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 hours of arrival to hospital 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 Psychological 50% incidence of PTSD after traumatic event involving orthopedic injuries females 4x more likely to develop PTSD 33% incidence of depression Evaluation Primary survey treat greatest threats to life first pelvic fractures can be life threatening if not 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 Hemorrhagic shock classification and 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 Dereased 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 normal < 2.5 mmol/L, < 45 mg/dL most sensitive indicator as to whether some circulatory beds remain inadequately perfused 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 vs. Septic shock Hypovolemic shock Septic Shock Systemic Vascular Resistance Increased Decreased Key variable to differentiate 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 patients are at increased risk of ARDS and multisystem failure during the 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