation)
  2. Dressing
  3. Healing by secondary intention
  4. Tetanus prophylaxis as indicated
  5. Antibiotic prophylaxis is controversial – generally recommended
  6. Associated fractures – treat based on fracture pattern (nonoperative or operative)
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14
Q

What is the management of high velocity gunshot wounds?

[JAAOS 2000;8:21-36]

A
  1. Aggressive irrigation and debridement in OR
    * Excise contaminated/devitalized tissue, explore wound tract
  2. Associated fractures are ex-fixed or IM nail
  3. IV antibiotics as per open fracture management
  4. Tetanus prophylaxis as indicated
  5. Repeat I&D in 48 hours
  6. Closure by secondary intention, possible graft
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15
Q

What are indications for removal of a bullet?

[JAAOS 2017;25:169-178] [JAAOS 2000;8:21-36]

A
  1. Intra-articular
  2. Retained in the intervertebral disc
  3. Compression on the spinal cord
  4. Lead toxicity
  5. Fragment in palm or sole
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16
Q

What are the risk factors associated with lead toxicity following gun shot wound?

[JAAOS 2017;25:169-178]

A
  1. Length of time projectile has been retained
  2. Fragmentation of the projectile
  3. Retained in or near synovial fluid
  4. Retained within the intervertebral disc
  5. Fracture secondary to gunshot
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17
Q

What are the principles of managing a trauma-related amputation or traumatic amputation?

[JBJS 2010;92:2852-68]

A
  1. 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
  1. 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
  1. 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
  • 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
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18
Q

Prior to performing an amputation following trauma, what should be documented in the chart?

[JAAOS 2010;18:108-117]

A
  1. Second opinion from another orthopedic surgeon, or preferably, a surgeon from another specialty (eg. plastics, vascular, trauma)
  2. Photographs from initial injury and debridement if available
  3. Discussion with patient and family