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Timing of Orthopaedic Surgery in Bleeding Patients - Concepts for Postgraduate Orthopaedic Exams
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Timing of Orthopaedic Surgery in Bleeding Patients - Concepts for Postgraduate Orthopaedic Exams
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Segment:0 .
Evening, everyone, welcome to Wednesday, Uh, teaching, Uh, that's running between forces mental group and/or are you OK today, our guest lecturer in Mr. ash vasili.
Mr vizard is a consultant, orthopedic trauma surgeon and King's College Hospital in London and pre-hospital care with air ambulance consultant ethics and Hertz air ambulance. And he is a lecturer in the Institute of pre hospital care at London air ambulance. Lecture alpizar Institute of trauma science at parts and the London medical school. Mr vizard is a fellowship trained orthopedic trauma surgeon specializing in the management of complex Auburn closed obalende, lower limb, pelvic and established fractures in both adults and children.
He works at Kings College Hospital. Major trauma Center in London. After completing his orthopedic registrar training programme, he completed both national and international orthopedic trauma fellowships. Mr 430 has a varied portfolio. Career is also a fully trained air ambulance doctor and works as a pre-hospital care consultant on a regional air ambulance service.
In addition, he also holds two academic lecture post lecture at the Institute of pre hospital care at London air ambulance and holiday clinical lecture at Blizzard Institute of trauma science, which is part of Queen Mary University Hospital of London. Thank you, Mr. vasili, for giving lectures today. Hey, no worries, thanks, Tony, for that very generous introduction. So again, thanks, chuck, for hosting this.
Thank you. Flexor-pronator for hosting this and both of you guys for inviting me today. Thanks again for inviting me. So the main purpose of my talk today will be to look at timing in orthopedic surgery and the bleeding patient. I think as well what else probably spent a decent amount of time today is talking about some basic principles, and we'll talk about shock and the response to bleeding while bleeding is actually still difficult to diagnose and can be difficult to diagnose.
The response to injury. What do you see on your blood pressure, heart rate monitor, et cetera that can give you an idea of the level of injury that's happened. We'll talk about coagulation. And then we'll talk about sirs, which often gets mentioned, but there are other things as well. And then we'll talk about principles of resuscitation and then we'll talk about damage control, resuscitation, damage control, surgery, at least until early appropriate care.
All these weird concepts and terms, which basically revolve around the package of intervention are the basics. So this is the problem that you have in your trauma bay, in your emergency department or can have and this can happen at a major trauma center. Most of the time these days, that's where it is. Occasionally, it can happen in a district general, but less often, but still a big problem.
So we need to think about what's going on here, what's happened and how we can treat this. So often in my pre-hospital care, hats on and when my priest pre-hospital care job, this is what I'm often going to this kind of level of incident quality trauma, significant amounts of injuries or multiple, usually multiple patients. But what governs everything that is going on in terms of how the body responds to trauma and trauma physiology?
And this is a big part and an important parts of the physics exam and an important part of the fastest syllabus within the traumatic chapter. And the whole thing that governs governs trauma. Physiological response is inflammation, hence the funny electron microscope artistic picture. It's all about inflammation and stuff that you would have heard and seen when you're at medical school.
It's the same thing. So we talk about response to bleeding, all of you, I'm presuming, have done the, of course. So you all have an idea of the classification of shock class one, class two, 3 and four the revolves around how much blood an individual has lost, and it's usually bracketed in percentage blood loss. So class one shock. Usually, they lose less than 15% in class Ii is 15 to 30, et cetera, et cetera.
If you need a good way of remembering this, just remember that tennis scores so 15 love, 30 love, et cetera. And then that gives you a way of remembering the percentages and then the general issues that the pulse rate goes up as you lose more blood. Yeah, sure. Blood pressure gradually goes down. Pulse pressure initially increases, then decreases. Pulse pressure is the difference.
Respiratory rate is the only thing that always goes up as you lose more blood. So there's a couple of things, though Atlas has a very nice table that explains it. If you get this kind of question in the vyver, they are looking for this kind of answer. You talk about percentage of blood loss, severity of shock and what you would accept, what you would expect to see in the patient.
But I wouldn't necessarily worry whether they'd actually ask for individual numbers. So I don't think they ask you for a respiratory rate in class three shocks. I wouldn't worry about that. Just broadly that certain things go up like heart rate and certain things go down like urine output and blood pressure. Importantly, though, in real life, the issue is that everything is not quite as simple, so when people have assessed the Atlas classification and kind of looked at it in clinical reality and how useful is it really?
The problem is it's actually found wanting. It's not really very clinically useful. Sometimes you can have people with excellent heart rates, maybe 80 90, and you could perceive that's not too bad. You can have people's blood pressures that seemingly OK. So you know, blood pressure of 105 over 80 in a very small petite person may seemingly be OK. So there's lots of issues, and we'll discuss why.
Actually, Atlas doesn't. The classification system doesn't work all that well. There's a phenomenon as well. Some of you may or may not see in patients with significant amounts of blood loss, either due to blunt trauma or penetrating trauma, and those of you who've seen patients who've been stabbed in the chest who've had significant bleeding from the heart or the lungs, for instance, they are frequently very bradycardia.
They don't Mount any kind of tachycardia at all. Or if they do, it's very mild. You won't see heart rates of 440 in these patients. They'll all be 80 90, and suddenly they'll become pretty chaotic. The blood pressure is usually maintained until the last minute. I highlighted this article here just as the case report, because I find it amusing that things like this get published.
This case reports and actually things like this were actually very well understood. Back in the 40s and fifties, and even in the Second World war, the First World war, people knew if you had blood loss and you were bradycardia, an imminent sign that you're about to arrest. So what's going on?
So the issue is that actually the body is not silly and the heart is not silly. So when you are losing lots of blood, it would be foolish for the heart, for instance, to continuously become tacky, chaotic, more and more, because that would effectively mean the heart needs more blood supply, more metabolites. It needs more blood to then take away all the waste products of metabolism.
And the problem is that the initial shock state, that's totally not what you need. You do not need an organ to force or to continuously require more and more blood, because that just makes this situation worse. Actually, there are multiple systems around the body, and I've just highlighted three of them that actually detect significant amounts of blood loss, either due to pressure issues or issues in the blood, and they then stimulate the autonomic nervous system to reduce the heart rate and gradually reduce the blood pressure as well because the heart is not silly.
It doesn't. It doesn't need to keep asking for more blood flow when there isn't any to go around as it is. OK, so when you have significant amounts of blood loss, your heart rate will actually might go slightly tachycardia, but will actually become bradycardia. And there's an evolutionary response to trauma as well. There lots of issues around leaky capillaries, and I'm kind of stepping into ICU level territory here, but it's important that we, as orthopedic surgeons understand this.
So with trauma, the capillaries become permeable. Yep, so all your tiny blood vessels become permeable. And so what that allows is it allows if you follow the blue block and the blue boxes, it allows white cells, white cells to go into the interstitium of the organs, and it allows fluid to go from the extravascular space, i.e. for the interstitial and last fluid to go into the intravascular play into intravascular space.
So effectively, the body is trying to replenish the intravascular volume by sucking out fluid from the interstitial. This helps increase your volume, increase your central venous pressure, and helps to keep cardiac output going. So that's what the evolutionary response is. The problem is that we continuously keep wanting to give people fluid and more fluid and more fluid, so we're actually fighting against a response that's been trained over generations.
So by giving fluid, you actually then force fluid to go from the intravascular space into extravascular space. You end up getting edema in the organs and you then get organ failure. So this is a big problem, and this is why we've gone away from using a lot of crystal Lloyds because it's just not very good practice. It causes a lot of problems, and we definitely have got away from using colloid because colloid elicits a huge inflammatory reaction.
So we've gone from the days of giving starch or other simple components. We've stopped all that and tried to stop using saline as well. So I told you earlier, two slides ago that if you lost a lot of blood, you become bradycardia, your blood pressure go down, et cetera, et cetera. But I know for sure that you guys have seen and I've seen patients with significant amounts of trauma have a significant tachycardia.
So the way to think about this is if you look down the middle here in the Black writing, these are typical numbers, you will see on any monitor systolic blood pressure, heart rate, respiratory rate and obviously as you measure. So these are what your patient exhibits, the external features that you can measure their parameters. You then need to split their trauma into two things the level of bleeding and the amount of injury they've had.
OK, and when I talk about injury level, I mean the amount of tissue destruction they've had. And when I talk about bleeding, I just mean pure blood loss. So the responses of these two can be very different. And it's how the two combine the leads you to have these funny numbers in the systolic blood pressure, heart rate or rest rate. So if you are bleeding and from a simple stab wound to the heart, for instance, blood pressure would be maintained for a while and then would be suddenly hypertensive.
