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Major Trauma for Orthopaedic Postgraduate Exams
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Major Trauma for Orthopaedic Postgraduate Exams
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Language: EN.
Segment:0 .
OK, so welcome, guys again to this Wednesday is teaching from the Ortho FRCS mentor group. Thank you all for joining. Tonight we have only one presentation. The theme is trauma and will be presented by Assad. And we have one supervising decision also. Please feel free to pop up your questions through the chat box and raise the hand symbol next to your name.
If you want to talk. And also, there would be an extended hotseat session after, so please start expressing your interest from now if you would like to join before the screen. Yeah, just before we could, we again give priority to the guys who are sitting in the exam in April. So whoever is sitting the exam in April, please put your hands up for it.
If not enough people are volunteering, then we'll move to the guys who are sitting in June. Yeah, that's a good point. Yeah, I think that's a very valid point. Good OK. Everybody see everything. Yeah now, OK, guys, so today's topic is trauma. Yes trauma is not an alien to us, and the trauma is probably it's probably what everyone knows.
Over here, we should consider all of you should consider this station as a gift, but be careful because that gift comes with a price and that price is they are not expecting anything less than a tutorial here. So once a trauma situation has been thrown to you, they expect you to know everything because they are expecting you to come in having trauma as the best ammunition of yours.
You know, trauma in your armory and you should be throwing references you should be throwing. You should be teaching them because last time they read trauma was probably when they have given exams. And for them to be an examiner, they have to be at least seven year consultant so that we are talking for a normal training at least 10 years before he comes, unless they are trauma surgeons and if their trauma surgeons are unlikely taking a trauma exam anyways.
Now, as I always say to you in my previous talks as well, you have to be, you know, I invented this term psychiatrist, rheumatologist. So you have to be a mini psychiatrist in your head, so you need to know what the examiner wants you to say. And that's I cannot teach you. You just have this intuition built into you for you to say, you know, whether this examiner wants me to say a b, CDE for every question, or whether this examiner wants me to just press on the accelerator and get on with things.
I tell you what the examiner is, what I have been known and examiners, what I've been around or examiner, what I have seen generally likes you to just get on with it. There are very few old dogs there that want you to say a bcde first before you embark on to the actual topic because five minutes are very less. So remember, you are a psychiatrist or hematologist, so the minute you sit on the hot seat and you see your two examiners start judging from their facial expressions, whatever you get that whether they are happy with the way you are proceeding or you need to slow down or you need to fasten up a bit now it's a driving test.
So apart from driving, everything else will be checked. The same is true for trauma. They know, you know, how to fix an ankle. They know, you know how to do a hemi. So they are not testing that. They just want you to be a safe surgeon who knows all the practicality and and controversies around a particular topic.
Again, remember buzzwords. Remember controversies? There are few words you need to say before you start. That will defuse the situation. Once you diffuse the situation, you then be able to take control. And then you will enjoy the rest of your station. If you don't diffuse it early enough like we do, we keep on asking the same question.
The station will not move forward, and that will be a very long Five minutes for that particular scenario. OK, let's just move forward. And of this pep talk. I think just to say this, what you said is extremely important. It's possibly as important as knowing the subject is exactly it's having the right approach, which you describe now.
So I thank you very much for this introduction. Thanks a lot, guys. Thank you for supporting. Now like everything in the exam, I can predict sitting here, 90% of the exam. Most of you will predict sitting here, almost 90% of the exams, if anything will come in your trauma session, it will be this X-ray what you can see on your screen. It will be an open book fracture, ok?
It will be in a situation where a patient will having a hypertension and all the other parameters of circulatory compromise. And you just have to rattle things out. You need to give that guy a tutorial. You need to talk about all the buzzwords that can come into your head. When we say if hypertension, damage control, orthopedics, trans dynamic acid, pelvic binder, we will go to it all in a systemic way.
But that's what should be clouding your mind, and you should then start rattling it out. OK, so that is going to if in a trauma situation, this pelvis is what you're going to see and you all know what it is. Anything that has got a Bose guideline, anything that has got a Bose guideline, you need to read that they are not exhaustive. There are 14 of them and and you just need to read it.
There are no two ways about it. You're sitting the most important exam in your life. Why would you not know those 14 pages? There is no excuse for it. If you keep on repeating it, they keep on saying to you they are not interested. There are guidelines, but they expect you to know. So those guidelines for pelvic trauma, I have copy pasted it from the post this thing and you all have resort to it.
Again, it's all new. It's all normal. It's all known to you. There is nothing I am teaching, which is not known. So it is standard practice audit. What is suspected. You suspect an active bleed. If you see this pelvic fracture and you start from atlas, they'll say everything is fine.
Cervical spine and mobilization. They'll say it's fine. You go straight onto the pelvis, you apply a pelvic binder in the correct position. It is that x-ray, which is there, and there is another X-ray with pelvic binder right at the abdomen. And then you need to comment on the pelvic binder as well. And you need to say the pelvic binder maybe is not in a correct position.
