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Poly-Trauma for Orthopaedic Exams
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Poly-Trauma for Orthopaedic Exams
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Language: EN.
Segment:0 .
Hello and good evening, everyone. Welcome to this teaching session, organized jointly by the farc, a mentor group and orthopedic Research UK. The speaker this evening is Mr Peter Bates. He's a consultant, trauma and orthopedic surgeon at the Royal London Hospital.
Mr Burns is a trauma surgeon, he's is head of the trauma at the Royal London Hospital. One of the busiest major trauma centers in the UK. His subspecialty interest is body trauma. And in particular, treatment of pelvic and acetabular fractures. He's elite faculty of multiple post-graduate courses, including MSC in trauma, orthopedic trauma sciences and also trauma sciences, online teaching, distant teaching programs.
Peter has trained in London, and he did there fellowships around the world, he went in London to Stanmore and he spent a long time in New Zealand and Nottingham and in the USA training in trauma. So a lot of experience in trauma, as well as in teaching. So we are very pleased to have him tonight with us. I'm certain that all of us will learn a lot from him tonight. Myself and Shiraz are now and I'll be modulating today and with me other mentors from the FARC splinter group.
We have KneeKG Evans and vertice for Choudhury Muhammad EMOM. So there will all be helping us to run the session and turn the feedback. This session cannot happen without the help of our UK, and we have Ruth, the head of education, as well as Hannah. Ruth will be the co-host and she will help us organize the teaching tonight and she will sort out your certificates and request you to fill feedback afterwards.
So the session, as you see there will be a short presentation at FRC level for the exam. This will be followed by 3 q questions, so please stay focused all the time. The and to answer these questions correctly, then we will invite you where you're always invited to ask questions throughout. And we will filter this question through and to Mr Bates. So please write your questions in the chat box.
Following this presentation, there will be case discussion, and we will ask some of you to take part in this and the following this will be followed afterwards by Viva practice hard drive practice session, and we have places for six candidates. So those who want to take part, please express your interest as early as you can raise the hand symbol next to your name or express your interest in the chat box and we will book you.
We're sorry we have only six places, so please let us know as soon as you can. So we as I said, we just maintain it. We try to keep it interactive, so encourage you to ask any questions you have a big question is a good question. And we have all been through this process of exam preparation. We know Viva practice could feel intimidating, but be assured that you are.
We all in any situation. We all support you and understand how you feel. And if you missed any part of the presentation, though, it will be on the YouTube channel of the farc, a splinter group, as well as on our UK website within a few days. So without further ado, I will leave you with Mr. Bates. Hey, guys, this is a well-attended session, thank you so much for coming in.
I'm honored to be invited. Thank you for our and to the Fox group. It really is, you know, it's a real honor to come to these things and speak to you guys and be invited by such influential people to these things. So thank you very much. I'll talk about trauma.
Poly trauma is one of those difficult things because in most surgical rotations, most orthopedic rotations, you don't get to see much polytrauma unless you sit for a length of time in a major trauma center. But even if you want to make sure things have just six months, you don't necessarily see that much polytrauma in terms of managing it, if you see what I mean. So you might see it at the trauma meeting. You don't necessarily like feel it in the midst of it, you kind of.
So I think it still is something that, particularly amongst trainees, there's quite a lot of misunderstanding and you're not quite sure what you know, what you should be thinking and things like that. So and the thought process are complicated. It's quite high testosterone poly trauma, particularly when you're in the Ed Bay. And so there's a lot of expressed emotion. It's quite like stressful and so clear.
Thinking is sometimes difficult in the heat of battle. Tenotomy OK, polytrauma orthopedic. This is about orthopedic decision making. Really, this is polytrauma generally starts in the bay, with a lot of people doing stuff and use the orthopedic surgeon. I like standing back. Maybe or maybe you're in the thick of it. Maybe you're putting a chest around, you know, maybe taking some blood or whatever it is you're doing, you're secretly thinking, what on Earth am I going to do with this orthopedic injuries?
You don't even know what all the injuries are. You've been told he's got a wobbly leg and his foot's hanging off and he's got wrist fracture and it looks like he's got some ribs or something. And it's been a bad injury. But that's kind of all, you know. And no one else gives a crap about the fractures. Everyone else is worrying about a, B and c, or they're worried about what the gas is or what, when's the next slide?
And things like that. But actually, what you're thinking about is what am I going to do with these orthopedic injuries? And of course, we have this national sense, don't we, of your spectrum of physiological status with stable being at this end and extremists being at this end and like borderline people or unstable people somewhere in the middle. And obviously, these guys at this end are the extremists end, get damaged, get damage control and the people at the stable end get early total care.
And what could be more simple than that? And that's a really elegant, very orthopedic kind of way of thinking about people, about these cases. And then the go somewhere you got borderline and unstable and we'll talk about those later, ok? So of course, on one side, you've got. You got damage control. What is damage control?
We all know what the weight came from, it's a military term, it's about the sinking of ships and all of that. But in orthopedics, it's basically not doing big interventional stuff. It's about putting on external fixations or putting people in traction and not doing nailing a female or nailing of tibia or like five hour operation. That's what damage control is in the orthopedic setting and.
Very obvious, it kind of keeps clicking off. And it all came about from gianniotis, Giannulli and papy back in the 80s and 90s came up with this, this kind of graph, which you're all everyone watching this video this thing will be recognize this guy. Yeah and you'll all know about the second hit, the inflammatory response after the trauma, the second hit phenomenon and and basically after trauma.
You have a little inflammatory response and then it kind of dies off afterwards. But if you do a big operation around this point here, what happens instead, you are sorry. Instead, you end up with this like bigger curve going over the top and everyone has. Every one of us has a predetermined genetic threshold for developing SARS. And so you end up if you exceed that threshold, you go on to develop AIDS or SARS or whatever it is of or, you know, goes by many names multi-organ dysfunction.
There are many names. It's basically an immunological response to trauma, which makes you very, very unwell. OK so and that was all pretty well understood as well, and it was backed up at the time, so I'm struggling with my translations of it. It was backed up at the time with a bunch of papers. This wasn't made up. This wasn't making a whole bunch of papers that are listed down there.
And if you look at the dates on them, they're all around the 80s and 90s. So these were this was a common problem. Patient comes in very, very banged up. He resuscitate them. You nail their femur and then they just die. And that definitely definitely happened. And so they coined this phrase of damage control orthopedics because it's better to be safe than sorry.
Yeah so rather than like, nail their femur, they die. Why don't we do something like an intermediate thing which is less impacting and then waiting to get a bit better and then nail their femur? Yeah and that was the theory and used to say, we're going to wait three days or wait five days or wait how many days it was in your head and then we can go ahead and nail their femur. That was the traditional teaching and that got a huge amount of traction for about 10 years or so.
I didn't get this bizarre. And that's what DCO generally looks like, it looks like an ex fix of some sort. It may be a little traction. But at the same time, at the same time as all of that, there were other studies around look at them around the same time around the same era that were basically saying not the opposite, but basically saying that if you take all patients and you nail all of those early within 24 hours.
Yeah, you get a federal nail into the early within 24 hours, you have reduced odds, embolism, syndrome, lakes versus all the rest. All that good stuff. So nailing early is great. And yet there are some people who just die, and it's clearly the final nail that killed them. So how do we level that? And then Valliere came along.
This is like this is like 20 years later. Yeah and these are the things I need to do the exam. These are the ones to focus on. And if you've got to focus on one of them, it will be that 2015 article, which is kind of the most recent. I'm going to walk you through them. She she's a trauma surgeon in Cleveland, Ohio, and she basically she's a bit of a like, you know, she's a proper stats.
You know, she's a good, she's a database person basically looking at huge databases and trying to make sense of them. And she looks at their trauma database and in and she coined the term early appropriate care. And that's the phrase for the exam early appropriate care. It started off here because in jayati in 2010, she did a retrospective review of a massive trauma database 6,045 patients.
And what she worked up because up until that, everyone had been fixated on femur fractures. It's all about nailing the femur, you know, is nailing the FEMA now good? Or then it was all about the female, but she was the first person to say, actually, maybe this be more of a fever, maybe typekit them or in this as well. So she looks at that, and she showed exactly the same thing as Larry bone and all those other guys had shown 20 years previously that not only is fixing the femur in the first 24 hours, good fixing the pelvis and acetabular in the first 24 hours is also good in terms of your outcomes.
Corrected for ISS and age. Is pelvis last time was suddenly in the mix as well. Then she mixed it up even further. Three years later, she produced this one being a cohort of patients still retrospective, being a cohort of patients, all of them over 18 but corrected for ISS. So they're kind of.
And for age so that their equivalent groups now it was pelvis. Spine fractures, fema, pelvis and spine fractures, what people have come to about axilo fractures like spine, that's not neck. That's kind of the lack of lumbar and pelvis and femur. And again, same defensive treatment, whereas clearly better when corrected for ISIS at an age. So you could argue, well, maybe it's the sick patients who were the worst, and they're the ones that didn't get it, but they still did badly.
And that just hasn't that hasn't borne out of the data. That's one of the obvious criticisms, but actually that hasn't borne out of the data. Another one same year, much bigger, serious 1,400 patients retrospective still again, FEMA pelvises. But this time she's changed the figure, though it's now 48 hours again, prove the same thing. This when she starts talking about lactate lactate less than four within eight hours.
And so start. We're starting to talk about lactate a bit more and we're trying to get it, and that's within eight hours. So if you can get the lactate down by below 4 within eight hours, then they do, then they do better with early treatment, but only if you can get it down within eight hours. Yes, so people who take ages to resuscitate and in this algorithm.
What about chest injuries? Traditionally, we've all been obsessed about chest injuries, so if you have a bad chest, so you've got bilateral femur fractures, but you've also got a bad chest. Now what was the chest? Because traditionally, is it all bad chest? Oh yeah, that makes them more susceptible to things. We better do damage control.
But actually, what she showed was that yes, if you have a bad chest injury, yes, you do have more pulmonary complications down the line and more as well. But damage control didn't improve that early surgery still had fewer complications. Even if you had a bad chest injury, so so chest injuries kind of out of the mix now.
2015 this is probably the article that most people are quoting nowadays, this is her most recent Foray into this because it's smaller numbers you'll notice, but it's prospective. She's taken an algorithm. And now now it's going forwards rather than backwards. She's run it prospectively and see what goes on. This is the one that was everyone was basically waiting for her to test her own algorithm prospectively and definitive treatment in 36 hours of injury, provided the right leg takes less than four within eight hours.
Same thing. So she's basically it's half the complication rate, half the complication rate. If you managed to get them done, what you might be asking your head, why didn't she get more than the why weren't half of them? Why weren't the group who didn't get surgery in that time? Why didn't they get the surgery? The answer is she.
She almost answered this question, she says. It's just because either there wasn't time or the surgeons chose not to do that. For example, maybe they said, oh, wait till morning or I'll do that tomorrow on my list or something along those lines. The surgeons chose not to do that was the reason, usually. So those are the articles that I would be quoting if I was taking the exam and the 2015 one is the one that's the most that's the most, most commonly quoted, however, and this is important too, if you can really get aced this one.
It's important to say that not everyone loves vallese work. Not everyone loves it and papy, because papa you nudists were like, you know, doing their stuff together and papa is really unimpressed. He's a German guy who works out of Hanover. Super famous, quite an old guy, but super famous on the trauma side. He is not bought into this at all, and he thinks this is a real step backwards and he's still obviously sorry.
Sorry, sorry, very much into the trauma, saying he feels her model, which is based on lactate and a little bit on fx, is way too simplistic. Just use acid base, and he feels that she's also overplayed the downsides of damage control. He feels that, you know, damage control is done well, X fixes, et cetera, done well. Actually, the morbidity is very low, and that's something he puts very strongly in his article.
And one thing is true, and now, guys, it's really important you understand this. So I am a follower of the much more of the Valley School of thought than I am of the pap. But one thing is definitely true lactate is good for that Ed setting that early, early, first 24 hours. Once you're out of the 24 hour setting, lactate becomes just one number in a much bigger picture of temperature, clotting, sepsis, ICP loads of factors all coming in, all playing into it, blood pressure, how responsive you are to fluids, et cetera, et cetera.
