The major trauma patient

This chapter describes the anaesthetic management of the major trauma patient. It begins with immediate trauma care, the patient journey, primary survey and resuscitation. The management of head and traumatic brain injury, thoracic injury, abdominal and pelvic injuries, spinal injury, limb and extremity injury, blast injury and gunshot wounds and traumatic cardiac arrest are discussed. The specific management of burns, paediatric trauma and silver trauma are covered. Anaesthesia for major trauma, including damage control resuscitation and damage control surgery are discussed.

Sacroiliac Separation that Can be Diagnosed After Pelvic Fixation During Surgery: A Case Report and Review of Literature

Introduction: Sacroiliac joint separation is a life-threatening serious condition in pelvic injuries. It should be diagnosed early and treated properly. Although these injuries can often be detected by imaging methods, in some cases, it is not diagnosed. Case presentation: We report a rare case of pelvic injury with sacroiliac separation during surgery, while the sacroiliac joint was completely normal on X-ray and CT and no pelvic binder was used in the patient. The sacroiliac separation noticed during the operation was fixed with a sacroiliac screw. Conclusion: Pelvic injuries, especially ligament injuries, may not be detected on both physical examination, direct radiography, and CT.

Epidemiologic, Postmortem Computed Tomography-Morphologic and Biomechanical Analysis of the Effects of Non-Invasive External Pelvic Stabilizers in Genuine Unstable Pelvic Injuries

Unstable pelvic injuries are rare (3–8% of all fractures) but are associated with a mortality of up to 30%. An effective way to treat venous and cancellous sources of bleeding prehospital is to reduce intrapelvic volume with external noninvasive pelvic stabilizers. Scientifically reliable data regarding pelvic volume reduction and applicable pressure are lacking. Epidemiologic data were collected, and multiple post-mortem CT scans and biomechanical measurements were performed on real, unstable pelvic injuries. Unstable pelvic injury was shown to be the leading source of bleeding in only 19%. All external non-invasive pelvic stabilizers achieved intrapelvic volume reduction; the T-POD® succeeded best on average (333 ± 234 cm3), but with higher average peak traction (110N). The reduction results of the VBM® pneumatic pelvic sling consistently showed significantly better results at a pressure of 200 mmHg than at 100 mmHg at similar peak traction forces. All pelvic stabilizers exhibited the highest peak tensile force shortly after application. Unstable pelvic injuries must be considered as an indicator of serious concomitant injuries. Stabilization should be performed prehospital with specific pelvic stabilizers, such as the T-POD® or the VBM® pneumatic pelvic sling. We recommend adjusting the pressure recommendation of the VBM® pneumatic pelvic sling to 200 mmHg.

890 Bilateral Acetabular Fractures Induced by An Epilepticseizure In a Paediatric Patient: A Unique Case Andits Management

Bilateral acetabular fractures following epileptic seizures are a rare but known occurrence in adults, with an 18.5% mortality rate. These fractures occurring post epileptic seizures have not been previously documented in children. We report a case of a 13-year-old boy who presented to hospital via ambulance following two violent generalised tonic–clonic seizures in a postictal state, metabolically acidotic and a low haemoglobin. Acute abdomen was suspected, and the patient underwent a CT scan which showed bilateral acetabular fractures with central dislocations of both femoral heads and free fluid in the abdomen. The patient underwent initial damage control intervention with insertion of bilateral distal femur skeletal traction. Definitive fixation of the acetabular fractures occurred 1 week later with an open reduction internal fixation with novel supra- pectineal plates using a Pfannenstiel incision. We use this report to increase awareness of significant pelvic injuries in paediatric patients post epileptic seizures.

Thromboembolic complications among multiple injured patients with pelvic injuries: identifying risk factors for possible patient-tailored prophylaxis

