Edited by Phil Grisdela and Matt Fury - 7/1/2021
Descriptors
Polytrauma will most often be called out ahead of time if possible, stratified by level of significance. At Brigham code Alpha is less severe, with code trauma being more imminent. Trauma alert at MGH is less severe, trauma stat you need to be there for right away.
Exam Pearls
Get the page - “Code trauma, here NOW, 55M GCS 3T, HR 121, BP 98/52 after MVC w/ prolonged extrication”
Go to trauma bay, gen surg and ED will be running primary and secondary survey. Get a sense of what the tone of the room is. High energy mechanism? Hemodynamically unstable? Assess for volume expanding pelvic injury. Good place to stand is at the foot of the bed feeling the distal pulses and listening to the secondary survey being run by the trauma team. Don’t press on anything or try to find injuries while secondary survey is going on as it will confuse the team. However, when the secondary survey gets to assessing pelvic stability, this is often a good opportunity (as the pelvis expert) to step in and assess stability by 1. Attempting to “open the book” with hands on the bilateral ASIS and then 2. Attempting to laterally compress both sides of the hemi-pelvis. This takes 3 seconds and then you step back to the foot of the bed and continue to observe. Are there obvious extremity deformities? Are all limbs moving? Are leg-lengths equal? This is not a passive role in the trauma bay.
If you hear ahead of time that there is an obvious deformity or injury (distal radius, open femur, etc) - try to have materials ready before. May need to splint before trip to CT, might need femoral traction or pelvic binder/sheeting.
Your first job is to identify an unstable pelvic fracture causing hemodynamic instability. This is done by checking vitals, and then advocating for a pelvic XR if patients that need it (high energy, MVC, significant fall, etc). Don’t miss a hip dislocation while you’re looking at the film.
Your next job is to assess for injuries that need to be stabilized in the ED. Frequently these people will get rushed to the CT scanner, and having splint stuff ready to immobilize significant injuries can help stabilize the patient before they go. It doesn’t have to be perfect. At a minimum for open injuries concerning for open fracture irrigate with saline +/- betadine, wrap with betadine kerlix
Regardless of whether we are on spine or hand, make sure you have a handle on the whole body. This means paying attention to the spine exam the ED does, doing your own if you don’t trust it. Press on everything, start from the clavicles and go down. Make sure no long bones have crepitus, look at the hands and feet for missed injuries like metacarpal fractures or finger dislocations. Anything that looks deformed, has crepitus, or more swelling than you would think should get an XR.
Irrigate open wounds with dilute betadine, wrap with a betadine soaked gauze or kerlix. Advocate for antibiotics (ancef for Gustillo-Anderson Type I/II, add CTX for type III) and tetanus for any concern for open fracture.
Workup
Radiographs: Standard protocol is CXR and pelvic XR for trauma. On the chest XR you can sometimes pick up shoulder dislocations, clavicle fractures or proximal humerus fractures that may be missed. Pelvic XR to assess for volume unstable (APC 2 or 3) pelvic ring injuries, hip dislocation. Anything that looks deformed, has crepitus, or more swelling than you would think should get an XR. Some need to be done bedside if you think you need to splint prior to CT, others can wait and get done after pan-scan.
Other imaging: Listen to the results of the FAST exam, if there is fluid in the belly or chest the gen surg team may re-route to the OR and your time window will close.
Labs: CBC, BMP, lactate under 2.5, base deficit -2 to +2, adequate urine output 0.5 - 1 ml/kg/hr
Other: When reporting on these patients on rounds if in the ICU you should know whether they are intubated, on pressors (how many?), are they getting blood or other products, hct, INR, lactate, and base deficit.
Management
Need for acute intervention: volume unstable pelvic ring injury gets a pelvic binder on the greater trochs, or a sheet with kelly clamps (can be found in venous cut down tray). Native hip dislocation needs to be reduced acutely, likely with conscious sedation and possible traction pin if significantly unstable or intra-articular comminution found.
Weight-bearing and range of motion: Low threshold to splint in situ here and make people NWB until full tertiary done
Type of immobilization: Be ready for splinting of extremity injuries, can need traction pin or thomas traction for femoral shaft fracture, unstable native hip dislocation or intra-articular fragments in hip joint.
Admission or discharge status: Isolated orthopaedic injuries (femur fracture and distal humerus, contralateral tibia plateau) go to ortho. Those with significant head injury, multiple rib fractures requiring monitoring, intra-abdominal pathology will go to Churchill
Anticoagulation: Be mindful of head bleeds, abdominal bleeds. Can suggest LVX 40 qhs unless contra-indicated from primary
Antibiotics: Classic teaching is ancef for Gustillo-Anderson type I and II, add aminoglycoside for III. Many times will add CTX for GA III. Add PCN G if farm injury or high contamination (prevents clostridium)
Surgical Indications
Absolute: Hemodynamically unstable patient with volume expanding pelvic ring injury needs to be placed into a binder, if they go to the OR with gen surg be ready for ex fix. Call for a Jackson table if possible so you can get fluoro.