Go off a cliff into a rest bleeding. You get a very mild tachycardia and then your heart would go bradycardia because your heart knows you haven't got much blood. So it's going to slow itself down. So it doesn't have to work too much because it knows there's not much blood to go around. Your arrest rate becomes technique because your lungs are still trying to get rid of excess co2, et cetera, and your course, reduces.
OK, so that's fairly straightforward. Now, if you didn't have much blood loss, but you had a really nasty injury, so you had a massive crush injury, but you didn't have any significant blood loss, you would actually become a little bit hypertensive. Your heart rate become very tachycardia, because this is a noxious stimulus, so your sympathetic system is super activated, your hormones like adrenaline from the adrenal cortex.
And from neuron endings are all being released. So you become tachycardic. You also become technique, so you start breathing harder as well for different reasons. And again, your focus falls and reduces. So how these two the bleeding combined with injury, how those two interact is actually leads to what you see on the blood pressure. And that's why sometimes with someone who's had a massive injury load and also a lot of bleeding, their systolic blood pressure looks vaguely normal and their heart rate might not be that bad.
But when you look at them, they're white as a sheet because they've lost so much blood. And so this is why it can be difficult to diagnose blood loss. So with. So this is a really interesting topic I find fascinating. Interestingly, most of the research from coagulopathy in trauma is all being done by General surgeons, mainly out of the Royal London trauma surgeons at the Royal London.
Not a lot of it has been done by actually hematologists. So anyway, so there is a coagulopathy in trauma, and it's not to do with loss of factors, not in early stages anyway. There's three perceived mechanisms. We'll talk about those in a second. You all know the lethal triad of death, which is coagulopathy hypothermia, and if you start, if you have these issues ongoing, you will increase your mortality risk and the issue mainly is around hypothermia.
And the lower your body temperature goes, the less effective enzymes work. And so your coagulation cascade doesn't work that well as well. And also you become more acidic. And again, that doesn't help the coagulation cascade. So lots of problems here. A vicious cycle. So the lethal triad.
And it's when we talk about trauma at different times, they used acute traumatic psychopathy, trauma induced coagulopathy that are all roughly looking at the same thing. In terms of I'll just pop back for a second in terms of the three mechanisms I'll touch on a little bit later, but there's three things that people believe happening. One, you don't form the clock properly to your fibrinolytics system that's responsible for breaking down the cloud, so that's the negative feedback loop.
That becomes hyper activated, and that's where chronic stomach acid comes in, because it works by inhibiting fiber releases, so helps maintain your clogs. And the third is there's a problem in the expression in the endothelium, so platelets don't work that well. So three mechanisms. Platelets don't work.
Fiber releases are activated, and the clot that you first form is not that good quality for some. Mason coagulopathy is an interesting thing, so if you think about this, you actually do want a little bit of coagulopathy again, this is another evolutionary response. If you're hyper bulimic and you've lost a lot of blood and you don't have medical care, what you effectively go into is a low flow state, so your body slowly pumps the blood around.
It doesn't do it too fast because it knows that you haven't got enough blood, so it just sends it around. But the problem is, if you have not that much blood, your body will probably want to start to clot this blood because there's not much of it. It's moving very slowly. There's a bit of stasis going on, so you start to get some of the features of virtuous triad where you eventually are at risk of getting a DVT or some kind of little clots.
So what is the body do to avoid getting these little clots everywhere, like the muscle of the gut? It basically makes the blood empathic so that it's extra thin and so it doesn't form these little clots. So again, it's all an evolution response, and we in trauma care are totally Messing with it. But we have to do something because not everyone would survive if we just left it to nature.
So as I said, this is a three mechanisms by which we currently believe that coagulopathy works or coagulopathy occurs in trauma. Activation of protein C pathway. So you don't get a proper formation of thrombin and the clot hyper fiber lysis. So excessive breakdown of your clot. And so this is where tranexamic acid works and platelet dysfunction.
So this is a really interesting thing about inflammation, I won't spend too long because this can be super boring. Effectively, most of you would have heard about the first and second hit. So you have something called the systemic inflammatory response syndrome and the counter and. The inflammatory response syndrome and effectively with this, and people have believed us for a long time, you get trauma that's a first hit and you Mount a systemic inflammatory response syndrome.
And people used to say that if you then did significant surgery, this could be a second hit and effectively you could get a certain response all over again. And this could effectively then place the patient at risk. I'll get. What people have actually found to be the case in reality now is that you have a systemic inflammatory response syndrome.
And the counter regulatory system, so that's the red and green actually both activate at the same time. How long they're activated and how one balances the other is still a lot to do with genetics and individuals and groups of people, and also some of it's to do with how we then treat the patient. So if we end up spending a long time operating on them and give them some kind of surgical insult, then there are risk of prolonging their says response and getting problems like multiple organ failure and edema.
I'll skip over this one. The next couple of graphs are just to show some interesting things. This graph basically has been looking at resuscitation in trauma patients in London about six eight years ago, so it's got a little bit of old data, but it shows you well. It will depict what I want to show, which is that as patients have when trauma patients are admitted as opposed to minor injury patients, but the trauma patients are admitted.
And as you start getting increasing blood transfusions, four units, eight units, 10 units, your coagulopathy profile gets worse and worse. OK, so something to bear in mind. And this is why massive transfusion protocols have been recommended, and it's why certain protocols have the components they have, and we can talk about that later if anyone wants. Also important to note that once you start having huge amounts of transfusion, either when you're in hospital and over time, your mortality risk increases.
So this is your mortality risk in hospital in one month and one year if you've either had four year transfusion, the gray box or a 10 unit plus transfusion. So you can see once you've kind of gone over 4 units and you're near 10 units of blood transfusion, your mortality rate increases significantly. I look at it that one year. There are still people dying, and we don't really know why.
Interestingly, lacked all of you would have heard about lactate as an important marker for shock. It can take ages for it to fall. So look at this group of patients. So they had a lactate. When they came in at 10, they were transfused. And even by one day, it's still like 2 and 1/2 a day, three, it's still probably one to two. So lactate takes a long time to go away.
In terms of the principles of resuscitation, I mean, the modern setting for resuscitation these days happens in every hospital, in the hospital environment, so at the scene with the ambulance service. And as I said, it's the service I used to work for a while ago and switch to a different one. And so they start your mercy medicine resuscitation. They start your acts at the scene, typically going to gunshots and stabbings.
This is a cyclist who got run over by a dumper truck, so they start all of that in the field, and it's important that they do that because it still takes over an hour to get a major trauma patient into a hospital, even in London, when there's four trauma centers within a few miles of each other. And so the hospital service do start all of that to begin with at the scene.
So we'll talk about some important components, the damage control resuscitation, so what I'm going to talk about now is basically concepts. It's not it's not a thing, it's a concept. So that's the key thing to remember. Damage control resuscitation is mainly for patients who are actively bleeding. So they're coming into your hospital, into your emergency department, they're still bleeding.
The aim that you need to bear in mind is the team needs to achieve hemostatic competence, i.e. you want to get the patient's blood to behave normally, transport oxygen and be able to clot properly. So you want to get a hemostatic competent. You want to achieve early hematuria, hemorrhage, control via surgery and/or interventional radiology.
You want to do something called permissive hypotension. It's called it's easy, yeah, it's called the Mason hypertension. It's called different terms these days, resuscitative management, lots of different terms. Basically, it's when you let people have a slightly lower than normal blood pressure in order to stop massive variations in their BP that may dislodge a clot.
And the target of your BP. We'll talk about it in a moment. You are limited to your fluid infusions, so don't get a. And you want to target any coagulopathy. Does the permissive hypotension good numbers do remember, just for your young fit adult is if you've got an isolated head injury, you want a systolic BP that's pretty near normal 120, you need to confuse the head at all costs.
If you have trauma with a head injury, you can aim usually for around 100. And if you are trauma with no head injury, you can let the systolic BP be lower. So 80. OK so these are reasonable numbers to hang your hat on. As we said, we want to limit fluid and infusion says avoid excessive Chris Lloyd with Western's coagulopathy, increases hypothermia and doesn't actually treat the blood loss problem.
You want to activate a massive transfusion protocol. And for all of you guys who are sitting the exam, I thoroughly recommend you have a brief look at your own hospitals major haemorrhage protocol, major major transfusion protocol or code, red protocol, or whatever it's called. Just so you're roughly familiar with it that it's not that hard, especially usually a sheet of paper one side.
