Polytrauma part 7 (Management)
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Successful management of Polytrauma must achieve the following goals, 1- Keep someone alive that would be dead without you 2- Prioritize treatment to prevent killing someone 3- Treat extremity injuries to return the patient to a functional life. The Priorities are 1- Life threatening, 2- Limb threatening, 3- Function threatening. The question about the best strategy in the management Polytrauma and the choice between an Early Total Care (ETC) vs. Damage Control Orthopedics (DCO) will be answered in this presentation.
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Polytrauma part 7 (Management)
- 1. Dr. Fathi Neana, MD Chief of Orthopaedics Dr. Fakhry & Dr. A. Al-Garzaie Hospital February, 04 - 2019 Polytrauma Part 7 Management of Polytrauma
- 3. 1- Keep someone alive that would be dead without you 2- Prioritize treatment to prevent killing someone 3- Treat extremity injuries to return the patient to a functional life Management of Polytrauma GOALS
- 4. Priorities • Life threatening • Limb threatening • Function threatening Electric shock in swimming pool 1- Un blugg AC 2- BLS - ABC 3- Call Hospital
- 5. The question is Early Total Care (ETC) vs. Damage Control 0rthopedics (DCO)
- 6. Pathophysiology evolving concepts Sequelae of trauma depends upon: – ( “First hit” ) initial injury – Individual biological response – ( “Second hit” ) type of treatment
- 7. Physiology of Damage Control Orthopaedics (DCO) 2-4 days 6-8 days
- 8. Systemic Effects of Trauma Injury (First Hit) 24 hours 48 hours Post Injury Inflammatory Response in 2 Patients Second Hit in susceptible patients ARDS, MODS Threshold IM Nailing as a Cause of Secondary Systemic Injury 2-4 days 6-8 days
- 9. Avoid • Excessive fluid shifts • Hypothermia • Coagulopathy • Pulmonary compromise Provide stability • Pain control • ↓ Inflammatory mediator release • ↓ Fat embolism • ↑ Mobilization Damage control orthopaedic surgery Rapid external fixation Delayed definitive fixation Timing of secondary surgery 2-4 days Worst days ↑ multiple organ failure ↑inflammatory markers 6-8 days Best
- 11. What to do ? Stabilized Stable UnstableBorderline Resuscitate Reevaluate DCOETC Uncertain
- 12. 1- At the scene of the accident 2- Transport 3- At the hospital Management of Polytrauma
- 13. At the scene of the accident • The doctor arriving the scene should be calm, confident and avoid injury to himself and others • Rapidly assess the situation and decide on priorities • Call the emergency services (ambulance, police, and fire)
- 14. • Bystanders can be taught how to maintain an airway with a jaw thrust or chin lift, maintain in- line immobilization of the neck and compress external bleeding points • Treatment of polytraumatized patients begins at once A = establish an airway but protect the cervical spine B = breathing C = circulation (arrest haemorrhage and combat shock examination, analgesia, splint fractures, dressing of open wounds At the scene of the accident
- 15. Transport • To move a severely injured patient onto a stretcher at least four people are required to transfer the patient as one straight piece • The ABC (airway, breathing &circulation ) should be checked again before the ambulance departs, and during the journey • Ambulances should be equipped with splints, dressings, airways, oxygen and transfusion apparatus
- 16. D. HANY ALSHAFEY MOTHER Quadriplegia during transport
- 18. At the hospital • A rapid primary survey with simultaneous resuscitation • A detailed secondary survey • Constant re-evaluation • Initiation of definitive care
- 19. Emergency life saving measures ABCDE – A Airway and cervical spine immobilisation – B Breathing – C Circulation (treatment and diagnosis of cause) – D Disability (head injury) – E Exposure (musculo-skeletal injury)
- 20. Emergency orthopaedic management • Life saving measures *Reducing a pelvic fracture in haemodynamically unstable patient *Applying pressure to reduce haemorrhage from open fracture • Complication saving *Early and complete diagnosis of the extent of injuries *Diagnosing and treating soft-tissue injuries
