Updated: 8/14/2018

Evaluation, Resuscitation & DCO

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Introduction
  • Trauma is a major public health problem with high disability, death, and societal cost
  • 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 shock, hypoxia, or 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
Evaluation
  • Primary survey
    • treat greatest threats to life first
      • pelvic fractures can be a life threatening intervened on by orthopedic surgeons
    • brief history
    • ABCDE's
      • Airway
        • includes cervical spine control
      • Breathing and ventilation
      • Circulation
        • includes hemorrhage control and resuscitation (below)
        • pregnant women should be placed in the left lateral decubitus position to limit positional hypotension
      • Disability
      • Exposure
  • Secondary survey
    • physical examination and updated history
    • obtain indicated imaging studies
  • Tertiary survey
    • repeat physical examination and additional imaging as indicated when mental status has stabilized
    • formal tertiary survey decreases chances of missed orthopedic inury
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  
    • 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
Non-hemorrhagic shock
  • Cardiogenic shock
    • the heart is unable to generate sufficient cardiac output
  • Neurogenic shock
    • hypotension and relative bradycardia from loss of sympathetic tone following spinal cord inury
  • Septic shock vs. hypovolemic shock
    • the key variable to differentiate septic shock and hemorrhagic 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
increased
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
    • image any extremity with pain, crepitus, ecchymosis, deformity
  • 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 (DCO)
  • Definition/History
    • definitive treatment delayed until physiology has improved
    • popularized in 2000
    • replaced the 1980s philosophy of Early Total Care (ETC), the concept of fixing long bone fractures as soon as possible because patients were "too sick not to operate"
      • ETC led to exacerbation of the "second-hit" in a subset of patients with hemodynamic instability, head, and/or chest injuries
  • 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
        • unstable pelvic fracture
        • compartment syndrome
        • fractures with vascular injuries
        • unreduced dislocations
        • traumatic amputations
        • unstable spine fractures
        • cauda equina syndrome
        • 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 exploratory laparotomy and/or 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)
Early Appropriate Care
  • Definition/History
    • identifies major trauma patients and definitively treats the most time-critical orthopaedic injuries while minimizing the secondary inflammatory response, guided by laboratory parameters of adequate resuscitation
    • popularized in 2013
  • Parameters 
    • lactate of < 4.0 mmol/L
    • pH ≥ 7.25
    • base excess ≥ -5.5 mmol/L
  • Optimal time of surgery
    • goal is to definitively treat spine, pelvis, femur, and acetabulum fractures within 36 hours of injury
  • Outcomes
    • decreased delay to surgery
    • decreased complication rates
    • increased hospital revenues
    • main reason for delay to treatment with implementation of this protocol was surgeon decision
 

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Questions (50)
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(OBQ04.141) Which of the following percentages of normal circulating blood loss would first result in a patient with tachycardia and a narrowed pulse pressure? Review Topic

QID: 1246
1

5%

0%

(8/1832)

2

10%

10%

(191/1832)

3

25%

65%

(1192/1832)

4

40%

22%

(398/1832)

5

50%

2%

(38/1832)

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(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 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? Review Topic

QID: 3050
FIGURES:
1

Irrigation and debridement of open tibia plateau fracture and traction stabilization of femur and tibia plateau fractures

6%

(135/2263)

2

Irrigation and debridement with open reduction internal fixation of tibial plateau fracture and intramedullary nail fixation of femur fracture

0%

(5/2263)

3

Irrigation and debridement with open reduction internal fixation of tibial plateau fracture and plate fixation of femur fracture

0%

(3/2263)

4

Irrigation and debridement with external fixation of tibia plateau fracture and reamed intramedullary nail fixation of femur fracture

4%

(91/2263)

5

Irrigation and debridement with external fixation of tibia plateau fracture and external fixation of femur fracture

89%

(2021/2263)

ML 1

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

QID: 859
1

Urine output of 0.8 mL/kg/hr

7%

(47/718)

2

SpO2 < 90%

1%

(5/718)

3

Platelet count < 80

1%

(4/718)

4

Base excess of 3.0 mEq/L

7%

(49/718)

5

Serum lactate of 4.5 mmol/L

84%

(606/718)

ML 1

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PREFERRED RESPONSE 5
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(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. As an alternative to lactate and base deficit measurements, which of the following would best indicate adequate resuscitation has been achieved? Review Topic

QID: 4378
1

Systolic blood pressure > 120

6%

(311/4926)

2

Heart rate between 60-100

16%

(793/4926)

3

Urine output equals 0.4 cc/kg/hr

19%

(919/4926)

4

Gastric intramucosal pH of 7.4

56%

(2768/4926)

5

Potassium between 3.5-4.5

2%

(108/4926)

ML 4

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PREFERRED RESPONSE 4
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(OBQ10.72) All of the following indicators of resuscitation may be within normal limits for a trauma patient that is in "compensated" shock EXCEPT: Review Topic

QID: 3160
1

Systolic blood pressure

3%

(54/1874)

2

Urine output

7%

(124/1874)

3

Heart rate

8%

(144/1874)

4

Serum lactate

80%

(1501/1874)

