Please rate topic.
Average 4.3 of 131 Ratings
A previously healthy 22-year-old male presents to the hospital after a motor vehicle accident. His injuries include a closed head injury, flail chest, intra-abdominal bleed and right femoral shaft fracture. Which of the following conventional indicators would support the role for "damage control orthopaedics" as opposed to "early total care" in the clinical decision making process of his femur fracture management?
Lactate level = 1.9 mmol/L
Fibrinogen = 1.1 g/dL
Platelet count = 20,000 per mcL
Urine output = 50 cc/hr
Base deficit = 2 mmol/L
Select Answer to see Preferred Response
Previously healthy, poly-trauma patients, presenting with platelet counts of <70,000 will fall into the pathophysiological category of 'in extremis'. This will support the role of damage control orthopaedics in the decision making process of this patients fracture management.
Damage control orthopaedics (DCO) is a staged approach for the management of polytrauma patients. It is most ideal for trauma patients that are clinically unstable or in extremis. In these patients, immediate surgery is thought to cause a “second hit” phenomenon, which may lead to ARDS, multi-organ failure, or even death. A patient is classified as 'unstable' or 'in extremis', if he or she meets the criteria in at least three of the four pathophysiological parameters; blood pressure <90mmHg, platelets count <70,000, temperature <32°C and major soft tissue injuries.
Pape et al. (2005) described four classes of patients, based on their clinical status: stable, borderline, unstable, and in extremes. The term “borderline” was coined to describe a patient who is categorized as stable before surgery, but is at significant risk of unexpected deterioration and organ dysfunction postoperatively.
Pape et al. (2009) outlined that stable patient can undergo early definitive fracture fixation as necessary. In contrast, unstable patient should be resuscitated and adequately stabilized with temporary fixation before receiving definitive orthopaedic care.
Illustration A shows a table outlining the classification system used by Pape to classify patients into their clinical status of stable, borderline, unstable, and in extremes.
Answer 1: Lactate level = 1.9 mmol/L (normal range <2.5 mmol/L) would classify this patient into a stable category.
Answer 2: Fibrinogen = 1.1 g/dL (normal range >1 g/dL) would classify this patient into a stable category.
Answer 4: Urine output = 50 cc/hr (normal range >150 cc/hr)would classify this patient into a borderline category.
Answer 5: Base deficit = 2 mmol/L (normal range -2 to +2 mmol/L) would classify this patient into a stable category.
Pape HC, Tornetta P, Tarkin I, Tzioupis C, Sabeson V, Olson SA
J Am Acad Orthop Surg. 2009 Sep;17(9):541-9. PMID: 19726738 (Link to Abstract)
Pape, JAAOS 2009
Pape HC, Giannoudis PV, Krettek C, Trentz O
J Orthop Trauma. 2005 Sep;19(8):551-62. PMID: 16118563 (Link to Abstract)
Pape, JOT 2005
Please rate question.
Average 3.0 of 22 Ratings
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. As an alternative to lactate and base deficit measurements, which of the following would best indicate adequate resuscitation has been achieved?
Systolic blood pressure > 120
Heart rate between 60-100
Urine output equals 0.4 cc/kg/hr
Gastric intramucosal pH of 7.4
Potassium between 3.5-4.5
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.
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: Potassium levels do not assess adequate resuscitation
Porter JM, Ivatury RR
J Trauma. 1998 May;44(5):908-14. PMID: 9603098 (Link to Abstract)
Porter, JT 1998
Roberts CS, Pape HC, Jones AL, Malkani AL, Rodriguez JL, Giannoudis PV.
Instr Course Lect. 2005;54:447-62. PMID: 15948472 (Link to Abstract)
Average 2.0 of 67 Ratings
A 36-year-old woman presents with a grade 2 open midshaft femoral shaft fracture as the result of a high-speed motor vehicle collision. Concomitant injuries include a high-grade splenic laceration requiring splenectomy as well as a subdural hematoma that requires monitoring and maintenance of cerebral perfusion pressure. After irrigation and debridement of the open fracture, which of the following is the most appropriate management of the femoral shaft fracture at this time?
Placement of antibiotic beads, wound closure and immobilization
Reamed antegrade intramedullary nailing
Unreamed antegrade intramedullary nailing
Wound closure and Hare traction splint placement
Placement of an external fixator
The clinical scenario is consistent with a femoral shaft fracture in a patient that is not stable from a neurosurgical perspective. Therefore, the most appropriate treatment at this time is placement of an external fixator.