- 21. 1- Polytrauma Patient 2- Multidisciplinary Team for Polytrauma management Dealing with Polytrauma means
- 22. Polytrauma Patient • ISS : Injury Severity Score: scale of anatomic injury (7sites – 5 grades) • AIS : (Abbreviated Injury Scale) (9sites – 6 grades) - 6 represents the 'threat to life • NISS: is the sum of the squares of the three highest AIS categories - Maximum ISS is 75 • Injury Severity Score >18 • Hemodynamic instability • Coagulopathy • Closed head injury • Pulmonary injury • Abdominal injury • Pelvic injury • Musculoskeletal
- 23. Polytrauma Multidisciplinary Team •Trauma Surgeon (TEAM LEADER) • Anesthesia • Musculoskeletal traumatologist • Neurosurgeon • Vascular •Cardiothoracic surgeon • Urology, Gynecology • Intensive care specialist •Interventional radiology • Hospital Staff : Nursing, PT, OT, Speech, Administration • Legal/Security • Social work •Ministry •
- 24. Trauma Surgeons and Fracture Care • Europe - General Surgeon Traumatologists (treat all injuries) • North America - Multidisciplinary team – Orthopaedic Traumatologist broad knowledge of treatment of injuries involving other organ systems to coordinate care optimally with colleagues Orthopaedic Traumatologist • General resuscitation / ICU care • Advantages / disadvantages of early stabilization of long bone fractures • Skilled sufficiently to do a procedure expeditiously with minimal risk of complications • Understands impact of treatment on multisystem injury Polytrauma Multidisciplinary Team
- 25. Principles of Resuscitation (ATLS) Advanced Trauma Life Support Phases 1- Primary Survey 2- Resuscitation 3- Secondary Survey 4- Definitive care Priorities •Airway •Breathing •Circulation •CNS •Digestive system •Excretory Tracts •Fractures
- 27. Airway • Establish an appropriate airway – obtain patency-jaw lift – oral or nasal airway – surgical airway • Control of the cervical spine • Lateral C-spine radiograph – not included in the initial radiographic evaluation in the revised ATLS protocol
- 28. Breathing • Assess breathing and oxygenation • Evaluation with Arterial Blood Gas (ABG) • Etiology of decreased oxygenation has to be determined – Tension pneumothorax-decompress – Open pneumothorax-seal and chest tube – Flail chest, pulmonary contusion-chest tube
- 29. Emergency Airways • Surgical cricothyroidotomy- procedure of choice when surgical access is needed • Needle cricothyroidotomy- preferred for children under age 12 Traditional open technique Wire-guided Percutaneous Cricothyrotomy
- 30. Indications for Intubation • Control of airway • Prevent aspiration in unconscious patient • Hyperventilation for increased intracranial pressure • Obstruction from facial trauma and edema
- 31. Circulation • Identifiable bleeding controlled with direct pressure • Always try direct pressure first • Avoid blind use of vascular clamps • Tourniquets are rarely indicated except for traumatic amputations
- 32. Assessment of Blood Pressure & Peripheral Perfusion Peripheral Pulse Radial Femoral Carotid capillary refill > 2 secs Systolic Blood Pressure 80 mm Hg 70 mm Hg 60 mm Hg Hypotensive
- 33. Parameter Class I II III IV Blood loss (ml) <750 750–1500 1500–2000 >2000 Blood loss (%) <15% 15–30% 30–40% >40% Pulse rate (beats/min) <100 >100 >120 >140 Blood pressure Normal Decreased Decreased Decreased Respiratory rate (breaths/min) 14–20 20–30 30–40 >35 Urine output (ml/hour) >30 20–30 5–15 Negligible CNS symptoms Normal Anxious Confused Lethargic Classification of hemorrhage
- 34. Resuscitation & Blood Transfusion Resuscitation •Two peripheral large bore IVs • Two liters of Ringers Lactate – If no response then severe hemorrhage has occurred – immediate blood is needed • Monitor – Blood pressure – Urinary output – Base deficit – Initial Hematocrit/Hemoglobin -unreliable Blood Transfusion •Crossed Matched – 1 hour • Type Specific – 10 minutes • Type O Rh neg – Immediately Blood warmer-prevents hypothermia, arrhythmias Blood filters-160 u macropore Coagulation status-Platelets monitored every 10 units Platelets < 100,000-replace Labile factors (fibrinogen)-replace with FFP