If you are going for gold, then you can say things. You will internally rotate the leg and all the rest. But these are minutia, but you need to know whether the pelvic binder goes. You need to familiarize yourself with a pelvic binder. It's a yellow color thing. It goes on the GT. That's what you need to see that should come out of your mouth. Yes and and if you don't know it, don't go for the exam, ok?
Please take my word now. Hemodynamic stability you need to know about the major trauma center MTC. It is, it is. It is the first page in barnosky which you need to know about MTC. You need to know about when this network being set up and who runs it. So, so I'm not going to teach you.
You need to go read that page. Transatlantic exit, ok? You need to know the mechanism of action. You need to know the first clot and you need to know why we give transit Kessler. OK you need to know crash one and crash two trials. Crash one. You just need to know the name. It may.
Sounds very complicated, but in a trauma setting, if you're not going to say crash and crash to style, you are doing injustice to yourself. You need to. You need to say these words. They are not. They are not a stranger to you. You have heard it thousands of times. So when you see that open book pelvis fracture in your exam, if trans dynamic, it is not coming out of your mouth, it's crash one.
Crash Ii trial is not coming from your mouth. You are doing it justice to yourself. OK, then scandal remembers. Can you remember CT with contrast? Yes remember what will you do if the patient continues to go downhill? So remember those four types of patient responders, transient responders. And remember that you have to have a strict protocol.
When you should ring the alarm bell for major transfusion protocol, then you need to know back one and pack two, and you need to know as per your trust. You can go and ask in the 80 what one contains and wrote back to contents. Generally, they're equal amount of fresh frozen plasma, platelets and RCC, but every trusts have got their own. You go talk to them and regurgitate the same thing in the exam, even if you make it up, even if you say what written in.
Ask it. That's it, that's what you need to say. That's what you need to say. OK, now you need to have a clear protocol for binder removal as well. You should not leave it beyond 24 hours because what will it do? It will be counterproductive. OK, and the clot should have formed by then.
And if it's not forming, the patient wouldn't be alive. OK, so that's another thing you should be remembering. You need to get the trauma team, the general surgeon on board if it's non responder. You need to know how the pelvic backing can be done, and you need to know. B, you need to know what, how to reassess, how to reassess, and you need to know something about the cycle.
Psychological, physical and neurological disabilities. And when to put catheter. And just be wary of that by the time you have regurgitate all these things. I'll take you are on a safe pathway. You have diffused the situation. The examiner is now enjoying the conversation, what you are having and you can get on with things even if you say something wrong.
It's going to be discarded because you have diffuse the situation by bringing the board guidelines in, by getting him back to his chair. Once you see him going back to his chair, that's it. You have diffuses the situation and now you can. You can start playing left, right and center. However, where you want it, the background is. Of all, the strand networks, sitting is started from 1960s where high complication rates with immediate surgery was done.
It was due to all methods, poor trauma, coordination and IQ support. So delaying treatment traction in interim leads to pulmonary GI skin, soft tissue problems, stiff joints, prolonged rehab, longer ICU stay, longer quality of life, a lesser quality of life improvement following a major trauma, but this has now changed. The trained network has changed at all. Now so what do you do?
You split the trauma patients into four, you need to know which one is for damage control orthopedics and which one is for early total care. You need to know stable, borderline unstable and extremities patient and then you divide. Remember this two diagrams, ok? One is how do you do the correlation test within that. So that the clot can maintain and retain and remember this triad of death in trauma setting?
It's hypothermia coagulopathy and metabolic acidosis? This is not a stranger to any of us. This is not a stranger to any of us. OK you should know about it, and you should know about how each of this is leading to leading to the problem, how each of this is leading to the problem. So you you need to know about the mechanism of action, how hypothermia drains platelets, how he does it and what lactic acidosis is.
I'm not going to teach you that, OK, there is enough to say. Remember, I said, remember the buzzwords? Remember the buzzwords acronym suspected poly trauma, MTC trauma trial of debt, compensation of blood loss, major transfusion protocol stopping blood loss, permissive hypertension, hemostatic resuscitation, damage control, orthopedics and why Kristi Lloyd's alkaloids should be avoided because there is a risk of loss of first clot.
Remember, first clot first clot is another possible. We shed some more light on damage control. Orthopedics what is damage control orthopedics? So initially, when patient were used to be taken to theta straight on, they used to get a phenomena which is called second hit that abuse. You try to overcome that phenomenon by giving a lot of fluids to the patient that fluids leak in the chest and give patient ards, which is detrimental to their further rehab.
And it doesn't do. The patient doesn't do well. So remember remember something about damage control orthopedics? Remember what you need to do as soon as you see the patient? So remember, the controversy begins with the CT scan and the fast scan. Whether the ct, the CT scan, what both suggest. You need to say that CT scan with intravenous canntrust's from head to mid-thigh is the best investigation.
