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Polytrauma in orthopaedics
1. Resuscitation Principles and recent advances
Polytrauma
Moderator : Dr Samarth Mittal
Co-Moderator: Dr Siva G Presenter: Dr Namith Rangaswamy
2. • ‘Significant injuries of three or more points in
two or more different anatomic AIS regions in
conjunction with one or more additional
variables from the five physiologic parameters’
• Hypotension (SBP <90 mm Hg)
• Level of consciousness (GCS < 8)
• Acidosis (base excess ≤ -6.0)
• Coagulopathy (INR≥1.4/ PT≥ 40 seconds)
• Age (>70 years)
4. • Solely the Berlin definition resulted in a patient number
reflecting clinical reality
5. INJURY SEVERITY SCORE
• Anatomic scoring
• Patient data is reduced to
number
• Degree of critical illness
• 6 body regions
• Baker SP et al, "The Injury Severity Score: a
method for describing patients with multiple
injuries and evaluating emergency care", J
Trauma 14:187-196;1974
6. ABBREVIATED INJURY SCALE
• Introduced in 1969 - updated against survival
• Ranked on a scale of 1 to 6
• Over 9 anatomic regions
Copes WS, Sacco WJ, Champion HR, Bain LW, "Progress in Characterising Anatomic Injury", In Proceedings of the 33rd Annual Meeting of the
Association for the Advancement of Automotive Medicine, Baltimore, MA, USA 205-218
7. Injury Severity Score
• Each injury is assigned an AIS and is allocated to one of six body
regions
• 3 most severely injured body regions have their score squared and
added together to produce the ISS score
• Values from 0 to 75
8. Epidemiology
• 9people die every minute from injuries or violence
• 5.8million people of all ages and economic groups die every year from
unintentional injuries and violence
• 20-50million significant injuries
• No 1 cause of death in < 40 years
* Data from ATLS Course Manual
9. INDIA
•4,13,457 deaths in 2015
•32.8 deaths per hour
•53 cases of road accidents took place every one hour during 2015,
wherein 17 persons were killed
*NCRBI, Annual Report 2015
11. Trimodal
distribution of
death in trauma
• Immediate death (50%): 0 to 1
hour
• Early death (30%): 1 to 3 hours
• Late death ( 20%): 1 to 6 weeks
12. Golden hour
• Period of time
following trauma
during which there
is the highest
likelihood that
prompt medical and
surgical treatment
will prevent death
14. ORGANISATION OF TRAUMA CENTRES
Level 1 –
Regional
Trauma Centre
Level 2 –
Community
Trauma Centre
Level 3 – Rural
Trauma Centre
15. Prehospital Phase
• Field triage
• Emphasize airway maintenance
• Control of external bleeding and
shock
• Immobilization of the patient
• Immediate transport to the closest
appropriate facility
• Page the hospital for preparation
• Oestern HJ, Garg B, Kotwal P. Trauma care in India and Germany. Clin Orthop Relat Res. 2013;471(9):2869–2877.
18. It is better to ‘’scoop and run’’ than ‘’stay and play’’
19. Air Ambulance
• Far from Trauma Centers
• Pitfalls : Under triage, High cost
and Crash
• 27% of US residents transported
within Golden hour
• $5000-$6000 more than ground
transport
• Expectation: 17% reduction in
mortality
23. CASE
Pt: 500183877
60year old male
Alleged history of fall from wooden ladder from
about 20 feet
No loss of consciousness
No ENT bleed
Severe pain in abdomen and pelvis
36. Definitive
airway
Inability to maintain a patent airway by
other means
Inability to maintain adequate
oxygenation
Obtundation
GCS <8
Orophalyngeal Intubation
37. Surgical Airway
• Needle Cricothyroidotomy
• Surgical Cricothyroidotomy
Edema of the glottis
Fracture of the larynx
Severe oropharyngeal hemorrhage
45. Massive Hemothorax
• Rapid accumulation of more than 1500 mL of
blood or one-third or more of the patient’s
blood volume in the chest cavity
• Volume replacement + chest decompression
46. • Accumulation of
fluid in the
pericardial sac
• Becks triad
• FAST/eFAST is a
rapid and accurate
• Emergency
thoracotomy or
sternotomy
• Subxiphoid
pericardiocentesis
47. CASE
BREATHING – Spontaneous ;RR-20/Min , SPO2-100%;
Chest – Decreased Air Entry Lt Side;
CCT- Positive
Pnemo Scan- Negative
Left sided ICD was inserted in 5th ICS under LA ,
gush of air and minimal blood with good column
movemnt
51. • Any injured patient who is cool to the touch and is
tachycardic should be considered to be in shock until
proven otherwise
• Causes
• Hypovolemic
• Cardiogenic
• Neurogenic
• Septic
52. • 90% of all trauma
patients could not be
classified according to
the ATLS1
classification of
hypovolemic shock.