So once you're into it.you, lactate becomes a bit much less of a sharp tool. And so it's wrong to use lactate to flow through like for 48 hours and then to keep going and going and going with lactate. All right. And that's why Valliere says you've got to get the lactate down below 4 within eight hours, because after that, eight, 12, 24 hour mark lactate is less useful as a predictor, and that's important if you can really nail this topic.
That's an important thing to come out. All right. Sorry struggling with a bit. Expects, particularly for fema, is not a free lunch, and I think that's also an important thing to understand. It prolongs your surgical episode, considerably slows down your rehab and there are lots of things that fixes don't do particularly well.
It also impacts your definitive treatment. So you can have a fixed pin site, infections or poor reduction, you know, you know, keeping the legs short for too long period and making the femoral now harder. It often makes your femoral nail a more difficult rather than easier one unless it's been absolutely anatomically reduced and none of the pin sites pus out. So damage control is not benign.
I'm not saying it's terrible, but it's not benign. Are and so the idea of damage control is the safe option, so why don't we just do something safe? Because that nailing the theme, although it can work out really well, can be very hazardous. That's that's also, you know, it's got to be a nuanced, balanced argument there. There is something other. The next fix you can detraction.
So this has been looked at again as a while ago. Now, bosses group from who's in North Carolina, I think, looked at something other of this. They looked at attraction instead of. They looked at school districts in the initial temporary session of federal self-righteous. Weirdly actually, they study, whether it wasn't significant. It showed a slight advantage to attraction over expects so because they had lower complication rates.
So I think most people now are thinking that damage control can look like skeletal traction. So that's. That's damage control. I want to just take you down. What about this borderline business? What about this middle ground? What's going on there?
Because you've got early total care on one side, damage control on the other. And so what pushes you towards damage control? And traditionally we've looked at a number of things just ignoring lactate for a second. You know, Admiral Paramus passed that kind of thing. Bilateral femur fractures was always something traditionally that we were oh, well, that's dangerous. You know, the patient might die.
Thoracic trauma, chest injuries. Hi excess. Sorry hi, it's geriatric trauma, hi, ICP. Open fractures, their resource, and you can see that. After a while, I mean, every multi patient almost always has one or two of those things, so there's a danger if you take too much notice of these, like these kind of tagline, like all bilateral femur fractures.
There's a danger of all of DCO becoming the default option. Well, we'll just do default because they've got a very low pH or because they've got high CDR or but you see what I mean. But the thing that has changed is this resuscitation is not what it was. Remember, I showed you those articles, they're all back in the 1980s and 90s at that point. This is what this is.
What? Oh man. This is what resuscitation used to look like. It was basically a bit of blood, if you're lucky, but mainly it was normal saline or Ringer's lactate. That was the crux of. You know, that was the nuts and bolts of resuscitation. It was all about restoring volume. It was like putting this volume up more saline, more saline.
And actually, nowadays it's totally different. Modern resuscitation is much more about is much more about restoring clotting. We've got binders. We've got massive transfusion protocols. We're giving tranexamic acid early. We're doing routine to people's kit. We are aiming for a system. We're not bringing systolic blood pressure up to rapidly because we might blow off a clot early.
Ct is right next door to the resus Bay. We've got these that thing in the bottom right, you see is a level one transducer on Belmont machine. These are things which can pump huge volumes of fluid into a patient very, very quickly. You know, and so actually, which gives you a lot of confidence, for example, to go to the CT scanner because now you know that even if they crash, you can still pump blood in very quickly blood products, not just blood, but but SFP cry and platelets.
And in the middle, there is a protocol. Life is so much more protocol nowadays, modern resuscitation. There's not a huge amount that like cerebral thinking that goes in because everybody knows what comes next. It's not automaton process, but modern resuscitation is heavily personalized and it's much sorry. It is much more. And there's also a lot of expertise because we centralized it in resuscitation, in empty seats.
So in the past, it was all about filling people up. Nowadays, it's much more about restoring clotting, turning off the tap, restoring physiology, reducing acidosis radically different, different way of resuscitating people nowadays. So if I take you back to this, this graph of scientists, you got your second hit of surgery. But what people didn't really describe at this time was doing a second hit when the patient is not fully resuscitated.
That's a really important point. Doing a big operation on someone who is not fully resuscitated is highly immunogenic that really gets your immune system pissed because basically the immune system is trying to get its head around being hypertensive and then you're doing something to it, which makes it even more expensive. And that is what can bring about your Serres. The theory goes if you rehabilitate, if you resuscitate people effectively, that's the bringing down the lactate thing, you make them able to tolerate that second hit.
And this comes back, you know, this is actually not a new concept. It blows the first person who talked about lactase had 50 versus 20% complication rate if the ISS was so if there lactate was less than 2.5 at the time of nailing. They did very much better. You know, the complication rate was more than halved.
So the idea of lactate being a predictor in this 24 hour period is nothing new. O'Toole in Baltimore, they had a traffic light system where they talked about 25. And now you've got valve. We're talking about less than 4 to eight hours. This is what we're lactate comes from. It's just that in the first 24 hours, it is a useful indicator.
A multiple different authors have shown that a different way. So when you're resuscitated, is that when you go back to this diagram, it's all about resuscitating people from their extremist state to their stable state. That's that's the problem with this diagram is that you're assuming that it's a static thing, but it's not as a dynamic picture.
You're taking someone who's an extremist, you're resuscitating them such that they're now stable patients and now they should be good for early total care. All right. That is what has changed is really resuscitation that has changed the gig here. And what is elevated, OK, this is the definition given by Chris Moran about five years ago, so this is fairly recent, but not that recent definitive fixation or long, long bones within 24 hours of injury was the patient is physiologically stable.
He wrote that about the same time as O'Toole came out with his thing in 2010 and in around about 27. Yes, but anyway, this was in response to O'Toole's paper talking about the traffic light system. Long bone fractures, what is a long bone fracture? What is the long bone fracture? It's a good question, isn't it? I mean, it's not that's not a long bone, right? OK, but a femur?
Let's call that is a long forearm. Is that at all? Well, they all quite long. You know, almost my forearm is probably longer than some girls femurs. But anyway, no one's pretending that a forearm fracture is actually like systemically upsetting you. Humerus is a totally a long bone, right? That's way longer than than, you know.
Here is a long way, but it's not. It doesn't count in this setting, so we don't see people putting on damage control surfaces on people's humerus, do we? What about tibia? That's a long bone, right? And yet, is it? No one has ever demonstrated no one has ever proven that needing someone's tip early gives you a better outcome or reduces your level of odds or scissor or mods or whatever.
Yeah so actually, tibia doesn't really fit the bill for a long bone, either. Weirdly so what is the long bone? I mean, if validated, to believe long is pelvis, spine and femur. So this term, long bone, you've got to try and get that out of your head in an exam setting. I would not be talking about long bone injuries because nowadays the systemically upsetting injuries are caused or axial injuries pelvis by feet.
And so early appropriate care is fixation of pelvis, spine of femur. Oh, there's one more as well. One more potential one which is yet is unproven and that's this one, the chest injury. Where does chest injury in that setting that we do not know yet, because we've got a randomized controlled trial?
One conclusion in Canada recently, which was which was equivocal. We've got the RF trial, which we're in the middle of right now, which is the UK version of that randomized controlled trial. Looking at fixing, this is no fix of rib fractures. We don't know whether fixing people's rib fractures improves quality, improves outcome, but it may turn out to be that that's yet another axilo fracture and could be added to that list.
But at the moment it is fema, pelvis and spine as the things to go for early. And I take you back to this. What about this identifying the borderline patient? Well, let's look at those. Let's look at this abnormal parameters pulse lactate. Those are all correctable. Remember, it's 36 hours you could do a line, 36 hours you could really resuscitate the hell out of someone in 36 hours.
You put their finger on traction and you just wait until I just went to wait until they're ready. So those are correctable items. Open fractures, thoracic trauma. Actually, if anything, that increases the urgency, we need to get them to get quickly before we develop complications from those other things. Hi is geriatric trauma. Same principles if you can bring the lactate down within eight hours, you're good to go.
Same with bilateral femur fractures. Fix, but cautiously fix now. I'm being a little bit aggressive with this because I'm making out that, you know, if the lactase down that you're good to go and you can close your AIIS and you can go ahead and nail that FEMA. And that isn't quite true because actually, if you got bilateral femurs, you can nail the first one you want to be seeing at that stage how they lactate going.
If the lactate is rising, you probably want to stop. So often you can have a bit of early total care or the only appropriate care and a little bit of damage control as well. Maybe I'll put that one on traction overnight. Hi, ICP, this is the one that kills us orthopedics, because often the neurosurgeons will not let us go to theater because the ICP is high, and so even though their lactate may be low, low, low and always been low, you still can't take their femur because that will raise their ICP.
So actually in our hospital, the thing that stops us going more often than is not high lactate, it's high ICP. So to conclude. Stable patients. Apologies, stable patients get early, definitive care, and that's fine, and no one's going to argue with that. All of the other three get resuscitation, and the early results are not the late resuscitation.
The early resuscitation sits around lactate and you can be patient. You do not have to dive in tonight. You don't even have to go tomorrow morning unless there's an open fracture, but you've got time to let this patient settle before you intervene. Some fractures, some patients will end up. Therefore, after you've sorted them out, they may end up into early, definitive treatment, in which case you're still in that great beneficial zone.
You prioritize the injuries to fema, pelvis, spine. Go first and then other things go second. What's the appropriate bit? Then what is this early appropriate care? And here it is. No one. No major surgery on resuscitated patients. That is the killer point. If there's one thing you take from this talk, it is do not be performing major surgery on people who are still under resuscitated.
OK, second point. Cease major surgery, if lactate is rising, that's what the appropriate bit is, is basically saying, yes, you can go and do your thing, but what I don't want you doing is making this patient worse just because you're blindly doing surgery. Six major surgery if you're a. Just I've got it's got a little blue hand there.
I thought there was no repeat. That's that's for the Viva. OK, great. I'll repeat that. Appropriate means no major surgery and under resuscitated patients, it also means that if you're doing a bilateral femur on someone, you do one femur and then you look at the lactate and then you save the anesthetist.
If the lactate starts rising during this operation, please tell me and I will stop and I will put skeletal traction on. OK that's what only appropriate care is. So in some way, damage control, orthopedics is not plan a x, fixes are not benign and nor skeletal traction for that matter. So resuscitate to allow early appropriate care and you'll get 90 percent, your patients will end up getting early appropriate care.
No major surgery surgery if lactate is high. Consider traction versus fix if you're in that damage control situation, early appropriate care, definitive treatment of pelvis, spine of femur within 36 hours provide your lactate is below for, I have to say, and I think you would all agree those of you living in the NHS would agree. That is a massive challenge for the NHS to get spine and pelvis and all femurs fixed within 36 hours.
It's quite a challenge and that's something I'm making out. This is the gold standard. We do not achieve that in our hospital every single time. And I want to pretend that we do because it's difficult. We don't really have the resources for that necessarily. Twice that's my talk, I think now's a good time for questions and then we can move on to other stuff. Lovely, peter, thank you very much.
That's thank you for all the energy you've put it into this presentation. You emphasized all the important points very nicely. I like how you put on this balance between damage control, early total care and have you reached to the early appropriate care afterwards? Very nicely smoothly. I think very clearly explained to all of us. I was there have been a lot of questions and you actually answered most of them during your talk.
So so but one of the questions we had from Rachel, which is a simple but meaningful question did she ask, how do you define poly trauma? Is do you have any, you know, if you know, a specific definition for it? Do you use any score? No, no. And it depends which article you read. Some define it as over greater than 8.
If you're working in a place that doesn't get much quality trauma, or most people define it as an ISIS greater than 15. That's usually what you say is someone who is probably traumatized. ISIS growing 15 is like the sort of is probably what people most accept, but some people draw that line differently. Yeah you know, when you're writing a retrospective paper, you look at all the iss, you think, well, these guys in as well.
So you've got to stretch it one way or the other. So to make your series is bigger. But most people would say ISIS greater than 15, I think that's the most commonly quoted. Thank you. And just for Rachel, I think what's going to be the next question from the examiner here? When you say that you're going to tell you, tell me about the isis, so be prepared.
So, Yeah. OK, so when you're defining isis, don't get bogged down into a square root of this. And the square of that and getting all. Don't overcomplicate it just to talk about the. Just talk about it simply and schematically, rather than trying to, like calculate an ISIS from a mythical patient. Otherwise, you will tie yourself in knots.