Ct scan intravenous contrast head to mid-thigh. Then you say in casualty, people can do fast scan. It's quick and it can, and it can tell you whether the patient is bleeding in the abdomen or chest. But you need to know the CT scan and CT scan with contrast. Head to Midtown. Once you say that they know what you are talking about, OK, they know what you're talking about. If there is any muscle alignment you see in any long bone, reduce it.
That's your kettle of fish. That's you should know what you do. What is the immediate management of a maligned bone in any reduce it? Splendid X. Yes if you can't produce it, you put it under OK. That's what it is now. Debbie's control orthopedics is again. You need to keep on reassessing, reassessing, reassessing.
How would you reassess? You reassess. We selected you reassess with the systolic blood pressure you reassess over the next few days and you see whether the patient can be then taken to surgery or not. Now, there are a few things what you need to remember here, the buzzwords are hemodynamically stable, no hypoxemia or hyperkalemia and serum lactate of less than $2 million per liter, normal coagulation, normal terminal and normal renal function.
What is a normal renal function? You know that it's less it's more than 1 mil 4 kilograms per hour for adults. For kids is different. It's probably 0.5. I don't know it, but I remember it for adults. You more than likely be facing adult trauma, so 1 mil per day per hour. What is a normal lected where you can operate?
It's less than two safe and proceed with definitive surgery if it's less than two you know about hypoxemia and hypercapnia and you are no stranger to systolic blood pressure. It's nineties, the magic word. Remember, 99 millimeters of mercury is the magic word. OK, now shed some light on where this reflected because when a selected. Is is again, it's one of the controversies now. We have talked about buzzwords.
Now we are coming about the controversies in this particular topic. So when slick it is, is because there is confusion in business, like if it's less than $2 million per liter, it's safe to proceed if it's more than 2.5. Then you need to continue research in ITU. Yes, so but there is a gap of 0.5 between two and and 2.5. So what would you do if it's between 2 and 2 point five?
So there are various studies and they're all originating from generators and leads that they are saying observe for trend. Now this is the gray area. They like to touch it if you're doing well. They like to touch the gray area. They like to stretch you. And this is where you are going to say, yes, I am the master. I know about 2 and 2.5. I will look at the trend.
I look at the trend because that bit you remember, if it's less than two, you proceed with surgery. If it's more than two point five, you stop, you observe the patient. And I tell you, what will you do in the middle? You look at the trend, you see if it's going down or if it's going up, if it's going up, you should not proceed. Ok?
so that's the long and short of it. I think that's what you need to do. You don't need to know the classification of pelvic fracture. You don't need to know anything because that's not what the scenario is all about. It's all about. It's all about what you need to say about artlols, about taking control of the situation, about coming up with the buzzwords.
I hope you will remember some buzzwords you remember and you remember pervasive hypertension. You remember first class. You remember these damage control orthopedics and you remember hemodynamically stable, patient assessing and all the rest and obviously coagulopathy and the stride of death. OK, guys, I think I'm till we do open fracture as well. Or you guys have enough?
Yeah, thank you. I thought it depends on we haven't had enough noise. Very interesting talk. OK how much time do we have? We can go. Have we have? About just over five minutes. OK, so we will quickly go open fracture because open fracture comes in the same setting, guys.
So open fracture again, open fracture comes in the same setting. Open fracture is no stranger to you to you, and open fracture has got a bone. Both guidelines attached to it, so you cannot. You screw it up. If this comes, expect no less than a tutorial. They are not expecting any less than a tutorial. You need to say, say, say, talk, talk, talk if I are someone hot seat, open fracture, if he let me talk for more than 30 seconds in that particular scenario.
That's it. I think he's doing injustice to himself and he's not even scoring. Passing marks, remember the buzzwords, the minute the open fracture comes, you need to say trauma network, you need to say or to plastic, you need to say IV antibiotics. Remember the timing for IV antibiotics? The timing for IV antibiotics in the post guidelines is one.
Don't confuse yourself, ok? It's one hours from their arrival in A&E. OK, it's there. It's there on the post guidelines. Don't say 30 minutes. Don't say 45 minutes. Don't say in the ambulance. Don't say outside the ambulance. One hour, one hour. OK that's what you need to say.
Remember it. It's in the post guidelines. It's not been made up. It's on Black and white. Say an hour. Be safe. Go to paper if they challenge you. And that paper is both guidelines. OK, remember to document neurovascular status.
OK once you document neurovascular status, you need to be clear about and specific. If it's foreign, you need to be specific about documenting all three nurses and their subdivisions radial their median opinion. You need if it's leg, you repeat the same once you aligned it and splint it. Excuse me. Repeat the neurovascular structure.
I repeat the neurovascular status and again documented. These are all legal documents. You are not safe if you're not saying this word. Yes and it's all part of it's all part of those guidelines. Again, if it's a part of if it's Costello and it's in three, see if it's arterial injury, then you need to call CT. You need to get a CT angiogram. You need to see if there is any bleeding loosens. You need to do a trauma scan and you need to do a limp CT as well to delineate further anatomy and for further planning.