When evaluating polytrauma patients with long bone fractures, timing of surgery must be approached considering all clinical conditions. One factor most likely to adversely affect long term outcome in polytrauma patients with severe brain injury is intra-operative hypotension; therefore, whenever a patient has a subdural hematoma that requires close observation, definitive surgery of long bone fractures should be delayed.
Flierl et al. review the immunopathophysiology of traumatic brain injury and the role of the orthopaedic surgeon in avoiding a "second hit" injury to the brain by appropriately timing the fixation of femoral shaft fractures. They recommend a multidisciplinary approach, taking individual patient-specific factors into consideration and in general, DCO principles for severe head-injured patients (GCS 3-13) and "early total care" principles for patients with mild head injury (GCS 14-15).
Illustration A is a visual representation of the treatment algorithm recommended in the article.
Answer choice 1 is incorrect because it does not appropriately address the fracture and there is no indication for bead placement.
Answer choices 2 and 3 are incorrect as this patient is not stable for prolonged surgery.
Answer 4 is incorrect as this patient is already under general anesthesia and external fixation is a better option than traction for stabilization of the fracture.
Flierl MA, Stoneback JW, Beauchamp KM, Hak DJ, Morgan SJ, Smith WR, Stahel PF
J Orthop Trauma. 2010 Feb;24(2):107-14. PMID: 20101135 (Link to Abstract)
Flierl, JOT 2010
Average 3.0 of 18 Ratings
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?
Heart rate of 80 beats per minute
Systolic blood pressure of 120 mmHg
Base deficit of -1.8 mEq/L
Serum lactate of 5 mmol/Liter
Urine output of 40ml/hour
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.
J Am Coll Surg. 1998 Nov;187(5):536-47. PMID: 9809573 (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.
Crit Care. 2010;14(2):R52. Epub 2010 Apr 6. PMID: 20370902 (Link to Abstract)
Average 4.0 of 19 Ratings
All of the following indicators of resuscitation may be within normal limits for a trauma patient that is in "compensated" shock EXCEPT:
Systolic blood pressure
Mean arterial pressure
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.
Average 4.0 of 28 Ratings
All of the following are characteristic of end-stage septic shock EXCEPT?
Increased systemic vascular resistance
Decreased cardiac output
Decreased pulmonary capillary wedge pressure
Decreased central venous pressure
Increased mixed venous oxygen saturation
Septic shock is associated with decreased systemic vascular resistance, decreased cardiac output, decreased pulmonary capillary wedge pressure, decreased central venous pressure, and increased 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 as high as 25%-50%.
Average 4.0 of 18 Ratings
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 is proceeding 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?
Irrigation and debridement of open tibia plateau fracture and traction stabilization of femur and tibia plateau fractures
Irrigation and debridement with open reduction internal fixation of tibial plateau fracture and intramedullary nail fixation of femur fracture
Irrigation and debridement with open reduction internal fixation of tibial plateau fracture and plate fixation of femur fracture
Irrigation and debridement with external fixation of tibia plateau fracture and reamed intramedullary nail fixation of femur fracture
Irrigation and debridement with external fixation of tibia plateau fracture and external fixation of femur fracture
Radiographs demonstrate a femoral shaft and high-energy tibia plateau fracture. The patient is medically unstable and the best treatment is expeditious debridement of the open 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.
Turen CH, Dube MA, LeCroy MC.
J Am Acad Orthop Surg. 1999 May-Jun;7(3):154-65. PMID: 10346824 (Link to Abstract)
Turen, JAAOS 1999
Average 4.0 of 31 Ratings
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:
Severe closed head injury
Pelvic ring injuries
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.
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.
J Trauma. 1996 Dec;41(6):935-51. PMID: 8970544 (Link to Abstract)
Loo, JTACS 1996
Average 3.0 of 41 Ratings
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 transmission from the transfusions?
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.
Wang B, Schreiber GB, Glynn SA, Kleinman S, Wright DJ, Murphy EL, Busch MP.
Transfusion. 2005 Jul;45(7):1089-96. PMID: 15987352 (Link to Abstract)
Average 3.0 of 36 Ratings
Which of the following factors has been shown to increase mortality in poly-trauma patients with severe head injuries?
Delayed fixation of fractures
Decreased intracranial pressure
Decreased platelet count
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.
Pietropaoli JA, Rogers FB, Shackford SR, Wald SL, Schmoker JD, Zhuang J.
