The Hip: Preservation, Replacement and Revision

Trauma Workup

I. Combat/Disaster Injuries
II. Battlefield/Austere Environment Trauma Systems
III. Extremity Soft Tissue Care and Amputation in an Austere Environment

- ATLS Assessment:  
(General Approach to Trauma)
    - ref: Evolution and Development of the Advanced Trauma Life Support (ATLS) Protocol: A Historical Perspective
    - airway protection:
            - anesthesia menu:  virtual anesthesia textbook / intubation menu 
            - anesthesia consideration for spine patients:
            - emergency airway management
   - breathing and ventilation:
            - pneumothorax
            - pulmonary contussion
            - management of respiratory failure
    - circulation:
            - cardiac contussion:
            - ACLS
            - fluid resusitation, pRBC transfusion
                    - subclavian vein approach / internal jugular approach for central line placement
    -
damage control orthopaedics:
    - disability (head trauma / glasgow
    - exposure / environmental control:
            - Heating pad for the bleeding: external warming during hemorrhage improves survival

- Adjunctive Studies:
     - portable lateral cervical spine, chest radiograph, and AP pelvis;
     - baseline labs: CBC, UA, electrolytes, blood gases, clotting studies, and type & crossmatch;
     - foley for urinary output: (caution with urinary and rectal injuries from pelvic frx)

 - General Survey Exam
         - cranio-maxillo-facial 
         - cardiovascular:
         - vascular trauma
    - Orthopaedic Assessment: 
         - assessment of perfusion: damage control orthopaedics:
                - surgical timing for femoral neck fracture
                - surgical timing in patients with head injury
                        - like compartment syndrome, hypotension may exacerbate process (decreases cerebral perfusion leading to cerebral edema);
                - surgical timing and prevention of pulmonary complications in patients with femur frx
         - T & L spine
                - management of the spine injured patient 
                - references:
                             - Lumbartransverse process fractures--A sentinel marker of abdominal organ injuries.
                             - Skeletal fracture demographics in spinal cord-injured patients 
                             - Falls from height: spine, spine, spine!
                             - Clinical Examination Is Insufficient to Rule Out Thoracolumbar Spine Injuries. 
          - Cervical Spine:
                - cervical radiographic clearance: 
                          - high index of suspcion for C spine injury with multitrauma, altered mentation, and/or blunt injury above clavicle;
                - pediatric cervical spine 
                          - children are immobilized so that shoulders are raised on a folded sheet (which counteracts tendency for the C-spine
                                    to be flexed on trauma board, due to the child's larger head size; 
                                    - Pediatric cervical-spine immobilization: achieving neutral position? 
                                    - Emergency transport and positioning of young children who have an injury of the cervical spine.
                 - cervical spine immobilization - adults:

                          - patients should be transported to the ER with the neck immobilized in C-collar and head taped between two sandbags
                          - without exception, trauma patients need to be taken off the trauma board ASAP to prevent decubiti;
                          - while moving one assistant controls the head while others help turn, check the scalp and back for lacerations and
                                    deformities, and then help to transfer to a padded mattress; 
                          - references:
                                    - Removing a patient from the spine board: is the lift and slide safer than the log roll?
                                    - Pressure ulcers, indentation marks and pain from cervical spine immobilization with extrication collars and headblocks: An observational study.

        pelvic fractures 
                  - radiographsAP view will help diagnose open book pelvic injuries, femoral neck frx, or verticle shear injuries;
                  - ref: Pelvic X-ray misses out on detecting sacral fractures in the elderly - Importance of CT imaging in blunt pelvic trauma.

         - extremities: 
                  - fractures (femur fracture)
                          - with high energy distal femur / proximal tibia fractures, consider spanning external fixation;
                          - references:
                                - Treatment of distal femur and proximal tibia fractures with external fixation followed by planned conversion to internal fixation.
                                - Tertiary survey in polytrauma patients should be an ongoing process

                  - dislocations - knee
                  - compartment syndromes (reperfusion injury)
                          - Fasciotomy rates in operations enduring freedom and iraqi freedom: association with injury severity and tourniquet use.
                  - vascular injury note: it is difficult to assess for vascular injuries when the SBP is less than 90 mm Hg;
                  - mangled extremity severity score generalized assessment 
                  - gun shot wounds 
                  - soft tissue coverage for the leg

- Misc: don't miss fractures:
      - Analysis of NHSLA Claims in Orthopedic Surgery




Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Sunday, November 20, 2016 7:16 am