• Raised critical
appraisal
54. Hypovolemic
shock
• Assess blood loss
• External or obvious
• Internal or Covert
• Chest
• Abdomen
• Limbs
• Pelvis
‘’Floor and four more’’
55. The basic management principle is to stop the bleeding and replace the
volume loss.
Controlling obvious
hemorrhage
Obtaining adequate
intravenous access
Assessing tissue
perfusion
The priority is to stop
the bleeding, not to
calculate the volume
of fluid lost
56. Fluid
replacement
Large bore cannula
Fluid warmer
Rapid infusion pump
Intraosseous access
Isotonic crystalloid solution 1 liter or
20ml/kg (in children)
‘’Permissive hypotension’’
60. Massive
Transfusion
Protocol
Designed to interrupt the lethal triad
Activated after transfusion of 4-10 units
Predefined ratio
Type O pRBCs
AB plasma
Patil V, Shetmahajan M. Massive transfusion and massive transfusion protocol. Indian J Anaesth 2014;58:590-5
63. Transient responders
• to the initial fluid bolusRespond
• if fluid/blood is slowedDeteriorate
• ongoing blood loss or inadequate resuscitationIndicate
• MTPInitiate
• rapid surgical interventionRequire
64. Non responders
Failure to
respond to
crystalloid and
blood
administration
1
Initiate MTP
2
Look for non
hemorrhagic
shock
3
Rush to OR
4
69. Exposure and
Environmental Control
• Completely undress the patient
• Cover the patient with warm blankets
• External warming device
• Warm intravenous fluid
73. • Sensitivity – 64-96%
• Specificity – 96-99%
• DPL has decreased from
9% to 1%
• Management has
changed in 32.8%
74. • FAST has excellent
diagnostic accuracy
• High negative
predictive value
99%
75. Rapid Ultrasound for Shock
and Hypotension
•Patients with
undifferentiated shock
•RUSH protocol
• The Pump
• The Tank
• The Pipes
Seif, Dina et al. “Bedside ultrasound in resuscitation and the rapid ultrasound in shock protocol.” Critical care research and practice vol. 2012 (2012): 503254.
81. CASE
CECT Torso with Cystogram
Confirmed CXR findings
Left spr & ipr #,Zone 2 sacral # left side, left L1
to L5 transverse process #, L2 to L4 spinous
process #.
Extraperitoneal bladder rupture with
extravasation of contrast in the anteroinferior
aspect of bladder, left lumbar artery muscular
branch contrast extravasation.
82.
83.
84. Hybrid OR.
Future of
Trauma
care?
• Operating Rooms with integrated Imaging
equipment
• Integration of IVR to surgical treatment
• Shorten the time-to-surgery
85. • highest mortality was from
falls >6 m.
• The ISS was 29 in survivors,
36 in non-survivors, and 54 in
the pelvic death subgroup.
• Type C fracture was a
predictor of mortality
• Pelvic death subgroup
received a mean of 10.7 units
of blood
86. • No improvement
in shock after
implementation
of MTP in pelvic
fracture patients
90. • Results in a shorter time
to intervention
• Lower mortality
compared to AE
Preperitoneal packing
91. • Successful outcome
• Justified surgery
• Efficient
hemorrhage control
• Can be definitive
fixation in some
cases
92. Resuscitative Endovascular Balloon Occlusion
of Aorta
• SBP increased from
60(35-75)mmHg to
115(91-128)mmHg
• Non invasive
• Balloon inflation in
zone 3
93. • Initial response to
resuscitation with
ANGIO is 73%.