J Trauma. 1992 Sep;33(3):403-7. PMID: 1404509 (Link to Abstract)
Pietropaoli, JTACS 1992
Chesnut RM, Marshall LF, Klauber MR, Blunt BA, Baldwin N, Eisenberg HM, Jane JA, Marmarou A, Foulkes MA.
J Trauma. 1993 Feb;34(2):216-22. PMID: 8459458 (Link to Abstract)
Chesnut, JTACS 1993
Average 3.0 of 31 Ratings
Residual end-organ hypoperfusion in a polytraumatized patient is shown by which of the following?
Urine output of 0.8 mL/kg/hr
SpO2 < 90%
Platelet count < 80
Base excess of 3.0 mEq/L
Serum lactate of 4.5 mmol/L
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, i.e., a base deficit of GREATER THAN 2 or a base excess of LESS THAN -2 is indicative of end-organ 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.
Average 4.0 of 33 Ratings
A 21-year-old second-trimester 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?
Left lateral decubitus
Right lateral decubitus
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.
Flik K, Kloen P, Toro JB, Urmey W, Nijhuis JG, Helfet DL.
J Am Acad Orthop Surg. 2006 Mar;14(3):175-82. PMID: 16520368 (Link to Abstract)
Flik, JAAOS 2006
Average 3.0 of 38 Ratings
A 30-year-old man sustains a head injury as well as femur and pelvis fractures as the result of a rollover motor-vehicle accident. He is initially comatose, 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?
wrist x-ray not initially obtained
x-ray obtained, but MRI necessary for diagnosis not obtained
forearm x-ray initially obtained did not show fracture
CT initially performed, but no 3-D images reconstructed
wrist x-ray initially obtained did not show fracture
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.
Born CT, Ross SE, Iannacone WM, Schwab CW, DeLong WG.
J Trauma. 1989 Dec;29(12):1643-6. PMID: 2593194 (Link to Abstract)
Born, JTACS 1989
Average 2.0 of 37 Ratings
Which of the following is indicative of a patient who has been successfully resuscitated following a trauma?
Urine output of 0.25 mL/kg/hour
Lactic acid of 1.9 mmol/L
Base deficit of 5.5
Gastric mucosal pH of 6.5
Pulse pressure of 15
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.
1: Urine output should be at least 0.5ml/kg/hr.
3: Base deficit should be less than 2.
4: Gastric mucosal pH is different than gastric fluid pH, and should be greater than 7.2.
5: Pulse pressure should be greater than 15mmHg.
Average 3.0 of 34 Ratings
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?
Intramedullary nailing of the tibia and femur
External fixation of the tibia and femur
Balanced skeletal traction
Circular external fixation of the tibia and intramedullary nailing of the femur
Uniplanar external fixation of the tibia and intramedullary nailing of the femur
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.
Average 3.0 of 42 Ratings
Which of the following percentages of normal circulating blood loss would result in a patient to become tachycardic with a narrowed pulse pressure?
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.
Illustration A shows the hemorrhagic shock class table.
Hak DJ, Smith WR, Suzuki T.
J Am Acad Orthop Surg. 2009 Jul;17(7):447-57. PMID: 19571300 (Link to Abstract)
Hak, JAAOS 2009
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?
CT scan of chest, abdomen, pelvis
Immediate sheet removal in exchange for a pelvic binder for added stability
Immediate external fixator placement in the emergency room
Pelvic arterial embolization
Definitive open reduction internal fixation
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.
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.
Average 4.0 of 48 Ratings
HPI - Patient was a front passenger injured his limb while hanging out of vehicle during the accident when it hit a metal fence.
We're 6 weeks down the road. Skin graft is taking (85%) no signs of infection clinically or lab wise. MRI & Nerve conduction studies weren't done due to technical difficulties (skin condition and ex fix) although clinically there was no improvement neurologically. Ex fix was removed from the forearm a week ago for definitive fixation.
Given the unfavourable skin condition and the neurological status (flail limb), how would you treat the BOTH-BONE FOREARM Fx at this time?
HPI - 25 year old who was run over, followed by loss of consciousness, brought to local hospital and while there, was diagnosed with fat embolism & treated with IV fluids. Now his vitals are stable - BP 100|70 mmHg, pulse 96/min, respirations 22\min
Which orthopaedic injury would you want to treat first?
HPI - 56 y/o male involved in head on MVA. Presents in hypovolemic shock as well bowel injury. Undergoes emergency laparotomy. After bowel exploration and repair, base deficit is 7, lactate is 6.5, and hematocrit is 26.5