Spam: Sequencing of complex ortho in major multisystem injury

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Dear Bjorn,
 
There is no good recipe for this.The best to have orthopaedic trauma surgeons with good understanding of physiology. There are few indicators, which we use when to go and what extent but it really depends on what surgery needs to be done. Generally between 3-7 days we just recommend to do relatively small interventions: repeated wash-outs, soft tissue closures, nerve repairs (these get difficult after a week), but even for this there is no golden rule if the patient tolerate you can go further. A general rule is that earlier fixation is better if you do not make the patient sicker (Second hit) and the local environment has the ability to heal (this is sometimes problematic during the immune paralysis phase). Sometimes you need to take the risk in the wrong time window to help the patient positioning and to help scratching off the ventilator with the help of pelvic/acetabular/long bone fixation. Immune monitoring might help in this in the future. Currently we do not have reliable indicators. Generally we like to go ahead when the patient has circulating PMN, platelets, not grossly edematous (fortunately we do not see this as frequently as in the past). Best Regards, Zsolt Balogh

>>> "Bjorn, Pret" <pbjorn at emh.org> 12/02/2009 6:30 am >>>
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Adult female, pedestrian vs train.  

Arrives in extremis, shocky.  Looks like she's been hit by a train.  

Injuries will be found to include flail chest with tension pneumothorax
and pulmonary contusion; high-grade splenic injury with active bleeding
and clinically evident hemoperitoneum; a left renal disruption with
retroperitoneal hematoma; stable pelvic rami fractures; and two open,
angulated, mangled extremities with diminished pulses (one arm, one
leg).

Airway control, ED thoracostomy, massive transfusion initiated and taken
promptly to OR for damage-control procedures (splenectomy and packing,
extremity debridement, reapproximations and ex-fixes).  

To ICU post op, recovers nicely over a few hours: warm, no acidosis,
normotensive, predictably anemic and thrombocytopenic but without
coagulopathy.  She is moving all extremities and has a negative brain
CT.  All the surgeons are considering her survival unexpected, and her
stable condition just short of astonishing.  She has good apparent
circulatory, sensory and motor function in her fixators.

The orthopedists are anxious to have a more methodical crack at her arm
and leg: multiple complicated surgeries taking several hours.  

How long should she rest in the ICU before definitive extremity repairs?

Pret Bjorn, RN
Bangor, ME USA


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