OK so when it comes to ct, if it's arterial injury, remember saying angiogram ok? And remember, scandal scandal gum is another buzzwords and it's kind. Grab his head to me. And it's one scout on AP, one on lateral. It will give you most of the information. Remember that now when you see an open fracture? There are two types.
One are so, so not two types of contamination. One is very dirty contamination and dirty contamination includes sewage marine farmyard wounds. They go to theater straight on. They cannot wait. OK they go to theater straight on and they get a rapid sequence. Anesthesia everything else. You clear the obvious dirt.
You take photographs. You put and you put a saline. So gauze. And remember, you put a clear film on it. You're not going to say anything, anything other than what it's written in the both guidelines. You read those guidelines and you regurgitated it, says clear dressing. Avoid many wash outs, but saline so goes, OK, take photographs.
And if you're not, the trauma unit involved the trauma. OK remember in a trauma setting in an open fracture setting? Remember this thing official to me. So remember remember compartment syndrome, a high index of suspicion for compartment syndrome should be there. Once debridement is carried out, patients stabilize.
You have splintered it. You need to have a plan for a definitive surgery within 72 hours or so, plastic or plastic again or to plastic. What is the controversy here? The controversy here is limb injury severity score. Remember that? And remember, if there is an amputation required, there are. It is not a decision to be taken lightly. You need to consultants.
You need to know there are strict indications for amputation. You need to just skim through all this. If an amputation is required, you need to have a injury severity score pattern, whether it Mrs. or whether it's injury severity score or whatever, whatever you find, easy to remember and just get that veteran. And studies have shown repeatedly, repeatedly that early amputation and rehab gives good quality of life improvement, then delaying it, delaying it by doing surgeries.
And then so that's why the trauma network, the trend and all the plastic cover is so important. So picture cover line is what I am going to say. Sorry, I'm running out of gas here now. So I think I'm going to stop. OK, great, great. Thank you. Thank you. I thought, I think we really can't really add much to what you said.
We can't teach trauma. It's really about teaching the approach to how you answer the question. And you know that all the first light is going to say that those words I wanted to highlight here in trauma tables, unlike any other table. Both guidelines are part of your initial answer not do, not come. They don't come at the end.
Please, OK. Don't say the most guideline to the end. Straightaway, open fracture, your first sentence, I will manage this patient, according to the post guidelines. Pelvic fracture the same radius fracture straight away, you say the first sentence manage the patient, according to the post guidelines, and the top marks come for mentioning trials, the crash trials for any trial that's related to trauma that comes later on.
But most guidelines come in your initial answer. One caveat to mention most early on is don't get it wrong. Once you caught it, you need to be Precice in what it says. OK, there's no signs of a heart yet. I would advise you all not just to read your post guidelines, but actually divide the recommendations into A&E management, Ward management, theater management and post-operative management and split them up and put them there.
So it's easier for you to remember them. And also it's easier for you to put them under those headings. I think that's great, thank you, Sean. We there was one question about what's the definition of trauma? And one has answered on the child, I don't know if you want to expand a little bit on that four.
So the problem is the terminology polytrauma is problematic, so not everyone uses that term. So what they tend to use is the multiple injured patients. If you take a look at the term network, it's trauma, audit and Research Network. You actually have a number of resources and definitions on that, including the injury severity score and the modified injury severity score. And they show if you go through that because a lot of guys are working in hospitals as opposed to MTC, so you won't have the experience of how these things are scored.
And even if you do work in an MTC, it's often done by special admit people that are hired specifically to make sure all this data is very accurate. The knowing a little bit about them so there's even about us tab is worthwhile because it shows you where the direction of trauma research and trauma MTC are going to go down the line. And have just to introduce Tamir here.
He is one of the mentors also, and he is supervising also tonight. Welcome to Thanks. Thanks and the presentation is very, very good. Excellent well, I think there is nothing to teach here. That's why I kept it. I kept it open. Yeah, that's the good thing. Just to the point bullets, rather than saying things that they know already, good people.
I think in trauma, guys, you'll be surprised. That's kind. Candidates quite frequently fail the trauma. Yes, exactly. Expectations are very high. So please take the trauma station very seriously. I know you guys are all excellent in trauma, but take this situation very seriously, what you say. So, so just question.
Someone just asked that those guidelines for open fracture did not mention anything about the type of antibiotics it is mentioned. Yeah, it is very specific. Yeah, it's very specific. Please, if you don't know the guidelines by heart, don't mention them. But I my advice is you should know them and you should. You should.
I think there's a new post guideline for open factor. Is that right? Yeah yeah, I think they have changed the open practice. They have changed. They have changed. They're the new one. So you need to know that they have even mentioned, even mentioned what to be given if a patient is allergic to penicillin.
So it's all there. Thank you, we will end this presentation. Now this session, and I will post another link to join the hot seat session. OK, so please guys, stay with us and rejoin. Another link will be posted in a couple of minutes. Thank you very much, everyone, for taking part. Thanks, Arthur. One AM also, we'll see you briefly.