It's not 100% straightforward, is the answer. Absolutely yeah, keep it simple. From your experience in working in a trauma center is a fat embolism with femoral fractures a common thing or. Yeah well, I would say it's common. I have one. Like last Friday, exactly that week, he had an isolated femur fracture.
It goes to theater young guys, often young men who experience it. And we know this female operation would very nicely didn't go on too long. It comes back to wakes up and he's fine. And then the next day, he's just all confused and he's all over the place and he ends up with. It turns out he's got a fat embolism. So yes, it definitely is a real thing.
Definitely and how about a pre preoperative fat embolism as a result of the fracture? Can that obviously it can happen, but is it? Is it common? Well, we didn't see that anymore. We just don't see that anymore because we're so aggressive about getting people to theater as soon as we can. So it's very, I mean, does sometimes in the people who are absolute extremists and they are almost dead when they arrived.
And so resuscitating them takes much longer than normal and they have a huge like surge response afterwards. You know, almost immediately afterwards and you basically the lactate never really comes down. Those those are people who often do develop serious injuries or whatever before you get to them, but they were terribly, terribly sick beforehand. The whole of the rest of the population, we generally get to them before.
So fat embolism, syndrome and AIDS. And these things tend to be post-operative rather than preoperative. Lovely because the question was from Rachel is whether you if you diagnosed fat embolism, whether you would nail or plate that patient, but you're saying you wait for them to get better, you just wait for them to get better and then you do it, wait for them and made it up to you. And then again, for 90, because that is by far the best operation for a FEMA fracture.
Yeah lovely. I think. Now you all qualify that if you decided that you wanted to put an ex fix on while you're waiting for that patient to settle down and like get all their metrics back together, and that would be a totally reasonable thing to do. But it wouldn't be then plating the femur in the hope that.
So I don't make this because, you know, we all know that placing a femur is a terrible operation because the plate just can't handle it and the plate will break and then the plate comes off and they're going to nailing and all the rest of it. So the nail is still the best operation for a FEMA fracture. It's just so I wouldn't compromise on that. But if you want to put them in an ex fix for a week or so while the patient settles and their fat embolism sorts itself out, then that's yeah, go for it.
So that you are in damage control situation there and the only appropriate thing goes out the window. Yeah and I think you highlighted how early appropriate care is applicable with appropriate after following appropriate resuscitation, and the results have improved with this reconfiguration of the trauma service and to more specialist trauma centers. So this all play part, isn't it in the outcome and no expertise is a huge thing.
So by bringing all these major injuries into major trauma centers, it's hugely changed the outcome. And Chris has got some awesome slides of how mortality from major trauma has come down massively since we, you know, it's NCTC started back in 2012, you know, and I think my advice is because this sort of an exam scenario is we put that in the answer to show high order of thinking that we've been there in the trauma centers and not just numbers of lactate or 36 or 24 or eight hours.
We show this other factors that expertise, that resuscitation, the advancement of resuscitation, other things that have to play important part in the outcome, not just simple numbers. Oh yeah, absolutely, absolutely. Yeah, that's right. The ground has shifted from the nudist and puppy days where they were talking about this. There was a real, real hot topic conversation.
A fundamental thing has happened, and that is that resuscitation has come on massively. And I don't know if that comes into your territory, but there is a question from Saab is asking how exactly the mechanism of fat embolism. They seem to be out of interest in fat embolism tonight. No, no. I don't think anyone really understands fat embolism. I think what most people are agreed.
It is not a lump of fat going into your brain. Yeah, it is. It is. I mean, it may start with that. It may start with some kind of fat in your system, but to suggest that there's more fat in a fat embolism present system than it is in any, you know, we know that if I was to nail your femur right now, for us, even an intact FEMA and I put a Doppler thing in your heart, you would see globs of fat bubbling through your right atrium as I nailed your femur.
That is that happens to everybody. So everyone gets like a bit of a fat, let's call it. But so, so everyone gets the fat. It's your response to the fat. So I think most people are now thinking that fat is fares odds SARS models. They are all different manifestations of an immune immunological response to trauma. Yeah so it could be.
Yeah, as you said, it's probably as you said, we don't know exactly the pathophysiology behind this. It could be inflammatory response. Yeah, it's some kind of massive release of interleukins into your system. So rather than acting in a crime level like, you know, locally, they're acting on a systemic level, which makes all cells in that area go crazy. And then you make that makes sense.
It's not a lump of, yeah, it's not the lump of fat that has went through the circulation and we're stuck in your brain. That's causing the problem. Yeah, that's right. And just do one more question is, are you waiting for a patient with a similar fracture with the fat embolism to be fit for surgery? Do you put them?
Do you give them put them an attraction or fix them? So someone who's had a fat embolism and they're waiting for surgery. Yeah, this is rare, isn't it? You said it's real. I think some people say dealer's choice putting someone on traction for more than two or three days is really problematic.
I mean, what? We've all seen that in our own practice, it's not a great thing. It's very difficult to nurse someone in traction and expect is a much better solution if you think that they're going to be better tomorrow. So you're waiting for them to just to come fit all. You're waiting for this to crop up, then you can put them in traction.
But I think if you're expecting like a three or four day wait till surgery, then putting them in the next fix is a very reasonable thing to do. Lovely thank you very much, Peter. Really appreciate your input. Yeah, I guess that talk very much feels like I'm dissing the X fix, and I'm like, god, you don't want to put these X's. They're all terrible.
There's definitely a role for Exelixis. I still put X fixes on femurs in very sick patients, but it's usually the very, very extremist people, all the people with head injuries or the people, as you say, who have had something weird going on. And for some reason, there's going to be a delay to fixing their femur for whatever reason. And I think just for purposes, whenever you presented with these questions, guys, it is just it is a changing situation.
We always continuously monitoring the patient condition intraoperatively post-operatively. So if you take a decision and you find the patient is not fit, you can always fix one limb and fix the other. You just always continuously. The next day you are monitoring the patient. You know, if they are better or slightly better, you can fix and think they stabilize even more.
So just show them that you monitoring the patient continuously and don't just make one decision and stick to it. You'll have to change your decision several times, maybe before you reach the final operation. Good so now we will move on to the execu questions. There are three questions if Ruth can kindly share them. So, OK, guys, so as usual, this questions three questions will give you a couple of minutes to answer.
I hope you can all see them. And just to remind everyone, it's anonymized, so please do have a go at answering the questions, no one will be able to see your answers. Thank you. Thank you for that reminder. And so please, every single one of you attempt. It just gives you an idea of where you are.
And in terms of your exam preparation and and it's very helpful for you to make sense of the answers afterwards, and Mr Bates will take us through this in another minute. So please ask everyone to. If anyone have any problem viewing these questions, please send us a message.
And once we're done with these questions, Peter will have a discussion. And there will be some more questions during the case discussion, which we have set up also. Is that correct route here? Yes, that's correct. So if everybody can attempt these questions, we'll wait until most people have answered them and just a reminder, it is anonymous, so please do attempt them.
Yeah, we have at the moment you have 191 participants, so. We'd be nice to have 191 votes. What answers?
So case discussion after this and then would be Viva the Viva session is not recorded, obviously, as usual. And we have already picked the candidates for the Viva. So Thanks, everyone who raised their hand and sorry if anyone didn't have the opportunity.
So three minutes now, we normally give you three minutes, but I think more of you are answering the questions, so we will give you a bit more time.
OK, so we have 80% answer rate at the moment, so should we? Are you happy, peter, to take us through these questions. Thank you. Pizza hang on, I think you've muted yourself, you've muted yourself, sorry. Yeah I thought, Peter element.
So the top the top three are all definitions of major and massive hemorrhage, and the bottom one is just something made up. Basically, you calculate massive hemorrhage on how much blood do you think they've lost? Not on how many products you've given them. That's why that last one is incorrect. The next one is 26-year-old guy rising after rta, anti-American wound or the right calf.
So he's got he's shocked, isn't he? 24 blood pressure, 83. Over 50 cold peripheries. He's got a right tibia fracture, which is open, isn't it? Because he's bleeding from an open wound on his right calf femur, multiple rib fractures? He's pretty banged up, which is not a first line action pressure to the leg. He's bleeding from his leg.
What do we do with bleeding? We press on it, don't we? You can put tourniquets on in the field, but that is very much an out of hospital thing. If you've got a long way to come and someone is literally got an arterial bleed that's hosing out and you haven't got someone to press on it. That's that's, you know, tourniquets pretty niche, honestly.
IV antibiotics, that is actually emergent care now, you know, based guidelines, IV antibiotics need to get in there within three hours, but ideally it's going to be within an hour soon. So IV antibiotics, they're part of the emergent setting tranexamic saying early first hours what those in ABGs everyone was not that lack lactate is that the avg really tells you what the systemic state is so that the anesthetist wants that straight away.
And if they're shocked that you are starting a massive transfusion protocol, rotem, the reason why that is wrong is because actually wrote him is not a great thing for when a patient comes in, you don't care what their clotting is. You're about to throw back into them and you're going to do that. Whatever happens. So whatever the clotting is at the start doesn't really matter.
You're going to throw paquet into them. And then after parkways gone in, you'd like to know what they're what, what they're clotting is doing. So routine is something you do like into the resuscitation almost as phase two rather than at phase one. The next one is. Damage control, orthopedics.
And systemic inflammatory response, so what was the right answer there? Ultimately, sorry, all of those are true except early. The fixation within 36 hours is strongly associated with a reduced SARS and AIDS. This one, in particular patients with chest injuries. Damage control is usually preferred. That is not the case anymore. That used to be the case, but as I was saying in my talk, chest injuries.
Now, if anything, a chest drives you to do draws you to do early appropriate care. Almost more forcefully, you want to get in there quickly before their chest deteriorates, because if you leave them and you don't do a damage control and you don't do your definitive nailing, but you do damage control, what you end up happening with is the patient now has a really bad chest and they have a broken femur, which are not sure what to do with.
So chest injuries almost drive early appropriate care more than they do previously. And that's why that middle one patients with chest injuries is the correct answer. So I got a bit muddled by now. You know, you're correct, it's a bit confusing the way it's set up. Yeah, because that's just the most commonly answered question I thought red that was the correct answer because all the other to the people have got the correct answer.
Yes yeah, Yeah. All right. Great Thanks. So thank you, guys. Thank you, peter, for explaining. And we can move. Can we move on now, please, to the case discussion? Yeah, sure. Let's do that.
Ready? Yes. To just to let you know, I've set up the two mic polls. So just let me know when you want me to run those questions to the audience during this. Oh, you set them up. I have. I've managed to, so just give me the heads up and I'll run them. OK, great.
All right. Lovely OK. So one at a time. So my still screen sharing, you still see my screen. Yes, we can see your screen. Lovely OK. So this is the case. This is the case. We've got a 14-year-old male most that you can read it all is right there.
He's found a lawyer for his, but it's obviously a big injury and he's got a whole load of injuries. I want you just to read those and just get your head around them. He had an office rapid sequence reduction at the scene because he was combative. And so obviously he's got a bit of a he's got a bit of a head injury and he was a bit shocked.
So they so he's intubated. There's bleeding from the groin, from the groin wound at the scene, but that has now stopped. So he's got this big groin. I'll show you in just a second. And he's any day now, and his human dynamics are improving with paquet. So actually, those figures that I'm showing you, there were the second lot.
The first lot was somewhat worse than that. OK, so he has improved a little bit with pack. All right, here's his stuff so that on the left of your screen, this is a different patient. I got I got off the internet because I haven't got a picture. This guy's growing laceration, but that's exactly what it looked like. His leg.
Is this his leg here? This is ball bag there, which has been pulled over to the left side and to his left side. And here it is. It's been stuffed with some packs and it's a big groin laceration. If you were to poke your finger in there, your finger will be straight down onto his pelvic bone and there's a fracture underneath.
I haven't got a picture of the pelvic fracture. That's his open tibia wounds about that long, about two or centimeters. Those are his X-rays. He's got his left femur and his right tibia. So, right, female to be. I've got this wrong around here. It's the other way around. So left egawa right tibia, tibia is open, femur is closed, and that's his groin laceration, which was bleeding heavily at the scene but is not bleeding anymore.
All right. He's also got a head injury, and he's got some maximum facial trauma. So first question. First, OK, one second. Brace yourselves. So I think the best way for this don't work out is this someone just puts their hand up and volunteers to just talk about what they think is probably their best choice answer.
