General Trauma, Management of Polytrauma Patients

Orthopaedic Management of polytrauma patients will have certain principles and these principles are:

· Pelvic fractures are an emergency

· Compartment syndrome is an emergency

· Open fractures are urgent

· Hip and knee dislocations are emergencies

· Femur fractures could be a problem

Pelvic Fractures

It is important to assess the resuscitation. For example: if the patient is under resuscitation, the medical professional should do provisional stabilization and if the patient is adequately resuscitated a definitive fixation should be done.

Imaging is crucial and x-rays of the cervical spine (C7-T1 should be checked), chest area — for possible aortic or lung problems, and pelvis. Nowadays, most trauma centers have CT scans and these images are beneficial as well.

If the patient has an unstable pelvis and the fracture is considered “open book”, then a binder or a sheet should be wrapped around the pelvis immediately to “close the book”. When the patient is brought to the operating room to repair the fracture, an external fixator may be used to stabilize the pelvis. If the patient is given four units of blood and they remain unstable with an obvious pelvic fracture, it may be necessary for an angiography and embolization. Usually in these cases, the superior gluteal artery is torn. Hemorrhage is the leading cause of death with pelvic fractures so it is important to monitor the patient closely.

A closed head injury can occur in lateral compression fractures. However, in open book Anterior Posterior Compression type III fractures, there is the highest rate of blood loss, blood transfusion, and mortality. Mortality directly correlates with shock at presentation.

Compartment Syndrome

Compartment Syndrome is another injury that needs to be dealt with immediately. The pain will present itself worse than the injury and typically causes swelling of the extremity. Pain will be experienced with a passive stretch of the compartment. Paresthesia is found in a specific area and usually happens later. Pulses and pallor typically occurs later — usually when it is too late. It is important to have a high index of suspicion. You cannot wait for all five “P’s” to appear, as these findings are considered to be late findings.

Late Findings (5 P’s):

1. Paralysis

2. Pallor

3. Paresthesia

4. Pulselessness

5. Pain/Swelling

A Compartment Syndrome diagnosis is needed early so that a fasciotomy can be done before the sixth hour or else there may be dead muscles within the compartment.

Pressure Monitoring can be used to diagnose or to confirm the diagnosis of compartment syndrome when the situation is not clear. If the compartmental pressure is 30mmHg or within 30mmHg of the diastolic pressure, then a fasciotomy is necessary. Delta P, which is the perfusion pressure, is currently used frequently. The Delta P is the diastolic blood pressure minus the compartment pressure. If the compartment pressure is within 30mmHg, this is critical and a fasciotomy is needed.

The anterior compartment is the compartment that is usually involved when dealing with compartment syndrome of the lower leg. When performing a fasciotomy on the lower leg, the classic two incision technique is commonly used. The lateral incision is made halfway between the tibia and the fibular for release of the anterior and lateral compartments. Be careful not to injure the superficial peroneal nerve! The medial leg incision is made 2cm posterior to the tibia. When you open the superficial posterior muscle compartment and the deep posterior muscle compartment, you must be careful of the saphenous nerve!

Open Fractures

The Gustillo-Anderson classification for an open fracture is:

· Grade I-1cm or less

· Grade II- 1–10cm

· Grade III- More than 10cm

o Grade IIIA

Adequate tissue for closure or coverage

Skin graft coverage

o Grade IIIB

Extensive periosteal stripping requires soft tissue coverage, local, or distant flap

o Grade IIIC

Indicates vascular injury requiring repair or amputation

Segmental fractures are considered Grade III even if they have a small wound. The most important thing to remember with open fractures, is that IV antibiotics should be given immediately. A delay in giving antibiotics can cause more infections as a result. Increased infection rate occurs when antibiotic administration is delayed for more than 3 hours. Antibiotics will be continually given for 48–72 hours following the index procedure. Urgent and adequate debridement should be done to prevent infection. The timing of irrigation and debridement is debatable as there is no difference in the rate of infection identified between early and late debridement. The 6 hour rule does not have a lot of support within the literature.

Early soft tissue coverage should be done within 7 days because this will decrease the infection rate.

