Evaluation, Resuscitation & DCO

Author: Derek Moore

Topic updated on 03/27/13 12:47pm

Introduction

Three peak times of death after trauma
- 50% within the first minutes of sustaining the injury
  - caused by massive blood loss or neurologic injury
- 30% within the first few days
  - most commonly from neurologic injury
- 20% within days to weeks following injury
  - multi system organ failure and infection are leading causes
Golden Hour
- period of time when life threating and limb threatening injuries should be treated in order to decrease mortality
- estimated 60% of preventable deaths can occur during this time ranging from minutes to hours
Use of an airbag in a head-on collision significantly decreases the rate of
- closed head injuries
- facial fractures
- thoracoabdominal injuries
- need for extraction

Primary Survey

Airway
- includes cervical spine control
Breathing
Circulation
- includes hemorrhage control and resuscitation (below)
- pregnant women should be placed in the left lateral decubitus position to limit positional hypotension

Hemorrhagic Shock Classification & Fluid Resuscitation

Class	% Blood Loss	HR	BP	Urine	pH	MS	Treatment
I	< 15% (<750ml)	normal	normal	> 30 mL/hr	normal	anxious	Fluid
II	15% to 30% (750-1500ml)	> 100 bpm	normal	20-30 mL/hr	normal	confused irritable combative	Fluid
III	25% to 40% (1500-2000ml)	> 120 bpm	decreased	5-15 mL/hr	decreased	lethargic irritable	Fluid & Blood
IV	> 40% (life threatening) (>2000ml)	> 140 bpm	decreased	negligible	decreased	lethargic coma	Fluid & Blood

Introduction
- average adult (70 kg male) has an estimated 4.7 - 5 L of circulating blood
- average child (2-10 years old) has an estimated 75 - 80 ml/kg of circulating blood
Methods of Resuscitation
- fluids
  - crystalloid isotonic solution
- blood options
  - O negative blood
  - Type specific blood
  - Cross-matched blood
Indicators of adequate resuscitation
- MAP > 60
- HR < 100
- urine output 0.5-1.0 ml/kg/hr (30 cc/hr)
- serum lactate levels
  - most sensitive indicator as to whether some circulatory beds remain inadequately perfused (normal < 2 mmol/L)
- gastric mucosal ph
- base deficit
  - normal -2 to +2
Risk of transfusion
- risk of viral transmission following allogenic blood transfusion
  - hepatitis B (HBV) has highest risk: 1 in 205,000 donations
  - hepatitis C (HCV): 1 in 1.8 million donations
  - human immunodeficiency virus (HIV): 1 in 1.9 million

Septic Shock

Septic shock vs. hypovolemic shock
- the key variable to differenitate septic shock and hypovolemic shock is that systemic vascular resistance is decreased with septic shock and increased with hypovolemic shock

	Hypovolemic Shock	Septic Shock
Systemic Vascular Resistance	increased	decreased
Cardiac Output	decreased	decreased
Pulmonary Capillary Wedge Pressure	decreased	decreased
Central Venous Pressure	decreased	decreased
Mixed Venous Oxygen	decreased	decreased

Imaging

Delay of fracture diagnosis is most commonly caused by failure to image extremity
AP Chest
- mediastinal widening
- pneumothorax
Lateral C-spine
- must visualize C7 on T1
AP Pelvis
- pelvic ring
  - further CT imaging should be delayed until preliminary pelvic stabilization has been accomplished
- acetabulum
- proximal femur
CT Scan
- C spine, chest, abdomen, pelvis
- often used in initial evaluation of trauma patient to rule out life threatening injuries

Damage Contol Orthopaedics

Involves staging defininitive management to avoid adding trauma to patient during vulnerable period
- the decision to operate and surgical timing on multiple injured trauma patients remains controversial
- intra-operative hypotension increases mortality rate in patients with head injury
Parameters that help decide who should be treated with DCO
- ISS >40 (without thoracic trauma)
- ISS >20 with thoracic trauma
- multiple injuries with severe pelvic/abdominal trauma and hemorrhagic shock
- bilateral femoral fractures
- pulmonary contusion noted on radiographs
- hypothermia <35 degrees C
- head injury with AIS of 3 or greater
Optimal time of surgery
- patient are at increased risk of ARDS and multisystem failure during acute inflammatory window (period from 2 to 5 days characterized by a surge in inflammatory markers)
  - therefore only potentially life-threatening injuries should be treated in this period including
    - compartment syndrome
    - fractures with vascular injuries
    - unreduced dislocations
    - long bone fractures
    - unstable spine fractures
    - open fractures
Stabilization followed by staged definitive management
- to minimize trauma, initial stabilization should be performed and followed by staged definitive management
  - includes initial pelvic volume reduction via sheet, binder, or external fixation
    - if hemodynamically stable
      - proceed with further imaging including CT chest, abdomen, pelvis
    - if not hemodynamically stable
      - consider pelvic angiography and embolization
- definitive treatment delayed for
  - 7-10 days for pelvic fractures
  - within 3 weeks for femur fractures (conversion from exfix to IMN)
  - 7-10 days for tibia fractures (conversion from external fixation to IMN)

Please Rate Educational Value!