Segment:0 .
OK, so welcome, guys again to this Wednesday is teaching from the Ortho FRCS mentor group. Thank you all for joining. Tonight we have only one presentation. The theme is trauma and will be presented by Assad. And we have one supervising decision also. Please feel free to pop up your questions through the chat box and raise the hand symbol next to your name.
If you want to talk. And also, there would be an extended hotseat session after, so please start expressing your interest from now if you would like to join before the screen. Yeah, just before we could, we again give priority to the guys who are sitting in the exam in April. So whoever is sitting the exam in April, please put your hands up for it.
If not enough people are volunteering, then we'll move to the guys who are sitting in June. Yeah, that's a good point. Yeah, I think that's a very valid point. Good OK. Everybody see everything. Yeah now, OK, guys, so today's topic is trauma. Yes trauma is not an alien to us, and the trauma is probably it's probably what everyone knows.
Over here, we should consider all of you should consider this station as a gift, but be careful because that gift comes with a price and that price is they are not expecting anything less than a tutorial here. So once a trauma situation has been thrown to you, they expect you to know everything because they are expecting you to come in having trauma as the best ammunition of yours.
You know, trauma in your armory and you should be throwing references you should be throwing. You should be teaching them because last time they read trauma was probably when they have given exams. And for them to be an examiner, they have to be at least seven year consultant so that we are talking for a normal training at least 10 years before he comes, unless they are trauma surgeons and if their trauma surgeons are unlikely taking a trauma exam anyways.
Now, as I always say to you in my previous talks as well, you have to be, you know, I invented this term psychiatrist, rheumatologist. So you have to be a mini psychiatrist in your head, so you need to know what the examiner wants you to say. And that's I cannot teach you. You just have this intuition built into you for you to say, you know, whether this examiner wants me to say a b, CDE for every question, or whether this examiner wants me to just press on the accelerator and get on with things.
I tell you what the examiner is, what I have been known and examiners, what I've been around or examiner, what I have seen generally likes you to just get on with it. There are very few old dogs there that want you to say a bcde first before you embark on to the actual topic because five minutes are very less. So remember, you are a psychiatrist or hematologist, so the minute you sit on the hot seat and you see your two examiners start judging from their facial expressions, whatever you get that whether they are happy with the way you are proceeding or you need to slow down or you need to fasten up a bit now it's a driving test.
So apart from driving, everything else will be checked. The same is true for trauma. They know, you know, how to fix an ankle. They know, you know how to do a hemi. So they are not testing that. They just want you to be a safe surgeon who knows all the practicality and and controversies around a particular topic.
Again, remember buzzwords. Remember controversies? There are few words you need to say before you start. That will defuse the situation. Once you diffuse the situation, you then be able to take control. And then you will enjoy the rest of your station. If you don't diffuse it early enough like we do, we keep on asking the same question.
The station will not move forward, and that will be a very long Five minutes for that particular scenario. OK, let's just move forward. And of this pep talk. I think just to say this, what you said is extremely important. It's possibly as important as knowing the subject is exactly it's having the right approach, which you describe now.
So I thank you very much for this introduction. Thanks a lot, guys. Thank you for supporting. Now like everything in the exam, I can predict sitting here, 90% of the exam. Most of you will predict sitting here, almost 90% of the exams, if anything will come in your trauma session, it will be this X-ray what you can see on your screen. It will be an open book fracture, ok?
It will be in a situation where a patient will having a hypertension and all the other parameters of circulatory compromise. And you just have to rattle things out. You need to give that guy a tutorial. You need to talk about all the buzzwords that can come into your head. When we say if hypertension, damage control, orthopedics, trans dynamic acid, pelvic binder, we will go to it all in a systemic way.
But that's what should be clouding your mind, and you should then start rattling it out. OK, so that is going to if in a trauma situation, this pelvis is what you're going to see and you all know what it is. Anything that has got a Bose guideline, anything that has got a Bose guideline, you need to read that they are not exhaustive. There are 14 of them and and you just need to read it.
There are no two ways about it. You're sitting the most important exam in your life. Why would you not know those 14 pages? There is no excuse for it. If you keep on repeating it, they keep on saying to you they are not interested. There are guidelines, but they expect you to know. So those guidelines for pelvic trauma, I have copy pasted it from the post this thing and you all have resort to it.
Again, it's all new. It's all normal. It's all known to you. There is nothing I am teaching, which is not known. So it is standard practice audit. What is suspected. You suspect an active bleed. If you see this pelvic fracture and you start from atlas, they'll say everything is fine.
Cervical spine and mobilization. They'll say it's fine. You go straight onto the pelvis, you apply a pelvic binder in the correct position. It is that x-ray, which is there, and there is another X-ray with pelvic binder right at the abdomen. And then you need to comment on the pelvic binder as well. And you need to say the pelvic binder maybe is not in a correct position.
