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

2. Complex Trauma Priorities

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

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

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

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

7. Airway Rapid assessment - pre-hospital Rapid assessment - pre-hospital Intubation Intubation Protect C spine Protect C spine

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

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

10. Disability Head - Brain Head - Brain Spine Spine Acute treatment part of resuscitation Acute treatment part of resuscitation

11. Extremities Pelvis Pelvis Open Fractures Open Fractures Femurs Femurs Crush - Compartment syndromes Crush - Compartment syndromes

12. Priorities Trauma Surgeon -team leader Trauma Surgeon -team leader Neurosurgery Neurosurgery Orthopaedic Surgery Orthopaedic Surgery Urology Urology Plastic Surgery Plastic Surgery

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

14. Goals not achieved in an “orthopaedic vacuum”

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

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

17. Threshold of Probable Patient Mortality As Time Elapses Decrease Inflammation Energy Absorbed = Acute Inflammation Injury 1stSurgery 2ndSurgery2ndSurgery Reduces Probability of Patient Mortality 3rdSurgery

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

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

20. Orthopaedic Care Strategy Goals Immediate Immediate Intermediate Intermediate Long-term Long-term

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

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

23. Urgent Dysvascular limbs Dysvascular limbs Compartment syndromes Compartment syndromes Irreducible dislocations Irreducible dislocations Open fractures Open fractures Severe wounds Severe wounds

24. Provisional External Fixation

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

26. Non Urgent Upper extremity fractures Upper extremity fractures Articular fractures Articular fractures Foot/ankle fractures Foot/ankle fractures

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

28. 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

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

30. YOUNG PATIENT HIGH-ENERGY

31. A.E. 96.12.26

32. A.E. 96.12.31

34. A.E. 97.06.23

36. A.E. 99.01.27

37. D.B. 99.05.29

38. D.B. 99.06.30

39. D.B. 99.09.15

40. R.B. 99.06.24

41. R.B. 97.06.24

42. R.B. 99.06.19

83. Threshold of Probable Patient Mortality As Time Elapses Decrease Inflammation Energy Absorbed = Acute Inflammation Injury 1stSurgery 2ndSurgery2ndSurgery Reduces Probability of Patient Mortality 3rdSurgery

84. Summary: Patient first ­Life life life Poly-fractured patient ­Multiple teams Poly-fractured bone ­Metaphyseal,joint fx’s first