4.0

Average 4.0 of 33 Ratings

Qbank (15 Questions)

TAG

(OBQ12.18) A 36-year-old man sustains blunt chest trauma, an open right femur fracture, and a closed left tibia fracture following a high-speed MVC. Upon presentation to the emergency room, blood pressure is 80/40, HR 135, and urine output is .4 cc/kg/hr. Fluids and blood products are administered, and the patient is transferred to the ICU for further care. Which of the following indicates adequate resuscitation has been achieved? Topic

Review Topic

1. Systolic blood pressure > 120
2. Heart rate between 60-100
3. Urine output equals 0.4 cc/kg/hr
4. Gastric intramucosal pH of 7.4
5. Normal mentation

PREFERRED RESPONSE ▶

DISCUSSION: Of the following variables, only a normal gastric mucosal pH (>7.3) is associated with restoration of tissue oxygenation.

Shock is an abnormality of the circulatory system that results in inadequate organ perfusion and tissue oxygenation. This leads to anaerobic metabolism with the development of lactic acidosis and oxygen debt. Shock is either classified as compensated or uncompensated. Compensated shock exists when there is evidence of ongoing inadequate tissue perfusion despite the normalization of blood pressure, heart rate, and urine output. Uncompensated shock occurs when there is inadequate tissue perfusion and abnormal blood pressure, heart rate, and urine output. Thus, a patient may have normal vital signs but still be in a state of compensated shock that requires additional resuscitation.

Porter et al. review the optimal end points of resuscitation in trauma patients. They conclude that using traditional end points such as blood pressure, urine output and heart rate, may leave up to 85% of patients in "compensated" shock. They urge the use of lactate, base deficit, and gastric intramucosal pH as appropriate end points of resuscitation.

Roberts et al. discuss various aspects of damage control orthopaedics in the multiply injured trauma patient. Although they do not discuss the end points for resuscitation, they note that they presence of shock is a clinical parameter associated with adverse outcomes in the trauma patient.

Incorrect answers:
Answers 1-3: A patient may have normalized blood pressure, heart rate, and urine output but may still be in a state of compensated shock requiring further resuscitation.
Answer 5: Mental status is not used to determine adequacy of resuscitation following a polytrauma.

REFERENCES:

1. Porter JM, Ivatury RR. In search of the optimal end points of resuscitation in trauma patients: a review. J Trauma. 1998 May;44(5):908-14. Review. PMID:9603098 (Link to Abstract)

2. Roberts CS, Pape HC, Jones AL, Malkani AL, Rodriguez JL, Giannoudis PV. Damage control orthopaedics: evolving concepts in the treatment of patients who have sustained orthopaedic trauma. Instr Course Lect. 2005;54:447-62. Review. PMID:15948472 (Link to Abstract)

Question Authors:

Mark Karadsheh MD, Jan Szatkowski MD, Ben Taylor MD,

Please Rate Educational Value!

3.0

Average 3.0 of 5 Ratings

TAG

(OBQ11.132) A 20-year-old female presents following a motor vehicle collision with the injuries seen in Figures A and B. She was initially hypotensive and tachycardic however she now has stable vital signs following a 2 liter bolus of saline and 2 units of packed red blood cells. Which of the following would indicate that this patient has occult end-organ hypoperfusion and should be further resuscitated prior to definitive fixation? Topic

Review Topic

FIGURES: A

1. Heart rate of 80 beats per minute
2. Systolic blood pressure of 120 mmHg
3. Base deficit of -1.8 mEq/L
4. Serum lactate of 5 mmol/Liter
5. Urine output of 40ml/hour

PREFERRED RESPONSE ▶

DISCUSSION: Figure A demonstrates an unstable pelvic fracture and subtrochanteric femur fracture and Figure B shows a scapular body and mutliple rib fractures. These high-energy fractures, along with the patient's initial hypotension and tacchycardia indicate a multiply injured patient in shock. Serum markers such as lactate (normal < 2 mmol/L) or base deficit are more sensitive markers of occult end-organ hypoperfusion and a serum lacate of 5mmol/Liter indicates an incompletely resuscitated patient.

Porter et al review the endpoints of resuscitation and note a high incidence of patients (as much as 85%) in "compensated" shock despite normal conventional parameters such as vital signs and urine output. Compensated shock occurs secondary to shunting of tissue oxygenation and blood flow away from splanchnic organs and towards vital organs such as heart and brain.

The review article by Elliott argues that serum lactate levels are the most reliable indicator of peripheral organ perfusion and tissue oxygenation. A base deficit between -2 and +2 is also an appropriate end point however may be non-specific in older patients with medical comorbidities leading to acid/base disturbances.

Rossaint et al put forth evidence-based recommendations regarding control of bleeding and resuscitation of trauma patients. They strongly recommend based on moderate-quality evidence (Grade 1B) that both serum lactate and base deficit be used to monitor the extent and progression of bleeding and shock.

REFERENCES:

1. Porter JM, Ivatury RR. In search of the optimal end points of resuscitation in trauma patients: a review. J Trauma. 1998 May;44(5):908-14. Review PMID:9603098 (Link to Abstract)

2. Elliott DC. An evaluation of the end points of resuscitation. J Am Coll Surg. 1998 Nov;187(5):536-47. Review PMID:9809573 (Link to Abstract)

3. Rossaint R, Bouillon B, Cerny V, Coats TJ, Duranteau J, Fernández-Mondéjar E, Hunt BJ, Komadina R, Nardi G, Neugebauer E, Ozier Y, Riddez L, Schultz A, Stahel PF, Vincent JL, Spahn DR; Task Force for Advanced Bleeding Care in Trauma. Management of bleeding following major trauma: an updated European guideline. Crit Care. 2010;14(2):R52. PMID:20370902 (Link to Abstract)

Question Authors:

Brian Weatherford MD, Jan Szatkowski MD, Ben Taylor MD,

Please Rate Educational Value!

