Sequencing of complex ortho in major multisystem injury

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Take a rest, surgeons and patient all have a sleep, come back for 
planned orthopaedic surgery as a planned case in daylight hours. Minimum 
is warmed to normothermia, haemodynamically stable, 'comfortable' 
ventilatory requirements, and coagulopathy / transfusion all resolved. 
How bad is her chest injury? [The chest might be the rate limiting step] 
Will she be going back for a second look in the abdomen? Might be safe 
to time things with that, or wait until after abdomen finished with. 
There is no particular hurry to do the definitive limb surgery, though 
from the perspective of treating the rest of the patient, the sooner the 
limbs are fixed the better.

Ian Seppelt, Sydney

Bjorn, Pret wrote:
> 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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