It's 600 PM this guy comes in at 600 PM. When does this patient need to go to theater? All right. OK, so guys, doing OK, fine, yeah, do in just a couple of minutes just to answer the poll, not that long, but just to let the poll go, and I'm not going to wait till all 181 have done.
But let's see what people are preferring. OK, so we've got a few right now we people liking to wait until the lactate is down and then go. OK, great. Like just another 20 seconds, and I'll close. Not right now, but within a few hours. OK right, so. I'm loving that you guys are waiting for the lactate to come down and then go, and that is actually not an unreasonable search.
The truth is this will become a bit of a theme. All of these are perfectly reasonable strategies as long as your rationale is correct. It's OK to take this patient to theater right now. That's perfectly OK. A lot of theater. Take it upstairs is absolutely fine. What's the downside of taking them to the theater right now? What's the downside of that?
Well, the downside is that you work, that lactate is still quite high. And even if it's there right now or within a few hours of now, if the lactate is still a little bit higher, there's only so much you can do to the patient. You can wash their wounds out and you could change those packs and wash it all out and put small packs in. And maybe you could put some fixes on.
So for the right now, people, and they're not right now, but within a few hours, people. That's not incorrect. That's perfectly reasonable thing to do. But if you do that, you're not doing definitive treatment of any of the fractures. Notice how the weird thing is, you could take this patient to theater right now. You could put you could put on the femur.
You could put an X on the femur and indeed on the tibia, and then you could bring them back and get back to the ICU. They could then come back again into the theater within 36 hours. Have all those expenses taken off and have it and have someone else put up a terminal put up, have the pelvis fixed. And if they had a spine injury, had the spine done so, it could still be early appropriate care and yet?
You are to put traction on you, put Exelixis on it with me, so just because something's early appropriate care doesn't mean it has to happen tonight. It can still happen tomorrow and still be early. Appropriate care tomorrow morning will be fine. Not many of you liking it, but actually at the Royal London hospital, that's often what happens. Patients come in like this and they end up and we see them. So we go, OK, let's recess them overnight.
Leave the binder on, and tomorrow we'll line them up to have all this fixed up because he's not dramatically bleeding within the next 24 hours. Agreed well, probably that's the only one that I probably would go against is because he's got a big open wound in his. And so the latest both guidelines for open fractures is that they should ideally be going to theater within 12 hours.
And so choosing someone who's 24 is a little bit outside of your post guidelines on that one for open fractures. So I probably wouldn't have gone with that one. Wait until that takes down there and then go, that's fine also, but only up to a point. So the red guy is the most common. That's totally fine. And that's actually the same as tomorrow morning will be fine. Those two are basically the same thing because tomorrow morning the lactate will be down and then you're fine to go and do it early, definitive.
So my preferred answer for me tomorrow will be fine. I'll wait for the lactate comes down, but the right now people are not wrong, you're just going down a slightly more aggressive damage control route. But you can still do early approach primary care even if you put them on traction. So that's my take on that one. Try the next one.
OK, I'm just going to leave that up. The patient goes to theater for non orthopedic reasons, so that's either a bolt get put in their head or they, the general surgeons, decide they want to do a laparoscopy for whatever reason or they have an ischemic leg. Something happened. There was not orthopedic, which forced the patient because they're now in theater that NIPE.
What are you going to do? They're in theater and they're saying, come on, Mr author, will you want to do? Haha, I love it that you're all split. It's great. Just let this pan out, but usually usually the proportions don't change that much as we go.
And again. 100 people have voted are going to crack on again. The funny thing about is all of those are perfectly reasonable strategies as long as you have a reason for doing it. So what? What is the common theme with all those four options? What's the common theme no one is wound wash out comes first. OK wound care in trauma.
You can fix bones and stuff, and that's great and you can put fixes on. And that's great. But one thing you do not want to go back to think about is if this patient gets sick and I just have to come off table right now, let's say that a heart attack or stroke on table, I have to stop and I downed tools and I have no more orthopedic treatment to do.
What do I not want them going back to the intensive care unit having not done? Do you see what I mean? What's the thing I don't want to leave undone when they go back, and one thing which is a real nuisance if you don't deal with it now is wound care. If patients have underpriced head wounds, they will fester and turn septic and it's all downhill. So wound traumatic wounds need to be a priority within that first visit to theater.
So all of those options you'll notice I put wound wash out as the first thing, because that is, that's the right thing to do. OK you could put traction on put a binder on if they're given a binder is perfectly reasonable. So even if you got a theater, you don't have to put an extra X on. You can still leave that, wash out the wound, put a binder back on and then and then come out.
That is all you could leave the binder off and just put it back on it. The hemodynamically unstable just because they've got a pelvic fracture doesn't mean they have to have a binder of pelvic binders or hemostatic ages there for stopping hemorrhage. They're not for they're not for making an X-ray look good or reducing a pelvic fracture.
They're there to stop bleeding wound wash up ex fix pelvis, fix femur again. Totally reasonable. As long as you're dividing the wounds, you get an x, fix everything else and come back another day. This patient may still be good for only appropriate care. As I said earlier on, when you wash up, then recheck the lactate. Yeah, absolutely.
Very reasonable. You've been really aggressive to take the data. You could wash out all the wounds and then see how they're doing. They might have been resuscitating enough. Lactate is now down at two point eight, in which case why not nail the female? They're in theater. Go for it, man, do it.
Finally, win wash X the pelvis skeletal traction to female again, perfectly reasonable. You can expect this in my head. X fix is a skeletal traction. Are interchangeable in that early stage in that early bit where you're trying to just temporizing patients waiting for them to resuscitate properly. All right. So actually, none of those are wrong.
All of those, you can argue, very, very reasonably provided you're taking care of their wounds at the first set of visit. OK right. I think that's it, isn't it? I think that's our poll done, that's done. Yeah Yes.
Great I'm going to go back to this guy now. So there he is. What are we going to do and what are we going to do with this guy? How do we make sense of all this stuff that's going on and it's more complicated, this is going to be there's going to be figures are going to be blood gases, there's going to be bees, there's going to be other people coming in with information.
So how do we make sense of what this patient needs? And here's how I rationalize it. Obviously, polytrauma is more complicated than this, and I'm not pretending it's all very, very straightforward. But here's how I rationalize this. Sorry this needs resuscitation, and I think we'd all agree with that. He still needs resuscitation, he's still acidic, therefore resuscitation needs to happen.
These guys need wound care. All right, and we've talked about wound care. These three need their bones stabilizing, the femur needs ephemeral now, tibia needs a tibial now, or it may be an asphyxia is open depending on how you want to play it and the pelvis needs fixing as well. And finally, you've got Max fax and you've got a head injury and you've got your open tibia and those need communication with other specialties.
Notice I've left wing with comms because that needs more than plastics. Also in his plastics as well? Yeah so whenever you see an open fracture, do not forget to see them say the word plastic surgeons. Yeah, and it should. Nowadays, it's plastics consultant. It's senior plastic surgeon post TCT plastic surgeon. All right, so.
And how do you how do you order those? Pretty much. In the order I've done, resuscitation comes first. Absolutely comes first. Then you want to know what other guys are planning, right? You want to know what, what, what, what they're doing about the head injury. What you do about the match facts. What do you want to do about these things?
Communication is the next thing down. Talk to your colleagues. What are you up to? Talk to the anesthetist. What are you up to? How bad is the patient? How was the systemic situation, et cetera? When you're going to go to theatre, the next priority is definitely wound care and then at the bottom of it is stabilized bones.
All right. So as a basic rule of principle, that is your order of service to resuscitate, communicate wound care, stabilize bones and stabilizing bones, of course, can be definitive or temporizing, and definitive is like a definitive is like, you know, like a femoral nail and temporizing is a sort of skeletal traction. And that's exactly what we did.
We discussed it with colleagues. I discussed the case and we gave it some time. You know what we did? We waited till morning. We waited till morning. And sure enough, when we got to the morning, the lactate was now down. At 2.8. The ICP was actually down.
Was not too bad. We gave it some time and now it's time for wound care. It's 10 hours. It's time to get in there and do something now because the lactate is down and we can move so we go to theater. The lactate, the whole thing. Nothing changes very much and we decided I decided because it was just it was the easiest thing to do.
The tibia was wobbling around. We divided the wound. The lactate was good, and so I thought I would. I would. I would nail the tibia. So we did that. So we did a tibial tibial nail the femur and temperature on the same side. We then did a retrograde femoral nail, and that was all good and and patient patient ends up doing well, recovered well or good.
Actually, it turned out that the laceration on the pelvis was nothing too serious and actually it was an LC one which didn't which which just needed an AC screw. And when we did that a few days later and we closed up all the wounds at the same time. So what I've given you, there is quite a nice, soft, easy polytrauma. Yeah, nice. Nothing too difficult. Nothing to complicate it.
But what happens if poly? So that's a true case. Now you're going to be thinking, yeah, but what if? Yeah, but yeah, OK, that. But what if, for example, there was a big chest injury? What if there was a major head injury? What if, if that subarachnoid, what is the ICP have been 20 three, not 13? What if there have been blood pouring out of that guy's pelvis, like pouring out and you pack it and pack it, and it's leaking around the packs and his team is dynamically unstable?
It still is. You know, what would you do in that situation? How does that change what you would do here? So let's walk through those OK, patients got a big chest injury. What would that? How would that change what I did? Honestly, that wouldn't change that situation. I would do exactly the same.
It it wouldn't come into the reckoning. Now what it might do has got really bad chest injury is it might make the lactate a little bit higher or harder to get down, in which case that yes, is the lactate stays high. Then you do have that drives you towards some kind of damage control situation. But if you can get the lactate down, the chest injury in my head doesn't actually come into it.
It is relevant, but it doesn't come into your orthopedic decision making. OK, so that's chest injury, and that goes back to the interview, we had earlier on. And is there evidence for that? Yes, there is value dealt with this in her article. In her articles, vallese dealt with this and she said, you know, she looked at a chest injury and leaving it.
Leaving a chest injury with damage control was worse than appropriate care with a chest injury. And we know how chest injuries can deteriorate, right? So this is a little old lady who stuck. That's an X-ray to begin with. And then literally two days later, two days later, sorry. Sorry man, that's how extra energy comes in, that's the X-ray tube days later, she now you see she's on CPAP.
And so she ends up getting getting, getting a chest fixed. Now I'm not saying, I'm not saying, I'm not claiming that rib fractures are things that need to be fixed immediately. What I'm saying is that chest injuries are relevant, but not your immediate orthopedic decision making at the moment, and that evidence may change next. What if there's a major what if there's a major bleed, a major head injury?
Well, that often drives you towards damage control. So if I knew that this patient's ICP was 25 or 36 or something, I would actually put X fixes on it, on that, on that femur, because I know that patient's not coming back to theater for at least three or four days, I'd either put a little traction or an ex fix major bleeding. Major bleeding needs controlling, so you've got to control the bridge, you're still in sea, you're not you haven't even got to communication yet, you're still in resuscitation, you're still level one, you've got to pack it to analyze it.
You've got to do whatever is required to stop that bleeding. And that may require general surgical access. And so you need your trauma, guys there. All right. So so other things do change the context. But ultimately, orthopedic decision making is one two three four in my head. so.
Would wound care. So when you do, your surgery speed is actually quite important. Familiarity is also important and having two teams can be really helpful when you're dealing with trauma. When I say spade, I don't mean you're trying to rush the operation. I'm just saying that getting an operation is done reasonably quickly.
Not spending four hours over a femoral nail really does help the patient. So doing a femoral now quickly is important and familiarity with that. Obviously, those two are linked. And having two teams that someone's fixing the forearm or somebody else is doing a retrograde femoral nail is really, really helpful to.
And keeping an eye on the lactate intra, OK, so if you're doing some major surgery on some warming issues, if the left lactate keeps creeping up, it starts creeping up. Please tell me and I will stop and I just put them in traction, ok? Great So prioritisation, in summary, is resuscitation, communication, surgical decision making about whether get ICU angle or theater that's in the Ed and then we don't have to go to the theater now you can do, but it limits your options a bit.
But but you but you don't have to. Wound care at the first visit, and there are different flavors of DCO, DCO can be, but some of the attraction for now and then fix them. And then turn back to theater in 20 for 48 hours or still within that early appropriate care window. And for definitive treatment, think about doing surgeries briskly so that, you know, it happens and it gets done and the patient's off table and keep him on their lactate while you do it.
