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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 30% 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 (universal donor)
      • Type specific blood
      • Cross-matched blood
      • transfuse in 1:1:1 ratio (red blood cells: platelets: plasma)
  • 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 < 2.5 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
      • transfused blood is screened for
        • HIV-1 (cause of AIDS)
        • HIV-2
        • hepatitis B
        • hepatitis C
        • West Nile virus
        • syphilis
    • clerical error leading to transfusion reaction (1:12,000 to 1:50,000)
    • bacterial contamination leading to sepsis (1:1million)
    • anaphylactic reaction (1:150,000)
Septic Shock
  • Septic shock vs. hypovolemic shock
    • the key variable to differentiate 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
increased
 
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
    • not commonly utilized in lieu of increased sensitivity with cervical spine CT 
  • 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 Control Orthopaedics
  • Involves staging definitive 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
    • GCS of 8 or below
    • 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
    • IL-6 values above 500pg/dL 
  • 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, pelvic packing, skeletal traction, 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)
 

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