And effectively, it says something lines along the lines of a senior member of the trauma team must declare a major transfusion or a code red or whatever the term is if a patient's BP is less than 90. They do not respond to some initial fluid resuscitation and you suspect ongoing or active hemorrhage. And then with that, you get a number of things, you get some packs of blood to begin with and that to ideally fill the patient with blood and the packs that you then get later are the packs that contain coagulation components like FFP platelets and precipitate.
Are the things that we cannot frequently see used to select schools, which is a hemostatic dressing that you'll see people stuffed into wounds, pelvic binders important for pelvic injuries. And you should think of pelvic binders as a he-man, as a resuscitative instrument, not a mechanical instrument for orthopedics, but rather it's important for hemostasis. You can have splints to manage people's femoral fractures.
Tourniquets occasionally use hospital. And again large dressings to stop the bleeding. Tranexamic acid use very often given hospital and another dose is usually given in hospital, and we don't really want to be using this saline, well, saline or Ringer's lactate, et cetera. We want to get people to the CT scanner as soon as possible. And then after that, we want to decide what their problem is, so either they go to surgery, they go to which is the top left to go to interventional radiology.
The bottom left or the go to intensive care for more supportive treatment, which is the right sided image. You'll occasionally hear about things like call from elastography. I won't spend too much time on this. Basically, it's a point of care blood test where you take a sample of blood of a patient. You put it in a special machine that basically whizzes the blood around and measures how fast it clots and then how long it takes for that clot to then disappear.
And then from that, you get various pictures and numbers that will then tell you what the problem is that the coagulation cascade is it that you don't have enough ffp? Is it you don't have enough platelets? It that the platelets don't work, et cetera, et cetera. And then you can do targeted ethnic management. Now, other things that you'll hear about is early total care. So this is defined as fixation of all fractures in the first 24 hours.
The old fractures are very variable term depending on which paper you read, but it was shown for a long time to be associated with reduced rates of fathomless ARDS organ failure and VTE venous thromboembolism. Main proponents started from a chap called bone in 1989 for America, and then it got used a lot everywhere in mainland Europe and here in the UK and also ongoing in America.
And then in 1999, Hans Christian slap began to show that there's high mortality and multiple injured patients. If you if you had operations that took a long time. So if you had operations that lasted long, mortality went up, so they decided, well, I think what we should do is something called damage control surgery, and that's when you had damage control, orthopedics, et cetera or the whole concept of damage control come about.
And in damage control, the aim is to control your hemorrhage, manage your sepsis, protect yourself from further injury and restore the physiology and minimize the second hit. And in reality, the principles of orthopedics, it was using a lot of exelixis, so you wanted to do stage treatment. You do some resuscitation in the emergency department. You expect all of your fractures. You go to ICU.
You leave the patient alone and then you take them back to deter when you convert them definitively to the definitive treatment. So I am nails or plates, and that can be anywhere from a few days to a few weeks' time. However, shoving fixes on everyone wasn't a great thing and has its own problems. And so over the last decade, there's this phenomenon the new one called early appropriate care, which is somewhere in the middle of early total care and damage control.
And so this effectively says that you should aim to do early total care or the appropriate care in this case once your patient has been appropriately resuscitated. It recommends trying to do that within an eight hour time frame of resuscitation. You want to meet your physiological targets, so get your lactate less than for your better than 7.25 bas status less than minus 5.5. So effectively, we want to bring your lactate down and try to get your patient not to be acidic.
Yeah, and that's usually managing people with blood transfusion, massive hemorrhage, protocol, et cetera. Now, in that eight hour time frame where you get to resuscitate them, if things are getting better, then you should aim to get them to within 36 hours to fix their long bones. So there's better outcomes, and this has been shown continuously by head evaluating all of the liver failure in all of her papers from 2010 to 2017.
And there's less complications. This is an elderly patients and in young adult patients, the question is what are long bones? So previously, in early total care, a long bone used to be considered as humerus, forearm, theme tibia, et cetera. But actually, if you dial down and some Villiers work, it actually is spine, pelvis as establishment femur. So these are the four long bones.
You'll realize that only one of them is actually a long bone and the rest are just bones. So pelvis, acetabulum, spine and FEMA. And the main reason you want to do this is that by fixing all of these patients can then be nursed better in ICU. They don't have log rolling restrictions, they don't have pelvic rolling restrictions. They can be sit up, set up, sorry.
They can be sat out in a chair and their respiratory physiology gets much better, that they don't get things like ventilator associated pneumonia and other problems. So that's the thing that a lot of us are kind of Gunning towards early fixation of the long bones. So overall, just kind of wind it up. The rough pathway through the emergency department for your given patient coming in, you have an unstable bleeding trauma patient.
OK, so you want to think about damage control, resuscitation, damage control, surgery, potentially. These are concepts, right? With damage control surgery, you want to limit the hemorrhage. So if there's any active bleeding, you want to stop that. And you know, that could easily be something from the spleen, the liver or from the peripheries and arterial injury in the leg or even potentially in the pelvis.
And we talk about that if anyone wants to manage any sepsis, so clean any wounds, protect the patient from further injury. Correct the physiology. So that's Ike's job, really and traction. Because for the low limbs and then for damage control resuscitation, we've talked about permissive hypotension, hemostatic resuscitation. I give them blood products and blood itself, manage and fix the coagulopathy and avoid the lethal triad, so keep them warm.
Don't let them become acidic and don't let them become coagulopathy or if they do, try and fix these. Patients then go sit on an ICU. Well, all of this is happening. They gradually recover and then once the timing is right, you then take them to death, ideally in the first day and a half 36 hours for early appropriate care. OK, so in summary, we kind of gone through quite a few things of trauma, physiology, the principles of resuscitation, and then talk through some of these concepts.
Also the mentor group. Group, that's again, charity basically trying to make sure that education is available at this level for each school visit as a YouTube channel or on a web page. And also we have courses as well for you guys to join, and I also want to plug our book as well. Concise orthopedics behind my head that we do think it is worthwhile to get it going on its own or online booksellers as well.
Thank you. Please do answer because the question was, which parameter is most appropriate in determining the severity of bleeding and hypo perfusion? All right. So hyperperfusion is basically shock, right? And so we've already said and just kind of masks, level lactate is the best thing for looking at Shock. I'll go through why the others don't work.
So well, so hate to be less than 100. So yeah, if your HP is low, then effectively, Yes. I guess as a surrogate marker, you're saying that there's not enough hemoglobin. But the problem is you'll find a lot of trauma. Patients don't have very low FBS to begin with it, even early on in the first few hours. HP does take a while for it. To really equilibrate and give you an accurate reality will give you a real level that's appropriate for that patient sets.
It's falsely reassuring if you were to look at HP initially in your patient. You mean, again, they're not really appropriate to use as a blood test to look at Hyper perfusion. I mean, they will be very elevated if there's kidney hyper renal hyper perfusion, but it's not a good accurate 1 to determine bleeding severity. Cerp is next to useless and glad now enough to fill that coagulation profile.
So coagulation profile? Yes, that is. The traditional coagulation tests were designed by hematologist to use for we to use as blood tests to monitor coagulant profiles like warfarin. Inr was invented for warfarin, APT was designed for heparin, and so using a coagulation profile for trauma doesn't work that well.
And so that's why we have things like tag and other profiles. But so overall lactate is the appropriate answer for that one. And next one, which vessel is the most commonly injured and pelvic ring injuries? Now I haven't really touched on this at all, but the answer is actually the superior political that's the Communist one. It's one of the first branches of the internal country.
Now, if you get an mk q question and they give you two options, they want the correct most accurate one. So you could kind of argue the case. The entire line is potentially correct, but no, the most correct answer in the list of options you have there is superior gluteal and then the last one. Yes so this is an interesting one. So what's the next most, most appropriate intervention for this patient?
So 40-year-old pedestrian struck by car brought in by ambulance at 12 PM so that's midday in the Mason department. He's vomiting, has noisy breathing signs of paradoxical chest movement, distended guarding abdomen, mangled leg. OK, so in the emergency department, he's vomiting. So that's not a good sign. Maybe a sign of head injury anyway.
Vomiting people are a risk to their airway, noisy breathing. He's got features that suggest problems with his OA. Signs of a paradoxical chest movement that's basically a flail chest. Again, he's got respiratory compromise. The standard regarding appointments, so has also got something that maybe necessitates a laparotomy at some point and a mangled leg, so clearly something that we, as orthopedic surgeons would want to manage as well.
What's the next most appropriate step as step as all of you know, from atlas, the next most appropriate step would be to secure his OA and say the only way of doing that is to do a rapid sequence induction. And obviously you wouldn't do that. The anesthetist would, but you would be expected to know that. Yeah, so what? The next most appropriate step is because this is just an Atlas type question.
