The Multiply Injured Patient

1. The Multiply Injured Patient 行政院衛生署台東醫院 骨 科 謝 繼 賢 2009-5-23

2. Outline • Injury Recognition ,Scoring Systems • Initial Management • Trauma Injury Management • The Pathophysiology of Multiple Injuries • Damage Control Orthopaedic Surgery • Prophylaxis Against Complication

3. Injury Recognition • Separate a physiologically unstable multiple trauma victim from a stable trauma patient • Predict outcome, ICU admission or mortality • Scoring systems:

4. Scoring Systems • Glasgow Coma Scale (GCS) • Revised Trauma Score (RTS) • Injury Severity Score (ISS) • New Injury Severity Score (NISS) * GCS<13 RTS< 11---tranported to comprehesive facilities

6. An example of the ISS calculation is shown below: ISS ranges from 1 to 75, an ISS of 75 is assigned to anyone with an AIS of 6.

7. AIS Score

8. Initial Management--outlined by ACS Advanced Trauma Life Support course • A: airway, cervical spine protection • B: breathing and ventilation • C: circulation, hemorrhage control • D: disability, neurological status • E: exposure, environment

9. Primary Survey • ABCDE assessment, resusciation is initiated • Adjuncts: BP , pulse oximetry, ABG, EKG Foley : urine output ( avoided if suspected urethral injury ) NG: decompression, decrease aspiration AP chest, AP pelvis, lateral C- spine • Evaluate response to resusciation

10. Shock • Hypovolemic: from hemorrhage • Neurogenic : injury to CNS, hypotension without tachycardia • Cardiogenic: direct trauma to heart, AMI, cardiac tamponade, tension pneumothorax

11. Hemorrhagic Shock • two large-caliber IV set, lactated Ringer’s or NS 1-2 L for adult, 20mL/kg for children • Blood loss assessed by response to fluid bolus, if vital signs… * weak or absence: severe blood loss >40% , untyped blood needed * response then deteriorate again: blood loss 20 % to 40 % , typed blood needed * if stable , blood loss is minimal, no blood needed

12. Secondary Survey • Framework for diagnostic work-up and treatment • Detailed head to toe physical examination • After primary survey ends or simultaneously

13. Missed Injuries • 10% in the blunt injury patient population • In patient of head injury, alcohol intoxication or intubation • Musculoskeletal injuries are the most frequent undiagnosed injuries • Common in spinal fractures, feet fractures or carpal injuries

14. Trauma Injury Management

15. Closed Head Injury

16. Closed Head Injury • Fluid management and rapid CT scan • Reduce cerebral hypertension • Hyperventilation ( PaCO2: 32—35 mmHg) • Head elevation • Osmotic diuresis ( mannitol or urea) for acute cerebral edema • Phenobarbital: reduce cerebral activity ?

17. Chest

18. Chest • Lung damage and resulting hypoxia • Pulmonary contussion, hemothorax,pulmonary laceration, pneumothorax • Tx: intubation, mechanical ventilation, tube thoracostomy

19. Chest • Thoracic aorta injury: with a wide mediastinum, aortography • Ventilation management: pressure support and permissive hypercapnia, lower energy use, reduce barotrauma

20. Abdomen • Unstable patients: peritoneal larvage • Stable patients: CT scanning • CT is more specific than larvage, but may miss small perforatrion of GI tracts • Ultrasound: does not require transport of patient, easily be repeated for follw-up

21. Peritoneal lavage

22. Pelvic Ring Injuries

23. Pelvic Ring Injuries • A marker for high-energy trauma, look for associated injuries • Hypovolemic shock: multifactorial , thoracic, intra-abdominal. Extremities, pelvic… • Emergent pelvic stabilization

24. APC ( anteroposterior compression ) fractures • Open book injuries: widening of pelvic ring and increase pelvic volume

25. Anterior external fixation frames • Reduction of open book injuires,decrease pelvic volume, • Promote self-tamponade of retroperitoneal venous bleeding, reduce blood loss

26. Anterior external fixation frames

27. Posterior pelvic clamps • Early stabilization, reduction of pelvic volume • Both forms of fixation are time-consuming in application or may be misapplied

29. Pelvic sheets or binders • Can be applied in ER, applied in minutes • Noninvasive • Does not delay transfer to OR • Can be left in place during an emergent laparotomy • Equally in reducing pelvic volume compared with external fixation

30. Pelvic sheets or binders

31. Cervical Spine Injuries

32. Cervical Spine Injuries • In the field: immobilization, a spine board, a rigid cervical collar • In ER: neck deformity? palpated tenderness? can move extremities ? Bulbocavernosus reflex ? • Lateral C spine x-ray, helical CT scanning ( more sensitive)

33. High-dose Corticosteroids • Motor function scores improve while given within 8 hours of injury • Methylprednisolone –by NASCIS 30 mg/kg loading dose 5.4 mg/kg/hour maintenance dose for 24 hours hours ( within 3 hours ) for 48 hours hours ( within 3-8 hours )

34. Displaced fracture-dislocation of cervical spince • Reduced soon to minimize cervical cord injury • Closed reduction with Garner-wells tongs traction • Safety of the procedure? Neurologic deterioration during reduction ? • Prereduction MRI if suspect presence of herniated disc

35. Gardner-Wells tongs

36. Take a Rest !

37. Open fracture

38. Open fracture • Early debridement within 6-8 hours? decrease infection rate? No evidence • Debridement as soon as medically stable • Appropriate IV antibiotics—prevention of infection

39. Type I open fracture. • Wound less than 1 cm, without contamination and minimal injury of soft tissue.

40. Type II open fracture • Wound between 1 and 10 cm, mild contamination, extensive soft tissue damage

41. Type III-A open fracture • Wound larger than 10 cm, severe contamination and severe crushing component.

42. Type III-B open fracture • Wound larger than 10 cm, severe contamination and severe loss of tissues

43. Type III-C open fracture • Wound larger than 10 cm, severe contamination and neurovascular injury

44. Antibiotics • Gustilo-Anderson type 1 1st generation cephalosporin • Gustilo-Anderson type 2 and type 3 1st generation cephalosporin + aminoglycoside • Heavily contaminated with soil penicillin added

45. Wound Closure • Delayed wound closure • Primary wound closure • The same rate of infection, but delayed closure have a higher rate of local wound complication

46. Compartment Syndrome

47. Compartment Syndrome • After a extremity fracture (commonly tibia ) or isolated muscle trauma • Direct blow or crushing injury • Muscle contussion→edema→tissue pressure↑ →tissue perfusion ↓→tissue ischemia→muscle and nerve function↓

48. Compartment Syndrome

49. Compartment Syndrome • Tense , painful compartment • Dysthesia or paresthesia : + or – • Dx: compartment pressure • Tissue pressure threshold: 30mmhg< diastolic BP

50. Fasciotomy