Segment:0 .
Hello and good evening, everyone. Welcome to this teaching session, organized jointly by the farc, a mentor group and orthopedic Research UK. The speaker this evening is Mr Peter Bates. He's a consultant, trauma and orthopedic surgeon at the Royal London Hospital.
Mr Burns is a trauma surgeon, he's is head of the trauma at the Royal London Hospital. One of the busiest major trauma centers in the UK. His subspecialty interest is body trauma. And in particular, treatment of pelvic and acetabular fractures. He's elite faculty of multiple post-graduate courses, including MSC in trauma, orthopedic trauma sciences and also trauma sciences, online teaching, distant teaching programs.
Peter has trained in London, and he did there fellowships around the world, he went in London to Stanmore and he spent a long time in New Zealand and Nottingham and in the USA training in trauma. So a lot of experience in trauma, as well as in teaching. So we are very pleased to have him tonight with us. I'm certain that all of us will learn a lot from him tonight. Myself and Shiraz are now and I'll be modulating today and with me other mentors from the FARC splinter group.
We have KneeKG Evans and vertice for Choudhury Muhammad EMOM. So there will all be helping us to run the session and turn the feedback. This session cannot happen without the help of our UK, and we have Ruth, the head of education, as well as Hannah. Ruth will be the co-host and she will help us organize the teaching tonight and she will sort out your certificates and request you to fill feedback afterwards.
So the session, as you see there will be a short presentation at FRC level for the exam. This will be followed by 3 q questions, so please stay focused all the time. The and to answer these questions correctly, then we will invite you where you're always invited to ask questions throughout. And we will filter this question through and to Mr Bates. So please write your questions in the chat box.
Following this presentation, there will be case discussion, and we will ask some of you to take part in this and the following this will be followed afterwards by Viva practice hard drive practice session, and we have places for six candidates. So those who want to take part, please express your interest as early as you can raise the hand symbol next to your name or express your interest in the chat box and we will book you.
We're sorry we have only six places, so please let us know as soon as you can. So we as I said, we just maintain it. We try to keep it interactive, so encourage you to ask any questions you have a big question is a good question. And we have all been through this process of exam preparation. We know Viva practice could feel intimidating, but be assured that you are.
We all in any situation. We all support you and understand how you feel. And if you missed any part of the presentation, though, it will be on the YouTube channel of the farc, a splinter group, as well as on our UK website within a few days. So without further ado, I will leave you with Mr. Bates. Hey, guys, this is a well-attended session, thank you so much for coming in.
I'm honored to be invited. Thank you for our and to the Fox group. It really is, you know, it's a real honor to come to these things and speak to you guys and be invited by such influential people to these things. So thank you very much. I'll talk about trauma.
Poly trauma is one of those difficult things because in most surgical rotations, most orthopedic rotations, you don't get to see much polytrauma unless you sit for a length of time in a major trauma center. But even if you want to make sure things have just six months, you don't necessarily see that much polytrauma in terms of managing it, if you see what I mean. So you might see it at the trauma meeting. You don't necessarily like feel it in the midst of it, you kind of.
So I think it still is something that, particularly amongst trainees, there's quite a lot of misunderstanding and you're not quite sure what you know, what you should be thinking and things like that. So and the thought process are complicated. It's quite high testosterone poly trauma, particularly when you're in the Ed Bay. And so there's a lot of expressed emotion. It's quite like stressful and so clear.
Thinking is sometimes difficult in the heat of battle. Tenotomy OK, polytrauma orthopedic. This is about orthopedic decision making. Really, this is polytrauma generally starts in the bay, with a lot of people doing stuff and use the orthopedic surgeon. I like standing back. Maybe or maybe you're in the thick of it. Maybe you're putting a chest around, you know, maybe taking some blood or whatever it is you're doing, you're secretly thinking, what on Earth am I going to do with this orthopedic injuries?
You don't even know what all the injuries are. You've been told he's got a wobbly leg and his foot's hanging off and he's got wrist fracture and it looks like he's got some ribs or something. And it's been a bad injury. But that's kind of all, you know. And no one else gives a crap about the fractures. Everyone else is worrying about a, B and c, or they're worried about what the gas is or what, when's the next slide?
And things like that. But actually, what you're thinking about is what am I going to do with these orthopedic injuries? And of course, we have this national sense, don't we, of your spectrum of physiological status with stable being at this end and extremists being at this end and like borderline people or unstable people somewhere in the middle. And obviously, these guys at this end are the extremists end, get damaged, get damage control and the people at the stable end get early total care.
And what could be more simple than that? And that's a really elegant, very orthopedic kind of way of thinking about people, about these cases. And then the go somewhere you got borderline and unstable and we'll talk about those later, ok? So of course, on one side, you've got. You got damage control. What is damage control?
We all know what the weight came from, it's a military term, it's about the sinking of ships and all of that. But in orthopedics, it's basically not doing big interventional stuff. It's about putting on external fixations or putting people in traction and not doing nailing a female or nailing of tibia or like five hour operation. That's what damage control is in the orthopedic setting and.
Very obvious, it kind of keeps clicking off. And it all came about from gianniotis, Giannulli and papy back in the 80s and 90s came up with this, this kind of graph, which you're all everyone watching this video this thing will be recognize this guy. Yeah and you'll all know about the second hit, the inflammatory response after the trauma, the second hit phenomenon and and basically after trauma.
You have a little inflammatory response and then it kind of dies off afterwards. But if you do a big operation around this point here, what happens instead, you are sorry. Instead, you end up with this like bigger curve going over the top and everyone has. Every one of us has a predetermined genetic threshold for developing SARS. And so you end up if you exceed that threshold, you go on to develop AIDS or SARS or whatever it is of or, you know, goes by many names multi-organ dysfunction.
There are many names. It's basically an immunological response to trauma, which makes you very, very unwell. OK so and that was all pretty well understood as well, and it was backed up at the time, so I'm struggling with my translations of it. It was backed up at the time with a bunch of papers. This wasn't made up. This wasn't making a whole bunch of papers that are listed down there.
And if you look at the dates on them, they're all around the 80s and 90s. So these were this was a common problem. Patient comes in very, very banged up. He resuscitate them. You nail their femur and then they just die. And that definitely definitely happened. And so they coined this phrase of damage control orthopedics because it's better to be safe than sorry.
Yeah so rather than like, nail their femur, they die. Why don't we do something like an intermediate thing which is less impacting and then waiting to get a bit better and then nail their femur? Yeah and that was the theory and used to say, we're going to wait three days or wait five days or wait how many days it was in your head and then we can go ahead and nail their femur. That was the traditional teaching and that got a huge amount of traction for about 10 years or so.
I didn't get this bizarre. And that's what DCO generally looks like, it looks like an ex fix of some sort. It may be a little traction. But at the same time, at the same time as all of that, there were other studies around look at them around the same time around the same era that were basically saying not the opposite, but basically saying that if you take all patients and you nail all of those early within 24 hours.
Yeah, you get a federal nail into the early within 24 hours, you have reduced odds, embolism, syndrome, lakes versus all the rest. All that good stuff. So nailing early is great. And yet there are some people who just die, and it's clearly the final nail that killed them. So how do we level that? And then Valliere came along.
This is like this is like 20 years later. Yeah and these are the things I need to do the exam. These are the ones to focus on. And if you've got to focus on one of them, it will be that 2015 article, which is kind of the most recent. I'm going to walk you through them. She she's a trauma surgeon in Cleveland, Ohio, and she basically she's a bit of a like, you know, she's a proper stats.
You know, she's a good, she's a database person basically looking at huge databases and trying to make sense of them. And she looks at their trauma database and in and she coined the term early appropriate care. And that's the phrase for the exam early appropriate care. It started off here because in jayati in 2010, she did a retrospective review of a massive trauma database 6,045 patients.
And what she worked up because up until that, everyone had been fixated on femur fractures. It's all about nailing the femur, you know, is nailing the FEMA now good? Or then it was all about the female, but she was the first person to say, actually, maybe this be more of a fever, maybe typekit them or in this as well. So she looks at that, and she showed exactly the same thing as Larry bone and all those other guys had shown 20 years previously that not only is fixing the femur in the first 24 hours, good fixing the pelvis and acetabular in the first 24 hours is also good in terms of your outcomes.
Corrected for ISS and age. Is pelvis last time was suddenly in the mix as well. Then she mixed it up even further. Three years later, she produced this one being a cohort of patients still retrospective, being a cohort of patients, all of them over 18 but corrected for ISS. So they're kind of.
And for age so that their equivalent groups now it was pelvis. Spine fractures, fema, pelvis and spine fractures, what people have come to about axilo fractures like spine, that's not neck. That's kind of the lack of lumbar and pelvis and femur. And again, same defensive treatment, whereas clearly better when corrected for ISIS at an age. So you could argue, well, maybe it's the sick patients who were the worst, and they're the ones that didn't get it, but they still did badly.
And that just hasn't that hasn't borne out of the data. That's one of the obvious criticisms, but actually that hasn't borne out of the data. Another one same year, much bigger, serious 1,400 patients retrospective still again, FEMA pelvises. But this time she's changed the figure, though it's now 48 hours again, prove the same thing. This when she starts talking about lactate lactate less than four within eight hours.
And so start. We're starting to talk about lactate a bit more and we're trying to get it, and that's within eight hours. So if you can get the lactate down by below 4 within eight hours, then they do, then they do better with early treatment, but only if you can get it down within eight hours. Yes, so people who take ages to resuscitate and in this algorithm.
What about chest injuries? Traditionally, we've all been obsessed about chest injuries, so if you have a bad chest, so you've got bilateral femur fractures, but you've also got a bad chest. Now what was the chest? Because traditionally, is it all bad chest? Oh yeah, that makes them more susceptible to things. We better do damage control.
But actually, what she showed was that yes, if you have a bad chest injury, yes, you do have more pulmonary complications down the line and more as well. But damage control didn't improve that early surgery still had fewer complications. Even if you had a bad chest injury, so so chest injuries kind of out of the mix now.
2015 this is probably the article that most people are quoting nowadays, this is her most recent Foray into this because it's smaller numbers you'll notice, but it's prospective. She's taken an algorithm. And now now it's going forwards rather than backwards. She's run it prospectively and see what goes on. This is the one that was everyone was basically waiting for her to test her own algorithm prospectively and definitive treatment in 36 hours of injury, provided the right leg takes less than four within eight hours.
Same thing. So she's basically it's half the complication rate, half the complication rate. If you managed to get them done, what you might be asking your head, why didn't she get more than the why weren't half of them? Why weren't the group who didn't get surgery in that time? Why didn't they get the surgery? The answer is she.
She almost answered this question, she says. It's just because either there wasn't time or the surgeons chose not to do that. For example, maybe they said, oh, wait till morning or I'll do that tomorrow on my list or something along those lines. The surgeons chose not to do that was the reason, usually. So those are the articles that I would be quoting if I was taking the exam and the 2015 one is the one that's the most that's the most, most commonly quoted, however, and this is important too, if you can really get aced this one.
It's important to say that not everyone loves vallese work. Not everyone loves it and papy, because papa you nudists were like, you know, doing their stuff together and papa is really unimpressed. He's a German guy who works out of Hanover. Super famous, quite an old guy, but super famous on the trauma side. He is not bought into this at all, and he thinks this is a real step backwards and he's still obviously sorry.
Sorry, sorry, very much into the trauma, saying he feels her model, which is based on lactate and a little bit on fx, is way too simplistic. Just use acid base, and he feels that she's also overplayed the downsides of damage control. He feels that, you know, damage control is done well, X fixes, et cetera, done well. Actually, the morbidity is very low, and that's something he puts very strongly in his article.
And one thing is true, and now, guys, it's really important you understand this. So I am a follower of the much more of the Valley School of thought than I am of the pap. But one thing is definitely true lactate is good for that Ed setting that early, early, first 24 hours. Once you're out of the 24 hour setting, lactate becomes just one number in a much bigger picture of temperature, clotting, sepsis, ICP loads of factors all coming in, all playing into it, blood pressure, how responsive you are to fluids, et cetera, et cetera.
So once you're into it.you, lactate becomes a bit much less of a sharp tool. And so it's wrong to use lactate to flow through like for 48 hours and then to keep going and going and going with lactate. All right. And that's why Valliere says you've got to get the lactate down below 4 within eight hours, because after that, eight, 12, 24 hour mark lactate is less useful as a predictor, and that's important if you can really nail this topic.