Giving tranexamic acid and antibiotics, yes, definitely a good thing to do and definitely, definitely worth doing, but it's not the next most appropriate intervention over the next appropriate intervention. The biggest problem this patient has is airway, and that's need securing. Invariably, he'll have to go to the theater for a laparotomy soon.
Yeah, invariably he'll need to have a CT scan. But if this guy's got OA compromise now, that needs to be assessed before going anywhere else. Thanks, Ruth. Slide yes, stop sharing. Yeah, thank you. Thank you. Thank you very much. So in terms of questions.
Is there a the list of questions? And I'll start off when is a hurry, abdullahi said, let's take a properly introduced in anticipation. Is it in the Department or in ICU, but in the future? Yes so some places trying doing the I think most people, though, would use it in ICU or in theaters. It's not necessarily something that's happening in most Ed straightaway.
But if someone does go up there, it's happening during that damage control surgery, during the laparotomy that would wash out, that's happening there if they're actively allopathic and bleeding, et cetera, and definitely happening in intensive care. That's where it generally does happen. It seems that most people, the summer she is actually far from the perfect binder.
She is stimulation the need a few days to have a patient who still look like experts. And that's. No, so no. That's an interesting question, and there's some philosophical issues and beliefs around different trauma centers about what needs to happen with pelvises. Remember, the binder is a hemostatic agent, and that's why you should think about it, not as a mechanical device.
There are definitely patients typically with a lateral compression type injury. Sorry, correct me. There are typically some patients, typically with AP type injury. So like an APC to something like that, or even the APC three who definitely feel better when they have a binder on like they find themselves more comfortable. I've definitely had lots of awake, stable patients.
24 hours, we want to take that binder off with an APC two or three injury and actually we take it off. They like who they start complaining that things doesn't feel right in their television and that in the lower back. And so they really like having the binder on as a comfort device. So but really think about it as hemostatic device, so you take it off. After 24 hours, clots are usually stabilized at that point, and you wouldn't necessarily need to routinely do an ex fix.
But those patients, just because you then have to wait a few days to definitively fix them, the only thing you would do is continue your pelvic rolling restrictions in the interim, if you need to apply next fix to a pelvis. It would be in the situation where they're going to get from the emergency department, either because they're bleeding from their pelvic injuries, or they may have an open pelvic injury or something with a rectal tear, et cetera or a peritoneal laceration, that kind of thing where you need to stabilize the pelvis.
So those patients typically will be the ones getting fixed. No, we're not really doing X fixes day one or two as an interim temporizing measure. I don't think that's really needed. And so just doing just your talking is really good, Mr. That's right. And it's obviously it's fine. I think it's very important topic and we really do appreciate the time you're giving to us.
But it's a testament to actually how well from the top. Nobody's really gotten too many questions because you've covered a lot of areas really well. One of the questions that has come about this whole body scan, do we do? We just do we do it with bas status patients as well? So, yeah, yes, this is a very interesting question. So in the past, obviously, we all know the term term donors of death.
So CT scan used to be the donor of death. Used to be called in Atlas courses. But actually, it's not really going to CT. Scan, especially within a major trauma center, is definitely seen as part of the resuscitation, right? Because you cannot target and cannot treat effectively what you don't know, right? And clinical assessment is just not good enough is not accurate enough.
So you really we recommend highly patients have a CT scan for the exam answered the most guidelines then, and NICE guidelines for major trauma. All say that you need to have a head to toe CT scan of everything to really get an idea of the injuries. And in that way you can get your list of injuries and reprioritize them or the trauma team leader can read, prioritize them and then you can manage them. One at a time and just go through it as opposed to kind of just finding the injuries as in when you randomly decided to find them.
So, yeah, I would advocate taking patients even if they're imminently unstable, but they're being actively resuscitated to the CT scan and have the CT scan. Here at King's, we are often taking the whole trauma team to the CT scan with the patient, so we just carry on the emergency department stuff in the CT scanning room. We step outside for the minute it takes to do the scan and then go back and carry on resuscitating them.
But then what about the patient who's had a trauma, but instead he to take them to the surgery is done? Yeah, Yeah. So we yes, I guess we have a most major trauma centres, not even us, necessarily. Most major trauma centers have a very low threshold to CT scan everyone. So if the mechanism fits unless people are effectively walking in without any significant injuries, most trauma patients are having a head to toe CT scan.
Yeah you know, especially the people being brought in by an ambulance with significant histories, significant mechanisms and abnormal initial hemodynamic monitoring from the ambulance crews. They'll all get a CT scan even if they begin to stabilize. They'll still get one just to make sure there's nothing that they've missed. And in terms of. So I'm not sure if we're going to cover this section, but I'll ask this question anyway in terms of other factors where you have uncontrolled bleeding.
What's the goal between radio so air versus surgery and radiotherapy versus the. Yeah a great question as kind of touching on it later. But great question. Let me deal with it now and then we can clarify it later if we need to. So the first thing to remember is that there are some general philosophical beliefs and institutional beliefs of how to manage pelvic fractures.
So if you were to go to North America, there is definitely a lot of trauma centers, really world renowned trauma centers that are really pro pelvic packing. OK, so. So you already have a little bit of confirmation bias because one group has a tendency to do one thing regardless. And then there's another cohort who will say that, yes, you can think about er, but the problem is out of ours.
It'll take you like an hour to get the item in from home to set up the room. And then, you know, it's just quicker to go to the surgery and fix it and fix everything and deal with it. So there's a number of competing issues. There are other things to then think about is one, if you're going to e.r., I are only really works or works very well if it's selective as if it's going after a name vessel and that's usually a branch of the superior gluteal, for example.
Yeah, you don't want ER to basically be taking out an entire internal iliac artery, right? That's just not a good thing, because it causes muscle wasting that leads to atrophy and soft tissue necrosis, certain areas. And actually, that can mean that there's a pelvic surgeon I can't go and treat surgically manage that area because the risk of infection that becomes ridiculously high.
So there's issues around that, so it needs to be selective. So what some people say is and a lot of trauma centers have a protocol for this, and I would strongly suggest for those using the exam is to find the protocol for this at your major trauma center. If you work at a trauma unit, i.e. you will have access to the major trauma centers policy on this within your own institution. And here at King's, it's like a little flowchart that tells you who goes where, what.
But generally, if you have someone who goes to a CT scan and on the. Scan there are signs of an arterial injury associated with the pelvic and/or acetabular fracture. And typically people talk about little blush on the CT scan with an arterial injury. Those patients are probably the ones that would do best to go from interventional radiology. Sometimes you find that actually by the time you get to air with your amazing resuscitation that you guys do in your hospitals, everything's sorted out and then so you then end up with a little bit of a negative air and that's OK.
All right. The other problem that happens is when you look at research studies that talk about pelvic packing and talk about e.r., if you look at how their patients are managed in the emergency department in those hospitals, the report on this, a lot of them, especially in North America, a lot of them are getting two liters of fluid, like one or two minutes of blood and no blood products.
So they're not getting any kind of what I call what we're doing in the UK here. Some really good resuscitation. And so that can really clouds the picture. So we can't really apply findings from American studies into UK practice because we're just slightly further along, I think, in the Ed resuscitation pre management than other centers. So overall, if you go CT scan, you find an arterial blush.
Think about ER that's probably your answer. If you don't find a blush, then the bleeding is either going to be venous or for the bone. And then that's where your binder, tranexamic acid and accurate resuscitation will help you. Then look at the trend of the patient, and if they're getting better over the next couple of hours, then you're done. You don't need to do anything if they're getting worse than their lactate, getting worse, and actually they're needing more and more blood transfusion, more products and the numbers are stabilizing, then yeah, they'll need to go somewhere.
OK, and that will probably be in that case, be a theater. Is that a lot? No, no, no. It's absolutely a perfect answer, and then the examiners in this scenario then push you to say, well, the patient's really unstable. Where do you choose to go? It's always different. I think the safest answer would be that if you have an arterial injury in a seat and if you are not artery injury identified on CT scan, then you should then speak to the examiners and say, you know, if you have access to interventional radiology, then yes, that you would discuss it with them.
And if they're happy, you take them to interventional radiology. But if it's not natural injury and it's kind of a general venous and ongoing bleeding from the bones, then surgery is your best option. Sometimes you've taken to surgery because say, air is not around and not available and then you pack everything, it doesn't settle down. Sometimes you end up going back to interventional radiology after surgery to just fix any outstanding arterial injuries.
Some centers are good, so they can do it in the operating theater as well. Oh no. Yeah, exactly. No, absolutely. There are. Some say, yeah, some. Some hospitals are blessed with a hybrid theater where you can CT scan air and operate all in the same place.