• Also identifies arterial
injury
Angio Embolization
94. Spine / SCI
• Level
• Severity of neurological deficit
• Spinal cord syndrome
• Always consider spine injury to be
unstable unless proved
96. National Emergency X-Radiography Utilization
Study (NEXUS) Criteria
• No posterior midline cervical-spine tenderness
• No evidence of intoxication
• A normal level of alertness
• No focal neurologic deficit
• No painful distracting injuries
NO NO X-RAY
Meets ALL low-risk criteria?
98. Open fracture
• Tourniquet if
bleeding is ongoing
• Wound wash
• Antibiotics
• Assess vascular and
Neurological status
• Splinting
99.
100. Blunt Trauma Abdomen
• Direct blow/ Shearing injuries
• Spleen (40% to 55%), liver (35% to 45%),
and small bowel
• FAST or DPL
• Laparotomy – surgical judgement to
determine timing of surgery
101.
102. Damage control orthopedics
• Limited early surgical intervention
• Limit ongoing hemorrhage and soft-tissue
injury , reduce contamination
• External fixation of long bone/pelvis
fractures
• Debridement of open fractures
• Prevent second hit – and development of
lethal triad
103. Whom?
• Polytrauma + ISS of >20 points and additional thoracic trauma
• Polytrauma with abdominal/pelvic trauma and hemorrhagic shock
• ISS of ≥40 points in the absence of additional thoracic injury
• Radiographic findings of bilateral lung contusion
• Initial mean pulmonary arterial pressure of >24 mm Hg
• >6 mm Hg in pulmonary arterial pressure during intramedullary
nailing
104.
105. CASE
Admitted under Trauma Surgery for
observation
Continuous vitals monitoring
Continuous urinary bladder irrigation
Pelvic binder with Supracondylar femoral
skeletal traction with 8 kg weight
107. • Nearly 4.4 lakh
deaths due to
preventable medical
error
• Patient safety –
priority
• Learn from errors
108. Q1. A 5-year-old boy is struck by an automobile and brought to the
emergency department. He is lethargic, but withdraws purposefully
from painful stimuli. His blood pressure is 90 mm Hg systolic, heart rate
is 140 beats per minute, and his respiratory rate is 36 breaths per
minute. The preferred route of venous access in this patient is
Percutaneous femoral vein cannulation
Cutdown on the saphenous vein at the ankle
Intraosseous catheter placement in the proximal tibia
Percutaneous peripheral veins in the upper extremities
Central venous access via the subclavian or internal jugular vein
109. Q2. A 32 year old man’s right leg is trapped beneath his overturned car
for nearly 2 hours before he is extricated. On arrival in the ER, his right
lower extremity is cool, mottled, insensate and motionless. Pulses cannot
be palpated below femoral vessels. During initial management of this
patient, which of the following is most likely to improve the chances for
limb salvage?
Applying skeletal traction
Anticoagulant therapy
Thrombolytic therapy
Right lower limb fasciotomy
Immediately transfer patient to Trauma Centre
118. Massive Blood Transfusion
• Replacement of one entire blood volume within 24 h
• Transfusion of >10 units of packed red blood cells (PRBCs) in 24 h
• Transfusion of >20 units of PRBCs in 24 h
• Transfusion of >4 units of PRBCs in 1 h when on-going need is
foreseeable
• Replacement of 50% of total blood volume (TBV) within 3 h
119. NEW INJURY
SEVERITY
SCORE
• Sum of the squares of the top three scores
regardless of body region
• Statistically outperform the traditional ISS score
120. EXPONENTIAL
INJURY
SEVERITY
SCORE
• Kuo SCH, Kuo PJ, Chen YC, Chien PC, Hsieh HY, et al.
(2017) Comparison of the new Exponential Injury Severity Score
with the Injury Severity Score and the New Injury Severity Score
in trauma patients: A cross-sectional study. PLOS ONE 12(11):
e0187871.
121.