4.0

Average 4.0 of 6 Ratings

TAG

(OBQ10.72) All of the following indicators of resuscitation may be within normal limits for a trauma patient that is in "compensated" shock EXCEPT: Topic

Review Topic

1. Systolic blood pressure
2. Urine output
3. Heart rate
4. Serum lactate
5. Mean arterial pressure

PREFERRED RESPONSE ▶

DISCUSSION: Historically, normal blood pressure, heart rate, and urine output have been endpoints to signal complete resuscitation in the polytrauma patient. The review article by Porter et al states that there is a high incidence of patients (as much as 85%) in "compensated" shock despite normal vital signs and urine output parameters. Compensated shock is secondary to a maldistribution of blood flow and tissue oxygenation as splanchnic organs have less distribution of the cardiac output compared to the heart and the brain. The article by Elliott is also a review, and it states that serum lactate is the best indicator of peripheral organ perfusion and tissue oxygenation. It also states that base deficit and gastric mucosal pH are appropriate end points to determine the complete resuscitation of trauma patients.

REFERENCES:

1. Elliott DC. An evaluation of the end points of resuscitation. J Am Coll Surg. 1998 Nov;187(5):536-47. Review. PMID:9809573 (Link to Abstract)

2. Porter JM, Ivatury RR. In search of the optimal end points of resuscitation in trauma patients: a review. J Trauma. 1998 May;44(5):908-14. PMID:9603098 (Link to Abstract)

Question Authors:

Michael Hughes MD,

Please Rate Educational Value!

3.0

Average 3.0 of 13 Ratings

TAG

(OBQ10.211) All of the following are characteristic of end-stage septic shock EXCEPT? Topic

Review Topic

1. Increased systemic vascular resistance
2. Decreased cardiac output
3. Decreased pulmonary capillary wedge pressure
4. Decreased central venous pressure
5. Decreased mixed venous oxygen saturation

PREFERRED RESPONSE ▶

DISCUSSION: Septic shock is associated with decreased systemic vascular resistance, decreased cardiac output, decreased pulmonary capillary wedge pressure, decreased central venous pressure, and decreased mixed venous oxygen saturation. Septic shock is different from hypovolemic shock in that the systemic vascular resistance is decreased, whereas it is increased in hypovolemic shock. Septic shock is a medical emergency caused by decreased tissue perfusion and oxygen delivery as a result of severe infection and sepsis, though the microbe may be systemic or localized to a particular site. It can cause multiple organ dysfunction syndrome (formerly known as multiple organ failure) and death. Its most common victims are children, immunocompromised individuals, and the elderly, as their immune systems cannot deal with the infection as effectively as those of healthy adults. The mortality rate from septic shock is reported to be 25%-50%.

REFERENCES:

1. Menth-Chiara WA, Norris B, Richard CM, Brown GA, Ullrich R. Pathophysiology of the polytrauma patient. In: Baumgaertner MR, Tornetta P III, eds. Orthopaedic Knowledge Update: Trauma 3. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2005:93-106.

2. Parillo JE, Dellinger RP, eds. Critical Care Medicine: Principles of Diagnosis and Management in the Adult, 2nd ed. St Louis, MO: Mosby; 2002:432-434.

Question Authors:

Ben Taylor MD,

Please Rate Educational Value!

4.0

Average 4.0 of 6 Ratings

TAG

(OBQ09.237) A 34-year-old man is brought to the trauma bay following a motorcycle collision with a left femoral shaft fracture and an open right tibial plateau fracture. Radiographs are provided in figures A and B. He has been taken to the operating room for an emergent splenectomy. The mean arterial pressure is 51 mmHg following 6 units of packed red blood cells as well as crystalloid replacement. Base deficit is 10 mmol/L. Neurosurgery is concerned for evolving subdural hematoma and is recommending serial head CT scans. Which of the following is the best immediate treatment option to address his fractures? Topic

Review Topic

FIGURES: A

1. Irrigation and debridement of open tibia plateau fracture and traction stabilization of femur and tibia plateau fractures
2. Irrigation and debridement with open reduction internal fixation of tibial plateau fracture and intramedullary nail fixation of femur fracture
3. Irrigation and debridement with open reduction internal fixation of tibial plateau fracture and plate fixation of femur fracture
4. Irrigation and debridement with external fixation of tibia plateau fracture and intramedullary nail fixation of femur fracture
5. Irrigation and debridement with external fixation of tibia plateau fracture and external fixation of femur fracture

PREFERRED RESPONSE ▶

DISCUSSION: Radiographs demonstrate a femoral shaft and high-energy tibia plateau fracture. The patient is medically unstable and the best treatment is expeditious debridement of open the fracture and stabilization of the fractures with definitive fixation at a later date. Early stabilization reduces the risk of cardiopulmonary complications including fat embolism syndrome.