But most of us aren't exactly where I work. Yes so thank you, Mr. We're done. Very excellent. Make sure when I will stop recording and we'll go to the best.
Segment:0 .
Evening, everyone, welcome to Wednesday, Uh, teaching, Uh, that's running between forces mental group and/or are you OK today, our guest lecturer in Mr. ash vasili.
Mr vizard is a consultant, orthopedic trauma surgeon and King's College Hospital in London and pre-hospital care with air ambulance consultant ethics and Hertz air ambulance. And he is a lecturer in the Institute of pre hospital care at London air ambulance. Lecture alpizar Institute of trauma science at parts and the London medical school. Mr vizard is a fellowship trained orthopedic trauma surgeon specializing in the management of complex Auburn closed obalende, lower limb, pelvic and established fractures in both adults and children.
He works at Kings College Hospital. Major trauma Center in London. After completing his orthopedic registrar training programme, he completed both national and international orthopedic trauma fellowships. Mr 430 has a varied portfolio. Career is also a fully trained air ambulance doctor and works as a pre-hospital care consultant on a regional air ambulance service.
In addition, he also holds two academic lecture post lecture at the Institute of pre hospital care at London air ambulance and holiday clinical lecture at Blizzard Institute of trauma science, which is part of Queen Mary University Hospital of London. Thank you, Mr. vasili, for giving lectures today. Hey, no worries, thanks, Tony, for that very generous introduction. So again, thanks, chuck, for hosting this.
Thank you. Flexor-pronator for hosting this and both of you guys for inviting me today. Thanks again for inviting me. So the main purpose of my talk today will be to look at timing in orthopedic surgery and the bleeding patient. I think as well what else probably spent a decent amount of time today is talking about some basic principles, and we'll talk about shock and the response to bleeding while bleeding is actually still difficult to diagnose and can be difficult to diagnose.
The response to injury. What do you see on your blood pressure, heart rate monitor, et cetera that can give you an idea of the level of injury that's happened. We'll talk about coagulation. And then we'll talk about sirs, which often gets mentioned, but there are other things as well. And then we'll talk about principles of resuscitation and then we'll talk about damage control, resuscitation, damage control, surgery, at least until early appropriate care.
All these weird concepts and terms, which basically revolve around the package of intervention are the basics. So this is the problem that you have in your trauma bay, in your emergency department or can have and this can happen at a major trauma center. Most of the time these days, that's where it is. Occasionally, it can happen in a district general, but less often, but still a big problem.
So we need to think about what's going on here, what's happened and how we can treat this. So often in my pre-hospital care, hats on and when my priest pre-hospital care job, this is what I'm often going to this kind of level of incident quality trauma, significant amounts of injuries or multiple, usually multiple patients. But what governs everything that is going on in terms of how the body responds to trauma and trauma physiology?
And this is a big part and an important parts of the physics exam and an important part of the fastest syllabus within the traumatic chapter. And the whole thing that governs governs trauma. Physiological response is inflammation, hence the funny electron microscope artistic picture. It's all about inflammation and stuff that you would have heard and seen when you're at medical school.
It's the same thing. So we talk about response to bleeding, all of you, I'm presuming, have done the, of course. So you all have an idea of the classification of shock class one, class two, 3 and four the revolves around how much blood an individual has lost, and it's usually bracketed in percentage blood loss. So class one shock. Usually, they lose less than 15% in class Ii is 15 to 30, et cetera, et cetera.
If you need a good way of remembering this, just remember that tennis scores so 15 love, 30 love, et cetera. And then that gives you a way of remembering the percentages and then the general issues that the pulse rate goes up as you lose more blood. Yeah, sure. Blood pressure gradually goes down. Pulse pressure initially increases, then decreases. Pulse pressure is the difference.
Respiratory rate is the only thing that always goes up as you lose more blood. So there's a couple of things, though Atlas has a very nice table that explains it. If you get this kind of question in the vyver, they are looking for this kind of answer. You talk about percentage of blood loss, severity of shock and what you would accept, what you would expect to see in the patient.
But I wouldn't necessarily worry whether they'd actually ask for individual numbers. So I don't think they ask you for a respiratory rate in class three shocks. I wouldn't worry about that. Just broadly that certain things go up like heart rate and certain things go down like urine output and blood pressure. Importantly, though, in real life, the issue is that everything is not quite as simple, so when people have assessed the Atlas classification and kind of looked at it in clinical reality and how useful is it really?
The problem is it's actually found wanting. It's not really very clinically useful. Sometimes you can have people with excellent heart rates, maybe 80 90, and you could perceive that's not too bad. You can have people's blood pressures that seemingly OK. So you know, blood pressure of 105 over 80 in a very small petite person may seemingly be OK. So there's lots of issues, and we'll discuss why.
Actually, Atlas doesn't. The classification system doesn't work all that well. There's a phenomenon as well. Some of you may or may not see in patients with significant amounts of blood loss, either due to blunt trauma or penetrating trauma, and those of you who've seen patients who've been stabbed in the chest who've had significant bleeding from the heart or the lungs, for instance, they are frequently very bradycardia.
They don't Mount any kind of tachycardia at all. Or if they do, it's very mild. You won't see heart rates of 440 in these patients. They'll all be 80 90, and suddenly they'll become pretty chaotic. The blood pressure is usually maintained until the last minute. I highlighted this article here just as the case report, because I find it amusing that things like this get published.
This case reports and actually things like this were actually very well understood. Back in the 40s and fifties, and even in the Second World war, the First World war, people knew if you had blood loss and you were bradycardia, an imminent sign that you're about to arrest. So what's going on?
So the issue is that actually the body is not silly and the heart is not silly. So when you are losing lots of blood, it would be foolish for the heart, for instance, to continuously become tacky, chaotic, more and more, because that would effectively mean the heart needs more blood supply, more metabolites. It needs more blood to then take away all the waste products of metabolism.
And the problem is that the initial shock state, that's totally not what you need. You do not need an organ to force or to continuously require more and more blood, because that just makes this situation worse. Actually, there are multiple systems around the body, and I've just highlighted three of them that actually detect significant amounts of blood loss, either due to pressure issues or issues in the blood, and they then stimulate the autonomic nervous system to reduce the heart rate and gradually reduce the blood pressure as well because the heart is not silly.
It doesn't. It doesn't need to keep asking for more blood flow when there isn't any to go around as it is. OK, so when you have significant amounts of blood loss, your heart rate will actually might go slightly tachycardia, but will actually become bradycardia. And there's an evolutionary response to trauma as well. There lots of issues around leaky capillaries, and I'm kind of stepping into ICU level territory here, but it's important that we, as orthopedic surgeons understand this.
So with trauma, the capillaries become permeable. Yep, so all your tiny blood vessels become permeable. And so what that allows is it allows if you follow the blue block and the blue boxes, it allows white cells, white cells to go into the interstitium of the organs, and it allows fluid to go from the extravascular space, i.e. for the interstitial and last fluid to go into the intravascular play into intravascular space.
So effectively, the body is trying to replenish the intravascular volume by sucking out fluid from the interstitial. This helps increase your volume, increase your central venous pressure, and helps to keep cardiac output going. So that's what the evolutionary response is. The problem is that we continuously keep wanting to give people fluid and more fluid and more fluid, so we're actually fighting against a response that's been trained over generations.
So by giving fluid, you actually then force fluid to go from the intravascular space into extravascular space. You end up getting edema in the organs and you then get organ failure. So this is a big problem, and this is why we've gone away from using a lot of crystal Lloyds because it's just not very good practice. It causes a lot of problems, and we definitely have got away from using colloid because colloid elicits a huge inflammatory reaction.
So we've gone from the days of giving starch or other simple components. We've stopped all that and tried to stop using saline as well. So I told you earlier, two slides ago that if you lost a lot of blood, you become bradycardia, your blood pressure go down, et cetera, et cetera. But I know for sure that you guys have seen and I've seen patients with significant amounts of trauma have a significant tachycardia.
So the way to think about this is if you look down the middle here in the Black writing, these are typical numbers, you will see on any monitor systolic blood pressure, heart rate, respiratory rate and obviously as you measure. So these are what your patient exhibits, the external features that you can measure their parameters. You then need to split their trauma into two things the level of bleeding and the amount of injury they've had.
OK, and when I talk about injury level, I mean the amount of tissue destruction they've had. And when I talk about bleeding, I just mean pure blood loss. So the responses of these two can be very different. And it's how the two combine the leads you to have these funny numbers in the systolic blood pressure, heart rate or rest rate. So if you are bleeding and from a simple stab wound to the heart, for instance, blood pressure would be maintained for a while and then would be suddenly hypertensive.
