Initial Assessment and

Management of the Multiply

Injured Patient
David Hubbard, MD
Original Author: Robert Harris, MD; March 2004
New Author: David Hubbard, MD; Revised January 2006

Orthopaedic Surgery
Specialty evolved after WW I
Heritage of Orthopaedic surgery is
TRAUMA
TRAUMA is the common thread of all
subspecialties in Orthopaedics

Trauma in the US
Leading cause of death
in < 45 age group
Blunt trauma accounts
for 80% of mortality in
the < 34 age group
$75 billion loss in
income due to death and
disability annually
Major modern
epidemic

Trauma Epidemiology
Number of polytrauma

patients increasing

Higher speed limits, aggressive

driving
Air bags-polytrauma patients
surviving

Some regional trauma

centers lack adequate funding

Trauma affects all
Orthopaedists regardless of
subspecialty and interest

Trauma Centers
One per population of 5 million or less
Studies demonstrate a 30-40% preventable
death rate due to inadequate trauma systems
West, Trunkey: Arch Surgery, 1979
West, Cales: Arch Surgery, 1983
Baker, et al: J Trauma, 1987

Trauma Mortality
Early phase-immediate death
severe brain injury, disruption of great vessels, cardiac
disruption

Second phase-minutes to hours

subdural, epidural hematomas, hemopneumothoraces,
severe abdominal injuries, multiple extremity injuries
(bleeding)

Third phase-delayed
multisystem organ failure
sepsis

Multidisciplinary Trauma Team

Trauma Surgeon TEAM

LEADER
Anesthesia
Musculoskeletal
traumatologist
Neurosurgeon
Vascular/CT surgeon
Urology, Gynecology

Interventional
radiology
Intensivist
Hospital Staff-Nursing,
PT, OT, Speech, Admin.
Legal/Security
Social work
Ministry

Trauma Surgeons and

Fracture Care
Europe - General
Surgeon Traumatologists
treat all injuries

North America Multidisciplinary team

Orthopaedic Traumatologistbroad 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 Patient
Injury Severity Score >18

Hemodynamic instability
Coagulopathy
Closed head injury
Pulmonary injury
Abdominal injury

Injury Severity Score

Def.: scale of anatomic injury
ISS is the sum of the squares of the three
highest AIS categories
AIS (Abbreviated Injury Scale) looks at five
categories: general, head and neck, chest,
abdominal, and extremities
Maximum ISS is 75

Principles of Resuscitation
ATLS
Phases of management

Primary Survey
Resuscitation
Secondary Survey
Definitive care

Priorities in treatment

Airway
Breathing
Circulation/CNS
Digestive system
Excretory Tracts
Fractures

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

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

Indications for Intubation

Control of airway
Prevent aspiration in unconscious patient
Hyperventilation for increased intracranial
pressure
Obstruction from facial trauma and edema

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

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

Hemorrhage Classification
Class

Percent
Blood
Volume

Blood
Blood
Loss (cc) pressure
change

Urinary
output

Treatment

15

< 800

None

None

Crystalloid

II

15-30

800-1500

Min

20-30cc/hr Crystalloid

III

30-40

2000

Hypotension 10-20cc/hr Cryst/

blood

IV

> 40

> 2000

significant

Min

Blood

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

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 sequela

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 statusPlatelets monitored every 10
units
Platelets < 100,000-replace

Labile factors

(fibrinogen)-replace with FFP

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

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
Glascow Coma ScoreGCS
Pupil exam-intracranial
pressure
Motor and Sensory - all
extremities in alert
patient

Secondary Survey
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

Secondary Survey
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

Neurological exam-document all findings

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

Increased Intracranial Pressure

Treatment

Patient positioning
Fluid restriction
Hyperosmotic diuretics-mannitol
Deliberate hypocapnia
controlled hyperventilation
maintain pCO2 at 25-30 mm Hg

Avoidance of stimuli

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

Thoracic Trauma
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

Thoracotomy Indications

Failure of resuscitation
Penetrating injury to the mediastinum
Continued thoracic hemorrhage
Failed pericardiocentesis
Tracheal, bronchial, esophageal rupture

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

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

Other Methods of Abdominal

Evaluation
Ultrasound
CT scan
Method used for abdominal evaluation is
often institutionally dependent

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

Trauma Severity Scores

Physiologic
Trauma Index-Kirkpatrick
and Youman
Glascow Coma Scale

Anatomic Damage
Abbreviated Injury Scale
(AIS)
Injury Severity Score (ISS)

Biochemical Indices

Orthopaedic Surgeon
Experienced and familiar with a number of
acceptable procedures
Some more demanding in terms of EBL,
duration, equipment required
Potential EBL
pelvis/acetabulum - 8-10 units
IM nail femur - 2-3 units
Tibia - 1-2 units

Orthopaedic Emergencies
Open fractures
Dislocations (hip and
spine)
Compartment syndromes
Cauda equina syndrome
Extremities with
neurological or vascular
compromise

Orthopaedic 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

Orthopaedic Options
Equipment
Surgeon must have full knowledge of all
trauma sets, implants, and where to find
them
Use of power instruments-drill,tap,screw
Elliott, Injury, 1992

External fixation-allows rapid temporary

stabilization
Can be adjusted or exchanged for internal fixation as
the condition dictates

Orthopaedic Options
Pelvic ring injuries
Lower extremity
long bone fractures
Fractures with
vascular injuries
Complex periarticular
fractures
Open fractures

Patient Stability
Adequacy of resuscitation
Vital signs of resuscitation deceptive
Laboratory parametersbase deficit, lactic acidosis

Anesthesia-agents-myocardial depressants
Coagulopathy-dilution, DIC, thrombocytopenia
As long as homeostasis is maintained no evidence of duration
of the procedure alone results in pulmonary or other organ
dysfunction or worsens the prognosis of the patient

Must be ready to change plan as the patient status

dictates

Decision Making
General surgery, Anesthesia, Orthopaedics
Magnitude of the procedure can be tailored to the
patients condition
Timing and extent of operative intervention based
on physiologic criteria
Too sick for an operation not acceptable given
current knowledge
May require damage control surgery as a
temporizing and stabilizing measure

Reasonable Approach
Timing (when?)
Titration (how much?)
Temporization
(when necessary)
Temptations (avoid)

Incomplete Resuscitation
Based on physiological assessment
ICU - monitoring, resuscitation, rewarming,
correction of coagulopathy and base deficit
Once patient is warm and oxygen delivery
is normalized reconsider further operative
procedures

Summary
Dynamic process
Requires cooperation of entire team
Orthopaedist must:
Appreciate the interrelationships between organ system
injuries to include musculoskeletal injury
Understand
options for treatment of orthopaedic injury
impact on the polytrauma patient
Provide timely and effective treatment
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