Roberts et al recommends damage control orthopaedics emphasizing fracture stabilization without definitive surgical treatment in the unstable trauma patient. They note that this treatment method adds little physiological stress to the traumatized patient.

Turen et al discusses the importance of early fixation of long bone fractures to mobilize the multiple extremity trauma patient and mitigate cardiopulmonary complications. They note, however, that understanding of the complexities of the multiply injured patient is necessary to avoid intensive surgical treatments that are likely to adversely affect outcome.

REFERENCES:

1. Roberts CS, Pape HC, Jones AL, : Damage control orthopaedics: Evolving concepts in the treatment of patients who have sustained orthopaedic trauma. Instr Course Lect 2005;54:447-462 PMID:15948472 (Link to Abstract)

2. Turen CH, Dube MA, LeCroy MC: Approach to the polytraumatized patient with musculoskeletal injuries. J Am Acad Orthop Surg 1999;7:154-165 PMID:10346824 (Link to Abstract)

Question Authors:

Ben Taylor MD, Michael Hughes MD,

Please Rate Educational Value!

4.0

Average 4.0 of 13 Ratings

TAG

(OBQ07.93) During head-on motor vehicle collisions occurring at highway speeds, airbag-protected individuals have a decreased rate (as compared to non-airbag protected individuals) of all of the following EXCEPT: Topic

Review Topic

1. Closed head injury
2. Facial fractures
3. Splenic rupture
4. Pelvic ring injuries
5. Flail chest

PREFERRED RESPONSE ▶

DISCUSSION: The referenced study by Loo et al. studied the interaction between airbags/seatbelts and mechanism of the crash (ie. front vs. side impact) and the injury patterns in these patients. They found that in frontal crashes, airbags reduced Glasgow Coma Scale severity in brain injury, facial fracture, shock, thoracoabdominal injuries and the need for extrication. Frontal airbags also had a protective effect on lower extremity fractures, but had no significant protective effect on pelvic fractures.

REFERENCES:

1. Loo GT, Siegel JH, Dischinger PC, Rixen D, Burgess AR, Addis MD, O'Quinn T, McCammon L, Schmidhauser CB, Marsh P, Hodge PA, Bents F. Airbag protection versus compartment intrusion effect determines the pattern of injuries in multiple trauma motor vehicle crashes. J Trauma. 1996 Dec;41(6):935-51. PMID:8970544 (Link to Abstract)

Question Authors:

Ben Taylor MD,

Please Rate Educational Value!

4.0

Average 4.0 of 12 Ratings

TAG

(OBQ07.101) A 48-year-old male is involved in a motorycycle accident and arrives in the trauma bay in hypovolemic shock. He receives 6 units of packed red blood cells during his resuscitation. Which of the following viral microbes is he most at risk of exposure from the transfusions? Topic

Review Topic

1. HIV
2. Staph Aureus
3. Hepatitis A
4. Hepatitis B
5. Hepatitis C

PREFERRED RESPONSE ▶

DISCUSSION: According to the article by Wang et al the risk of viral transmission following a screened blood donation is: 1 in 1.9 million donations for human immunodeficiency virus (HIV), 1 in 1.8 million donations for hepatitis C virus (HCV), and 1 in 205,000 donations for hepatitis B virus (HBV). West Nile and Human T-cell leukemia viruses are even more rare in the general population, and both are screened in blood banks. Hepatitis A virus is not a blood borne viral disease. It is contracted by the fecal-oral route. Staph Aures is a bacteria, not a virus.

REFERENCES:

1. Wang B, Schreiber GB, Glynn SA, Kleinman S, Wright DJ, Murphy EL, Busch MP: Does prevalence of transfusion-transmissible viral infection reflect corresponding incidence in United States blood donors? Transfusion. 2005 Jul;45(7):1089-96. PMID:15987352 (Link to Abstract)

Question Authors:

John Badylak MD, Patrick McCulloch MD, Patrick McCulloch MD,

Please Rate Educational Value!

2.0

Average 2.0 of 15 Ratings

TAG

(OBQ07.171) Which of the following factors has been shown to increase mortality in poly-trauma patients with severe head injuries? Topic

Review Topic

1. Delayed fixation of fractures
2. Decreased intracranial pressure
3. Intra-abdominal injury
4. Intra-operative hypotension
5. Decreased platelet count

PREFERRED RESPONSE ▶

DISCUSSION: The factor most likely to adversely affect long term outcome in poly-trauma patients with severe brain injury is intraoperative hypotension.

Chesnut et al demonstrated that hypotension (SBP <90mmHg) was profoundly detrimental, occurring in 35% of these patients and associated with 150% increase in mortality.

Pietropaoli et al reviewed 53 patients with severe head injuries and required early surgical intervention (surgery within 72 hours of injury). All patients were initially normotensive on arrival. There were 17 patients (32%) who developed intra-operative hypotension and 36 (68%) who remained normotensive throughout surgery. The mortality rate was 82% in the IH group and 25% in the normotensive group.

REFERENCES:

1. Pietropaoli JA, Rogers FB, Shackford SR, Wald SL, Schmoker JD, Zhuang J. The deleterious effects of intraoperative hypotension on outcome in patients with severe head injuries. J Trauma. 1992 Sep;33(3):403-7. PMID:1404509 (Link to Abstract)

2. Chesnut RM, Marshall LF, Klauber MR, et al. The role of secondary brain injury in determining outcome from severe head injury. J Trauma. 1993 Feb;34(2):216-22. PMID:8459458 (Link to Abstract)

Question Authors:

Greg Galano MD, John Badylak MD, Michael Hughes MD,

Please Rate Educational Value!