- 35. Types of Shock • Hemorrhagic • Cardiogenic - pericardial tamponade • Neurogenic -CHI, spinal cord injury – hypotension without tachycardia – Vasoconstrictive meds not administered until volume is restored • Septic - late sequelae Management of Shock Summary • Direct Control of Bleeding sources • Large bore IV access-Fluid Replacement • Monitor-urine output, CVP, pH, lactate level • Blood Replacement- indicated by clinical response
- 37. Secondary Survey Head – skull trauma – reevaluate pupillary size and reaction – blood/fluid at tympanic membranes and nares – facial and ethmoid fractures Cervical spine – swelling, crepitus, expanding hematoma Neurological Exam Glasgow Coma Score-GCS Pupil exam-intracranial pressure Motor and Sensory - all extremities in alert patient
- 39. Chest reevaluate for crepitus, fractures, flail segments, open wounds Abdomen inspect, auscultate, palpate – seat belt injury-spinal or intraabodominal injury Pelvis-exam for tenderness, instability Rectal exam tone, sensory, prostate injury if abnormal, do not pass foley-consult Urology Extremity exam palpate for crepitus, swelling, pain, instability, range of motion Document all findings Secondary Survey
- 40. Head Injury • Oxygenation and cerebral circulation • Loss of consciousness (LOC) > 5 mins – observation for 24 hours – potential for seizures • CT scan of head Intracranial Hemorrhage • Meningeal • Brain tissue • Suspect in unconsciousness patient or lateralizing signs – fixed pupil
- 41. Increased Intracranial Pressure Treatment • Patient positioning • Fluid restriction • Hyper osmotic diuretics-manitol • Deliberate hypocapnia – controlled hyperventilation – maintain pCO2 at 25-30 mm Hg • Avoidance of stimuli Figure 3 Intracranial herniations. (A) Cingulate herniation. (B) Uncal herniation. Most common clinically observed herniation. Uncus of temporal lobe herniates between rostral brain stem and tentorial edge into the posterior fossa, resulting in a clinical syndrome of progressively impaired consciousness, dilated ipsilateral pupil, and contralateral hemiplegia. (C) Tonsillar herniation. The tonsils of the cerebellum herniate through the foramen magnum into the upper spinal canal, compressing the medulla. Clinically this may result in cardio respiratory impairment, hypertension, high pulse pressure, Cheynes-Stoke respiration, neurogenic hyperventilation, impaired consciousness, and death. The combination of bradycardia and hypertension is known as Cushing’s response, and occurs in about one third of cases of tonsillar herniation.
- 42. Thoracic Trauma • Accounts for 50-75 % of fatalities in blunt trauma • 15% of injuries require surgical intervention • Second leading cause of death • Life saving procedures performed during the primary survey
- 43. • Secondary survey – pulmonary contusion, aortic disruption, airway disruption, traumatic diaphragmatic disruption, myocardial contusion • CXR-aortic disruption – widened mediastinum, fracture of 1st and 2nd ribs, sternum fracture, loss of aortic knob, trachea and esophageal deviation • Aortagram of the aortic arch Thoracic Trauma
- 44. Thoracotomy Indications • Failure of resuscitation • Penetrating injury to the mediastinum • Continued thoracic hemorrhage • Failed pericardiocentesis • Tracheal, bronchial, esophageal rupture
- 45. Abdominal Trauma • Most common site for occult hemorrhage – liver, spleen, kidney, pancreas, bowel – No peritoneal signs in 40% of hemoperitoneum • NG tube to decompress gastric contents • Foley to decompress bladder – Contraindications • blood at the meatus, scrotal or perineal hematoma, high riding prostate