If you are going for gold, then you can say things. You will internally rotate the leg and all the rest. But these are minutia, but you need to know whether the pelvic binder goes. You need to familiarize yourself with a pelvic binder. It's a yellow color thing. It goes on the GT. That's what you need to see that should come out of your mouth. Yes and and if you don't know it, don't go for the exam, ok?
Please take my word now. Hemodynamic stability you need to know about the major trauma center MTC. It is, it is. It is the first page in barnosky which you need to know about MTC. You need to know about when this network being set up and who runs it. So, so I'm not going to teach you.
You need to go read that page. Transatlantic exit, ok? You need to know the mechanism of action. You need to know the first clot and you need to know why we give transit Kessler. OK you need to know crash one and crash two trials. Crash one. You just need to know the name. It may.
Sounds very complicated, but in a trauma setting, if you're not going to say crash and crash to style, you are doing injustice to yourself. You need to. You need to say these words. They are not. They are not a stranger to you. You have heard it thousands of times. So when you see that open book pelvis fracture in your exam, if trans dynamic, it is not coming out of your mouth, it's crash one.
Crash Ii trial is not coming from your mouth. You are doing it justice to yourself. OK, then scandal remembers. Can you remember CT with contrast? Yes remember what will you do if the patient continues to go downhill? So remember those four types of patient responders, transient responders. And remember that you have to have a strict protocol.
When you should ring the alarm bell for major transfusion protocol, then you need to know back one and pack two, and you need to know as per your trust. You can go and ask in the 80 what one contains and wrote back to contents. Generally, they're equal amount of fresh frozen plasma, platelets and RCC, but every trusts have got their own. You go talk to them and regurgitate the same thing in the exam, even if you make it up, even if you say what written in.
Ask it. That's it, that's what you need to say. That's what you need to say. OK, now you need to have a clear protocol for binder removal as well. You should not leave it beyond 24 hours because what will it do? It will be counterproductive. OK, and the clot should have formed by then.
And if it's not forming, the patient wouldn't be alive. OK, so that's another thing you should be remembering. You need to get the trauma team, the general surgeon on board if it's non responder. You need to know how the pelvic backing can be done, and you need to know. B, you need to know what, how to reassess, how to reassess, and you need to know something about the cycle.
Psychological, physical and neurological disabilities. And when to put catheter. And just be wary of that by the time you have regurgitate all these things. I'll take you are on a safe pathway. You have diffused the situation. The examiner is now enjoying the conversation, what you are having and you can get on with things even if you say something wrong.
It's going to be discarded because you have diffuse the situation by bringing the board guidelines in, by getting him back to his chair. Once you see him going back to his chair, that's it. You have diffuses the situation and now you can. You can start playing left, right and center. However, where you want it, the background is. Of all, the strand networks, sitting is started from 1960s where high complication rates with immediate surgery was done.
It was due to all methods, poor trauma, coordination and IQ support. So delaying treatment traction in interim leads to pulmonary GI skin, soft tissue problems, stiff joints, prolonged rehab, longer ICU stay, longer quality of life, a lesser quality of life improvement following a major trauma, but this has now changed. The trained network has changed at all. Now so what do you do?
You split the trauma patients into four, you need to know which one is for damage control orthopedics and which one is for early total care. You need to know stable, borderline unstable and extremities patient and then you divide. Remember this two diagrams, ok? One is how do you do the correlation test within that. So that the clot can maintain and retain and remember this triad of death in trauma setting?
It's hypothermia coagulopathy and metabolic acidosis? This is not a stranger to any of us. This is not a stranger to any of us. OK you should know about it, and you should know about how each of this is leading to leading to the problem, how each of this is leading to the problem. So you you need to know about the mechanism of action, how hypothermia drains platelets, how he does it and what lactic acidosis is.
I'm not going to teach you that, OK, there is enough to say. Remember, I said, remember the buzzwords? Remember the buzzwords acronym suspected poly trauma, MTC trauma trial of debt, compensation of blood loss, major transfusion protocol stopping blood loss, permissive hypertension, hemostatic resuscitation, damage control, orthopedics and why Kristi Lloyd's alkaloids should be avoided because there is a risk of loss of first clot.
Remember, first clot first clot is another possible. We shed some more light on damage control. Orthopedics what is damage control orthopedics? So initially, when patient were used to be taken to theta straight on, they used to get a phenomena which is called second hit that abuse. You try to overcome that phenomenon by giving a lot of fluids to the patient that fluids leak in the chest and give patient ards, which is detrimental to their further rehab.
And it doesn't do. The patient doesn't do well. So remember remember something about damage control orthopedics? Remember what you need to do as soon as you see the patient? So remember, the controversy begins with the CT scan and the fast scan. Whether the ct, the CT scan, what both suggest. You need to say that CT scan with intravenous canntrust's from head to mid-thigh is the best investigation.
