Download The Pathophysiology of Multiple Injuries

The Multiply Injured
Patient
行政院衛生署台東醫院
骨 科
2009-5-23
謝繼賢
Outline
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Injury Recognition ,Scoring Systems
Initial Management
Trauma Injury Management
The Pathophysiology of Multiple Injuries
Damage Control Orthopaedic Surgery
Prophylaxis Against Complication
Injury Recognition
 Separate a physiologically unstable
multiple trauma victim from a stable
trauma patient
 Predict outcome, ICU admission or
mortality
 Scoring systems:
Scoring Systems
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Glasgow Coma Scale (GCS)
Revised Trauma Score (RTS)
Injury Severity Score (ISS)
New Injury Severity Score (NISS)
* GCS<13 RTS< 11---tranported to
comprehesive facilities
Figure 2. Revised Trauma Score (RTS). The values for the three parameters are
summed to give the Triage-RTS. Weighted values are summed for the RTS.
Clinical Parameter
Category
Score
x weight
Respiratory rate
(Breaths per
minute)
10-29
4
0.2908
>29
3
6-9
2
1-5
1
0
0
>89
4
76-89
3
50-75
2
1-49
1
0
0
13-15
4
9-12
3
6-8
2
4-5
1
3
0
Systolic blood
Pressure
Glasgow Coma
Scale
0.7326
0.9368
An example of the
ISS calculation is shown below:
Region
Injury
Description
AIS
Square
Top Three
Head & Neck
Cerebral Contusion
3
9
Face
No Injury
0
Chest
Flail Chest
4
16
Abdomen
Minor Contusion of
Liver
Complex Rupture
Spleen
2
5
25
Extremity
Fractured femur
3
External
No Injury
0
Injury Severity Score:
50
ISS ranges from 1 to 75, an ISS of 75 is assigned to anyone with an AIS of 6.
AIS Score
AIS Score
1
Injury
Minor
2
3
4
Moderate
Serious
Severe
5
6
Critical
Unsurvivable
Initial Management
--outlined by ACS Advanced Trauma Life Support course
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A: airway, cervical spine protection
B: breathing and ventilation
C: circulation, hemorrhage control
D: disability, neurological status
E: exposure, environment
Primary Survey
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ABCDE assessment, resusciation is initiated
Adjuncts:
BP , pulse oximetry, ABG, EKG
Foley : urine output ( avoided if suspected
urethral injury )
NG: decompression, decrease aspiration
AP chest, AP pelvis, lateral C- spine
Evaluate response to resusciation
Shock
 Hypovolemic: from hemorrhage
 Neurogenic : injury to CNS, hypotension
without tachycardia
 Cardiogenic: direct trauma to heart, AMI,
cardiac tamponade, tension pneumothorax
Hemorrhagic Shock
 two large-caliber IV set, lactated Ringer’s or NS 12 L for adult, 20mL/kg for children
 Blood loss assessed by response to fluid bolus, if
vital signs…
* weak or absence: severe blood loss >40% ,
untyped blood needed
* response then deteriorate again: blood loss
20 % to 40 % , typed blood needed
* if stable , blood loss is minimal, no blood needed
Secondary Survey
 Framework for diagnostic work-up and
treatment
 Detailed head to toe physical examination
 After primary survey ends or
simultaneously
Missed Injuries
 10% in the blunt injury patient population
 In patient of head injury, alcohol
intoxication or intubation
 Musculoskeletal injuries are the most
frequent undiagnosed injuries
 Common in spinal fractures, feet
fractures or carpal injuries
Trauma Injury
Management
Closed Head Injury
Closed Head Injury
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Fluid management and rapid CT scan
Reduce cerebral hypertension
Hyperventilation ( PaCO2: 32—35 mmHg)
Head elevation
Osmotic diuresis ( mannitol or urea) for
acute cerebral edema
 Phenobarbital: reduce cerebral activity ?