- 46. Peritoneal Lavage Indications • Blunt trauma when PE is not adequate to assess- altered mental status • Unexplained hypotension – pelvis, lumbar spine, lower ribs fractures • Polytrauma patient lost to continual monitoring- General Anesthesia • Contraindications-multiple abdominal operations, obvious need for operation Peritoneal Lavage Positive Criteria Frank blood Fluid aspirate-unspun > 100,000 RBC/mm3 > 500 WBC/ mm3 hematocrit > 2% presence of bile, bacteria, fecal material
- 47. Other Methods of Abdominal Evaluation • Ultrasound • CT scan • Method used for abdominal evaluation is often institutionally dependent
- 48. Genitourinary Injuries • Seen in 15% of blunt abdominal injuries • Clinical signs – lower rib fracture, flank discoloration, lower abdominal mass, genitalia discoloration, inability to void, blood at the meatus, hematuria • Evaluation – Retrograde urethrogram-before foley is placed – Hematuria-IVP, cystogram, excretory urethrogram
- 51. Trauma Severity Scores • Physiologic – Trauma Index-Kirkpatrick and Youman – Glascow Coma Scale • Anatomic Damage – Injury Severity Score (ISS) – Abbreviated Injury Scale (AIS) – The New Injury Severity Score (NISS) – LD50 • Biochemical Indices
- 52. Trauma Index can be used to rapidly evaluate patients with traumatic injury. Point assignment for injury severity 1.minimal injury: 1 2.moderate injury: 3 or 4 3.severe injury: 6 Interpretation •minimum score with trauma: 2 •maximum score: 30 •scores >7 need admission to the hospital Limitations •The index is not intended for burn patients. Parameter Finding Points region head or neck 6 chest or abdomen 4 back 3 skin or extremities 1 type of injury missile 6 blunt 4 stab wound 3 laceration or contusion 1 cardiovascular status absent pulses 6 blood pressure <80, pulse >140 4 blood pressure <100, pulse >100 3 external hemorrhage 1 normal 0 central nervous system status coma 6 motor or sensory loss 4 stupor 3 drowsy 1 normal 0 respiratory status apnea or cyanosis 6 evidence of aspiration 4 dyspnea or hemoptysis 3 chest pain 1 normal 0
- 53. Orthopaedic Surgeon • Experienced & familiar with a number of acceptable procedures • Some more demanding in terms of EBL, duration, equipment required • Potential EBL (estimated blood loss) – pelvis/acetabulum - 8-10 units – IM nail femur - 2-3 units – Tibia - 1-2 units
- 55. Orthopaedic Emergencies *Open fractures • Dislocations (hip & spine) • Compartment syndromes • Cauda equina syndrome • Extremities with vascular or neurological compromise
- 56. Orthopaedic Emergencies Priorities *Reduce and stabilize dislocations *Fasciotomies in compromised limbs *Proper debridement and irrigation of open injuries *Stabilization of long bone injuries *Secure fixation of intra-articular fractures *Proper splinting of other injuries
- 57. Orthopaedic Options Equipment • Surgeon must have full knowledge of all trauma sets, implants, & where to find them • Use of power instruments- drill, tap, screw – Elliott, Injury, 1992 *External fixation Rapid temporary stabilization Can be adjusted or Exchanged for internal fixation Pelvic ring injuries Lower extremity – long bone fractures Fractures with vascular injuries Complex periarticular fractures Open fractures
- 59. Management of Polytrauma • Dynamic process • Requires cooperation of entire team • Orthopaedist must – Provide timely and effective treatment – Appreciate the interrelationships between organ system injuries to include musculoskeletal injury – Understand • options for treatment of orthopaedic injury • impact on the polytrauma patient
- 60. Management of Polytrauma Remember The lethal triad Hypothermia Acidosis Coagulopathy The Killers in polytrauma • Head injury 66% • Hemorrhagic shock 21% • ARDS & FE • Sepsis (MOF) 13% • Coagulopathy VTE & DIC • Massive transfusions
- 61. The lethal triad in polytrauma Coagulopathy Metabolic AcidosisHypothermia Lactic Acidosis Less energy Decrease Myocardial performance Halt coagulation Cascade
- 63. Management of Polytrauma Priorities EMERGENCY LIFE SAVING MEASURES (ABCDE) • Assisted Resuscitation (Airway- Breathing-Circulation) EMERGENCY ORTHOPAEDIC MANAGEMENT • Immediate surgical Stabilization • Immediate Physiological Stabilization • Elective Surgical Operations • Recovery & Rehabilitation
