Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Case Examples – severe lower limb injuries March 2014 Trauma Conference Andy Gray Newcastle Hospitals Example 1 • • • • • 42 year old fit and well male RTA – 28th March 2013 (1 year ago!) Transferred to RVI A,B,C normal. GCS 15 Pan CT scan – no significant injury to head, neck, thoracolumbar spine, chest, abdo etc Secondary survey • • • • • • Bilateral distal femoral shaft fractures Left thigh wound Both kneecaps damaged Classic ‘dashboard’ injury Hips and pelvis fine Arterial line being inserted into wrist during secondary survey • Ortho trauma theatre free (consultant led) • On call consultant going to fracture clinic Theatre • • • • • • Stable patient / base excess OK (no acidosis) Debridement and irrigation of wound Bilateral retrograde nailing Left performed / supervised by consultant 1 Right performed by consultant 2 Transferred to ITU/HDU after surgery Day 1 post op • Left wrist pain • Pins and needles median nerve • Going to theatre for 2nd debridement and DPC of open femur – plastics present • Dislocated IP joint big toe Additional surgery ARDS / Fat embolus Syndrome • Aeitilogy after major trauma – Haemodynamic (Crowel 2000) –occult hypovolaemia – Embolic – Coagulative – Inflammatory – Injury Severity Score – Associated injuries (e.g. chest) Over next 2 weeks • Recovered from ARDS • Began rehab on ortho trauma ward • Repatriation to local DGH near Manchester Transferred to hospital closer to home • • • • As per national guidelines Case discussed with receiving team Good communication Patient spent 1 week in hospital before requesting re-transfer back to RVI Issues • • • • • • Receiving unit critical of care received No ownership of patient -no consultant review K wires removed from toe deformity recurred Critical of position of wrist plate Critical of missed screw “How old was your treating surgeon?” • Worried and confused patient. 2 months after surgery – wound infection left anterior knee wound Admitted – wound debridement and exchange nail 9 months after injury – femurs healed and doing well apart from toe!! Issues for discussion • Importance of repeating the secondary survey • Repatriation of patients – In theory everybody agrees with this – ? Dealing with complications – ? Patients need secondary procedures – Ownership of the patient – Avoiding criticising treatment of patient – ‘I would have managed this differently’ Case 2- 35 year old male / MBA / isolated lower limb injury / 22 stone Spanning ex fix applied 2.5 weeks Definitive fixation – 2 incisions Infection / wound necrosis / plastics and salvage / rotational flap to distal tibia / free lat dorsi flap over knee 6 weeks later – lifted flap / bone graft / reattached extensor mechanism Discussion points • Expect the unexpected • Importance of having allied specialties (plastics/vascular) available on-site • Development of a gold standard regional service for open fractures and complex lower limb reconstruction Thank-You