122. REVISED TRAUMA SCORE
• Physiologic scoring
• range 0 to 7.8408
Champion HR et al, "A Revision of the Trauma Score", J Trauma 29:623-629,1989
125. • How are the numerical identifiers structured ?
ex: 851814.3
• 8 = Body Region: Lower Extremity
• 5 =Type of Anatomic Structure: Skeletal
• 18 =Specific Anatomic Structure: Femur
• 14= Level of injury: Shaft
• .3 = AIS: Severity score
126.
127. INTERNATIONAL CLASSIFICATION OF DISEASES
INJURY SEVERITY SCORE (ICISS)
• Utilizes the ICD-9 codes assigned to each patient
• Measured survival risk ratios are assigned to all ICD-9 trauma codes
• Simple product of all such ratios
• ICISS = (SRR)injury1 x (SRR)injury2 x (SRR)injury3 X (SRR)injury4…
• Can be calculated from existing hospital information without the need
for a dedicated trauma registrar
• Even non-clinical hospital coders are able to accurately interpret and
document the injuries sustained
number of definitions of polytrauma have been reported in the literature generally referring to trauma patients whose injuries involve multiple body regions and in whom the combination of injuries would cause a life-threatening condition
To objectify
New definition proposed in 2014 in Berlin with consensus of various international trauma associations
Various Definitions put to test by Frenzel, they found that
To understand the definition better it is necessary to know ISS
One of very few scoring system according to consider anatomic region
Which is a process by which complex and variable patient data is reduced to a single number
And indicate degree of critical illness
Injuries are ranked on a scale of 1 to 6, with 1 being minor, 5 severe, and 6 a nonsurvivable injury
The AIS is monitored by a scaling committee of the Association for the Advancement of Automotive Medicine
If an injury is assigned an AIS of 6 (unsurvivable injury), the ISS score is automatically assigned to 75
drawback of the ISS is that it only considers one injury in each body region
The ISS score is virtually the only anatomical scoring system in use and correlates linearly with mortality, morbidity, hospital stay and other measures of severity
Its weaknesses are that any error in AIS scoring increases the ISS error
Global stats, ATLS MANUAL
In India,
NCRBI, ANUUAL REPORT 2015
Death in trauma can be divided into three time periods
The first peak occurs within seconds to minutes of injury
During this immediate period, deaths generally result from apnea due to severe brain or high spinal cord injury or rupture of the heart, aorta, or other large blood vessels. Very few of these patients can be saved because of the severity of their injuries. Only prevention can significantly reduce this peak of trauma-related deaths
second peak occurs within minutes to several hours
Deaths that occur during this period are usually due to subdural and epidural hematomas, hemopneumothorax, ruptured spleen, lacerations of the liver, pelvic fractures, and/or multiple other injuries associated with significant blood loss
third peak, which occurs several days to weeks after the initial injury
often due to sepsis and multiple organ system dysfunctions
Generally considered to be 1st hour
Causes of death during that period is stoppage of heart, disturbed airway followed by hemorrhage. Needs care in that sequence
ATLS – American College of surgeon
ETC – European Resuscitation council
JATEC- Japanese Association for the surgery in trauma
Only 56% of the ambulances have one or more paramedics
To cut short such crisis, CATS was started in New Delhi
Smith published a study in Injury Journal comparing two strategies of Prehospital care and found it is always better to scoop and run than stay and play
2014 Apr 25, annals of emergency medicine
Delgado in his study found that
ZPS is intended to interrogate and manage AND
optimize non-clinical processes before and during a resuscitation
Look
Inspect
feel
One person always stabilizes spine while the other expands the helmet to remove it
Indicated when there is
Inability to maintain a patent airway by other means, with impending or potential airway compromise (e.g., following inhalation injury, facial fractures, or retropharyngeal hematoma
Inability to maintain adequate oxygenation by facemask oxygen supplementation, or the presence of apnea
Obtundation or combativeness resulting from cerebral hypoperfusion
(Glasgow Coma Scale [GCS] score of 8 or less
Principle of management is to
Promptly close the defect with a sterile occlusive dressing that is large enough to overlap the wound’s edges. Tape it securely on three sides to provide a flutter-valve effect.
FAST is 90–95% accurate in identifying the presence of pericardial fluid for the experienced operator
Emergency thoracotomy or sternotomy
Subxiphoid pericardiocentesis
The second step in managing shock is to identify the probable cause of shock and adjust treatment accordingly
Look for
Mutschler published a study in INJURY where he criticized the earlier classification given by ATLS of Hypovolaemic shock.
