Dr. Ebraheim’s educational animated video describes information associated with mutiple trauma patients.
-Orthopedic management of polytrauma patients as in severe head injury or open fractures.
-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.
Access the resuscitation! if the patient is under resuscitated do provisional stabilization. If the patient is adequately resuscitated, do definitive fixation.
-Need to get x-rays! -Cervical spin x-rays (check the area from C7-T1) -Get a chest image to see if there is possible aortic problem or lung problem. -Get x-rays of the pelvis -Most centers are routinely getting CT scans.
Unstable pelvis
If the patient is unstable, the pelvis is unstable and if it is an open book type, then apply a binder or a sheet around the pelvis immediately. Unstable pelvis use an external fixator if the patient is in the operating room.
Compartment syndrome
-Pain more than the injury -Swelling of the extremity -Pain with passive stretch of the compartment -Paresthesia in a specific area and usually occurs later. -Pulses, pallor occurs later
Need to have high index of suspicion. Do not wait for all 5 p’s to appear, as these findings are considered to be late findings.
Need to diagnose CS early! you need to do fasciotomy before 6 hours 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 compartment pressure is 30 mmHg or within 30 mmHg of the diastolic pressure then you will do fasciotomy.
Open fractures
Gustillo-Anderson classification
-Grade I: 1 cm or less -Grade II: 1-10 cm -Grade III: more than 10 cm
-Grade IIIa: adequate tissue for closure or coverage. Skin graft coverage is grade IIIa. -Grade IIIb: extensive periosteal stripping requires soft tissue coverage local or distant flap. -Grade IIIc : vascular injury requiring repair or amputation. Segmental fractures are considered to be grade III even if they have a small wound.
Give IV antibiotics as soon as possible. Delay in giving antibiotics will result in more infections. Increased infection rate occurs when antibiotics administration is delayed more than 3 hours. You will continue the antibiotics for 48-72 hours following the index procedure.
Pregnancy
Trauma is the most common cause of maternal death during pregnancy. There is a problem with pregnancy and getting x-rays, especially within the first trimester, because the fetus is at risk. When the patient is more than 20 weeks along in pregnancy, position the mother in the left lateral decubitus position to avoid compression of the aorta and the inferior vena cava by the uterus. If the spine of the patient is o.k, 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 thought to contribute to deep venous thrombosis (DVT): Virchow’s triad.
1-Endothelial injury 2-Venous stasis 3-Hypercoagulability
You need to get the patient out of bed. Mechanical compression devices in surgery, in bed and in the hospital, might prevent venous stasis and increase systemic endogenous fibrinolytic activity. you can also give low molecular weight heparin (LMWH) for deep venous thrombosis.
What if you get acute PE?
-Will have increased ventilation pressure.
-Acute onset of dyspnea, tachypnea and tachycardia.
-Decreased oxygen saturation with increased PaCO2 End-tidal CO2 gradient.
-If this occurs in the operating room, do damage control orthopedics. Get CT scan of the chest. Stabilize the patient and you will probably place a filter in some indications.
Traumatic amputations
Need to control the bleeding. It is the severity of the soft tissue injury that has the highest impact on the decision-making process (if you amputate or not) absence of plantar fixation is also important, but it is not an absolute contraindication to reconstruction.
Complications
Fat embolism syndrome
-Occurs in about 10% of multiple trauma patients
-Occurs in up to 2% of isolated fractures
-Usually occurs 24-48 hours after injury.
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