Polytrauma and Open Fractures

two or more injuries, one of which may be life threatening, sustained in the same incident that affect multiple body parts or organ systems and result in physical, cognitive, psychological, or psychosocial impairments and functional disability

polytrauma

theory used to describe the pathophysiology of polytrauma by which primary trauma results in a cascade of events that goes in one direction unless patients are treated as soon as possible

two-hit theory

what are the four components of the "lethal diamond"?

hypothermia

acidosis

coaguloapathy

hypocalcemia

immediate concerns for penetrating wounds?

direct organ damage

large volume pneumothorax

hemothorax

pericardial effusion

severe hemorrhage

most common form of penetrating injury?

bite wounds

trauma that causes damage from compression, acceleration, deceleration, or shear force on tissues (e.g. HBC, fall, hit by an object)

blunt trauma

types of injuries that may result from blunt trauma?

direct impact injury

acceleration/deceleration injury

crush/asphyxiation injury

what is the purpose of primary survey?

rapidly identify and manage impending or actual life threats to the patient

what are the components of triage/primary survey?

airway

breathing

circulation

disability (e.g. neuro status)

exposure (e.g. body temp, trauma, bleeding)

what body systems are included in a focused physical exam for life threatening issues?

Cardiovascular

Respiratory

Neurologic

abnormalities on TFAST commonly seen with polytrauma?

absent glide sign (e.g. pneumothorax)

B-lines (e.g. contusions)

pleural effusion

step sign (e.g. rib fracture)

goals of initial stabilization for polytrauma?

improve oxygenation

protect airway

restore tissue perfusion

what is included in the secondary survey?

Reassess vitals and primary survey post stabilization

Evaluate other body systems and triage

Develop problem list, ddx, and plan

what should you prior to starting pain medications in a polytrauma patient?

perform a brief neuro/ortho assessment

analgesic options for polytrauma?

opioids

ketamine

local blocks

what analgesics should be avoided with polytrauma?

nsaids

steroids

what can be put on wounds while clipping to prevent hair from getting into it?

surgical lubricant/sterile water soluble gel

recommended lavage pressure for initial wound management?

1L bag pressurized to 300mmHg

considerations for acute open wound management?

debride obviously non-viable tissue ASAP

provide drainage

it is ideal to start broad spectrum antimicrobials for wounds within the first ? of injury

6 hours

classification scheme for open fractures that considers the degree of soft tissue damage and mechanism of trauma

gustilo-anderson system (types I-III)

open fracture where low energy trauma causes the sharp margin of bone to penetrates skin from within resulting in a

type I

open fracture where high energy external force creates the wound resulting in moderate soft tissue damage, a wound >1cm,

type II

what open fracture type can be treated as a closed fracture?

type I and II

open fracture where high energy trauma results in substantial soft tissue damage with a severely contaminated wound

type III

type III open fracture that requires no major reconstructive surgery

IIIa

type III open fracture that cannot be closed without reconstructive surgery (e.g. skin flaps)

IIIb

type III open fracture with major arterial injury

IIIc

emergency management of closed fractures?

Provide external coaptation

Provide analgesia

Wait for definitive fracture repair

emergency management of open fractures?

COVER WOUND while dealing with life threatening concerns

Once stabilized, clip/clean and place temporary sterile bandage

Evaluate neurovascular status

Antibiotics asap

Analgesia

Radiographs

what should you do prior to assessing neurovascular status for a limb with an open fracture?

appropriately fluid resuscitate

poor prognostic indicator for open fractures?

sustained monoplegia or loss of nociception

most commonly used definitive fracture fixation method for open fractures because they allow for wound access and care

external skeletal fixation