That's an important thing to come out. All right. Sorry struggling with a bit. Expects, particularly for fema, is not a free lunch, and I think that's also an important thing to understand. It prolongs your surgical episode, considerably slows down your rehab and there are lots of things that fixes don't do particularly well.
It also impacts your definitive treatment. So you can have a fixed pin site, infections or poor reduction, you know, you know, keeping the legs short for too long period and making the femoral now harder. It often makes your femoral nail a more difficult rather than easier one unless it's been absolutely anatomically reduced and none of the pin sites pus out. So damage control is not benign.
I'm not saying it's terrible, but it's not benign. Are and so the idea of damage control is the safe option, so why don't we just do something safe? Because that nailing the theme, although it can work out really well, can be very hazardous. That's that's also, you know, it's got to be a nuanced, balanced argument there. There is something other. The next fix you can detraction.
So this has been looked at again as a while ago. Now, bosses group from who's in North Carolina, I think, looked at something other of this. They looked at attraction instead of. They looked at school districts in the initial temporary session of federal self-righteous. Weirdly actually, they study, whether it wasn't significant. It showed a slight advantage to attraction over expects so because they had lower complication rates.
So I think most people now are thinking that damage control can look like skeletal traction. So that's. That's damage control. I want to just take you down. What about this borderline business? What about this middle ground? What's going on there?
Because you've got early total care on one side, damage control on the other. And so what pushes you towards damage control? And traditionally we've looked at a number of things just ignoring lactate for a second. You know, Admiral Paramus passed that kind of thing. Bilateral femur fractures was always something traditionally that we were oh, well, that's dangerous. You know, the patient might die.
Thoracic trauma, chest injuries. Hi excess. Sorry hi, it's geriatric trauma, hi, ICP. Open fractures, their resource, and you can see that. After a while, I mean, every multi patient almost always has one or two of those things, so there's a danger if you take too much notice of these, like these kind of tagline, like all bilateral femur fractures.
There's a danger of all of DCO becoming the default option. Well, we'll just do default because they've got a very low pH or because they've got high CDR or but you see what I mean. But the thing that has changed is this resuscitation is not what it was. Remember, I showed you those articles, they're all back in the 1980s and 90s at that point. This is what this is.
What? Oh man. This is what resuscitation used to look like. It was basically a bit of blood, if you're lucky, but mainly it was normal saline or Ringer's lactate. That was the crux of. You know, that was the nuts and bolts of resuscitation. It was all about restoring volume. It was like putting this volume up more saline, more saline.
And actually, nowadays it's totally different. Modern resuscitation is much more about is much more about restoring clotting. We've got binders. We've got massive transfusion protocols. We're giving tranexamic acid early. We're doing routine to people's kit. We are aiming for a system. We're not bringing systolic blood pressure up to rapidly because we might blow off a clot early.
Ct is right next door to the resus Bay. We've got these that thing in the bottom right, you see is a level one transducer on Belmont machine. These are things which can pump huge volumes of fluid into a patient very, very quickly. You know, and so actually, which gives you a lot of confidence, for example, to go to the CT scanner because now you know that even if they crash, you can still pump blood in very quickly blood products, not just blood, but but SFP cry and platelets.
And in the middle, there is a protocol. Life is so much more protocol nowadays, modern resuscitation. There's not a huge amount that like cerebral thinking that goes in because everybody knows what comes next. It's not automaton process, but modern resuscitation is heavily personalized and it's much sorry. It is much more. And there's also a lot of expertise because we centralized it in resuscitation, in empty seats.
So in the past, it was all about filling people up. Nowadays, it's much more about restoring clotting, turning off the tap, restoring physiology, reducing acidosis radically different, different way of resuscitating people nowadays. So if I take you back to this, this graph of scientists, you got your second hit of surgery. But what people didn't really describe at this time was doing a second hit when the patient is not fully resuscitated.
That's a really important point. Doing a big operation on someone who is not fully resuscitated is highly immunogenic that really gets your immune system pissed because basically the immune system is trying to get its head around being hypertensive and then you're doing something to it, which makes it even more expensive. And that is what can bring about your Serres. The theory goes if you rehabilitate, if you resuscitate people effectively, that's the bringing down the lactate thing, you make them able to tolerate that second hit.
And this comes back, you know, this is actually not a new concept. It blows the first person who talked about lactase had 50 versus 20% complication rate if the ISS was so if there lactate was less than 2.5 at the time of nailing. They did very much better. You know, the complication rate was more than halved.
So the idea of lactate being a predictor in this 24 hour period is nothing new. O'Toole in Baltimore, they had a traffic light system where they talked about 25. And now you've got valve. We're talking about less than 4 to eight hours. This is what we're lactate comes from. It's just that in the first 24 hours, it is a useful indicator.
A multiple different authors have shown that a different way. So when you're resuscitated, is that when you go back to this diagram, it's all about resuscitating people from their extremist state to their stable state. That's that's the problem with this diagram is that you're assuming that it's a static thing, but it's not as a dynamic picture.
You're taking someone who's an extremist, you're resuscitating them such that they're now stable patients and now they should be good for early total care. All right. That is what has changed is really resuscitation that has changed the gig here. And what is elevated, OK, this is the definition given by Chris Moran about five years ago, so this is fairly recent, but not that recent definitive fixation or long, long bones within 24 hours of injury was the patient is physiologically stable.
He wrote that about the same time as O'Toole came out with his thing in 2010 and in around about 27. Yes, but anyway, this was in response to O'Toole's paper talking about the traffic light system. Long bone fractures, what is a long bone fracture? What is the long bone fracture? It's a good question, isn't it? I mean, it's not that's not a long bone, right? OK, but a femur?
Let's call that is a long forearm. Is that at all? Well, they all quite long. You know, almost my forearm is probably longer than some girls femurs. But anyway, no one's pretending that a forearm fracture is actually like systemically upsetting you. Humerus is a totally a long bone, right? That's way longer than than, you know.
Here is a long way, but it's not. It doesn't count in this setting, so we don't see people putting on damage control surfaces on people's humerus, do we? What about tibia? That's a long bone, right? And yet, is it? No one has ever demonstrated no one has ever proven that needing someone's tip early gives you a better outcome or reduces your level of odds or scissor or mods or whatever.
Yeah so actually, tibia doesn't really fit the bill for a long bone, either. Weirdly so what is the long bone? I mean, if validated, to believe long is pelvis, spine and femur. So this term, long bone, you've got to try and get that out of your head in an exam setting. I would not be talking about long bone injuries because nowadays the systemically upsetting injuries are caused or axial injuries pelvis by feet.
And so early appropriate care is fixation of pelvis, spine of femur. Oh, there's one more as well. One more potential one which is yet is unproven and that's this one, the chest injury. Where does chest injury in that setting that we do not know yet, because we've got a randomized controlled trial?
One conclusion in Canada recently, which was which was equivocal. We've got the RF trial, which we're in the middle of right now, which is the UK version of that randomized controlled trial. Looking at fixing, this is no fix of rib fractures. We don't know whether fixing people's rib fractures improves quality, improves outcome, but it may turn out to be that that's yet another axilo fracture and could be added to that list.
But at the moment it is fema, pelvis and spine as the things to go for early. And I take you back to this. What about this identifying the borderline patient? Well, let's look at those. Let's look at this abnormal parameters pulse lactate. Those are all correctable. Remember, it's 36 hours you could do a line, 36 hours you could really resuscitate the hell out of someone in 36 hours.
You put their finger on traction and you just wait until I just went to wait until they're ready. So those are correctable items. Open fractures, thoracic trauma. Actually, if anything, that increases the urgency, we need to get them to get quickly before we develop complications from those other things. Hi is geriatric trauma. Same principles if you can bring the lactate down within eight hours, you're good to go.
Same with bilateral femur fractures. Fix, but cautiously fix now. I'm being a little bit aggressive with this because I'm making out that, you know, if the lactase down that you're good to go and you can close your AIIS and you can go ahead and nail that FEMA. And that isn't quite true because actually, if you got bilateral femurs, you can nail the first one you want to be seeing at that stage how they lactate going.
If the lactate is rising, you probably want to stop. So often you can have a bit of early total care or the only appropriate care and a little bit of damage control as well. Maybe I'll put that one on traction overnight. Hi, ICP, this is the one that kills us orthopedics, because often the neurosurgeons will not let us go to theater because the ICP is high, and so even though their lactate may be low, low, low and always been low, you still can't take their femur because that will raise their ICP.
So actually in our hospital, the thing that stops us going more often than is not high lactate, it's high ICP. So to conclude. Stable patients. Apologies, stable patients get early, definitive care, and that's fine, and no one's going to argue with that. All of the other three get resuscitation, and the early results are not the late resuscitation.
The early resuscitation sits around lactate and you can be patient. You do not have to dive in tonight. You don't even have to go tomorrow morning unless there's an open fracture, but you've got time to let this patient settle before you intervene. Some fractures, some patients will end up. Therefore, after you've sorted them out, they may end up into early, definitive treatment, in which case you're still in that great beneficial zone.
You prioritize the injuries to fema, pelvis, spine. Go first and then other things go second. What's the appropriate bit? Then what is this early appropriate care? And here it is. No one. No major surgery on resuscitated patients. That is the killer point. If there's one thing you take from this talk, it is do not be performing major surgery on people who are still under resuscitated.
OK, second point. Cease major surgery, if lactate is rising, that's what the appropriate bit is, is basically saying, yes, you can go and do your thing, but what I don't want you doing is making this patient worse just because you're blindly doing surgery. Six major surgery if you're a. Just I've got it's got a little blue hand there.
I thought there was no repeat. That's that's for the Viva. OK, great. I'll repeat that. Appropriate means no major surgery and under resuscitated patients, it also means that if you're doing a bilateral femur on someone, you do one femur and then you look at the lactate and then you save the anesthetist.
If the lactate starts rising during this operation, please tell me and I will stop and I will put skeletal traction on. OK that's what only appropriate care is. So in some way, damage control, orthopedics is not plan a x, fixes are not benign and nor skeletal traction for that matter. So resuscitate to allow early appropriate care and you'll get 90 percent, your patients will end up getting early appropriate care.
No major surgery surgery if lactate is high. Consider traction versus fix if you're in that damage control situation, early appropriate care, definitive treatment of pelvis, spine of femur within 36 hours provide your lactate is below for, I have to say, and I think you would all agree those of you living in the NHS would agree. That is a massive challenge for the NHS to get spine and pelvis and all femurs fixed within 36 hours.
It's quite a challenge and that's something I'm making out. This is the gold standard. We do not achieve that in our hospital every single time. And I want to pretend that we do because it's difficult. We don't really have the resources for that necessarily. Twice that's my talk, I think now's a good time for questions and then we can move on to other stuff. Lovely, peter, thank you very much.
That's thank you for all the energy you've put it into this presentation. You emphasized all the important points very nicely. I like how you put on this balance between damage control, early total care and have you reached to the early appropriate care afterwards? Very nicely smoothly. I think very clearly explained to all of us. I was there have been a lot of questions and you actually answered most of them during your talk.
So so but one of the questions we had from Rachel, which is a simple but meaningful question did she ask, how do you define poly trauma? Is do you have any, you know, if you know, a specific definition for it? Do you use any score? No, no. And it depends which article you read. Some define it as over greater than 8.
If you're working in a place that doesn't get much quality trauma, or most people define it as an ISIS greater than 15. That's usually what you say is someone who is probably traumatized. ISIS growing 15 is like the sort of is probably what people most accept, but some people draw that line differently. Yeah you know, when you're writing a retrospective paper, you look at all the iss, you think, well, these guys in as well.
So you've got to stretch it one way or the other. So to make your series is bigger. But most people would say ISIS greater than 15, I think that's the most commonly quoted. Thank you. And just for Rachel, I think what's going to be the next question from the examiner here? When you say that you're going to tell you, tell me about the isis, so be prepared.
So, Yeah. OK, so when you're defining isis, don't get bogged down into a square root of this. And the square of that and getting all. Don't overcomplicate it just to talk about the. Just talk about it simply and schematically, rather than trying to, like calculate an ISIS from a mythical patient. Otherwise, you will tie yourself in knots.