Go off a cliff into a rest bleeding. You get a very mild tachycardia and then your heart would go bradycardia because your heart knows you haven't got much blood. So it's going to slow itself down. So it doesn't have to work too much because it knows there's not much blood to go around. Your arrest rate becomes technique because your lungs are still trying to get rid of excess co2, et cetera, and your course, reduces.
OK, so that's fairly straightforward. Now, if you didn't have much blood loss, but you had a really nasty injury, so you had a massive crush injury, but you didn't have any significant blood loss, you would actually become a little bit hypertensive. Your heart rate become very tachycardia, because this is a noxious stimulus, so your sympathetic system is super activated, your hormones like adrenaline from the adrenal cortex.
And from neuron endings are all being released. So you become tachycardic. You also become technique, so you start breathing harder as well for different reasons. And again, your focus falls and reduces. So how these two the bleeding combined with injury, how those two interact is actually leads to what you see on the blood pressure. And that's why sometimes with someone who's had a massive injury load and also a lot of bleeding, their systolic blood pressure looks vaguely normal and their heart rate might not be that bad.
But when you look at them, they're white as a sheet because they've lost so much blood. And so this is why it can be difficult to diagnose blood loss. So with. So this is a really interesting topic I find fascinating. Interestingly, most of the research from coagulopathy in trauma is all being done by General surgeons, mainly out of the Royal London trauma surgeons at the Royal London.
Not a lot of it has been done by actually hematologists. So anyway, so there is a coagulopathy in trauma, and it's not to do with loss of factors, not in early stages anyway. There's three perceived mechanisms. We'll talk about those in a second. You all know the lethal triad of death, which is coagulopathy hypothermia, and if you start, if you have these issues ongoing, you will increase your mortality risk and the issue mainly is around hypothermia.
And the lower your body temperature goes, the less effective enzymes work. And so your coagulation cascade doesn't work that well as well. And also you become more acidic. And again, that doesn't help the coagulation cascade. So lots of problems here. A vicious cycle. So the lethal triad.
And it's when we talk about trauma at different times, they used acute traumatic psychopathy, trauma induced coagulopathy that are all roughly looking at the same thing. In terms of I'll just pop back for a second in terms of the three mechanisms I'll touch on a little bit later, but there's three things that people believe happening. One, you don't form the clock properly to your fibrinolytics system that's responsible for breaking down the cloud, so that's the negative feedback loop.
That becomes hyper activated, and that's where chronic stomach acid comes in, because it works by inhibiting fiber releases, so helps maintain your clogs. And the third is there's a problem in the expression in the endothelium, so platelets don't work that well. So three mechanisms. Platelets don't work.
Fiber releases are activated, and the clot that you first form is not that good quality for some. Mason coagulopathy is an interesting thing, so if you think about this, you actually do want a little bit of coagulopathy again, this is another evolutionary response. If you're hyper bulimic and you've lost a lot of blood and you don't have medical care, what you effectively go into is a low flow state, so your body slowly pumps the blood around.
It doesn't do it too fast because it knows that you haven't got enough blood, so it just sends it around. But the problem is, if you have not that much blood, your body will probably want to start to clot this blood because there's not much of it. It's moving very slowly. There's a bit of stasis going on, so you start to get some of the features of virtuous triad where you eventually are at risk of getting a DVT or some kind of little clots.
So what is the body do to avoid getting these little clots everywhere, like the muscle of the gut? It basically makes the blood empathic so that it's extra thin and so it doesn't form these little clots. So again, it's all an evolution response, and we in trauma care are totally Messing with it. But we have to do something because not everyone would survive if we just left it to nature.
So as I said, this is a three mechanisms by which we currently believe that coagulopathy works or coagulopathy occurs in trauma. Activation of protein C pathway. So you don't get a proper formation of thrombin and the clot hyper fiber lysis. So excessive breakdown of your clot. And so this is where tranexamic acid works and platelet dysfunction.
So this is a really interesting thing about inflammation, I won't spend too long because this can be super boring. Effectively, most of you would have heard about the first and second hit. So you have something called the systemic inflammatory response syndrome and the counter and. The inflammatory response syndrome and effectively with this, and people have believed us for a long time, you get trauma that's a first hit and you Mount a systemic inflammatory response syndrome.
And people used to say that if you then did significant surgery, this could be a second hit and effectively you could get a certain response all over again. And this could effectively then place the patient at risk. I'll get. What people have actually found to be the case in reality now is that you have a systemic inflammatory response syndrome.
And the counter regulatory system, so that's the red and green actually both activate at the same time. How long they're activated and how one balances the other is still a lot to do with genetics and individuals and groups of people, and also some of it's to do with how we then treat the patient. So if we end up spending a long time operating on them and give them some kind of surgical insult, then there are risk of prolonging their says response and getting problems like multiple organ failure and edema.
I'll skip over this one. The next couple of graphs are just to show some interesting things. This graph basically has been looking at resuscitation in trauma patients in London about six eight years ago, so it's got a little bit of old data, but it shows you well. It will depict what I want to show, which is that as patients have when trauma patients are admitted as opposed to minor injury patients, but the trauma patients are admitted.
And as you start getting increasing blood transfusions, four units, eight units, 10 units, your coagulopathy profile gets worse and worse. OK, so something to bear in mind. And this is why massive transfusion protocols have been recommended, and it's why certain protocols have the components they have, and we can talk about that later if anyone wants. Also important to note that once you start having huge amounts of transfusion, either when you're in hospital and over time, your mortality risk increases.
So this is your mortality risk in hospital in one month and one year if you've either had four year transfusion, the gray box or a 10 unit plus transfusion. So you can see once you've kind of gone over 4 units and you're near 10 units of blood transfusion, your mortality rate increases significantly. I look at it that one year. There are still people dying, and we don't really know why.
Interestingly, lacked all of you would have heard about lactate as an important marker for shock. It can take ages for it to fall. So look at this group of patients. So they had a lactate. When they came in at 10, they were transfused. And even by one day, it's still like 2 and 1/2 a day, three, it's still probably one to two. So lactate takes a long time to go away.
In terms of the principles of resuscitation, I mean, the modern setting for resuscitation these days happens in every hospital, in the hospital environment, so at the scene with the ambulance service. And as I said, it's the service I used to work for a while ago and switch to a different one. And so they start your mercy medicine resuscitation. They start your acts at the scene, typically going to gunshots and stabbings.
This is a cyclist who got run over by a dumper truck, so they start all of that in the field, and it's important that they do that because it still takes over an hour to get a major trauma patient into a hospital, even in London, when there's four trauma centers within a few miles of each other. And so the hospital service do start all of that to begin with at the scene.
So we'll talk about some important components, the damage control resuscitation, so what I'm going to talk about now is basically concepts. It's not it's not a thing, it's a concept. So that's the key thing to remember. Damage control resuscitation is mainly for patients who are actively bleeding. So they're coming into your hospital, into your emergency department, they're still bleeding.
The aim that you need to bear in mind is the team needs to achieve hemostatic competence, i.e. you want to get the patient's blood to behave normally, transport oxygen and be able to clot properly. So you want to get a hemostatic competent. You want to achieve early hematuria, hemorrhage, control via surgery and/or interventional radiology.
You want to do something called permissive hypotension. It's called it's easy, yeah, it's called the Mason hypertension. It's called different terms these days, resuscitative management, lots of different terms. Basically, it's when you let people have a slightly lower than normal blood pressure in order to stop massive variations in their BP that may dislodge a clot.
And the target of your BP. We'll talk about it in a moment. You are limited to your fluid infusions, so don't get a. And you want to target any coagulopathy. Does the permissive hypotension good numbers do remember, just for your young fit adult is if you've got an isolated head injury, you want a systolic BP that's pretty near normal 120, you need to confuse the head at all costs.
If you have trauma with a head injury, you can aim usually for around 100. And if you are trauma with no head injury, you can let the systolic BP be lower. So 80. OK so these are reasonable numbers to hang your hat on. As we said, we want to limit fluid and infusion says avoid excessive Chris Lloyd with Western's coagulopathy, increases hypothermia and doesn't actually treat the blood loss problem.
You want to activate a massive transfusion protocol. And for all of you guys who are sitting the exam, I thoroughly recommend you have a brief look at your own hospitals major haemorrhage protocol, major major transfusion protocol or code, red protocol, or whatever it's called. Just so you're roughly familiar with it that it's not that hard, especially usually a sheet of paper one side.
And effectively, it says something lines along the lines of a senior member of the trauma team must declare a major transfusion or a code red or whatever the term is if a patient's BP is less than 90. They do not respond to some initial fluid resuscitation and you suspect ongoing or active hemorrhage. And then with that, you get a number of things, you get some packs of blood to begin with and that to ideally fill the patient with blood and the packs that you then get later are the packs that contain coagulation components like FFP platelets and precipitate.