3.0

Average 3.0 of 7 Ratings

TAG

(OBQ07.198) Residual end-organ hypoperfusion in a polytraumatized patient is shown by which of the following? Topic

Review Topic

1. Urine output of 0.8 mL/kg/hr
2. SpO2 < 90%
3. Platelet count < 80
4. Base excess of +3.0 mEq/L
5. Serum lactate of 4.5 mmol/L

PREFERRED RESPONSE ▶

DISCUSSION: Traditional endpoints for shock, including BP, HR, and urine output are good endpoints for uncompensated shock, but most trauma patients are in a state of compensated shock, where these endpoints have normalized. There is evidence that continued inadequate tissue perfusion exists in these patients, causing anaerobic metabolism, development of tissue acidosis and oxygen debt. New endpoints for adequate resuscitation include serum lactate (normal < 2 mmol/L), base deficit (normal -2 to +2, anything less than -2 indicates hypoperfusion), and gastric mucosal pH (normal is 7.30 - 7.35). Lactate is produced by breakdown of pyruvate by cells in the absence of O2. Normalization of lactate within 24 hours has been shown to be a good prognostic indicator in the trauma patient. Base deficit is a global marker of tissue hypoperfusion. The referenced article by Roberts et al is an excellent review of damage control orthopedics and the basic science behind this concept. The referenced article by Porter et al is a review of the available measurable end points in looking for appropriate resuscitation.

REFERENCES:

1. Roberts CS, Pape HC, Jones AL, Malkani AL, Rodriguez JL, Giannoudis PV. Damage control orthopaedics: evolving concepts in the treatment of patients who have sustained orthopaedic trauma. Instr Course Lect. 2005;54:447-62. PMID:15948472 (Link to Abstract)

2. Porter JM, Ivatury RR. In search of the optimal end points of resuscitation in trauma patients: a review. J Trauma. 1998 May;44(5):908-14 PMID:9603098 (Link to Abstract)

Question Authors:

Ben Taylor MD,

Please Rate Educational Value!

4.0

Average 4.0 of 13 Ratings

TAG

(OBQ07.225) A 21-year-old pregnant female arrives in the trauma bay with a closed head injury as well as an open ankle injury. During evaluation, what positioning is recommended to limit positional hypotension? Topic

Review Topic

1. Reverse trendelenburg
2. Trendelenburg
3. Left lateral decubitus
4. Right lateral decubitus
5. Supine

PREFERRED RESPONSE ▶

DISCUSSION: An important hemodynamic consideration in the pregnant trauma patient is the potential hypotensive effect of supine positioning. This effect, which is caused by aortocaval compression by the enlarged uterus, may decrease cardiac output by 25%. Use of a right hip wedge, manual displacement of the uterus, or lateral tilt positioning of the patient may help avoid this situation. Patient positioning must be determined with a focus on the well-being of the fetus. To avoid compression of the inferior vena cava in the patient who is in her second or third trimester, the left lateral decubitus position (left side down) should be used. The referenced review article by Flik et al reviews the appropriate physiological changes of pregnancy and covers the treatment of orthopedic trauma in the face of pregnancy.

REFERENCES:

1. Flik K, Kloen P, Toro JB, Urmey W, Nijhuis JG, Helfet DL. Orthopaedic trauma in the pregnant patient. J Am Acad Orthop Surg. 2006 Mar;14(3):175-82. PMID:16520368 (Link to Abstract)

Question Authors:

Ben Taylor MD,

Please Rate Educational Value!

3.0

Average 3.0 of 18 Ratings

TAG

(OBQ05.38) A 30-year-old man sustains a head injury as well as a femur and pelvis fractures as the result of a rollover motor vehicle accident. He is initially comatosed, but recovers cognitive function after 10 days in the hospital. Soon after awakening he complains of wrist pain and an x-ray demonstrates a distal radius fracture. What is the most likely explanation for this delayed diagnosis? Topic

Review Topic

1. wrist x-ray not initially obtained
2. x-ray obtained, but MRI necessary for diagnosis not obtained
3. forearm x-ray initially obtained did not show fracture
4. CT initially performed, but no 3-D images reconstructed
5. wrist x-ray initially obtained did not show fracture

PREFERRED RESPONSE ▶

DISCUSSION: According to the cited article by Born et al, who prospectively studied the incidence of delayed recognition of skeletal injury at a Level I trauma center over an 18-month period, the majority of missed skeletal injuries result from failure to image the affected extremity. These authors identified 39 fractures in 26 of 1,006 consecutive blunt trauma patients that were not diagnosed in a timely fashion (delays ranging from 1-91 days). Although other factors contributed to the diagnostic failure (23% were visible on admission films and not recognized; 10% were not visible due to inadequate x-rays of appropriate limb; 13% had adequate x-rays but diagnosis could not be made from initial studies), 55% of the fractures that were delayed in diagnosis resulted from failure to image the affected extremity. They went on to conclude that, “although the delay of fracture identification was not felt to contribute to additional long-term cosmetic, functional, or neurologic problems,” continued radiographic surveillance is necessary to prevent diagnostic failure.