Ct scan intravenous contrast head to mid-thigh. Then you say in casualty, people can do fast scan. It's quick and it can, and it can tell you whether the patient is bleeding in the abdomen or chest. But you need to know the CT scan and CT scan with contrast. Head to Midtown. Once you say that they know what you are talking about, OK, they know what you're talking about. If there is any muscle alignment you see in any long bone, reduce it.
That's your kettle of fish. That's you should know what you do. What is the immediate management of a maligned bone in any reduce it? Splendid X. Yes if you can't produce it, you put it under OK. That's what it is now. Debbie's control orthopedics is again. You need to keep on reassessing, reassessing, reassessing.
How would you reassess? You reassess. We selected you reassess with the systolic blood pressure you reassess over the next few days and you see whether the patient can be then taken to surgery or not. Now, there are a few things what you need to remember here, the buzzwords are hemodynamically stable, no hypoxemia or hyperkalemia and serum lactate of less than $2 million per liter, normal coagulation, normal terminal and normal renal function.
What is a normal renal function? You know that it's less it's more than 1 mil 4 kilograms per hour for adults. For kids is different. It's probably 0.5. I don't know it, but I remember it for adults. You more than likely be facing adult trauma, so 1 mil per day per hour. What is a normal lected where you can operate?
It's less than two safe and proceed with definitive surgery if it's less than two you know about hypoxemia and hypercapnia and you are no stranger to systolic blood pressure. It's nineties, the magic word. Remember, 99 millimeters of mercury is the magic word. OK, now shed some light on where this reflected because when a selected. Is is again, it's one of the controversies now. We have talked about buzzwords.
Now we are coming about the controversies in this particular topic. So when slick it is, is because there is confusion in business, like if it's less than $2 million per liter, it's safe to proceed if it's more than 2.5. Then you need to continue research in ITU. Yes, so but there is a gap of 0.5 between two and and 2.5. So what would you do if it's between 2 and 2 point five?
So there are various studies and they're all originating from generators and leads that they are saying observe for trend. Now this is the gray area. They like to touch it if you're doing well. They like to touch the gray area. They like to stretch you. And this is where you are going to say, yes, I am the master. I know about 2 and 2.5. I will look at the trend.
I look at the trend because that bit you remember, if it's less than two, you proceed with surgery. If it's more than two point five, you stop, you observe the patient. And I tell you, what will you do in the middle? You look at the trend, you see if it's going down or if it's going up, if it's going up, you should not proceed. Ok?
so that's the long and short of it. I think that's what you need to do. You don't need to know the classification of pelvic fracture. You don't need to know anything because that's not what the scenario is all about. It's all about. It's all about what you need to say about artlols, about taking control of the situation, about coming up with the buzzwords.
I hope you will remember some buzzwords you remember and you remember pervasive hypertension. You remember first class. You remember these damage control orthopedics and you remember hemodynamically stable, patient assessing and all the rest and obviously coagulopathy and the stride of death. OK, guys, I think I'm till we do open fracture as well. Or you guys have enough?
Yeah, thank you. I thought it depends on we haven't had enough noise. Very interesting talk. OK how much time do we have? We can go. Have we have? About just over five minutes. OK, so we will quickly go open fracture because open fracture comes in the same setting, guys.
So open fracture again, open fracture comes in the same setting. Open fracture is no stranger to you to you, and open fracture has got a bone. Both guidelines attached to it, so you cannot. You screw it up. If this comes, expect no less than a tutorial. They are not expecting any less than a tutorial. You need to say, say, say, talk, talk, talk if I are someone hot seat, open fracture, if he let me talk for more than 30 seconds in that particular scenario.
That's it. I think he's doing injustice to himself and he's not even scoring. Passing marks, remember the buzzwords, the minute the open fracture comes, you need to say trauma network, you need to say or to plastic, you need to say IV antibiotics. Remember the timing for IV antibiotics? The timing for IV antibiotics in the post guidelines is one.
Don't confuse yourself, ok? It's one hours from their arrival in A&E. OK, it's there. It's there on the post guidelines. Don't say 30 minutes. Don't say 45 minutes. Don't say in the ambulance. Don't say outside the ambulance. One hour, one hour. OK that's what you need to say.
Remember it. It's in the post guidelines. It's not been made up. It's on Black and white. Say an hour. Be safe. Go to paper if they challenge you. And that paper is both guidelines. OK, remember to document neurovascular status.
OK once you document neurovascular status, you need to be clear about and specific. If it's foreign, you need to be specific about documenting all three nurses and their subdivisions radial their median opinion. You need if it's leg, you repeat the same once you aligned it and splint it. Excuse me. Repeat the neurovascular structure.
I repeat the neurovascular status and again documented. These are all legal documents. You are not safe if you're not saying this word. Yes and it's all part of it's all part of those guidelines. Again, if it's a part of if it's Costello and it's in three, see if it's arterial injury, then you need to call CT. You need to get a CT angiogram. You need to see if there is any bleeding loosens. You need to do a trauma scan and you need to do a limp CT as well to delineate further anatomy and for further planning.
