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; March 2011
 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 • Interventional

TEAM LEADER radiology
• Anesthesia • Intensivist
• Musculoskeletal • Hospital Staff-Nursing,
traumatologist PT, OT, Speech, Admin.
• Neurosurgeon • Legal/Security
• Vascular/CT surgeon • Social work
• Urology, Gynecology • Ministry
 Trauma Surgeons and
Fracture Care
• Europe - General
Surgeon Traumatologists
– treat all injuries
• North America -
Multidisciplinary team
– Orthopaedic
Traumatologist- broad
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 six
categories: head and neck, face, chest,
abdominal, extremities, and external (soft-
tissue) injury
Maximum ISS is 75
 Principles of Resuscitation
ATLS
• Phases of management • Priorities in treatment
– Primary Survey – Airway
– Resuscitation – Breathing
– Secondary Survey – Circulation/CNS
– Definitive care – Digestive system
– Excretory Tracts
– Fractures
 Airway

• Establish and maintain 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
• Mechanical assistance with ventilation may be
required
 Indications for Intubation
• Control of airway
• Prevent aspiration in unconscious patient
• Hyperventilation for increased intracranial
pressure
• Combative Patient
• Obstruction from facial trauma and edema
• Prophylactic Intubation for impending
indications above
 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 or when direct
pressure will not control hemorrhage
 Assessment of Blood Pressure
Peripheral Perfusion
Peripheral Pulse Systolic Blood Pressure
radial 80 mm Hg
femoral 70 mm Hg
carotid 60 mm Hg

capillary refill > 2 secs Hypotensive

 Hemorrhage Classification
Class Percent Blood Blood Urinary Treatment
Blood Loss (cc) pressure output
Volume change
I 15 < 800 None Unchanged 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
• BOLUS 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 (hypovolemic)
• Cardiogenic-(e.g. 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 • Blood warmer-prevents
hypothermia, arrhythmias
– 1 hour
• Blood filters-160 u macropore
• Type Specific
– 10 minutes
• Coagulation status-Platelets
monitored every 10 units
• Type O Rh neg – Platelets < 100,000-replace
– immediately – If continued hemorrhage-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 Score-

GCS
• 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 (i.e. high-riding prostate), 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
– good for quick, short term correction of ↑ICP
• 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
•Nowadays, CT scan if available, is
usually preferred.
 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
– Closed Femur - 2-3 units
– Closed Tibia - 1-2 units
– Open fractures will bleed more!
 Orthopaedic Emergencies

• Open fractures
• Dislocations
• 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
 Judgment: Proper Timing and
Execution of the 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 parameters—base deficit, lactic acidosis
• Anesthesia-agents-myocardial depressants
• Coagulopathy-dilution, DIC, thrombocytopenia
• As long as hemodynamic stability is maintained, there is
no evidence that 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
patient’s 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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