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Management of Polytrauma Patients/Life Threatening Conditions

The assessment of severely injured patient consists of four overlapping phases:
  1. Rapid primary evaluation
  2. Restoration of vital functions
  3. Detailed secondary evaluation
  4. Definitive care
The ABC,s of trauma care identifies & treat life threatening conditions — and can be rememebered as
  1. = Airway maintenance, with cervical spine control. The cervical spine should be carefully protected at all time and not be hyperextended, hyper flexed or rotated to obtain a patent airway. A chin lift or jaw thurst maneuver should be used to establish an airway.
  2. = Breathing with special emphasis on tension pneumothorax, open pneumothorx, flail chest with pulmonary contusion & massive hemothorax.
  3. = Circulation
  4. = Disability (neurological status) by Glasgow coma scale
  5. = Exposure and environmental control (undress the patient but prevent hypothermia)
  6. = Fracture splintage. Recognition & splintage of major fracture, adequate immobilization of cervical spine, and proper handling of injured patient are essential to prevent further damage to the neurovsculr elements. As a general rule following measures should be taken:


  1. Airway with c-spine protection
  2. Breathing with adequate oxygenation
  3. Circulation with hemorrhage control
  4. Disability
  5. Exposure / Environment
Priorities in surgical management of musculoskeletal injury
  1. Save life
  2. Save limb
  3. Save joints
  4. Restore function

Indicators of adequate resuscitation

  1. MAP > 60
  2. HR < 100
  3. Urine output 0.5-1.0 ml/kg/hr (30 cc/hr)
  4. Serum lactate levels: Most sensitive indicator as to whether some circulatory beds remain inadequately perfused (normal < 2 mmol/L)

Fracture healing (Given by Frost)

  1. Stage of hematoma formation
  2. Stage of granulation tissue (inflammation and cellular proliferation)
  3. Stage of callus
  4. Stage of remodeling
  5. Stage of modeling

Abnormal Healing (Any deviation from above mentioned stage)

  1. Malunion
    When fragments join in unsatisfactory position (unacceptable angulation, rotation or shortening) the fracture is said to malunited
    1. Causes:
      • Failure to reduce fracture adequately
      • Failure to hold reduction
      • Gradual prolapse or comminuted or osteoporotic bone
    2. Presentation:
      • Deformity
      • Functional impairment
  2. Delayed union
    1. Union is considered delayed when healing has not advanced at the average rate for the location and type of fracture
    2. Presentation: Tenderness persists
    3. X-ray: fracture line visible and there is very little callus formation or periosteal reaction, however bone neither sclerosed nor atrophic
  3. Non union
    When fracture does not unite at all.
    Import factors are:
    1. Fracture factor: few fractures are prone to go into non union eg
    2. Mnemonic FLUTS: Fracture Neck of femur, Lateral condyle of humerus, Ulna lower third, Talus, Scaphoid.
    3. Patient factor: malnutrition, smoking, systemic diseases. (Note: osteoporis is not a cause of non union)
    4. Environment factors: Open fracture, infection, soft tissue interposition

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