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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

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
Orthopaedic Surgery
  • Specialty evolved after WW I
  • Heritage of Orthopaedic surgery is TRAUMA
  • TRAUMA is the common thread of all subspecialties
    in Orthopaedics

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

Trauma Epidemiology
  • Number of polytrauma patients increasing
  • Higher speed limits, aggressive driving
  • Air bags-polytrauma patients surviving
  • Some regional trauma centers lack adequate
  • Trauma affects all Orthopaedists regardless of
    subspecialty and interest

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

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

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

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

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

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

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

Principles of Resuscitation ATLS
  • Phases of management
  • Primary Survey
  • Resuscitation
  • Secondary Survey
  • Definitive care
  • Priorities in treatment
  • Airway
  • Breathing
  • Circulation/CNS
  • Digestive system
  • Excretory Tracts
  • Fractures

  • 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

  • Assess breathing and oxygenation
  • Evaluation with Arterial Blood Gas (ABG)
  • Etiology of decreased oxygenation has to be
  • Tension pneumothorax-decompress
  • Open pneumothorax-seal and chest tube
  • Flail chest, pulmonary contusion-chest tube

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

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

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

Assessment of Blood Pressure Peripheral Perfusion
  • Peripheral Pulse
  • radial
  • femoral
  • carotid
  • capillary refill 2 secs
  • Systolic Blood Pressure
  • 80 mm Hg
  • 70 mm Hg
  • 60 mm Hg
  • Hypotensive

Hemorrhage Classification
  • Two peripheral large bore IVs
  • Two liters of Ringers Lactate
  • If no response then severe hemorrhage has
  • immediate blood is needed
  • Monitor
  • Blood pressure
  • Urinary output
  • Base deficit
  • Initial Hematocrit/Hemoglobin -unreliable

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

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
  • Platelets
  • Labile factors (fibrinogen)-replace with FFP

Management of Shock Summary
  • Direct control of bleeding sources
  • Large bore IV access-Fluid replacement
  • Monitor-urine output, CVP, pH, lactate level
  • Blood replacement-indicated by clinical response

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

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

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

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

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

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

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

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

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

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

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

Peritoneal Lavage Indications
  • 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

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

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

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

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

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

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

Orthopaedic Priorities
  • Reduce and stabilize dislocations
  • Fasciotomies in compromised limbs
  • Proper debridement and irrigation of open
  • Stabilization of long bone injuries
  • Secure fixation of intra-articular fractures
  • Proper splinting of other injuries

Orthopaedic Options Equipment
  • 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
  • Can be adjusted or exchanged for internal
    fixation as the condition dictates

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

Patient Stability
  • Adequacy of resuscitation
  • Vital signs of resuscitation deceptive
  • Laboratory parametersbase deficit, lactic
  • 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

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

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

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

  • 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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