Lecture on Trauma (Part 1)

Introduction

• Presenter: Tom Schaller
• Focus: General principles, pelvic trauma, upper extremity trauma (excluding hand and wrist)
• Importance: Recognition of critical interventions and avoiding aggressive treatment of benign conditions

General Principles of Trauma

• ATLS (Advanced Trauma Life Support):
  • ABCs of trauma care
  • Prioritizing airway maintenance in multiply injured patients
  • Recognition of pneumothorax or hemoneumothorax on x-ray
  • Hemorrhage control and shock management

Shock

• Understanding circulating volume: 5 liters
• Class III shock at 1500 cc loss
• Key signs: tachycardia, decreased urine output, altered mental state
• Resuscitation: starts with 2 liters fluid; use of O-blood, type-specific, or crossmatched blood
• Massive transfusion protocol: 1:1 ratio of PAC cells, platelets, FFP
  • Side effects: Thrombocytopenia, hypocalcemia

Systemic Inflammatory Response to Trauma

• Characterized by elevated cytokines and inflammatory mediators
• Damage Control Orthopedics: Staging of care to limit trauma
• Early Appropriate Care: Safe definitive care after resuscitation (measured by normal lactate)

Timeframes for Orthopedic Surgery

• Conversion from temporary to definitive fixation:
  • Femur: ~3 weeks
  • Tibia: 7-10 days

Complications

• Fat embolism syndrome (1-3 days post-trauma)
  • Triad: Hypoxemia, mental changes, petechial rash
• Acute respiratory distress syndrome
  • Positive pressure ventilation needed

Orthopedic-Specific Principles

Open Fractures

• Antibiotics and irrigation critical
• Irrigation: High flow saline equivalent to pulsatile lavage

Fracture Management

• Negative pressure wound therapy
• Bone grafting with polymethyl methacrylate spacer

Thromboembolic Complications

• Common in pelvic fractures
• Management: Early mobilization, compression devices, pharmacologic agents

Compartment Syndrome

• Five P’s: Focus on pain out of proportion, pain with passive stretch
• Critical pressure: 30 mm Hg

Pelvic Trauma

• Complex ligamentous structures provide stability
• Radiographic Evaluation: AP, inlet, outlet views
• Classification: Young-Burgess system based on force direction
  • Predicts transfusion requirement, not direct mortality

Hemodynamic and Mechanical Instability

• Sources of blood loss: intra-abdominal, intra-thoracic, pelvic

Acute Management

• Use of pelvic binder for stabilization
• Algorithm for hemodynamic instability

Pelvic Ring Injuries

• Management involves non-operative or surgical intervention
• Surgical Options: External fixation, ORIF, iliosacral screws

Upper Extremity Trauma

• Sternoclavicular dislocation: Importance of CT scan and serendipity view
• Clavicle fractures: Middle third most common, treated non-operatively
• AC joint injuries: Operative management for types 4-6

Key Points

• Understanding key resuscitation markers
• Recognition of systemic inflammatory response and appropriate orthopedic intervention
• Use of imaging for injury assessment and appropriate treatment planning