Sequencing of complex ortho in major multisystem injury

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We know that early fixation of fractures is a good thing. I would suggest if you have a stable patient and have met the routine end points of resucitation, (lactate, urine output, good gasses, etc)  then you let the ortho guys do their thing. we frequently stop in the OR ourselves though and make sure things are going okay and if things are not, have pulled people off the table before everything gets done in patients like this. 
 
Robert Schulze MD FACS
Clin Asst Dean, 
Trauma and Critical Care Surgery,]
SUNY Downstate/Kings County Hospital

>>> "Bjorn, Pret" <pbjorn at emh.org> 2/11/2009 2:30 PM >>>
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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