Orthopaedics Flashcards
(33 cards)
Why are pelvic fractures important in trauma?
- Represent high energy injury
- Commonly associated with vascular injury
What are complications of pelvic fractures?
- Organ injury eg GI, bladder, genital
- Neurovascular injury
- Skeletal injury including spine
What is the initial management of pelvic fractures?
- Primary and secondary survery simultaneously with volume replacement and resuscitation
- Minimal movement and immobilize - pelvic binder
- Permissive hypotension, early haemorrhage control, early blood products
When should pelvic trauma go to OT for packing?
- Co-existing major abdo/thoracic haemorrage
- Major bleeding from open pelvis
- Unstable with nil angio available
What is angio useful for in pelvic fractures?
- Bleeding from branches of iliac artery
- Isolated pelvic injury
What is the inital assessment and management of unstable spinal injury?
- assess c spine without removing collar
- Radiologically
- Clinically (NEXUS criteria) - GCS 15, not intoxicated, nil distracting injuries
What is neurogenic shock?
loss of sympathetic outflow resulting in a bradycardic, vasoplegic, hypotensive state (distributive shock)
What is the managment of acute spinal cord injury and neurogenic shock?
A - ?resp failure. Intubate with C spine precautions
B - supplemental O2, lung protective ventilation
C- Large bore access, resuscitate and optomize spinal cord perfusion
D- sequential neurological exam
What is cemented implant syndrome?
- hypoxia, hypotension, arrythmia and CVS collapse
- possibly fat embolism, air embolism or direct effect of the cement (causing release of inflamm mediators)
- typically occurs at cementation, prothesis insertion, reduction of the joint or deflation of the tourniquet
What is the management of cemented implant syndrome?
-Time limited event
- Increase FiO2
- treat RV failure i.e IV fluids, pulm vasodilators
- Inotropes to maintain RV contactility eg dobutamine and milrinone
What is the management of haemorrhage?
- Find the bleeding
- Stop the bleeding
- Rapid and effective restoration of blood volume
Initial measures are pressure, elevation, dressings etc
Invasive measures are sutures, tamponade, IR
Correct coagulopathy (avoiding hypothermia and acidosis)
What is the normal blood product replacement strategy?
1:1:1, PRBC, FFP, Platelets then reassess
Often then 1:1:10 PRBC, FFP, cryo
What parameters/blood tests need to be measured in critical bleeding?
- Temp
- Acid/base
- Hb
- iCa
- Platelets
- Fibrinogen
- APTT/INR
What is crush syndrome?
prolonged ischaemic and muscular damaged leading to rhabdomyolysis and reperfusion injury on release
What is the management of crush syndrome?
- Reduce fractures and splint joints in functional position
- Manage compartment syndrome if present
- Target normal pH and urine output
What are complications of crush syndrome?
Hypovolaemia
Hyperkalemia
Hypocalcaemia
Metabolic acidosis
Acute myoglobinuric renal failure
Acute compartment syndrome
What is compartment syndrome?
- When circulation and tissues within a closed space are compromised by increased pressure leading to ischaemia
What is re-perfusion injury?
- Biochemical change secondary to returning circulation to a previously ischaemic limb
- Increase systemic K, lactate, Co2, vasoactive substances
- causes reduction in systemic blood pressure
What is fat embolism syndrome?
- clinical diagnosis
- triad of: resp changes (dyspnoea/hypoxia), neurological abnormalities eg altered GCS, petechial rash
- higher risk in trauma, delayed immbolisation of fracture and conversvative mx
What is the management of fat embolism syndrome?
- supportive
- early aggressive resus
- Steroid use is controversial
- Usually resolves within 7 days
What are the issues with patients undergoing scolioisis surgery?
- Analgesia intra and post op
- PONV
- Antibiotic prophylaxis
- Blood loss
- Spinal cord protection (i.e MAP >60)
- Spinal cord monitoring
- Spinal surgery in prone position
How do you do spinal cord monitoring in scoliosis surgery?
- somatosensory evoked potnetials and motor evoked potentials
What is the usual managment of scoliosis surgery?
- TIVA (lower PONV and doesn’t effect spinal monitoring)
- Remifentail (avoid NMB so facilitate spinal cord monitoring)
- Pre warming to avoid hypothermia
- TXA to prevent blood loss
- Antibiotics
- Spinal cord monitoring
- Multi-modal analgesia
What are common intra-operative neuromonitoring modalities?
- Somatosensory evoked potentials
- Motor evoked potentials
- EMG
- EEG