It's not 100% straightforward, is the answer. Absolutely yeah, keep it simple. From your experience in working in a trauma center is a fat embolism with femoral fractures a common thing or. Yeah well, I would say it's common. I have one. Like last Friday, exactly that week, he had an isolated femur fracture.
It goes to theater young guys, often young men who experience it. And we know this female operation would very nicely didn't go on too long. It comes back to wakes up and he's fine. And then the next day, he's just all confused and he's all over the place and he ends up with. It turns out he's got a fat embolism. So yes, it definitely is a real thing.
Definitely and how about a pre preoperative fat embolism as a result of the fracture? Can that obviously it can happen, but is it? Is it common? Well, we didn't see that anymore. We just don't see that anymore because we're so aggressive about getting people to theater as soon as we can. So it's very, I mean, does sometimes in the people who are absolute extremists and they are almost dead when they arrived.
And so resuscitating them takes much longer than normal and they have a huge like surge response afterwards. You know, almost immediately afterwards and you basically the lactate never really comes down. Those those are people who often do develop serious injuries or whatever before you get to them, but they were terribly, terribly sick beforehand. The whole of the rest of the population, we generally get to them before.
So fat embolism, syndrome and AIDS. And these things tend to be post-operative rather than preoperative. Lovely because the question was from Rachel is whether you if you diagnosed fat embolism, whether you would nail or plate that patient, but you're saying you wait for them to get better, you just wait for them to get better and then you do it, wait for them and made it up to you. And then again, for 90, because that is by far the best operation for a FEMA fracture.
Yeah lovely. I think. Now you all qualify that if you decided that you wanted to put an ex fix on while you're waiting for that patient to settle down and like get all their metrics back together, and that would be a totally reasonable thing to do. But it wouldn't be then plating the femur in the hope that.
So I don't make this because, you know, we all know that placing a femur is a terrible operation because the plate just can't handle it and the plate will break and then the plate comes off and they're going to nailing and all the rest of it. So the nail is still the best operation for a FEMA fracture. It's just so I wouldn't compromise on that. But if you want to put them in an ex fix for a week or so while the patient settles and their fat embolism sorts itself out, then that's yeah, go for it.
So that you are in damage control situation there and the only appropriate thing goes out the window. Yeah and I think you highlighted how early appropriate care is applicable with appropriate after following appropriate resuscitation, and the results have improved with this reconfiguration of the trauma service and to more specialist trauma centers. So this all play part, isn't it in the outcome and no expertise is a huge thing.
So by bringing all these major injuries into major trauma centers, it's hugely changed the outcome. And Chris has got some awesome slides of how mortality from major trauma has come down massively since we, you know, it's NCTC started back in 2012, you know, and I think my advice is because this sort of an exam scenario is we put that in the answer to show high order of thinking that we've been there in the trauma centers and not just numbers of lactate or 36 or 24 or eight hours.
We show this other factors that expertise, that resuscitation, the advancement of resuscitation, other things that have to play important part in the outcome, not just simple numbers. Oh yeah, absolutely, absolutely. Yeah, that's right. The ground has shifted from the nudist and puppy days where they were talking about this. There was a real, real hot topic conversation.
A fundamental thing has happened, and that is that resuscitation has come on massively. And I don't know if that comes into your territory, but there is a question from Saab is asking how exactly the mechanism of fat embolism. They seem to be out of interest in fat embolism tonight. No, no. I don't think anyone really understands fat embolism. I think what most people are agreed.
It is not a lump of fat going into your brain. Yeah, it is. It is. I mean, it may start with that. It may start with some kind of fat in your system, but to suggest that there's more fat in a fat embolism present system than it is in any, you know, we know that if I was to nail your femur right now, for us, even an intact FEMA and I put a Doppler thing in your heart, you would see globs of fat bubbling through your right atrium as I nailed your femur.
That is that happens to everybody. So everyone gets like a bit of a fat, let's call it. But so, so everyone gets the fat. It's your response to the fat. So I think most people are now thinking that fat is fares odds SARS models. They are all different manifestations of an immune immunological response to trauma. Yeah so it could be.
Yeah, as you said, it's probably as you said, we don't know exactly the pathophysiology behind this. It could be inflammatory response. Yeah, it's some kind of massive release of interleukins into your system. So rather than acting in a crime level like, you know, locally, they're acting on a systemic level, which makes all cells in that area go crazy. And then you make that makes sense.
It's not a lump of, yeah, it's not the lump of fat that has went through the circulation and we're stuck in your brain. That's causing the problem. Yeah, that's right. And just do one more question is, are you waiting for a patient with a similar fracture with the fat embolism to be fit for surgery? Do you put them?
Do you give them put them an attraction or fix them? So someone who's had a fat embolism and they're waiting for surgery. Yeah, this is rare, isn't it? You said it's real. I think some people say dealer's choice putting someone on traction for more than two or three days is really problematic.
I mean, what? We've all seen that in our own practice, it's not a great thing. It's very difficult to nurse someone in traction and expect is a much better solution if you think that they're going to be better tomorrow. So you're waiting for them to just to come fit all. You're waiting for this to crop up, then you can put them in traction.
But I think if you're expecting like a three or four day wait till surgery, then putting them in the next fix is a very reasonable thing to do. Lovely thank you very much, Peter. Really appreciate your input. Yeah, I guess that talk very much feels like I'm dissing the X fix, and I'm like, god, you don't want to put these X's. They're all terrible.
There's definitely a role for Exelixis. I still put X fixes on femurs in very sick patients, but it's usually the very, very extremist people, all the people with head injuries or the people, as you say, who have had something weird going on. And for some reason, there's going to be a delay to fixing their femur for whatever reason. And I think just for purposes, whenever you presented with these questions, guys, it is just it is a changing situation.
We always continuously monitoring the patient condition intraoperatively post-operatively. So if you take a decision and you find the patient is not fit, you can always fix one limb and fix the other. You just always continuously. The next day you are monitoring the patient. You know, if they are better or slightly better, you can fix and think they stabilize even more.
So just show them that you monitoring the patient continuously and don't just make one decision and stick to it. You'll have to change your decision several times, maybe before you reach the final operation. Good so now we will move on to the execu questions. There are three questions if Ruth can kindly share them. So, OK, guys, so as usual, this questions three questions will give you a couple of minutes to answer.
I hope you can all see them. And just to remind everyone, it's anonymized, so please do have a go at answering the questions, no one will be able to see your answers. Thank you. Thank you for that reminder. And so please, every single one of you attempt. It just gives you an idea of where you are.
And in terms of your exam preparation and and it's very helpful for you to make sense of the answers afterwards, and Mr Bates will take us through this in another minute. So please ask everyone to. If anyone have any problem viewing these questions, please send us a message.
And once we're done with these questions, Peter will have a discussion. And there will be some more questions during the case discussion, which we have set up also. Is that correct route here? Yes, that's correct. So if everybody can attempt these questions, we'll wait until most people have answered them and just a reminder, it is anonymous, so please do attempt them.
Yeah, we have at the moment you have 191 participants, so. We'd be nice to have 191 votes. What answers?
So case discussion after this and then would be Viva the Viva session is not recorded, obviously, as usual. And we have already picked the candidates for the Viva. So Thanks, everyone who raised their hand and sorry if anyone didn't have the opportunity.
So three minutes now, we normally give you three minutes, but I think more of you are answering the questions, so we will give you a bit more time.
OK, so we have 80% answer rate at the moment, so should we? Are you happy, peter, to take us through these questions. Thank you. Pizza hang on, I think you've muted yourself, you've muted yourself, sorry. Yeah I thought, Peter element.
So the top the top three are all definitions of major and massive hemorrhage, and the bottom one is just something made up. Basically, you calculate massive hemorrhage on how much blood do you think they've lost? Not on how many products you've given them. That's why that last one is incorrect. The next one is 26-year-old guy rising after rta, anti-American wound or the right calf.
So he's got he's shocked, isn't he? 24 blood pressure, 83. Over 50 cold peripheries. He's got a right tibia fracture, which is open, isn't it? Because he's bleeding from an open wound on his right calf femur, multiple rib fractures? He's pretty banged up, which is not a first line action pressure to the leg. He's bleeding from his leg.
What do we do with bleeding? We press on it, don't we? You can put tourniquets on in the field, but that is very much an out of hospital thing. If you've got a long way to come and someone is literally got an arterial bleed that's hosing out and you haven't got someone to press on it. That's that's, you know, tourniquets pretty niche, honestly.
IV antibiotics, that is actually emergent care now, you know, based guidelines, IV antibiotics need to get in there within three hours, but ideally it's going to be within an hour soon. So IV antibiotics, they're part of the emergent setting tranexamic saying early first hours what those in ABGs everyone was not that lack lactate is that the avg really tells you what the systemic state is so that the anesthetist wants that straight away.
And if they're shocked that you are starting a massive transfusion protocol, rotem, the reason why that is wrong is because actually wrote him is not a great thing for when a patient comes in, you don't care what their clotting is. You're about to throw back into them and you're going to do that. Whatever happens. So whatever the clotting is at the start doesn't really matter.
You're going to throw paquet into them. And then after parkways gone in, you'd like to know what they're what, what they're clotting is doing. So routine is something you do like into the resuscitation almost as phase two rather than at phase one. The next one is. Damage control, orthopedics.
And systemic inflammatory response, so what was the right answer there? Ultimately, sorry, all of those are true except early. The fixation within 36 hours is strongly associated with a reduced SARS and AIDS. This one, in particular patients with chest injuries. Damage control is usually preferred. That is not the case anymore. That used to be the case, but as I was saying in my talk, chest injuries.
Now, if anything, a chest drives you to do draws you to do early appropriate care. Almost more forcefully, you want to get in there quickly before their chest deteriorates, because if you leave them and you don't do a damage control and you don't do your definitive nailing, but you do damage control, what you end up happening with is the patient now has a really bad chest and they have a broken femur, which are not sure what to do with.
So chest injuries almost drive early appropriate care more than they do previously. And that's why that middle one patients with chest injuries is the correct answer. So I got a bit muddled by now. You know, you're correct, it's a bit confusing the way it's set up. Yeah, because that's just the most commonly answered question I thought red that was the correct answer because all the other to the people have got the correct answer.
Yes yeah, Yeah. All right. Great Thanks. So thank you, guys. Thank you, peter, for explaining. And we can move. Can we move on now, please, to the case discussion? Yeah, sure. Let's do that.
Ready? Yes. To just to let you know, I've set up the two mic polls. So just let me know when you want me to run those questions to the audience during this. Oh, you set them up. I have. I've managed to, so just give me the heads up and I'll run them. OK, great.
All right. Lovely OK. So one at a time. So my still screen sharing, you still see my screen. Yes, we can see your screen. Lovely OK. So this is the case. This is the case. We've got a 14-year-old male most that you can read it all is right there.
He's found a lawyer for his, but it's obviously a big injury and he's got a whole load of injuries. I want you just to read those and just get your head around them. He had an office rapid sequence reduction at the scene because he was combative. And so obviously he's got a bit of a he's got a bit of a head injury and he was a bit shocked.
So they so he's intubated. There's bleeding from the groin, from the groin wound at the scene, but that has now stopped. So he's got this big groin. I'll show you in just a second. And he's any day now, and his human dynamics are improving with paquet. So actually, those figures that I'm showing you, there were the second lot.
The first lot was somewhat worse than that. OK, so he has improved a little bit with pack. All right, here's his stuff so that on the left of your screen, this is a different patient. I got I got off the internet because I haven't got a picture. This guy's growing laceration, but that's exactly what it looked like. His leg.
Is this his leg here? This is ball bag there, which has been pulled over to the left side and to his left side. And here it is. It's been stuffed with some packs and it's a big groin laceration. If you were to poke your finger in there, your finger will be straight down onto his pelvic bone and there's a fracture underneath.
I haven't got a picture of the pelvic fracture. That's his open tibia wounds about that long, about two or centimeters. Those are his X-rays. He's got his left femur and his right tibia. So, right, female to be. I've got this wrong around here. It's the other way around. So left egawa right tibia, tibia is open, femur is closed, and that's his groin laceration, which was bleeding heavily at the scene but is not bleeding anymore.
All right. He's also got a head injury, and he's got some maximum facial trauma. So first question. First, OK, one second. Brace yourselves. So I think the best way for this don't work out is this someone just puts their hand up and volunteers to just talk about what they think is probably their best choice answer.