Chest
Chest
 Lung damage and resulting hypoxia
 Pulmonary contussion,
hemothorax,pulmonary laceration,
pneumothorax
 Tx: intubation, mechanical ventilation,
tube thoracostomy
Chest
 Thoracic aorta injury: with a wide
mediastinum, aortography
 Ventilation management: pressure
support and permissive hypercapnia,
lower energy use, reduce barotrauma
Abdomen
 Unstable patients: peritoneal larvage
 Stable patients: CT scanning
 CT is more specific than larvage, but may
miss small perforatrion of GI tracts
 Ultrasound: does not require transport
of patient, easily be repeated for follw-up
Peritoneal lavage
Pelvic Ring Injuries
Pelvic Ring Injuries
 A marker for high-energy trauma, look for
associated injuries
 Hypovolemic shock: multifactorial ,
thoracic, intra-abdominal. Extremities,
pelvic…
 Emergent pelvic stabilization
APC ( anteroposterior
compression ) fractures
 Open book injuries: widening of pelvic ring
and increase pelvic volume
Anterior external fixation
frames
 Reduction of open book injuires,decrease
pelvic volume,
 Promote self-tamponade of retroperitoneal
venous bleeding, reduce blood loss
Anterior external fixation
frames
Posterior pelvic clamps
 Early stabilization, reduction of pelvic
volume
 Both forms of fixation are timeconsuming in application or may be
misapplied
Pelvic sheets or binders
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Can be applied in ER, applied in minutes
Noninvasive
Does not delay transfer to OR
Can be left in place during an emergent
laparotomy
 Equally in reducing pelvic volume
compared with external fixation
Pelvic sheets or binders
Cervical Spine Injuries
Cervical Spine Injuries
 In the field: immobilization, a spine board,
a rigid cervical collar
 In ER: neck deformity? palpated
tenderness? can move extremities ?
Bulbocavernosus reflex ?
 Lateral C spine x-ray, helical CT scanning
( more sensitive)
High-dose Corticosteroids
 Motor function scores improve while
given within 8 hours of injury
 Methylprednisolone –by NASCIS
30 mg/kg loading dose
5.4 mg/kg/hour maintenance dose
for 24 hours hours ( within 3 hours )
for 48 hours hours ( within 3-8 hours )
Displaced fracturedislocation of cervical
spince
 Reduced soon to minimize cervical cord
injury
 Closed reduction with Garner-wells tongs
traction
 Safety of the procedure? Neurologic
deterioration during reduction ?
 Prereduction MRI if suspect presence of
herniated disc
Gardner-Wells tongs
Take a Rest !
Open fracture
Open fracture
 Early debridement within 6-8 hours?
decrease infection rate? No evidence
 Debridement as soon as medically stable
 Appropriate IV antibiotics—prevention of
infection
Type I open fracture.
 Wound less than 1 cm, without contamination
and minimal injury of soft tissue.
Type II open fracture
 Wound between 1 and 10 cm, mild contamination,
extensive soft tissue damage
Type III-A open fracture
 Wound larger than 10 cm, severe
contamination and severe crushing
component.
Type III-B open fracture
 Wound larger than 10 cm, severe
contamination and severe loss of tissues
Type III-C open fracture
 Wound larger than 10 cm, severe
contamination and neurovascular injury
Antibiotics
 Gustilo-Anderson type 1
1st generation cephalosporin
 Gustilo-Anderson type 2 and type 3
1st generation cephalosporin +
aminoglycoside
 Heavily contaminated with soil
penicillin added
Wound Closure
 Delayed wound closure
 Primary wound closure
 The same rate of infection, but delayed
closure have a higher rate of local wound
complication
Compartment Syndrome
Compartment Syndrome
 After a extremity fracture (commonly
tibia ) or isolated muscle trauma
 Direct blow or crushing injury
 Muscle contussion→edema→tissue
pressure↑ →tissue perfusion ↓→tissue
ischemia→muscle and nerve function↓
Compartment Syndrome
Compartment Syndrome
 Tense , painful compartment
 Dysthesia or paresthesia : + or –
 Dx: compartment pressure
 Tissue pressure threshold: 30mmhg<
diastolic BP
Fasciotomy
The
Pathophysiology of
Multiple Injuries
Caloric