- 64. Management of Polytrauma Immediate surgical Stabilization Prerequisites: 1- Hemodynamic stabilization 2- No life threatening conditions 3- Adequate Laboratory & Roentgenographic evaluation 4- Adequate Equipments, Manpower, Physion & Nursing support 1- Stop continued bleeding, intra-thoracic, intra-abdominal 2- Major chest injuries 3- Rupture Abdominal viscera 4- Open wounds 5- Skeletal stabilization
- 65. Management of Polytrauma Immediate surgical Stabilization Contra indications The lethal triad • Hypothermia • Acidosis • Coagulopathy 1- Hypothermia 2- Coagulopathy 3- Head injury is not a contraindication with an expert anaesthiologist
- 66. What to do ? Stabilized Stable UnstableBorderline Resuscitate Reevaluate DCOETC Uncertain
- 67. Immediate Skeletal Stabilization Saves lot of Life's & Money Decrease Incidence of ARDS & FE Decrease rate of Septic Shock Decrease rate of Thromboembolism & DIC Facilitates Nursing & Physiotherapy Reduce Hospital stay & Costs
- 68. Immediate Skeletal Stabilization Saves lot of Life's & Money 342 Long bones fractures (Finland) 10 Deaths (ARDS) with conservative 0 Deaths (ARDS ) with operative fixation 371 Polytrauma (Belgium) 1.8% septic Death with early fixation in 24 hours 13.5% with conservative means Musculoskeletal injuries can cause fatal haemorrhage Fixation of Pelvic & Major fractures decrease the mortality rate Early long bones fixation improve the chances of survival & decrease later respiratory complications (Goris et al,1982)
- 69. Immediate Skeletal Stabilization Please Fix and Stabilize the Skeleton Before The patient become so sick to operate upon Christopher colton Polytrauma symposium Eastern Province, K.S.A. 1988 Polytrauma (AO advanced course) Riyadh, K.S.A. 1990
Hinweis der Redaktion
- In general these criteria, injuries and complications define the nature of polytrauma patients.
- The Multidisciplinary Trauma Team is comprised of many subspecialties with the Trauma surgeon as the team leader. This individual needs constant input from the other members about timing and management of multisystem injuries. Orthopaedics play a major role in restoring stabilization of pelvic injuries, long bone fractures, and other emergency care of extremity trauma. The team has expertise in many areas of medical, legal administrative and rehabilitation to provide the optimal outcome for the trauma patient.
- The central theme of system management during resuscitation is simultaneous rather that sequential. The Orthopaedic surgeon is an integral part of the ATLS protocol and participates in the primary survey to assess and temporarily stabilize pelvic ring injuries. Based on ATLS developed by American College of Surgeons, Committee on Trauma
- The central theme of system management during resuscitation is simultaneous rather that sequential. The Orthopaedic surgeon is an integral part of the ATLS protocol and participates in the primary survey to assess and temporarily stabilize pelvic ring injuries. Based on ATLS developed by American College of Surgeons, Committee on Trauma
- A patent airway is the most urgent priority with complete assessment of the respiratory system 15% of unresponsive patients may have and unstable cervical injury therefore C-spine precautions and stabilization should be initiated at the scene of the accident and maintained until properly cleared. In the new revised ATLS protocol the C-spine radiograph is not included. Experience has shown this may not be appropriate in the primary survey of ATLS but can be done with later assessments and studies.
- ABG should be drawn and analyzed immediately to determine the adequacy of oxygenation. The three most common traumatic conditions compromising ventilation are Tension pneumothorax, Open pneumothorax, and Flail chest with pulmonary contusion. Visual inspection palpation and auscultation PE findings combined with vital signs can help diagnose the cause of the respiratory compromise and the appropriate treatment.