Are the things that we cannot frequently see used to select schools, which is a hemostatic dressing that you'll see people stuffed into wounds, pelvic binders important for pelvic injuries. And you should think of pelvic binders as a he-man, as a resuscitative instrument, not a mechanical instrument for orthopedics, but rather it's important for hemostasis. You can have splints to manage people's femoral fractures.
Tourniquets occasionally use hospital. And again large dressings to stop the bleeding. Tranexamic acid use very often given hospital and another dose is usually given in hospital, and we don't really want to be using this saline, well, saline or Ringer's lactate, et cetera. We want to get people to the CT scanner as soon as possible. And then after that, we want to decide what their problem is, so either they go to surgery, they go to which is the top left to go to interventional radiology.
The bottom left or the go to intensive care for more supportive treatment, which is the right sided image. You'll occasionally hear about things like call from elastography. I won't spend too much time on this. Basically, it's a point of care blood test where you take a sample of blood of a patient. You put it in a special machine that basically whizzes the blood around and measures how fast it clots and then how long it takes for that clot to then disappear.
And then from that, you get various pictures and numbers that will then tell you what the problem is that the coagulation cascade is it that you don't have enough ffp? Is it you don't have enough platelets? It that the platelets don't work, et cetera, et cetera. And then you can do targeted ethnic management. Now, other things that you'll hear about is early total care. So this is defined as fixation of all fractures in the first 24 hours.
The old fractures are very variable term depending on which paper you read, but it was shown for a long time to be associated with reduced rates of fathomless ARDS organ failure and VTE venous thromboembolism. Main proponents started from a chap called bone in 1989 for America, and then it got used a lot everywhere in mainland Europe and here in the UK and also ongoing in America.
And then in 1999, Hans Christian slap began to show that there's high mortality and multiple injured patients. If you if you had operations that took a long time. So if you had operations that lasted long, mortality went up, so they decided, well, I think what we should do is something called damage control surgery, and that's when you had damage control, orthopedics, et cetera or the whole concept of damage control come about.
And in damage control, the aim is to control your hemorrhage, manage your sepsis, protect yourself from further injury and restore the physiology and minimize the second hit. And in reality, the principles of orthopedics, it was using a lot of exelixis, so you wanted to do stage treatment. You do some resuscitation in the emergency department. You expect all of your fractures. You go to ICU.
You leave the patient alone and then you take them back to deter when you convert them definitively to the definitive treatment. So I am nails or plates, and that can be anywhere from a few days to a few weeks' time. However, shoving fixes on everyone wasn't a great thing and has its own problems. And so over the last decade, there's this phenomenon the new one called early appropriate care, which is somewhere in the middle of early total care and damage control.
And so this effectively says that you should aim to do early total care or the appropriate care in this case once your patient has been appropriately resuscitated. It recommends trying to do that within an eight hour time frame of resuscitation. You want to meet your physiological targets, so get your lactate less than for your better than 7.25 bas status less than minus 5.5. So effectively, we want to bring your lactate down and try to get your patient not to be acidic.
Yeah, and that's usually managing people with blood transfusion, massive hemorrhage, protocol, et cetera. Now, in that eight hour time frame where you get to resuscitate them, if things are getting better, then you should aim to get them to within 36 hours to fix their long bones. So there's better outcomes, and this has been shown continuously by head evaluating all of the liver failure in all of her papers from 2010 to 2017.
And there's less complications. This is an elderly patients and in young adult patients, the question is what are long bones? So previously, in early total care, a long bone used to be considered as humerus, forearm, theme tibia, et cetera. But actually, if you dial down and some Villiers work, it actually is spine, pelvis as establishment femur. So these are the four long bones.
You'll realize that only one of them is actually a long bone and the rest are just bones. So pelvis, acetabulum, spine and FEMA. And the main reason you want to do this is that by fixing all of these patients can then be nursed better in ICU. They don't have log rolling restrictions, they don't have pelvic rolling restrictions. They can be sit up, set up, sorry.
They can be sat out in a chair and their respiratory physiology gets much better, that they don't get things like ventilator associated pneumonia and other problems. So that's the thing that a lot of us are kind of Gunning towards early fixation of the long bones. So overall, just kind of wind it up. The rough pathway through the emergency department for your given patient coming in, you have an unstable bleeding trauma patient.
OK, so you want to think about damage control, resuscitation, damage control, surgery, potentially. These are concepts, right? With damage control surgery, you want to limit the hemorrhage. So if there's any active bleeding, you want to stop that. And you know, that could easily be something from the spleen, the liver or from the peripheries and arterial injury in the leg or even potentially in the pelvis.
And we talk about that if anyone wants to manage any sepsis, so clean any wounds, protect the patient from further injury. Correct the physiology. So that's Ike's job, really and traction. Because for the low limbs and then for damage control resuscitation, we've talked about permissive hypotension, hemostatic resuscitation. I give them blood products and blood itself, manage and fix the coagulopathy and avoid the lethal triad, so keep them warm.
Don't let them become acidic and don't let them become coagulopathy or if they do, try and fix these. Patients then go sit on an ICU. Well, all of this is happening. They gradually recover and then once the timing is right, you then take them to death, ideally in the first day and a half 36 hours for early appropriate care. OK, so in summary, we kind of gone through quite a few things of trauma, physiology, the principles of resuscitation, and then talk through some of these concepts.
Also the mentor group. Group, that's again, charity basically trying to make sure that education is available at this level for each school visit as a YouTube channel or on a web page. And also we have courses as well for you guys to join, and I also want to plug our book as well. Concise orthopedics behind my head that we do think it is worthwhile to get it going on its own or online booksellers as well.
Thank you. Please do answer because the question was, which parameter is most appropriate in determining the severity of bleeding and hypo perfusion? All right. So hyperperfusion is basically shock, right? And so we've already said and just kind of masks, level lactate is the best thing for looking at Shock. I'll go through why the others don't work.
So well, so hate to be less than 100. So yeah, if your HP is low, then effectively, Yes. I guess as a surrogate marker, you're saying that there's not enough hemoglobin. But the problem is you'll find a lot of trauma. Patients don't have very low FBS to begin with it, even early on in the first few hours. HP does take a while for it. To really equilibrate and give you an accurate reality will give you a real level that's appropriate for that patient sets.
It's falsely reassuring if you were to look at HP initially in your patient. You mean, again, they're not really appropriate to use as a blood test to look at Hyper perfusion. I mean, they will be very elevated if there's kidney hyper renal hyper perfusion, but it's not a good accurate 1 to determine bleeding severity. Cerp is next to useless and glad now enough to fill that coagulation profile.
So coagulation profile? Yes, that is. The traditional coagulation tests were designed by hematologist to use for we to use as blood tests to monitor coagulant profiles like warfarin. Inr was invented for warfarin, APT was designed for heparin, and so using a coagulation profile for trauma doesn't work that well.
And so that's why we have things like tag and other profiles. But so overall lactate is the appropriate answer for that one. And next one, which vessel is the most commonly injured and pelvic ring injuries? Now I haven't really touched on this at all, but the answer is actually the superior political that's the Communist one. It's one of the first branches of the internal country.
Now, if you get an mk q question and they give you two options, they want the correct most accurate one. So you could kind of argue the case. The entire line is potentially correct, but no, the most correct answer in the list of options you have there is superior gluteal and then the last one. Yes so this is an interesting one. So what's the next most, most appropriate intervention for this patient?
So 40-year-old pedestrian struck by car brought in by ambulance at 12 PM so that's midday in the Mason department. He's vomiting, has noisy breathing signs of paradoxical chest movement, distended guarding abdomen, mangled leg. OK, so in the emergency department, he's vomiting. So that's not a good sign. Maybe a sign of head injury anyway.
Vomiting people are a risk to their airway, noisy breathing. He's got features that suggest problems with his OA. Signs of a paradoxical chest movement that's basically a flail chest. Again, he's got respiratory compromise. The standard regarding appointments, so has also got something that maybe necessitates a laparotomy at some point and a mangled leg, so clearly something that we, as orthopedic surgeons would want to manage as well.
What's the next most appropriate step as step as all of you know, from atlas, the next most appropriate step would be to secure his OA and say the only way of doing that is to do a rapid sequence induction. And obviously you wouldn't do that. The anesthetist would, but you would be expected to know that. Yeah, so what? The next most appropriate step is because this is just an Atlas type question.
Giving tranexamic acid and antibiotics, yes, definitely a good thing to do and definitely, definitely worth doing, but it's not the next most appropriate intervention over the next appropriate intervention. The biggest problem this patient has is airway, and that's need securing. Invariably, he'll have to go to the theater for a laparotomy soon.
