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Initial Assessment and Management of the Multiply Injured Patient

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Title: Initial Assessment and Management of the Multiply Injured Patient


1
Initial Assessment and Management of the Multiply
Injured Patient
David Hubbard, MD Original Author Robert
Harris, MD March 2004 New Author David
Hubbard, MD Revised January 2006
2
Orthopaedic Surgery
  • Specialty evolved after WW I
  • Heritage of Orthopaedic surgery is TRAUMA
  • TRAUMA is the common thread of all subspecialties
    in Orthopaedics

3
Trauma in the US
  • Leading cause of death in
  • Blunt trauma accounts for 80 of mortality in
    the
  • 75 billion loss in income due to death and
    disability annually
  • Major modern epidemic

4
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

5
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

6
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

7
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

8
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

9
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

10
Polytrauma Patient
  • Injury Severity Score 18
  • Hemodynamic instability
  • Coagulopathy
  • Closed head injury
  • Pulmonary injury
  • Abdominal injury

11
Injury Severity Score
  • Def. scale of anatomic injury
  • ISS is the sum of the squares of the three
    highest AIS categories
  • AIS (Abbreviated Injury Scale) looks at five
    categories general, head and neck, chest,
    abdominal, and extremities
  • Maximum ISS is 75

12
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

13
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

14
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

15
Emergency Airways
  • Surgical cricothyroidotomy-procedure of choice
    when surgical access is needed
  • Needle cricothyroidotomy-preferred for children
    under age 12

16
Indications for Intubation
  • Control of airway
  • Prevent aspiration in unconscious patient
  • Hyperventilation for increased intracranial
    pressure
  • Obstruction from facial trauma and edema

17
Circulation
  • Identifiable bleeding controlled with direct
    pressure
  • Always try direct pressure first
  • Avoid blind use of vascular clamps
  • Tourniquets are rarely indicated except for
    traumatic amputations

18
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

19
Hemorrhage Classification
20
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

21
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

22
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
  • Labile factors (fibrinogen)-replace with FFP

23
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

24
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

25
Neurological Exam
  • Glascow Coma Score-GCS
  • Pupil exam-intracranial pressure
  • Motor and Sensory - all extremities in alert
    patient

26
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

27
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

28
Head Injury
  • Oxygenation and cerebral circulation
  • Loss of consciousness (LOC) 5 mins
  • observation for 24 hours
  • potential for seizures
  • CT scan of head

29
Intracranial Hemorrhage
  • Meningeal
  • Brain tissue
  • Suspect in unconsciousness patient or
    lateralizing signs
  • fixed pupil

30
Increased Intracranial PressureTreatment
  • Patient positioning
  • Fluid restriction
  • Hyperosmotic diuretics-mannitol
  • Deliberate hypocapnia
  • controlled hyperventilation
  • maintain pCO2 at 25-30 mm Hg
  • Avoidance of stimuli

31
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

32
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

33
Thoracotomy Indications
  • Failure of resuscitation
  • Penetrating injury to the mediastinum
  • Continued thoracic hemorrhage
  • Failed pericardiocentesis
  • Tracheal, bronchial, esophageal rupture

34
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

35
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

36
Peritoneal Lavage Positive Criteria
  • Frank blood
  • Fluid aspirate-unspun
  • 100,000 RBC/mm3
  • 500 WBC/ mm3
  • hematocrit 2
  • presence of bile, bacteria, fecal material

37
Other Methods of Abdominal Evaluation
  • Ultrasound
  • CT scan
  • Method used for abdominal evaluation is often
    institutionally dependent

38
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

39
Trauma Severity Scores
  • Physiologic
  • Trauma Index-Kirkpatrick and Youman
  • Glascow Coma Scale
  • Anatomic Damage
  • Abbreviated Injury Scale (AIS)
  • Injury Severity Score (ISS)
  • Biochemical Indices

40
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

41
Orthopaedic Emergencies
  • Open fractures
  • Dislocations (hip and spine)
  • Compartment syndromes
  • Cauda equina syndrome
  • Extremities with neurological or vascular
    compromise

42
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

43
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

44
Orthopaedic Options
  • Pelvic ring injuries
  • Lower extremity
  • long bone fractures
  • Fractures with
  • vascular injuries
  • Complex periarticular
  • fractures
  • Open fractures

45
Patient Stability
  • Adequacy of resuscitation
  • Vital signs of resuscitation deceptive
  • Laboratory parametersbase 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

46
Decision Making
  • General surgery, Anesthesia, Orthopaedics
  • Magnitude of the procedure can be tailored to the
    patients 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

47
Reasonable Approach
  • Timing (when?)
  • Titration (how much?)
  • Temporization
  • (when necessary)
  • Temptations (avoid)

48
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

49
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 treatment

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