Orthopaedic Trauma

The Stanmore and Royal London Guide

Sebastian Dawson-Bowling, Pramod Achan, Timothy Briggs, Manoj Ramachandran, Sebastian Dawson-Bowling, Pramod Achan, Timothy Briggs, Manoj Ramachandran

• Publisher: CRC Press
• Year: 2014
• Print ISBN: 9781444148824
• eBook ISBN: 9780429586514
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

Highly Commended, BMA Medical Book Awards 2015Orthopaedic Trauma: The Stanmore and Royal London Guide is a definitive and practical guide to musculoskeletal trauma surgery with an emphasis on the techniques employed and the reasoning behind them. Written with the needs of trainees in orthopaedic surgery in mind, this comprehensive book systematical

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Principles of resuscitation and polytrauma management

DAUD CHOU, MATTHEW BARRY AND KARIM BROHI

Overview

Classification

Initial resuscitation and primary survey

Secondary and tertiary surveys

Physiological staging

Investigations

Surgical priorities and strategy

Basic science of polytrauma

Paediatric polytrauma

MCQs

Viva questions

OVERVIEW

In the United Kingdom, trauma causes more than 14 500 deaths per year. Motor vehicle– related injuries account for the majority and are associated with the highest mortality. Men are more prone to trauma, and major peaks in incidence occur in the 16–24 and 35–44 age groups. The principles of organized trauma care – including injury prevention, pre-hospital care, in-hospital care and rehabilitation – have been shown dramatically to improve outcomes. The development of the concepts of early total care (ETC) and damage control surgery, together with significant advances in intensive care and the understanding of a systemic response to polytrauma, has played a key role in this process.

Definition of Polytrauma

‘A syndrome of multiple injuries exceeding a defined severity with sequential systemic reactions that may lead to dysfunction or failure of remote organs and vital systems, which have not themselves been directly injured’.

– Trentz

CLASSIFICATION

The principle of a classification/scoring system for polytrauma is based on converting a number of independent factors into a single numerical value that represents the severity of injury. The objective is to provide a common language for clinical practice and for research purposes.

Ideally a trauma scoring system should reflect the following:

• Severity of anatomical trauma.

• Level of physiological response.

• Patient demographics and co-morbidities.

• Autoimmune and genetic predisposition.

There are several existing systems in fairly widespread usage:

1. INJURY SEVERITY SCORE

This anatomically based scoring system has the Abbreviated Injury Score (AIS) as its foundation. The AIS assigns a score of 1–6 for each of the 6 body systems (head, face, chest, abdomen, extremities including pelvis and external structures), with 1 representing a minor injury and 6 representing an un-survivable injury. The Injury Severity Score (ISS) is the sum of the squares of the AIS values of the 3 most injured body systems. The highest attainable ISS is 75, and if any single body system is assigned a score of 6, the ISS automatically becomes 75. This system reflects the severest injuries in 3 body systems and so would under score a patient with multiple severe injuries in a single body system. Therefore a new ISS (NISS) has been proposed which sums the square of the AIS of the 3 most severe injuries irrespective of body system. A score of more than 16 has been shown to have an associated mortality of 10 per cent.

2. REVISED TRAUMA SCORE (RTS)

The Revised Trauma Score (RTS) is a physiologically based scoring system calculated by incorporating the respiratory rate, systolic blood pressure and Glasgow Coma Scale (GCS) score. Each parameter is assigned a score between 0 and 4, with 0 as the worst score and 4 representing normal physiology. A score of less than 11 has been suggested as the threshold for transfer to a trauma centre.

3. ACUTE PHYSIOLOGY AND CHRONIC HEALTH EVALUATION

The Acute Physiology and Chronic Health Evaluation (APACHE) is a complex scoring system used in intensive care units and incorporating parameters such as age, co-morbidities, physiological markers, previous surgery or intensive care unit stay, source of admission and diagnosis. APACHE has been shown to be a good prognostic indicator.

4. TRAUMA AND INJURY SEVERITY SCORE

The Trauma and Injury Severity Score (TRISS) is a sophisticated scoring system calculated by combining the RTS and ISS with a number of coefficients derived from the Major Trauma Outcome Study (MTOS). It has been used to predict the probability of survival.

INITIAL RESUSCITATION AND PRIMARY SURVEY

The evaluation and management of polytrauma have been divided into the pre-hospital and in-hospital phases. Trauma deaths occur in three phases:

• Immediate phase – most frequently the result of severe central nervous system or circulatory system disruption and not usually amenable to medical cure.

• Early phase – treatable injuries which would benefit from timely intervention at an appropriate centre. This time frame is referred to as the Golden Hour, after which a patient’s chances of survival rapidly diminish.

• Late phase – most often the result of sepsis or multiorgan failure.

The universal acceptance of Advanced Trauma Life Support (ATLS) and Pre-hospital Trauma Life Support (PHTLS) has greatly improved and standardized this process. These protocols are centred around the use of a universal algorithm for the initial assessment of all patients, irrespective of the precise injuries sustained – the ‘ABCDEs of trauma care’. As this is being undertaken a brief history should be obtained, either from the patient or from a witness or member of the ambulance staff, using the AMPLE format:

• Allergies.

• Medications used.

• Previous medical history (including pregnancy).

• Last meal.

• Events leading to trauma.

It should be remembered that the primary survey is a dynamic process; after any intervention the process should be started again to assess the response of all systems.

1. AIRWAY MANAGEMENT AND CERVICAL SPINE CONTROL

All patients should be initially managed as if a cervical spinal injury is present, with a collar, blocks and log roll precautions. To clear the cervical spine (C-spine) one should refer to local protocols, which should themselves reflect the published guidelines from the British Orthopaedic Association (BOA) and the Eastern Association for the Surgery of Trauma (EAST). An assessment of the airway is undertaken; this comprises inspection (for facial fractures, blood and foreign material in the mouth, nose or pharynx) and listening for abnormal sounds such as stridor or gurgling. The early management of the compromised airway may warrant the use of adjuncts such as an oropharyngeal or nasopharyngeal airway. However, such devices are ...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Preface
• Acknowledgements
• List of contributing authors
• 1 Principles of resuscitation and polytrauma management
• 2 Open fractures and associated soft tissue injuries
• 3 Principles of fracture fixation
• 4 Complications of fracture healing
• 5 Fragility fractures
• 6 Fractures of the thoracolumbar spine
• 7 Cervical spine trauma
• 8 Shoulder girdle and proximal humerus
• 9 Humeral shaft fractures
• 10 Trauma of the elbow
• 11 Radius and ulnar shaft
• 12 Distal forearm
• 13 Carpal injuries
• 14 Hand trauma
• 15 Pelvic trauma
• 16 Acetabulum
• 17 Hip and proximal femur fractures
• 18 Femoral shaft, distal femoral and periprosthetic fractures
• 19 Knee and proximal tibia
• 20 Tibial shaft and plafond
• 21 Ankle injuries
• 22 Foot injuries
• 23 Principles of paediatric trauma
• 24 Paediatric upper limb trauma
• 25 Paediatric lower limb trauma
• 26 Peripheral nerve injuries
• 27 Pathological fractures
• Answers to MCQs
• Index