AOK team Glan Clwyd Hospital * Dept of Orthopaedics
Jan 16, 2016
AOK team
Glan Clwyd Hospital * Dept of Orthopaedics
ø Scope of the problemø Classificationø Anatomyø Emergency department ø Orthopodø Management options ?ø Treatment algorithm
ø Severe soft tissue involvementø Other serious injuriesø Trauma =97 % ,gunshot, fall from heightø Male 20-30 years
ø Head 42% Chest 28% Abdo 16%ø Open #s 50%,Vascular injuries 30 % Nerve
injuries 10%ø Knee ligament injuries 30%ø Children uncommon
Floating knee – Blake and Mc Bryde 1975
• Popliteal artery at risk for being tethered • Adductor hiatus
• Soleus arch
• If blood flow through popliteal artery disrupted Inadequate blood supply distally
On site resus - paramedicsFluidsTourniquet Helicopter ?
Open fractureIrreducible dislocations 70 kg 5 litVascular injury Femur # ~ 2lit/Tibia # ~ 1litAmputation 3/5x100% = 60%Compartment syndromeUnstable pelvic fracture/ hemodynamic instabilityMultiply-injured patientSpinal cord injuryDisplaced femoral neck < 65 and talar neck fractures
ABC approach of ATLS Guides!!ABC approach of ATLS Guides!!
ø ATLSø BOA BAPRAS Guidance for open fractures ø Look up transfer protocol to tertiary institution
Temp 26 * Ph 6.4, she has a condition I have
not seen before ‘’Asystole’’
Resuscitate/TourniquetAssess/Order investigations
PhotographSplint
Call for help
Who goes first?-Discuss with vascular surgeon
Temporary shunts-Will benefit some patients
Fracture stabilization-Consider provisional ex fix
Salvage vs amputation-Trend toward salvage (LEAP)
Fasciotomies-Prophylactic after Ischemia
ø Progressive ischemiaø Compartment syndromeø Tissue necrosisø Blood loss
Irreversible damage after 6 hours
ø Vascular ø Bone
Major hemorrhage/hypotensionArterial bleedingExpanding hematomaAltered distal pulsesPallorTemperature differential between extremitiesInjury to anatomically-related nerve
Physical exam
Doppler pressure (ABI)
Duplex scanning
Arteriogram
Exploration
Careful physical exam and high index of suspicion are most important !
Blood loss
Ischemia
Compartment syndrome
Tissue necrosis
Amputation
Death
Level and type of vascular injury
Collateral circulation
Shock/hypotension
Tissue damage (crush injury)
Warm ischemia time
Patient factors/medical conditions
Rapid resuscitation
Complete, rapid evaluation
Urgent surgical treatment
PROTOCOL IS ESSENTIAL !
Direct pressureHemostatic packsTourniquetsPositioning Pressure points
“No patient should die from ext hemorrhage !”
Control bleeding
Replace volume loss
Cover wounds
Reduce fractures & dislocations
Splint
Re-evaluate
ø Gauze –celluloseø Chitosan P-NAGø Hemcon- cream side down !ø Zeoliteø Polysaccharidesø Fibrin
No ideal hemostatic pack developed yet
Asymmetric pulses warrant doppler examination (determine ABI)
Absent pulses warrant emergent vascular consultation/surgical exploration
Determine presence/absence of arterial supply
Assess adequacy of flow
PRESENCE OF SIGNAL DOES NOT EXCLUDE ARTERIAL INJURY !
NoninvasiveSafeRapidReliable for
Injury to arteries and veinsA-V fistulasPseudo aneurysms
Locates site of injury
Characterizes injury
Defines status of vessels proximal and distal
May afford therapeutic intervention
Alternative
Good sensitivity and specificity
Costs much more
ANGIOGRAPHY WILL DELAY REVASCULARISATION
It is not indicated in cases with absent pulses/complete transection, which should go immediately to surgery
Redmond, et al. Orthopedics 2008
Single view in operating room
Rapid
Excellent for detecting site of injury
Immediate exploration is indicated for:
Obvious arterial injury on exam
No doppler signal
Site of injury is apparent
Prolonged warm ischemia time
Vascular injuries are dynamicEvaluation should continue after the initial injury or
surgeryAdditional debridement and/or fixation undertaken
after successful revascularization
Circulation
Neurologic function
Compartment pressures
External fixation with vascular repairNailing ?2nd sitting in 2 weeksIntramedullary nailing - antegrade femur and tibia -retrograde femur,antegrade tibiaORIF plate and screws,MIPO
Tibial compartments decompression
Fasciotomy
DiscussionDiscussion