Yeah, invariably he'll need to have a CT scan. But if this guy's got OA compromise now, that needs to be assessed before going anywhere else. Thanks, Ruth. Slide yes, stop sharing. Yeah, thank you. Thank you. Thank you very much. So in terms of questions.
Is there a the list of questions? And I'll start off when is a hurry, abdullahi said, let's take a properly introduced in anticipation. Is it in the Department or in ICU, but in the future? Yes so some places trying doing the I think most people, though, would use it in ICU or in theaters. It's not necessarily something that's happening in most Ed straightaway.
But if someone does go up there, it's happening during that damage control surgery, during the laparotomy that would wash out, that's happening there if they're actively allopathic and bleeding, et cetera, and definitely happening in intensive care. That's where it generally does happen. It seems that most people, the summer she is actually far from the perfect binder.
She is stimulation the need a few days to have a patient who still look like experts. And that's. No, so no. That's an interesting question, and there's some philosophical issues and beliefs around different trauma centers about what needs to happen with pelvises. Remember, the binder is a hemostatic agent, and that's why you should think about it, not as a mechanical device.
There are definitely patients typically with a lateral compression type injury. Sorry, correct me. There are typically some patients, typically with AP type injury. So like an APC to something like that, or even the APC three who definitely feel better when they have a binder on like they find themselves more comfortable. I've definitely had lots of awake, stable patients.
24 hours, we want to take that binder off with an APC two or three injury and actually we take it off. They like who they start complaining that things doesn't feel right in their television and that in the lower back. And so they really like having the binder on as a comfort device. So but really think about it as hemostatic device, so you take it off. After 24 hours, clots are usually stabilized at that point, and you wouldn't necessarily need to routinely do an ex fix.
But those patients, just because you then have to wait a few days to definitively fix them, the only thing you would do is continue your pelvic rolling restrictions in the interim, if you need to apply next fix to a pelvis. It would be in the situation where they're going to get from the emergency department, either because they're bleeding from their pelvic injuries, or they may have an open pelvic injury or something with a rectal tear, et cetera or a peritoneal laceration, that kind of thing where you need to stabilize the pelvis.
So those patients typically will be the ones getting fixed. No, we're not really doing X fixes day one or two as an interim temporizing measure. I don't think that's really needed. And so just doing just your talking is really good, Mr. That's right. And it's obviously it's fine. I think it's very important topic and we really do appreciate the time you're giving to us.
But it's a testament to actually how well from the top. Nobody's really gotten too many questions because you've covered a lot of areas really well. One of the questions that has come about this whole body scan, do we do? We just do we do it with bas status patients as well? So, yeah, yes, this is a very interesting question. So in the past, obviously, we all know the term term donors of death.
So CT scan used to be the donor of death. Used to be called in Atlas courses. But actually, it's not really going to CT. Scan, especially within a major trauma center, is definitely seen as part of the resuscitation, right? Because you cannot target and cannot treat effectively what you don't know, right? And clinical assessment is just not good enough is not accurate enough.
So you really we recommend highly patients have a CT scan for the exam answered the most guidelines then, and NICE guidelines for major trauma. All say that you need to have a head to toe CT scan of everything to really get an idea of the injuries. And in that way you can get your list of injuries and reprioritize them or the trauma team leader can read, prioritize them and then you can manage them. One at a time and just go through it as opposed to kind of just finding the injuries as in when you randomly decided to find them.
So, yeah, I would advocate taking patients even if they're imminently unstable, but they're being actively resuscitated to the CT scan and have the CT scan. Here at King's, we are often taking the whole trauma team to the CT scan with the patient, so we just carry on the emergency department stuff in the CT scanning room. We step outside for the minute it takes to do the scan and then go back and carry on resuscitating them.
But then what about the patient who's had a trauma, but instead he to take them to the surgery is done? Yeah, Yeah. So we yes, I guess we have a most major trauma centres, not even us, necessarily. Most major trauma centers have a very low threshold to CT scan everyone. So if the mechanism fits unless people are effectively walking in without any significant injuries, most trauma patients are having a head to toe CT scan.
Yeah you know, especially the people being brought in by an ambulance with significant histories, significant mechanisms and abnormal initial hemodynamic monitoring from the ambulance crews. They'll all get a CT scan even if they begin to stabilize. They'll still get one just to make sure there's nothing that they've missed. And in terms of. So I'm not sure if we're going to cover this section, but I'll ask this question anyway in terms of other factors where you have uncontrolled bleeding.
What's the goal between radio so air versus surgery and radiotherapy versus the. Yeah a great question as kind of touching on it later. But great question. Let me deal with it now and then we can clarify it later if we need to. So the first thing to remember is that there are some general philosophical beliefs and institutional beliefs of how to manage pelvic fractures.
So if you were to go to North America, there is definitely a lot of trauma centers, really world renowned trauma centers that are really pro pelvic packing. OK, so. So you already have a little bit of confirmation bias because one group has a tendency to do one thing regardless. And then there's another cohort who will say that, yes, you can think about er, but the problem is out of ours.
It'll take you like an hour to get the item in from home to set up the room. And then, you know, it's just quicker to go to the surgery and fix it and fix everything and deal with it. So there's a number of competing issues. There are other things to then think about is one, if you're going to e.r., I are only really works or works very well if it's selective as if it's going after a name vessel and that's usually a branch of the superior gluteal, for example.
Yeah, you don't want ER to basically be taking out an entire internal iliac artery, right? That's just not a good thing, because it causes muscle wasting that leads to atrophy and soft tissue necrosis, certain areas. And actually, that can mean that there's a pelvic surgeon I can't go and treat surgically manage that area because the risk of infection that becomes ridiculously high.
So there's issues around that, so it needs to be selective. So what some people say is and a lot of trauma centers have a protocol for this, and I would strongly suggest for those using the exam is to find the protocol for this at your major trauma center. If you work at a trauma unit, i.e. you will have access to the major trauma centers policy on this within your own institution. And here at King's, it's like a little flowchart that tells you who goes where, what.
But generally, if you have someone who goes to a CT scan and on the. Scan there are signs of an arterial injury associated with the pelvic and/or acetabular fracture. And typically people talk about little blush on the CT scan with an arterial injury. Those patients are probably the ones that would do best to go from interventional radiology. Sometimes you find that actually by the time you get to air with your amazing resuscitation that you guys do in your hospitals, everything's sorted out and then so you then end up with a little bit of a negative air and that's OK.
All right. The other problem that happens is when you look at research studies that talk about pelvic packing and talk about e.r., if you look at how their patients are managed in the emergency department in those hospitals, the report on this, a lot of them, especially in North America, a lot of them are getting two liters of fluid, like one or two minutes of blood and no blood products.
So they're not getting any kind of what I call what we're doing in the UK here. Some really good resuscitation. And so that can really clouds the picture. So we can't really apply findings from American studies into UK practice because we're just slightly further along, I think, in the Ed resuscitation pre management than other centers. So overall, if you go CT scan, you find an arterial blush.
Think about ER that's probably your answer. If you don't find a blush, then the bleeding is either going to be venous or for the bone. And then that's where your binder, tranexamic acid and accurate resuscitation will help you. Then look at the trend of the patient, and if they're getting better over the next couple of hours, then you're done. You don't need to do anything if they're getting worse than their lactate, getting worse, and actually they're needing more and more blood transfusion, more products and the numbers are stabilizing, then yeah, they'll need to go somewhere.
OK, and that will probably be in that case, be a theater. Is that a lot? No, no, no. It's absolutely a perfect answer, and then the examiners in this scenario then push you to say, well, the patient's really unstable. Where do you choose to go? It's always different. I think the safest answer would be that if you have an arterial injury in a seat and if you are not artery injury identified on CT scan, then you should then speak to the examiners and say, you know, if you have access to interventional radiology, then yes, that you would discuss it with them.
And if they're happy, you take them to interventional radiology. But if it's not natural injury and it's kind of a general venous and ongoing bleeding from the bones, then surgery is your best option. Sometimes you've taken to surgery because say, air is not around and not available and then you pack everything, it doesn't settle down. Sometimes you end up going back to interventional radiology after surgery to just fix any outstanding arterial injuries.
Some centers are good, so they can do it in the operating theater as well. Oh no. Yeah, exactly. No, absolutely. There are. Some say, yeah, some. Some hospitals are blessed with a hybrid theater where you can CT scan air and operate all in the same place.
But most of us aren't exactly where I work. Yes so thank you, Mr. We're done. Very excellent. Make sure when I will stop recording and we'll go to the best.
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