5

Mean arterial pressure

2%

(43/1874)

ML 2

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PREFERRED RESPONSE 4

(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: Review Topic

QID: 754
1

Severe closed head injury

10%

(54/552)

2

Facial fractures

21%

(115/552)

3

Splenic rupture

16%

(88/552)

4

Pelvic ring injuries

47%

(258/552)

5

Flail chest

6%

(34/552)

ML 4

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PREFERRED RESPONSE 4

(OBQ13.221) 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? Review Topic

QID: 4856
1

Lactate level = 1.9 mmol/L

31%

(879/2836)

2

Fibrinogen = 1.1 g/dL

2%

(62/2836)

3

Platelet count = 20,000 per mcL

52%

(1473/2836)

4

Urine output = 50 cc/hr

2%

(53/2836)

5

Base deficit = 2 mmol/L

12%

(354/2836)

ML 5

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PREFERRED RESPONSE 3

(OBQ12.252) 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? Review Topic

QID: 4612
1

Placement of antibiotic beads, wound closure and immobilization

1%

(42/4403)

2

Reamed antegrade intramedullary nailing

7%

(295/4403)

3

Unreamed antegrade intramedullary nailing

3%

(119/4403)

4

Wound closure and Hare traction splint placement

1%

(27/4403)

5

Placement of an external fixator

89%

(3901/4403)

ML 1

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PREFERRED RESPONSE 5

(OBQ05.38) 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? Review Topic

QID: 75
1

wrist x-ray not initially obtained

98%

(681/697)

2

x-ray obtained, but MRI necessary for diagnosis not obtained

0%

(1/697)

3

forearm x-ray initially obtained did not show fracture

1%

(5/697)

4

CT initially performed, but no 3-D images reconstructed

1%

(4/697)

5

wrist x-ray initially obtained did not show fracture

0%

(3/697)

ML 1

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PREFERRED RESPONSE 1

(OBQ07.225) 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? Review Topic

QID: 886
1

Reverse Trendelenburg

5%

(31/630)

2

Trendelenburg

6%

(37/630)

3

Left lateral decubitus

78%

(493/630)

4

Right lateral decubitus

6%

(40/630)

5

Supine

4%

(25/630)

ML 2

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PREFERRED RESPONSE 3

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

QID: 3304
1

Increased systemic vascular resistance

72%

(569/791)

2

Decreased cardiac output

3%

(27/791)

3

Decreased pulmonary capillary wedge pressure

6%

(51/791)

4

Decreased central venous pressure

2%

(16/791)

5

Increased mixed venous oxygen saturation

16%

(127/791)

ML 2

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PREFERRED RESPONSE 1

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

QID: 1124
1

Urine output of 0.25 mL/kg/hour

7%

(139/1974)

2

Lactic acid of 1.9 mmol/L

79%

(1554/1974)

3

Base deficit of 5.5

7%

(129/1974)

4

Gastric mucosal pH of 6.5

6%

(119/1974)

5

Pulse pressure of 15

1%

(26/1974)

ML 2

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PREFERRED RESPONSE 2

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

QID: 832
1

Delayed fixation of fractures

10%

(64/622)

2

Decreased intracranial pressure

4%

(26/622)

3

Intra-abdominal injury

9%

(57/622)

4

Intra-operative hypotension

72%

(448/622)

5

Decreased platelet count

4%

(24/622)

ML 2

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PREFERRED RESPONSE 4

(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? Review Topic

QID: 3555
FIGURES:
1

Heart rate of 80 beats per minute

0%

(15/3671)

2

Systolic blood pressure of 120 mmHg

0%

(7/3671)

3

Base deficit of -1.8 mEq/L

10%

(356/3671)

4

Serum lactate of 5 mmol/Liter

87%

(3204/3671)

5

Urine output of 40ml/hour

2%

(77/3671)

ML 1

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PREFERRED RESPONSE 4

(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? Review Topic

QID: 1275
FIGURES:
1

CT scan of chest, abdomen, pelvis

82%

(1011/1232)

2

Immediate sheet removal in exchange for a pelvic binder for added stability

2%

(30/1232)

3

Immediate external fixator placement in the emergency room

4%

(53/1232)

4

Pelvic arterial embolization

5%

(62/1232)

5

Definitive open reduction internal fixation

5%

(66/1232)

ML 2

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PREFERRED RESPONSE 1

(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? Review Topic

QID: 1185
FIGURES:
1

Intramedullary nailing of the tibia and femur

82%

(325/397)

2

External fixation of the tibia and femur

13%

(51/397)

3

Balanced skeletal traction

1%

(4/397)

4

Circular external fixation of the tibia and intramedullary nailing of the femur

2%

(9/397)

5

Uniplanar external fixation of the tibia and intramedullary nailing of the femur

2%

(7/397)

ML 2

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PREFERRED RESPONSE 1

(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 transmission from the transfusions? Review Topic

QID: 762
1

HIV

1%

(9/611)

2

Staph Aureus

4%

(23/611)

3

Hepatitis A

2%

(14/611)

4

Hepatitis B

50%

(304/611)

5

Hepatitis C

42%

(259/611)

ML 4

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