Blood loss of <15, 15-30, 31-40 and over 40 percent for class I,II,III and IV respectively
Mutschler added Base deficit and GCS in this newer classification
Richard Buckley
General Principles of Fracture Care
Canadian Orthopaedic Association, Orthopaedic Trauma Association
Earlier recommendation for to use upto 2L of crystalloid, However newer studies and so ATLS currently recommends 1 liter of crystalloid
Permissive hypotension – organ perfusion and tissue oxygenation with the avoidance of rebleeding by accepting a lower-than-normal blood pressure
Also called as “controlled resuscitation,” “balanced resuscitation,” “hypotensive resuscitation
• Obtain surgical consultation for definitive hemorrhage control.
table
PRBC, plasma and platelets given in ratio 1:1:1
Restore the oxygen-carrying capacity of the intravascular volume
complete crossmatching process requires approximately 1 hour
type O pRBCs (Rh negative preferred in female)
AB plasma
MTP describes the process of management of blood transfusion requirements in major bleeding episodes, assisting the interactions of the treating clinicians and the blood bank and ensuring judicious use of blood and blood components
Main aim is to interrupt the lethal triad
Generally this is activated after transfusion of 4-10 units. MTPs have a predefined ratio of RBCs, FFP/cryoprecipitate and platelets units (random donor platelets) in each pack
Once the patient is in the protocol, the blood bank ensures rapid and timely delivery of all blood components together to facilitate resuscitation
Sterile collection of blood from body cavities and processing it through anticoagulants and cell saver system where the packed cells are prepared to preset hematocrit.
The GCS is a quick, simple, and objective method of determining the level of consciousness
Prevention of secondary brain injury by maintaining adequate oxygenation and perfusion are the main goals of initial manage ment
After completing the assessment, cover the patient with warm blankets or an external warming device to prevent him or her from developing hypothermia in the trauma receiving area
bedside ultrasound in patients with undifferentiated shock allows for rapid evaluation of reversible causes of shock
Pump: pericardial effusion, ventricular sizes, contractility
Tank: reserve- venecava, leakiness-fast/thoracic, compromise – pneumothorax
Pipe: leak-aneurysm,rupture /obstruction-dvt
Trauma CT protocol – Vertex to coccyx, preferred than selective CT
They save the time needed to transfer patients, who are medically unstable, from the operating room to the angiography suite
All though evidence are limited to case reports this could be future of integrated trauma care
One such case report was published international journal of em medicine by Japanese medical experts where they saved almost 1 hour of acute care time with such integration
Coming to importance of pelvic fractures, study by palmcrantz showed that
And hence need for definite control of bleeding
World society of emergency surgery has very recently given guidelines and classification of pelvic trauma severity
Study by clay cothren burlew showed that preperitoneal packing lowers mortality compared to AE and is time saving
Prospective study
Study comparing Exfix with angio and determined that initial response to resuscitation with angio was 73% .
Determine the level and severity of neurological deficit
Identify cord syndromes
Presence of high risk or absence of low risk of if patient is voluntarily able to rotate neck 45degree
judicious use of a tourniquet can be lifesaving and/or limb-saving in the presence of ongoing hemorrhage
Instructional course material was put together by American academy of Orthopaedic Surgeons and published in JBJS
RECENTLY INTRODUCED, 2004
The EISS was computed as the simple change in AIS values by raising each AIS severity score (1–6) by 3 taking a power of AIS minus 2, and then summing the three most severe scores (i.e., highest AIS values), regardless of body regions. If
utilizes the ICD-9 codes assigned to each patient
Measured survival risk ratios are assigned to all ICD-9 trauma codes
The simple product of all such ratios for an individual patient's injuries have been found to predict outcome more accurately than ISS
ICISS = (SRR)injury1 x (SRR)injury2 x (SRR)injury3 X (SRR)injury4…
ICISS is promoted as being able to be calculated from existing hospital information without the need for a dedicated trauma registrar.
This assumes, however, that the non-clinical hospital coders are able to accurately interpret and document the injuries sustained.