OK so when it comes to ct, if it's arterial injury, remember saying angiogram ok? And remember, scandal scandal gum is another buzzwords and it's kind. Grab his head to me. And it's one scout on AP, one on lateral. It will give you most of the information. Remember that now when you see an open fracture? There are two types.
One are so, so not two types of contamination. One is very dirty contamination and dirty contamination includes sewage marine farmyard wounds. They go to theater straight on. They cannot wait. OK they go to theater straight on and they get a rapid sequence. Anesthesia everything else. You clear the obvious dirt.
You take photographs. You put and you put a saline. So gauze. And remember, you put a clear film on it. You're not going to say anything, anything other than what it's written in the both guidelines. You read those guidelines and you regurgitated it, says clear dressing. Avoid many wash outs, but saline so goes, OK, take photographs.
And if you're not, the trauma unit involved the trauma. OK remember in a trauma setting in an open fracture setting? Remember this thing official to me. So remember remember compartment syndrome, a high index of suspicion for compartment syndrome should be there. Once debridement is carried out, patients stabilize.
You have splintered it. You need to have a plan for a definitive surgery within 72 hours or so, plastic or plastic again or to plastic. What is the controversy here? The controversy here is limb injury severity score. Remember that? And remember, if there is an amputation required, there are. It is not a decision to be taken lightly. You need to consultants.
You need to know there are strict indications for amputation. You need to just skim through all this. If an amputation is required, you need to have a injury severity score pattern, whether it Mrs. or whether it's injury severity score or whatever, whatever you find, easy to remember and just get that veteran. And studies have shown repeatedly, repeatedly that early amputation and rehab gives good quality of life improvement, then delaying it, delaying it by doing surgeries.
And then so that's why the trauma network, the trend and all the plastic cover is so important. So picture cover line is what I am going to say. Sorry, I'm running out of gas here now. So I think I'm going to stop. OK, great, great. Thank you. Thank you. I thought, I think we really can't really add much to what you said.
We can't teach trauma. It's really about teaching the approach to how you answer the question. And you know that all the first light is going to say that those words I wanted to highlight here in trauma tables, unlike any other table. Both guidelines are part of your initial answer not do, not come. They don't come at the end.
Please, OK. Don't say the most guideline to the end. Straightaway, open fracture, your first sentence, I will manage this patient, according to the post guidelines. Pelvic fracture the same radius fracture straight away, you say the first sentence manage the patient, according to the post guidelines, and the top marks come for mentioning trials, the crash trials for any trial that's related to trauma that comes later on.
But most guidelines come in your initial answer. One caveat to mention most early on is don't get it wrong. Once you caught it, you need to be Precice in what it says. OK, there's no signs of a heart yet. I would advise you all not just to read your post guidelines, but actually divide the recommendations into A&E management, Ward management, theater management and post-operative management and split them up and put them there.
So it's easier for you to remember them. And also it's easier for you to put them under those headings. I think that's great, thank you, Sean. We there was one question about what's the definition of trauma? And one has answered on the child, I don't know if you want to expand a little bit on that four.
So the problem is the terminology polytrauma is problematic, so not everyone uses that term. So what they tend to use is the multiple injured patients. If you take a look at the term network, it's trauma, audit and Research Network. You actually have a number of resources and definitions on that, including the injury severity score and the modified injury severity score. And they show if you go through that because a lot of guys are working in hospitals as opposed to MTC, so you won't have the experience of how these things are scored.
And even if you do work in an MTC, it's often done by special admit people that are hired specifically to make sure all this data is very accurate. The knowing a little bit about them so there's even about us tab is worthwhile because it shows you where the direction of trauma research and trauma MTC are going to go down the line. And have just to introduce Tamir here.
He is one of the mentors also, and he is supervising also tonight. Welcome to Thanks. Thanks and the presentation is very, very good. Excellent well, I think there is nothing to teach here. That's why I kept it. I kept it open. Yeah, that's the good thing. Just to the point bullets, rather than saying things that they know already, good people.
I think in trauma, guys, you'll be surprised. That's kind. Candidates quite frequently fail the trauma. Yes, exactly. Expectations are very high. So please take the trauma station very seriously. I know you guys are all excellent in trauma, but take this situation very seriously, what you say. So, so just question.
Someone just asked that those guidelines for open fracture did not mention anything about the type of antibiotics it is mentioned. Yeah, it is very specific. Yeah, it's very specific. Please, if you don't know the guidelines by heart, don't mention them. But I my advice is you should know them and you should. You should.
I think there's a new post guideline for open factor. Is that right? Yeah yeah, I think they have changed the open practice. They have changed. They have changed. They're the new one. So you need to know that they have even mentioned, even mentioned what to be given if a patient is allergic to penicillin.
So it's all there. Thank you, we will end this presentation. Now this session, and I will post another link to join the hot seat session. OK, so please guys, stay with us and rejoin. Another link will be posted in a couple of minutes. Thank you very much, everyone, for taking part. Thanks, Arthur. One AM also, we'll see you briefly.
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