REFERENCES:

1. Born CT, Ross SE, Iannacone WM, Schwab CW, DeLong WG. Delayed identification of skeletal injury in multisystem trauma: the 'missed' fracture. Journal of Trauma, 1989 Dec; 29(12):1643-6. PMID:2593194 (Link to Abstract)

Question Authors:

Greg Galano MD, Patrick McCulloch MD,

Please Rate Educational Value!

2.0

Average 2.0 of 12 Ratings

TAG

(OBQ05.238) Which of the following is indicative of a patient who has been successfully resuscitated following a trauma? Topic

Review Topic

1. Urine output of 0.25 mL/kg/hour
2. Lactic acid of 1.9 mmol/L
3. Base deficit of -5.5
4. Gastric mucosal pH of 6.3
5. Pulse pressure of 15

PREFERRED RESPONSE ▶

DISCUSSION: Rapid fluid resuscitation is the cornerstone of therapy for hypovolemic shock. Fluid should be infused at a rate sufficient to rapidly correct the deficit. If the estimated blood loss is greater than 30% of the total volume(class III), blood replacement is also indicated. In general, a favorable response to fluid replacement therapy includes increased urinary output (at least 0.5ml/kg/hr), improved level of consciousness, increased peripheral perfusion, and changes in vital signs (such as increased BP, increased pulse pressure, and decreased heart rate). Lab values that are important include lactic acid, which is increased if the shock is severe enough to cause anaerobic metabolism, and decreased serum bicarbonate which leads to a negative base deficit. Successful resuscitation in a shock patient will therefore lead to a falling lactate and normalizing pH. Successful resuscitation in a shock patient will therefore lead to a falling lactate (i.e. <2.0mmol/L) and a normalizing pH.

REFERENCES:

1. Mullins R: Management of shock. In Trauma, McGraw Hill, 2000, pp195-232

Question Authors:

Ben Taylor MD, Michael Hughes MD,

Please Rate Educational Value!

3.0

Average 3.0 of 11 Ratings

TAG

(OBQ04.80) A 27-year-old female sustains injuries to the left femur and ipsilateral tibia shown in Figures A and B following an ATV accident. Her injury severity score (ISS) is 27 for her musculoskeletal and abdominal injuries. Her left limb is neurovascularly intact and there are no signs of compartment syndrome. What is the most appropriate definitive management? Topic

Review Topic

FIGURES: A

1. Intramedullary nailing of the tibia and femur
2. External fixation of the tibia and femur
3. Balanced skeletal traction
4. Circular external fixation of the tibia and intramedullary nailing of the femur
5. Uniplanar external fixation of the tibia and intramedullary nailing of the femur

PREFERRED RESPONSE ▶

DISCUSSION: Polytrauma patients with ipsilateral femoral and tibial fractures (floating knee injuries) often require aggressive hemodynamic resuscitation and immediate stabilization via external fixation following tenets of damage-control orthopaedics. However, goals for definitive management of these fractures include obtaining anatomic alignment, early joint range of motion, and early weightbearing. If the floating knee injury is an isolated injury and the patient is hemodynamically stable then immediate intramedullary nailing of the tibia and femur is acceptable. Of the choices listed, intramedullary nailing of both the femoral and the tibial fracture is the optimal form of fixation for these transverse fractures. The technique of antegrade intramedullary nailing of both the femur and the tibia has been well described. Retrograde femoral nails and antegrade tibial nails can be advantageous because it allows simultaneous surgical setup for both the femoral and the tibial fracture.

REFERENCES:

1. Browner BD, Jupiter JB, Levine AM, Trafton PG (eds): Skeletal Trauma, ed 2. Philadelphia, PA, WB Saunders, 1998, pp 1650-1681, pp 1754-1767.

2. Kellam JF, Fischer TJ, Tornetta P III, Bosse MJ, Harris MB (eds): Orthopaedic Knowledge Update: Trauma 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 147-150.

Question Authors:

Michael Hughes MD, John Badylak MD, Ben Taylor MD,

Please Rate Educational Value!

4.0

Average 4.0 of 10 Ratings

TAG

(OBQ04.141) What percentage of normal circulating blood loss is needed for a patient to become tachycardic with a narrowed pulse pressure? Topic

Review Topic

1. 5%
2. 10%
3. 25%
4. 40%
5. 50%

PREFERRED RESPONSE ▶

DISCUSSION: Hemorrhagic shock is divided into four classes - class I is <15% loss and shows compensation for the blood loss (no tachycardia/hypotension) and is treated with crystalloid replacement as necessary. Class II is a loss of 15-30% and is the target of this question. In this class, vasoconstriction leads to maintenance of perfusion pressure and tachycardia helps maintain cardiac output in the face of a decreased overall volume. The vasoconstriction leads to an elevated diastolic pressure, which is the cause of the narrowed pulse pressure (the difference between systolic and diastolic). Treatment remains control of ongoing bleeding and crystalloid replacement. Class III is a 30-40% loss, and is the first stage where hypotension is present. Signs of end organ hypoperfusion, such as confusion and decreased urine output, is seen. Treatment is crystalloid replacement and blood product replacement. Class IV is a loss of >40% and is often fatal.

