- Discussion:
         - trauma workup
                 - bleeding from pelvic fractures
         - lethal triad: metabolic acidosis (base deficit or serum lactate), hypothermia, and coagulopathy
         - assessment of shock:
                 - metabolic acidosis:  base deficit and serum lactate
                 - contraindications for non emergent orthopaedic surgery:
                          - following all can indicate occult hypoperfusion and are a relative contraindication for surgery;
                          - serum lactate level of >2.5 mmol/L
                                 - The Role of Elevated Lactate as a Risk for Pulmonary Morbidity After Early Fixation of Femoral Frxs.
                                 - Lactate clearance and survival following injury.
                          - base excess of >8 mmol/L
                                 - Base Deficit From the First Peripheral Venous Sample: A Surrogate for Arterial Base Deficit in the Trauma Bay
                                 - Femoral nailing during serum bicarbonate-defined hypo-perfusion predicts pulmonary organ dysfunction in multi-system trauma patients.
                          - pH of <7.24
                          - coagulation: (coagulation labs / blood product menu)
                                  - reversal of coagulopathy prior to non emergent surgery;
                          - temperature of <35°C 
                                  - core body temperature must be restored prior to non emergent surgery;
                          - thoracic injury with hypoxemia is a relative contraindication;
                                  - need to avoid IM nailing and to instead consider external fixation; 
                          - elevated IL6: marker for increased inflammatory response to deficient perfusion;

         - references:
                - Occult hypoperfusion is associated with increased morbidity in patients undergoing early femur fracture fixation.
                - Femoral Shaft Fracture Fixation and Chest Injury After Polytrauma
                - Early fracture stabilisation in the presence of subclinical hypoperfusion
                - Admission base deficit predicts transfusion requirements and risk of complications. 
                - Factors associated with pelvic fracture-related arterial bleeding during trauma resuscitation: a prospective clinical study.

- first "hit"
        - initial trauma: causes hypoxia, hypotension, hypothermia, organ and soft-tissue injuries;
- second "hits":
        - surgical procedures and sepsis:
        - leads to hypoperfusion, hypoxia/ischemia, reperfusion, blood loss due to acute endothelial injury, and tissue damage
                   causing local necrosis, inflammation, and acidosis;

- references:
        - Early femur fracture fixation is associated with a reduction in pulmonary complications and hospital charges: a decade of experience with 1,376 diaphyseal femur fractures.
        - Changes in the management of femoral shaft fractures in polytrauma patients: from early total care to damage control orthopedic surgery.
        - Damage control orthopedics in patients with multiple injuries is effective, time saving, and safe.
        - Damage control orthopaedics: lessons learned.
        - Safety and efficacy of damage control external fixation versus early definitive stabilization for femoral shaft fractures in the multiple-injured patient.
        - Temporizing External Fixation of the Lower Extremity: A Survey of the Orthopaedic Trauma Association Membership