- Indications for intubation include for the unconscious patient control of the airway to prevent aspiration or to hyperventilate. Early intubation for trauma to the head and neck region to avoid obstruction from edema, bleeding or secretions
- Sterile dressings should be applied to control identifiable bleeding, while avoiding the blind use of clamps in the emergency setting. The use of a tourniquet is indicated in a traumatic amputation
- In the severely injured patient time may not permit blood pressure measurements on the initial survey. This chart provides general guidelines to assess the BP by palpation of the peripheral pulses. Hypotension is suggested by a delayed capillary refill of more than 2 secs
- The central theme of system management during resuscitation is simultaneous rather that sequential. The Orthopaedic surgeon is an integral part of the ATLS protocol and participates in the primary survey to assess and temporarily stabilize pelvic ring injuries. Based on ATLS developed by American College of Surgeons, Committee on Trauma
- Starting at the head , one should evaluate all lacerations, palpate for crepitus, examine all orifices. The face should be examined for potential airway compromise from fractures or edema. The palate and midface should be examined for ethmoid fractures which would require the NG tube to be placed through the mouth rather than the nose. Cervical spine precautions should be observed in an unresponsive patients or with maxillofacial trauma.
- Starting at the head , one should evaluate all lacerations, palpate for crepitus, examine all orifices. The face should be examined for potential airway compromise from fractures or edema. The palate and midface should be examined for ethmoid fractures which would require the NG tube to be placed through the mouth rather than the nose. Cervical spine precautions should be observed in an unresponsive patients or with maxillofacial trauma.
- In suspected head injury the first step in management is proper oxygenation and circulation to restore oxygen to the brain. If LOC has occurred for &gt; 5min hospital admission is warranted to observe for potential complications-retrograde amnesia, emesis, and high potential for seizures. In patients with a cerebral contusion with prolonged LOC and alteration in focal neurological signs will need a CT and close observation. Intracranial hemorrhage is also evaluated by CT
- Cerebral edema can cause increased intracranial pressure. This is managed with fluid restriction, diuretics (hyperosmolar), deliberate hypocapnia. Hyperventilation to maintain pCO2 at 25-30 mm Hg may decrease ICP but may deleteriously affect brain oxygenation. Used if other measures fail.
- Secondary survey looks for signs of pulmonary contusion, aortic disruption, airway disruption, esophageal disruption, traumatic diaphragmatic herniation and myocardial contusion. CXR can aid in the diagnosis of pulmonary contusion, and signs of traumatic aortic disruption which is confirmed with arch arteriography. Distal airway injuries may present with free air on the CXR
- Secondary survey looks for signs of pulmonary contusion, aortic disruption, airway disruption, esophageal disruption, traumatic diaphragmatic herniation and myocardial contusion. CXR can aid in the diagnosis of pulmonary contusion, and signs of traumatic aortic disruption which is confirmed with arch arteriography. Distal airway injuries may present with free air on the CXR
- These are indications for thoracotomy and are performed in the Primary survey
- Most common site for occult bleeding in the trauma patient with the above organs the most often involved. A high index of suspicion must be maintained since up to 40% will not have peritoneal signs. Ng tube is placed to relieve gastric dilatation and prevent potential aspiration. A foley is needed for bladder decompression, UA, and to follow urinary output. Contraindications are listed and placement of a suprapubic catheter by Urology is needed. If anterior pelvic ring requires ORIF, suprabubic catheter may be contraindicated
- Indications for Peritoneal Lavage for inadequate PE in unresponsive patient (head injuries, drugs, ETOH, spinal cord trauma), unexplained hypotension, patient that will be lost to continued monitoring such as those undergoing GA for other procedures. Contraindications-multiple abdominal operations, obvious need for operation-Ex-Lap
- Ultrasound is highly operator dependent but increasing in popularity. Capable of detecting free fluid in the abdomen but does not otherwise characterize solid organ injury. CT scanning provides details of solid organ injury and demonstrates intraperitoneal free fluid but may be time consuming (less so with modern trispiral scanners). For more complete explanation go to www.east.org and look under practice guidelines, blunt abdominal trauma.