 Caloric requirements: in major
mechanical or thermal injuries; 150% ↑ in
severely burned patients
 Provision of adequate nutrition in trauma
care
Systemic Inflammatory
Response
 trauma→cytokines↑→ activate immune
system, complement system
 A compensatory anti-inflammatory
response→post-traumatic
immunosupression
Systemic Inflammatory
Response
Exaggerated inflammatory response
→ Neutrophil demargination, vascular
endothelium disruption
→ Microcirculation disturbance, tissue
hypoxia
→ parenchymal necrosis
→ ARDS, multiple organ failure
ARDS (Adult Respiratory
Distress Syndrome)
 ARDS following trauma ia rare ( 0.5%)
but fatal
 Most caused by sepsis ,G(-) bacteremia
 Direct lung parenchymal injury or
prolonged inflammatory response
 ISS= or< 9, rare develops
ARDS (Adult Respiratory
Distress Syndrome)
 Pulmonary ARDS: from direct lung injury,
injury of pulmonary alveolar epithelum,
→lung fibrosis
 Extrapulmonary ARDS: caused by
sepsis or systemic inflammatory, injury of
capillary endothelium →interstitial edema
Multiple Organ Failure
 Potential final fatal pathway for severe
trauma
 Cellular hypoxia and parenchymal
necrosis, with end-organ failure
 Renal and GI system more sensitive
 Renal tubular necrosis→renal failure,
anuria
 Disruption of intestinal mucosa
→translocation of bacteria →sepsis
“two hit “ hypothesis
 Initial trauma, surgical intervention: 2 hits
 Surgery performed in posttraumatic
peroid may increase inflammation
response ( marker) and cause multiple
organ failure or ARDS
 38% of secondary surgery in multiple
injuried patients preceded a deterioration
in organ function
Inflammatory Markers
 Interleukin(IL)-1, IL-6, IL-8, IL-10, CRP,
TNF-‫ﻪ‬
 Measure and monitor inflammatory
response to major trauma
 IL-6 is recommended
 Help orthopaedic surgeon to determine
appropriate timing of fracture fixation in
severely injuried patients
Damage Control
Orthopaedic Surgery
 Rapid stabilization of orthopaedic
injuries,avoid prolonged procedure
 Minimize hypothermia,acidosis and
coagulopathy, bleeding
 Open wound washed out and
debrided,external fixation for temporary
fixation
Damage Control
Orthopaedic Surgery
 Definitive treatment is postponed until
resusciated and stable
 Minimize systemic inflammatory
response and reduce second hit of
proloned surgical procedure
Prophylaxis Against
Complication
Prophylatic therapies
1. Determining nutritional needs
2. Preventing stress bleeding,venous
thrombosis and pressure sores
3. Assessing antibiotics coverage
Nutrition
 Early nutrition is a critical part in care of
multiply injured patients
 Early institution of parenteral nutrition ?
 Current recommendation: provide early
enteral nutrition to patient with functional
GI tracts
Nutrition
 New immune-enhancing formulations;
decrease the complications associated
with immune suppression which may
occur with parenteral nutrition or no
nutrition
Nutrition
 Goal:
support of early hypermetabolism
associated with injury and prevention of
protein calorie malnutrition that occurs
within 1—2 day of injury
Nutrition
 Many septic complications can be
minimized by early enteral nutrition
 even after abdominal procedure, feeding
into small bowel by NG or jejunostomy
tubes is tolerated without severe ileus
 Early enteral nutrition doesn’t result in
severe diarrhea
Prevention of Stress
bleeding
 Severely injured patient exhibit a stress
response to stimulate gastric acid
production
 Histamine blockade or mucosal barrier is
requied in any significantly injured patient,
especially in those not being fed enterally
Deep venous thrombosis
and Pulmonary embolism
 Passive motion of lower extremities
 Segmental compression devices for the
extremities
 Vitamine K antagonist ( warfarin,
Coumadin )
 Low dose heparin
 Early ambulation
 Placement of a vena cava filter
Pressure Sores
 Appropriate bed
 Removing patient from rigid spine board
as rapidly as possible
 Mobilizing patient as early as is feasible
 Frequently these measures are begun
after the problems happened