Hak reviews the ATLS classification of hemorrhage in his review article on pelvic fractures and bleeding.

REFERENCES:

1. OKU Trauma 2, 2000; pp 229-237

2. Hak DJ, Smith WR, Suzuki T. Management of hemorrhage in life-threatening pelvic fracture. J Am Acad Orthop Surg. 2009 Jul;17(7):447-57. PMID:19571300 (Link to Abstract)

Question Authors:

Ben Taylor MD, Patrick McCulloch MD, Michael Hughes MD,

Please Rate Educational Value!

3.0

Average 3.0 of 14 Ratings

TAG

(OBQ04.170) A 34-year-old male sustains the injury seen in Figure A after being struck by a truck while crossing the street. Upon arrival in the trauma bay, he is initially tachycardic and hypotensive, but after application of a pelvic sheet and administration of intravenous fluids, his vitals normalize. Radiographs of his neck, chest, and pelvis are then obtained after pelvic sheeting; his new pelvis radiograph is shown in Figure B. Which of the following is the most appropriate next step? Topic

Review Topic

FIGURES: A

1. CT scan of chest, abdomen, pelvis
2. Immediate sheet removal in exchange for a pelvic binder for added stability
3. Immediate external fixator placement in the emergency room
4. Pelvic arterial embolization
5. Definitive open reduction internal fixation

PREFERRED RESPONSE ▶

DISCUSSION: The clinical presentation is consistent for an anterior-posterior compression (APC) pelvic injury. The patient has been hemodynamically stabilized and the next step in treatment is a CT scan of chest, abdomen, pelvis to rule out other life threatening injuries.

APC injuries are highly unstable and can produce high mortality rates by pelvic exsanguination. Pelvic venous bleeding is far more common than arterial bleeding. The initial treatment intervention should be to reduce the pelvic volume by any means possible (sheet, binder, ex-fix) to reduce further intrapelvic bleeding. After application of the pelvic sheet in the above scenario, the patient has become stabilized and can undergo further workup to rule out other life threatening injuries.

Illustration A is a useful algorithm for treating trauma patients with pelvic injuries.

Incorrect Answers:
Answer 2: If the patient is hemodynamically stable there is no need for immediate pelvic fixation.
Answer 3: If the patient is hemodynamically stable there is no need to change to a pelvic binder.
Answer 4: If pelvic volume reduction failed to stabilize the patient, and other sources of hemorrhage, such as chest or abdomen were ruled out with radiographs or FAST exam, pelvic angiography and embolization would be the next appropriate step to treat potential pelvic arterial injury.
Answer 4: There is no role for acute definitive open reduction internal fixation.

Illustrations: A

REFERENCES:

1. Scalea T, Burgess A; Pelvic Fracture; 824-5 Trauma eds Mattox, Feliciano, Moore McGraw Hill, NY 1999

2. Browner BD, Jupiter JB (et al): Skeletal Trauma ed 2. Philadelphia, PA WB Saunders, 1998 p 133-144

3. Kellam JF, Fischer TJ (et al) Eds. OKU Trauma 2. Rosemont, IL, AAOS 2000, p 229-237

Question Authors:

David Abbasi MD, Ben Taylor MD, John Badylak MD,

Please Rate Educational Value!

4.0

Average 4.0 of 15 Ratings

Cases

http://upload.orthobullets.com/cases/1033/external fixation of left femur.jpg

http://upload.orthobullets.com/cases/1033/external fixation of right femur.jpg

Bilateral femur fractures, pelvic fracture (C1033)

Trauma - - Evaluation, Resuscitation & DCO

HPI - 56 y/o male involved in head on MVA. Presents in hypovolemic shock as well bowel...

1. When to definitely fix fractures? 2. Do you under ream or use non ream...

2/26/2011

3 responses

See More Cases

Groups

ABOS II: Evaluation, Resuscitation & DCO

General - Oral Boards Review

7/29/2011

0 responses

See More Groups

Evidence & References Show References

Level of Evidence 3 (Retrospective Cohort Study or Case-Control Study)

Loo GT, Siegel JH, Dischinger PC, Rixen D, Burgess AR, Addis MD, O'Quinn T, McCammon L, Schmidhauser CB, Marsh P, Hodge PA, Bents F. Airbag protection versus compartment intrusion effect determines the pattern of injuries in multiple trauma motor vehicle crashes. J Trauma. 1996 Dec;41(6):935-51. PMID:8970544 (Link to Abstract)

Level of Evidence 4 (Case Series)

Wang B, Schreiber GB, Glynn SA, Kleinman S, Wright DJ, Murphy EL, Busch MP: Does prevalence of transfusion-transmissible viral infection reflect corresponding incidence in United States blood donors? Transfusion. 2005 Jul;45(7):1089-96. PMID:15987352 (Link to Abstract)

