Скачать презентацию Surgical trauma Traumatic disease Multiple injuries Certain types Скачать презентацию Surgical trauma Traumatic disease Multiple injuries Certain types

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Surgical trauma. Traumatic disease. Multiple injuries. Certain types of damage. L. Yu. Ivashchuk Surgical trauma. Traumatic disease. Multiple injuries. Certain types of damage. L. Yu. Ivashchuk

Complex Trauma Priorities Complex Trauma Priorities

Overview • Priorities in Multiply Injured Patient – Resuscitation – Fracture Fixation • Pelvic Overview • Priorities in Multiply Injured Patient – Resuscitation – Fracture Fixation • Pelvic Trauma • Mangled Extremity

Resuscitation • ATLS Principles: – Primary survey : emergency/casualty • identify and treat life Resuscitation • ATLS Principles: – Primary survey : emergency/casualty • identify and treat life threatening injuries – Secondary Survey: emergency/casualty • reassess and diagnosis limb and non life threatening injuries – Definitive care: OR, ICU, ward, rehab • treatment of all injuries in logical team approach

Primary Survey • Airway: #1 cause of death • Breathing: lungs • Circulation: blood Primary Survey • Airway: #1 cause of death • Breathing: lungs • Circulation: blood loss • Disability: brain • Expose/Extremities

Primary Survey • Airway: #1 cause of death • Breathing: lungs • Circulation: blood Primary Survey • Airway: #1 cause of death • Breathing: lungs • Circulation: blood loss • Disability: brain • Expose/Extremities

Airway • Rapid assessment - pre-hospital • Intubation • Protect C spine Airway • Rapid assessment - pre-hospital • Intubation • Protect C spine

Breathing • Tension pneumothorax: A killer • Flail chest • Pulmonary contusion • Open Breathing • Tension pneumothorax: A killer • Flail chest • Pulmonary contusion • Open injuries • Hemothorax • TREATMENT: O 2 and CHEST TUBES

Circulation • Hypovolemic shock - blood loss – abdomen, chest, fractures, retroperitoneum • Pump Circulation • Hypovolemic shock - blood loss – abdomen, chest, fractures, retroperitoneum • Pump failure - rare • TREATMENT: SURGICAL DISEASE – Diagnosis – Stop – Replace

Disability • Head - Brain • Spine • Acute treatment part of resuscitation Disability • Head - Brain • Spine • Acute treatment part of resuscitation

Extremities • Pelvis • Open Fractures • Femurs • Crush - Compartment syndromes Extremities • Pelvis • Open Fractures • Femurs • Crush - Compartment syndromes

Priorities • Trauma Surgeon -team leader • Neurosurgery • Orthopaedic Surgery • Urology • Priorities • Trauma Surgeon -team leader • Neurosurgery • Orthopaedic Surgery • Urology • Plastic Surgery

Multiple Trauma Patients • Learn to prioritize/temporize • Haemodynamics • Coagulation Profile • Pulmonary Multiple Trauma Patients • Learn to prioritize/temporize • Haemodynamics • Coagulation Profile • Pulmonary Status • Brain Injury Then, consider orthopaedic needs

Goals not achieved in an “orthopaedic vacuum” Goals not achieved in an “orthopaedic vacuum”

Timing of Care Communication/Negotiation • How much care? • How fast? • Continually reassess Timing of Care Communication/Negotiation • How much care? • How fast? • Continually reassess changing situation

Titration • Avoid temptations Too much surgery Too complex reconstructions • Recognize predictable “windows” Titration • Avoid temptations Too much surgery Too complex reconstructions • Recognize predictable “windows” Plan non-critical procedures KNOW WHEN TO QUIT

Energy Absorbed = Acute Inflammation Threshold of Probable Patient Mortality 2 nd Surgery 1 Energy Absorbed = Acute Inflammation Threshold of Probable Patient Mortality 2 nd Surgery 1 st Surgery Reduces Probability of Patient Mortality 2 nd Surgery Injury 3 rd Surgery As Time Elapses Decrease Inflammation

Virtual Reality Orthopaedic Trauma Surgery • Nothing goes well at night • Anaesthetic support Virtual Reality Orthopaedic Trauma Surgery • Nothing goes well at night • Anaesthetic support is variable • Double the planned OR time • Triple the estimated blood loss

Orthopaedic care • Present at bedside • Acknowledge extremity injuries recoverable • Preserve vital Orthopaedic care • Present at bedside • Acknowledge extremity injuries recoverable • Preserve vital organs

Orthopaedic Care Strategy Goals • Immediate • Intermediate • Long-term Orthopaedic Care Strategy Goals • Immediate • Intermediate • Long-term

Immediate/Urgent Care • Priority procedures first • Multiple surgical teams if possible • Quick Immediate/Urgent Care • Priority procedures first • Multiple surgical teams if possible • Quick procedures Optimal fixation is often “sub-optimal plan”

Immediate Goals • Enhance resuscitative effort • Maintain/establish perfusion • Prevent infection • Stabilise Immediate Goals • Enhance resuscitative effort • Maintain/establish perfusion • Prevent infection • Stabilise major fractures to improve ICU care decrease blood loss decrease pain ? enhance pulmonary recovery

Urgent • Dysvascular • • limbs Compartment syndromes Irreducible dislocations Open fractures Severe wounds Urgent • Dysvascular • • limbs Compartment syndromes Irreducible dislocations Open fractures Severe wounds

Provisional External Fixation Provisional External Fixation

Intermediate Goals • Performed in “windows” once patient • • • stable Convert external Intermediate Goals • Performed in “windows” once patient • • • stable Convert external fixation to ORIF(long bones) Obtain soft tissue coverage Restore length/alignment of intra-articular fractures

Non Urgent • Upper extremity fractures • Articular fractures • Foot/ankle fractures Non Urgent • Upper extremity fractures • Articular fractures • Foot/ankle fractures

Long Term Goals • Fracture union • Joint motion • Muscle rehabilitation • Return Long Term Goals • Fracture union • Joint motion • Muscle rehabilitation • Return to max. possible performance

Even if the result is a malunion or a non-union, late reconstruction options are Even if the result is a malunion or a non-union, late reconstruction options are available and yield acceptable results Surgery is performed on a stable and healthy patient

Stabilization of long bone fx’s in the polytraumatized patient Stabilization of long bone fx’s in the polytraumatized patient

YOUNG PATIENT HIGH-ENERGY YOUNG PATIENT HIGH-ENERGY

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Energy Absorbed = Acute Inflammation Threshold of Probable Patient Mortality 2 nd Surgery 1 Energy Absorbed = Acute Inflammation Threshold of Probable Patient Mortality 2 nd Surgery 1 st Surgery Reduces Probability of Patient Mortality 2 nd Surgery Injury 3 rd Surgery As Time Elapses Decrease Inflammation

Summary: • Patient first L ife life • Poly fractured patient M ultiple teams Summary: • Patient first L ife life • Poly fractured patient M ultiple teams • Poly fractured bone M etaphyseal, joint fx’s first