For Grade I and Grade II open fractures, you should use first generation Cephalosporin antibiotics. For Grade III open fractures, you should use first generation Cephalosporin plus Aminoglycoside antibiotics. Penicillin antibiotics can also be used for cross-contamination, farm injuries, or bowl ischemia. If there is water contamination, use fluoroquinolone antibiotics.

If there is a critical piece of bone missing, you can put it back and fix the fracture. It is probably better to try to replace the bone then to throw it away (antibiotics or betadine solution can be used to sterilize it). If there is a metaphyseal defect in the bone and a big gap, you may use cement with antibiotics.

Wound vacs are very helpful in the treatment of open fractures.

Trauma is the most common cause of maternal death during pregnancy. There is a problem with pregnancy and getting s-rays, especially within the first trimester because the fetus is at risk. If the patient is more than 20 weeks along, position the mother on the left lateral decubitus position or avoid compression of the aorta and the inferior vena cava by the uterus. The supine position will decrease the cardiac output by about 30% while the left lateral decubitus position will improve the output. If the spine of the patient is okay, then she should be in the left lateral decubitus position. Resuscitation should focus on the mother. The fetus can die from maternal shock or maternal death.

There are three factors that are though to contribute to deep venous thrombosis (DVT):

1. Endothelial Injury

2. Venous Stasis

3. Hypercoagulability

It is important to get the patient out of bed — early mobilization. Mechanical compression devices in surgery, in bed and in the hospital might prevent venous stasis and increase systemic endogenous fibrinolytic activity. Low-molecular-weight heparin may be given for deep vein thrombosis and a filter can be used in high-risk polytrauma patients or in other specific indications. DVT has an approximate 60% occurrence rate in pelvic fractures with a high pulmonary embolism (PE) incidence. An exam is the most helpful in diagnosing DVT. There will be pain and swelling and the Homans’ sign is not specific.

In the event of an acute pulmonary embolism, the patient will have increased ventilation pressure, acute onset of dyspnea, tachypnea, and tachycardia as well as a decreased oxygen saturation with increased PaCO2 End-Tital CO2 Gradient. If this occurs in the operating room damage control orthopaedics must be done. The patient will need to be stabilized and a filter may need to be placed in some indications, a CT scan of the chest should be ordered as well.

During a traumatic amputation, it is vital to get the bleeding under control. The severity of the soft tissue injury determines whether or not amputation is necessary. The absence of plantar fixation is also important, but it is not an absolute contraindication to reconstruction. The outcome, especially return to work, is not really different between amputation and reconstruction of the extremity at the 2 year follow-up.

Complications

Fat Embolism syndrome

o Occurs in about 10% of multiple trauma patients

o Occurs in up to 2% of isolated fractures

o Usually occurs 24–48 hours after injury

The difference between fat embolism syndrome (FES) and pulmonary embolism (PE) is the interval between the injury and the symptoms. Fat embolism occurs earlier than pulmonary embolism. The mortality rate of fat embolism is about 20%. There is an inflammatory response to all emboli zed fat globules. It can be mechanical, like within the bone marrow, or metabolic. An early fracture fixation and stabilization decreases the incidence of fat embolism.

In diagnosing Fat Embolism Syndrome, the greatest indicator is hypoxemia, followed by The Classic Triad: CNS abnormality (depression and confusion), a petechial rash, and pulmonary edema (oxygen level below 60mmHG).

The diagnostic criteria includes: Tachycardia, pyrexia, retinal emboli, fat in the urine/sputum, thrombocytopenia, a decrease in hematocrit, dyspnea, anxiety, and tachypnea. Treatment is high ventilator support with a high level of positive end-expiratory pressure (PEEP) in addition to prevention and have a high index of suspicion.

Another common complication is Acute Respiratory Distress Syndrome (ARDS), and acute lung injury that leads to:

o Refractory hypoxemia

o Decreased lung compliance with poor gas exchange

o Patient will have pulmonary edema with diffuse infiltrative changes on x-ray

o The patient will have dyspnea with resistant hypoxemia

o Cardiac pulmonary edema and bilateral pneumonia will need to be ruled out.

Treatment for ARDS consists of PEEP ventilation, steroids, and prophylaxis with early stabilization of long bone fractures (especially the femur). The patient could die from sepsis or due to multisystem organ failure. This is typically caused by acute endothelial damage and has a high mortality rate that can reach up to 50%.


Originally published at medium.com on August 7, 2017.

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