It's 600 PM this guy comes in at 600 PM. When does this patient need to go to theater? All right. OK, so guys, doing OK, fine, yeah, do in just a couple of minutes just to answer the poll, not that long, but just to let the poll go, and I'm not going to wait till all 181 have done.
But let's see what people are preferring. OK, so we've got a few right now we people liking to wait until the lactate is down and then go. OK, great. Like just another 20 seconds, and I'll close. Not right now, but within a few hours. OK right, so. I'm loving that you guys are waiting for the lactate to come down and then go, and that is actually not an unreasonable search.
The truth is this will become a bit of a theme. All of these are perfectly reasonable strategies as long as your rationale is correct. It's OK to take this patient to theater right now. That's perfectly OK. A lot of theater. Take it upstairs is absolutely fine. What's the downside of taking them to the theater right now? What's the downside of that?
Well, the downside is that you work, that lactate is still quite high. And even if it's there right now or within a few hours of now, if the lactate is still a little bit higher, there's only so much you can do to the patient. You can wash their wounds out and you could change those packs and wash it all out and put small packs in. And maybe you could put some fixes on.
So for the right now, people, and they're not right now, but within a few hours, people. That's not incorrect. That's perfectly reasonable thing to do. But if you do that, you're not doing definitive treatment of any of the fractures. Notice how the weird thing is, you could take this patient to theater right now. You could put you could put on the femur.
You could put an X on the femur and indeed on the tibia, and then you could bring them back and get back to the ICU. They could then come back again into the theater within 36 hours. Have all those expenses taken off and have it and have someone else put up a terminal put up, have the pelvis fixed. And if they had a spine injury, had the spine done so, it could still be early appropriate care and yet?
You are to put traction on you, put Exelixis on it with me, so just because something's early appropriate care doesn't mean it has to happen tonight. It can still happen tomorrow and still be early. Appropriate care tomorrow morning will be fine. Not many of you liking it, but actually at the Royal London hospital, that's often what happens. Patients come in like this and they end up and we see them. So we go, OK, let's recess them overnight.
Leave the binder on, and tomorrow we'll line them up to have all this fixed up because he's not dramatically bleeding within the next 24 hours. Agreed well, probably that's the only one that I probably would go against is because he's got a big open wound in his. And so the latest both guidelines for open fractures is that they should ideally be going to theater within 12 hours.
And so choosing someone who's 24 is a little bit outside of your post guidelines on that one for open fractures. So I probably wouldn't have gone with that one. Wait until that takes down there and then go, that's fine also, but only up to a point. So the red guy is the most common. That's totally fine. And that's actually the same as tomorrow morning will be fine. Those two are basically the same thing because tomorrow morning the lactate will be down and then you're fine to go and do it early, definitive.
So my preferred answer for me tomorrow will be fine. I'll wait for the lactate comes down, but the right now people are not wrong, you're just going down a slightly more aggressive damage control route. But you can still do early approach primary care even if you put them on traction. So that's my take on that one. Try the next one.
OK, I'm just going to leave that up. The patient goes to theater for non orthopedic reasons, so that's either a bolt get put in their head or they, the general surgeons, decide they want to do a laparoscopy for whatever reason or they have an ischemic leg. Something happened. There was not orthopedic, which forced the patient because they're now in theater that NIPE.
What are you going to do? They're in theater and they're saying, come on, Mr author, will you want to do? Haha, I love it that you're all split. It's great. Just let this pan out, but usually usually the proportions don't change that much as we go.
And again. 100 people have voted are going to crack on again. The funny thing about is all of those are perfectly reasonable strategies as long as you have a reason for doing it. So what? What is the common theme with all those four options? What's the common theme no one is wound wash out comes first. OK wound care in trauma.
You can fix bones and stuff, and that's great and you can put fixes on. And that's great. But one thing you do not want to go back to think about is if this patient gets sick and I just have to come off table right now, let's say that a heart attack or stroke on table, I have to stop and I downed tools and I have no more orthopedic treatment to do.
What do I not want them going back to the intensive care unit having not done? Do you see what I mean? What's the thing I don't want to leave undone when they go back, and one thing which is a real nuisance if you don't deal with it now is wound care. If patients have underpriced head wounds, they will fester and turn septic and it's all downhill. So wound traumatic wounds need to be a priority within that first visit to theater.
So all of those options you'll notice I put wound wash out as the first thing, because that is, that's the right thing to do. OK you could put traction on put a binder on if they're given a binder is perfectly reasonable. So even if you got a theater, you don't have to put an extra X on. You can still leave that, wash out the wound, put a binder back on and then and then come out.
That is all you could leave the binder off and just put it back on it. The hemodynamically unstable just because they've got a pelvic fracture doesn't mean they have to have a binder of pelvic binders or hemostatic ages there for stopping hemorrhage. They're not for they're not for making an X-ray look good or reducing a pelvic fracture.
They're there to stop bleeding wound wash up ex fix pelvis, fix femur again. Totally reasonable. As long as you're dividing the wounds, you get an x, fix everything else and come back another day. This patient may still be good for only appropriate care. As I said earlier on, when you wash up, then recheck the lactate. Yeah, absolutely.
Very reasonable. You've been really aggressive to take the data. You could wash out all the wounds and then see how they're doing. They might have been resuscitating enough. Lactate is now down at two point eight, in which case why not nail the female? They're in theater. Go for it, man, do it.
Finally, win wash X the pelvis skeletal traction to female again, perfectly reasonable. You can expect this in my head. X fix is a skeletal traction. Are interchangeable in that early stage in that early bit where you're trying to just temporizing patients waiting for them to resuscitate properly. All right. So actually, none of those are wrong.
All of those, you can argue, very, very reasonably provided you're taking care of their wounds at the first set of visit. OK right. I think that's it, isn't it? I think that's our poll done, that's done. Yeah Yes.
Great I'm going to go back to this guy now. So there he is. What are we going to do and what are we going to do with this guy? How do we make sense of all this stuff that's going on and it's more complicated, this is going to be there's going to be figures are going to be blood gases, there's going to be bees, there's going to be other people coming in with information.
So how do we make sense of what this patient needs? And here's how I rationalize it. Obviously, polytrauma is more complicated than this, and I'm not pretending it's all very, very straightforward. But here's how I rationalize this. Sorry this needs resuscitation, and I think we'd all agree with that. He still needs resuscitation, he's still acidic, therefore resuscitation needs to happen.
These guys need wound care. All right, and we've talked about wound care. These three need their bones stabilizing, the femur needs ephemeral now, tibia needs a tibial now, or it may be an asphyxia is open depending on how you want to play it and the pelvis needs fixing as well. And finally, you've got Max fax and you've got a head injury and you've got your open tibia and those need communication with other specialties.
Notice I've left wing with comms because that needs more than plastics. Also in his plastics as well? Yeah so whenever you see an open fracture, do not forget to see them say the word plastic surgeons. Yeah, and it should. Nowadays, it's plastics consultant. It's senior plastic surgeon post TCT plastic surgeon. All right, so.
And how do you how do you order those? Pretty much. In the order I've done, resuscitation comes first. Absolutely comes first. Then you want to know what other guys are planning, right? You want to know what, what, what, what they're doing about the head injury. What you do about the match facts. What do you want to do about these things?
Communication is the next thing down. Talk to your colleagues. What are you up to? Talk to the anesthetist. What are you up to? How bad is the patient? How was the systemic situation, et cetera? When you're going to go to theatre, the next priority is definitely wound care and then at the bottom of it is stabilized bones.
All right. So as a basic rule of principle, that is your order of service to resuscitate, communicate wound care, stabilize bones and stabilizing bones, of course, can be definitive or temporizing, and definitive is like a definitive is like, you know, like a femoral nail and temporizing is a sort of skeletal traction. And that's exactly what we did.
We discussed it with colleagues. I discussed the case and we gave it some time. You know what we did? We waited till morning. We waited till morning. And sure enough, when we got to the morning, the lactate was now down. At 2.8. The ICP was actually down.
Was not too bad. We gave it some time and now it's time for wound care. It's 10 hours. It's time to get in there and do something now because the lactate is down and we can move so we go to theater. The lactate, the whole thing. Nothing changes very much and we decided I decided because it was just it was the easiest thing to do.
The tibia was wobbling around. We divided the wound. The lactate was good, and so I thought I would. I would. I would nail the tibia. So we did that. So we did a tibial tibial nail the femur and temperature on the same side. We then did a retrograde femoral nail, and that was all good and and patient patient ends up doing well, recovered well or good.
Actually, it turned out that the laceration on the pelvis was nothing too serious and actually it was an LC one which didn't which which just needed an AC screw. And when we did that a few days later and we closed up all the wounds at the same time. So what I've given you, there is quite a nice, soft, easy polytrauma. Yeah, nice. Nothing too difficult. Nothing to complicate it.
But what happens if poly? So that's a true case. Now you're going to be thinking, yeah, but what if? Yeah, but yeah, OK, that. But what if, for example, there was a big chest injury? What if there was a major head injury? What if, if that subarachnoid, what is the ICP have been 20 three, not 13? What if there have been blood pouring out of that guy's pelvis, like pouring out and you pack it and pack it, and it's leaking around the packs and his team is dynamically unstable?
It still is. You know, what would you do in that situation? How does that change what you would do here? So let's walk through those OK, patients got a big chest injury. What would that? How would that change what I did? Honestly, that wouldn't change that situation. I would do exactly the same.
It it wouldn't come into the reckoning. Now what it might do has got really bad chest injury is it might make the lactate a little bit higher or harder to get down, in which case that yes, is the lactate stays high. Then you do have that drives you towards some kind of damage control situation. But if you can get the lactate down, the chest injury in my head doesn't actually come into it.
It is relevant, but it doesn't come into your orthopedic decision making. OK, so that's chest injury, and that goes back to the interview, we had earlier on. And is there evidence for that? Yes, there is value dealt with this in her article. In her articles, vallese dealt with this and she said, you know, she looked at a chest injury and leaving it.
Leaving a chest injury with damage control was worse than appropriate care with a chest injury. And we know how chest injuries can deteriorate, right? So this is a little old lady who stuck. That's an X-ray to begin with. And then literally two days later, two days later, sorry. Sorry man, that's how extra energy comes in, that's the X-ray tube days later, she now you see she's on CPAP.
And so she ends up getting getting, getting a chest fixed. Now I'm not saying, I'm not saying, I'm not claiming that rib fractures are things that need to be fixed immediately. What I'm saying is that chest injuries are relevant, but not your immediate orthopedic decision making at the moment, and that evidence may change next. What if there's a major what if there's a major bleed, a major head injury?
Well, that often drives you towards damage control. So if I knew that this patient's ICP was 25 or 36 or something, I would actually put X fixes on it, on that, on that femur, because I know that patient's not coming back to theater for at least three or four days, I'd either put a little traction or an ex fix major bleeding. Major bleeding needs controlling, so you've got to control the bridge, you're still in sea, you're not you haven't even got to communication yet, you're still in resuscitation, you're still level one, you've got to pack it to analyze it.
You've got to do whatever is required to stop that bleeding. And that may require general surgical access. And so you need your trauma, guys there. All right. So so other things do change the context. But ultimately, orthopedic decision making is one two three four in my head. so.
Would wound care. So when you do, your surgery speed is actually quite important. Familiarity is also important and having two teams can be really helpful when you're dealing with trauma. When I say spade, I don't mean you're trying to rush the operation. I'm just saying that getting an operation is done reasonably quickly.
Not spending four hours over a femoral nail really does help the patient. So doing a femoral now quickly is important and familiarity with that. Obviously, those two are linked. And having two teams that someone's fixing the forearm or somebody else is doing a retrograde femoral nail is really, really helpful to.
And keeping an eye on the lactate intra, OK, so if you're doing some major surgery on some warming issues, if the left lactate keeps creeping up, it starts creeping up. Please tell me and I will stop and I just put them in traction, ok? Great So prioritisation, in summary, is resuscitation, communication, surgical decision making about whether get ICU angle or theater that's in the Ed and then we don't have to go to the theater now you can do, but it limits your options a bit.
But but you but you don't have to. Wound care at the first visit, and there are different flavors of DCO, DCO can be, but some of the attraction for now and then fix them. And then turn back to theater in 20 for 48 hours or still within that early appropriate care window. And for definitive treatment, think about doing surgeries briskly so that, you know, it happens and it gets done and the patient's off table and keep him on their lactate while you do it.
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