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Roberts CS, Pape HC, Jones AL, Malkani AL, Rodriguez JL, Giannoudis PV. Damage control orthopaedics: evolving concepts in the treatment of patients who have sustained orthopaedic trauma. Instr Course Lect. 2005;54:447-62. PMID:15948472 (Link to Abstract)
Elliott DC. An evaluation of the end points of resuscitation. J Am Coll Surg. 1998 Nov;187(5):536-47. Review PMID:9809573 (Link to Abstract)
Elliott DC. An evaluation of the end points of resuscitation. J Am Coll Surg. 1998 Nov;187(5):536-47. Review. PMID:9809573 (Link to Abstract)
Flik K, Kloen P, Toro JB, Urmey W, Nijhuis JG, Helfet DL. Orthopaedic trauma in the pregnant patient. J Am Acad Orthop Surg. 2006 Mar;14(3):175-82. PMID:16520368 (Link to Abstract)
Hak DJ, Smith WR, Suzuki T. Management of hemorrhage in life-threatening pelvic fracture. J Am Acad Orthop Surg. 2009 Jul;17(7):447-57. PMID:19571300 (Link to Abstract)
Porter JM, Ivatury RR. In search of the optimal end points of resuscitation in trauma patients: a review. J Trauma. 1998 May;44(5):908-14 PMID:9603098 (Link to Abstract)
Porter JM, Ivatury RR. In search of the optimal end points of resuscitation in trauma patients: a review. J Trauma. 1998 May;44(5):908-14. PMID:9603098 (Link to Abstract)
Porter JM, Ivatury RR. In search of the optimal end points of resuscitation in trauma patients: a review. J Trauma. 1998 May;44(5):908-14. Review PMID:9603098 (Link to Abstract)
Porter JM, Ivatury RR. In search of the optimal end points of resuscitation in trauma patients: a review. J Trauma. 1998 May;44(5):908-14. Review. PMID:9603098 (Link to Abstract)
Roberts CS, Pape HC, Jones AL, Malkani AL, Rodriguez JL, Giannoudis PV. Damage control orthopaedics: evolving concepts in the treatment of patients who have sustained orthopaedic trauma. Instr Course Lect. 2005;54:447-62. Review. PMID:15948472 (Link to Abstract)
Rossaint R, Bouillon B, Cerny V, Coats TJ, Duranteau J, Fernández-Mondéjar E, Hunt BJ, Komadina R, Nardi G, Neugebauer E, Ozier Y, Riddez L, Schultz A, Stahel PF, Vincent JL, Spahn DR; Task Force for Advanced Bleeding Care in Trauma. Management of bleeding following major trauma: an updated European guideline. Crit Care. 2010;14(2):R52. PMID:20370902 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Mullins R: Management of shock. In Trauma, McGraw Hill, 2000, pp195-232
Browner BD, Jupiter JB, Levine AM, Trafton PG (eds): Skeletal Trauma, ed 2. Philadelphia, PA, WB Saunders, 1998, pp 1650-1681, pp 1754-1767.
Kellam JF, Fischer TJ, Tornetta P III, Bosse MJ, Harris MB (eds): Orthopaedic Knowledge Update: Trauma 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 147-150.
Menth-Chiara WA, Norris B, Richard CM, Brown GA, Ullrich R. Pathophysiology of the polytrauma patient. In: Baumgaertner MR, Tornetta P III, eds. Orthopaedic Knowledge Update: Trauma 3. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2005:93-106.
OKU Trauma 2, 2000; pp 229-237
Parillo JE, Dellinger RP, eds. Critical Care Medicine: Principles of Diagnosis and Management in the Adult, 2nd ed. St Louis, MO: Mosby; 2002:432-434.

Undefined

Born CT, Ross SE, Iannacone WM, Schwab CW, DeLong WG. Delayed identification of skeletal injury in multisystem trauma: the 'missed' fracture. Journal of Trauma, 1989 Dec; 29(12):1643-6. PMID:2593194 (Link to Abstract)
Browner BD, Jupiter JB (et al): Skeletal Trauma ed 2. Philadelphia, PA WB Saunders, 1998 p 133-144
Chesnut RM, Marshall LF, Klauber MR, et al. The role of secondary brain injury in determining outcome from severe head injury. J Trauma. 1993 Feb;34(2):216-22. PMID:8459458 (Link to Abstract)
Kellam JF, Fischer TJ (et al) Eds. OKU Trauma 2. Rosemont, IL, AAOS 2000, p 229-237
Pietropaoli JA, Rogers FB, Shackford SR, Wald SL, Schmoker JD, Zhuang J. The deleterious effects of intraoperative hypotension on outcome in patients with severe head injuries. J Trauma. 1992 Sep;33(3):403-7. PMID:1404509 (Link to Abstract)
Roberts CS, Pape HC, Jones AL, : Damage control orthopaedics: Evolving concepts in the treatment of patients who have sustained orthopaedic trauma. Instr Course Lect 2005;54:447-462 PMID:15948472 (Link to Abstract)
Scalea T, Burgess A; Pelvic Fracture; 824-5 Trauma eds Mattox, Feliciano, Moore McGraw Hill, NY 1999
Turen CH, Dube MA, LeCroy MC: Approach to the polytraumatized patient with musculoskeletal injuries. J Am Acad Orthop Surg 1999;7:154-165 PMID:10346824 (Link to Abstract)

Topic Comments

Subscribe status: On Off

Recent on Bottom | Recent on Top

Page:1

Evaluation, Resuscitation & DCO

Qbank (15 Questions)

Question Comments

Question Comments

Question Comments

Question Comments

Question Comments

Question Comments

Question Comments

Question Comments

Question Comments

Question Comments

Question Comments

Question Comments

Question Comments

Question Comments

Question Comments

Cases

Groups

Evidence & References Show References

Topic Comments