Background Patients with pelvic and/or acetabular fractures are at high risk of developing thromboembolic (TE) complications. In our study we investigate TE complications and the potential negative effects of concomitant pelvic or acetabular injuries in multiple injured patients according to pelvic/acetabular injury severity and fracture classification. Methods The TraumaRegister DGU® was analyzed between 2010 and 2019. Multiple injured patients with pelvic and/or acetabular fractures with ISS ≥ 16 suffering from TE complications were identified. We conducted a univariate and multivariate analysis with TE events as independent variable to examine potential risk factors and contributing factors. Results 10.634 patients met our inclusion criteria. The overall TE incidence was 4.9%. Independent risk factors for the development of TE complications were sepsis, ≥ 10 operative interventions, mass transfusion (≥ 10 PRBCs), age ≥ 65 years and AISAbdomen ≥ 3 (all p < 0.001). No correlation was found for overall injury severity (ISS), moderate traumatic brain injury, additional injury to lower extremities, type B and C pelvic fracture according to Tile/AO/OTA and closed or open acetabular fracture. Conclusions Multiple injured patients suffering from pelvic and/or acetabular fractures are at high risk of developing thromboembolic complications. Independent risk factors for the development of thromboembolic events in our study cohort were age ≥ 65 years, mass transfusion, AISAbdomen ≥ 3, sepsis and ≥ 10 surgery procedures. Among multiple injured patients with acetabular or pelvic injuries the severity of these injuries seems to have no further impact on thromboembolic risk. Our study, however, highlights the major impact of early hemorrhage and septic complications on thromboembolic risk in severely injured trauma patients. This may lead to individualized screening examinations and a patient-tailored thromboprophylaxis in high-risk patients for TE. Furthermore, the number of surgical interventions should be minimized in these patients to reduce thromboembolic risk.

Management of LC Type I (LC-1) Pelvic Injuries with Complete Sacral Fracture : Is there a Role for Solitary Anterior Fixation?

Background: Management of LC-1 type pelvic injuries, particularly in patients with complete sacral fracture (LC-1 PICSF, OTA type 61-B2.1) remains controversial. Specific indications for solitary fixation remain unclear, and there is a paucity of outcomes data in comparison to combined fixation. We undertook a retrospective study in patients with LC-1 PICSFs to compare outcomes between solitary anterior fixation and combined anterior-posterior fixation.Methods: A retrospective cohort study was conducted with enrollment from 2014 to 2015 at a single tertiary-referral center in China. Adults with operatively managed LC-1 PICSFs were enrolled. Patients with sacral displacement <1 cm as assessed by axial CT received solitary anterior ring fixation (Group A); patients with displacement ≥1 cm received combined fixation of both the anterior and posterior rings (Group B). Reduction was confirmed by manipulation under anesthesia. Patients followed up for at least 24 months post-operatively. Primary outcome was function (Majeed score). Secondary outcomes included intraoperative characteristics, pain (VAS score), quality of fracture reduction (Tornetta and Matta radiographic grading), rate of non-union, early weight-bearing status, and complication rate.Results: 68 (89%) of 76 enrolled patients completed follow-up. Patients in Group A exhibited improved operative times, less time under fluoroscopy, and less blood loss as compared to Group B. There were no significant differences between Groups A and B regarding quality of fracture reduction, rate of union, functional outcomes, or rate of complications. Notably, Group B patients were more likely to achieve full early weight-bearing.Conclusion: LC-1 PFCSFs can get benefits from ORIF; the treatment algorithm should be differently made following the degree of the sacral fractures displacement. Less than 1cm sacral fracture displacement may get good functional outcomes from solitary anterior fixation. However, for the sacral fractures displacement greater or equal to 1cm, both the anterior and posterior pelvic ring should be surgical stabilization.

Falls from Great Heights: Risk to Sustain Severe Thoracic and Pelvic Injuries Increases with Height of the Fall

Falls from a height are a common cause of polytrauma care in Level I Trauma Centers worldwide. The expected injury consequences depend on the height of the fall and the associated acceleration, as well as the condition of the ground. In addition, we further hypothesize a correlation between the cause of the fall, the age of the patient, and the patient’s outcome. A total of 178 trauma patients without age restriction who were treated in our hospital after a fall >3 m within a 5-year period were retrospectively analyzed. The primary objective was a clinically and radiologically quantifiable increase in the severity of injuries after falls from different relevant heights (>3 m, >6 m, and >9 m). The cause of the fall, either accidental or suicidal; age and duration of intensive care unit stay, including duration of ventilation; and total hospital stay were analyzed. Additionally, the frequency of urgent operations, such as, external fixation of fractures or hemi-craniectomies, laboratory parameters; and clinical outcomes were also among the secondary objectives. Sustaining a thoracic trauma or pelvis fractures increases significantly with height, and vital parameters are significantly compromised. We also found significant differences in urgent pre- and in-hospital emergency interventions, as well as organ complications and outcome parameters depending on the fall’s height.