- Fifteen percent of abdominal trauma results in GU injuries. Injuries occur form direct blows, rib fractures, improperly worn seat belts, pelvis injuries. A history of blunt trauma to the abdomen, lower chest, flank , or genitalia/perineum should alert the surgeon to possible GU injuries. Clinical signs are listed. If an urethral injury is suspected a retrograde urethrogram should be performed before a foley is passed. When hematuria is present an excretory urethrogram, cystogram, and IVP should be performed
- Many forms of Trauma scores have developed for retrospective reviews of outcomes. Some are more predictive of mortality and some outcome. This slides presents a general summary of the three types of scoring categories. Physiologic: The body responds to injury with physiologic changes. These changes from normal parameters of vital signs and level of consciousness can be correlated to mortality, response to therapy and predicting outcome. Kirkpatrick and Youman’s Trauma Index was an early attempt to develop a system based on vital signs-A numerical system that was easy to use and predict the need for hospitalization but is less predictive of morbidity an d mortality. GCS widely used index that reliably assesses the degree of coma in patients with craniocerebral injuries. It is based on 3 behavioral responses 1. Eye opening, 2. Best verbal response and 3. Best motor response. Scores range from 3-15 and has been correlated with mortality. I t has been incorporated into the Trauma Score and Revised Trauma score. AIS-work began in 1969 and is a list of several hundred injuries which are assigned a score (1-minor to 6-fatal). Several revisions have occurred AIS-90 includes more details on injuries to the head chest and abdomen, including vascular injuries to the head and brain. Wounds are quantified. The system has been used in medical discharge coding. Because the AIS assigns severities to individual injuries summary scores are needed to characterize the trauma patient. ISS-is a summary score for multiple traumatic injuries . Values range fro 1-75. The ISS is calculated by summing the squares of the three highest AIS scores for injuries to 5 different body regions: head and neck; face; thorax; abdomen and pelvic contents; pelvic ring and extremities; and skin. ISS correlates with mortality but has limitations in that it only considers the highest AIS score from any body region, and considers injuries with equal AIS scores to be of equal value regardless of body region. Therefore it is a poor predictor of outcome in cohorts of patients with heterogeneous injury combinations Biochemical Indices have been used to measure injury severity as well. Kapsh found that plasminogen concentrations were initially depressed in patients after trauma but there was an greater increase in fibrinolytic activity. Other researchers have evaluated plasma cathecholinamine levels which has no prognostic significance, Kenney evaluated correlation coefficients for serum glucose , osmolality and cortisol were useful in patients with major occult injury
- The Orthopaedic surgeon must be trained and familiar with a number of acceptable procedures to stabilize the patients bony injuries. Awareness of the potential blood loss, time of certain procedures and equipment needed will help guide the care provided initially and subsequent procedures based on the stability of the patient.
- After initial life saving procedures are performed, the Orthopaedic surgeon must closely evaluate for potential surgical emergencies. All dislocations should be identified and relocated ASAP in the appropriate setting. Open fractures, compartment syndrome and neuro vascular compromise must be identified and approximately treated within certain time frames to decrease the morbidity associated with these injuries. The role of emergent wash out of open fractures is changing especially for Type I and II fractures.
- After initial life saving procedures are performed, the Orthopaedic surgeon must closely evaluate for potential surgical emergencies. All dislocations should be identified and relocated ASAP in the appropriate setting. Open fractures, compartment syndrome and neuro vascular compromise must be identified and approximately treated within certain time frames to decrease the morbidity associated with these injuries. The role of emergent wash out of open fractures is changing especially for Type I and II fractures.
- It is the treating surgeons responsibility to have full working knowledge of all sets , implants, and their location in the hospital for cases at any time of the night. The surgeon has to check all the needed equipment and implants and insure the proper equipment is available and have a back up plan such as temporary Ex-Fix available in the room or in the sterile hallway in case the patients condition becomes unstable. The use of power equipment for implant or pin insertion can lessen the operative time. Elliott et al demonstrated no difference in screws placed in cortical bone by traditional AO techniques and with power instruments. In emergency situations long bone fractures can rapidly be stabilized with bridging knee frames. A recent study out of Shock Trauma has demonstrated no increased risk of complications with conversion to and intramedullary nail when the patient is stable and can tolerate the procedure.