Trauma - Nonspecific (Complete) 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 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
