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KEY POINTS

KEY POINTS

  • Hemorrhage from pelvic injuries is frequently underestimated, leading to delayed diagnosis and treatment.

  • Pelvic ring injuries are commonly associated with other significant injuries resulting in major morbidity and mortality.

  • Initial management of pelvic injuries requires hemorrhage control and volume resuscitation.

  • Resuscitative stabilization of the pelvis using a binder is a key element in the initial control of hemorrhage from pelvic fractures.

  • Rapid control of pelvic bleeding followed by mechanical stabilization of the pelvis yields the best outcomes.

  • The mechanism of injury is important in predicting the type and severity of extremity injuries.

  • Extremity fractures, though frequently not life threatening, require accurate diagnosis and appropriate management to prevent significant disability and morbidity.

  • Complications of extremity injuries, such as compartment syndrome and neurovascular compromise, can best be detected by a high index of suspicion, serial assessment, and institution of appropriate preventive measures.

INTRODUCTION

Patients sustaining major pelvic and extremity trauma are frequently managed in the ICU setting. These patients may present with significant hemodynamic and physiologic instability owing to their associated injuries, and this can be compounded by inadequate resuscitation resulting from underestimation of the volume of blood loss associated with such injuries. The following information is provided to assist the intensivist in understanding pelvic ring and extremity injuries, thus allowing early diagnosis with prompt and appropriate management aimed at preventing major morbidity and mortality.

PHASES OF CARE FOR ORTHOPEDIC INJURIES IN THE MULTITRAUMA PATIENT

The assessment and treatment of orthopedic injuries in the multitrauma patient can best be divided into three phases of care: resuscitation, provisional skeletal stabilization, and definitive treatment. The progression from one phase to the next is based on the hemodynamic and physiologic status within the context of mechanical skeletal stability.

There are advantages to treating certain orthopedic injuries, such as femoral shaft fractures, as early as possible since the mechanical instability of the fracture increases the risk of complications like fat embolism syndrome (FES), which carry a high mortality rate. However, with improved ability to operatively treat complex orthopedic injuries to obtain better functional outcomes earlier, there are situations where doing too much too early may actually lead to more significant systemic complications.

There is an acute systemic inflammatory response associated with major trauma, which has been related to multiorgan system failure (MOSF) and ARDS, described as the “first hit.” A subsequent systemic stress or “second hit” may trigger an additional inflammatory response, leading to a higher likelihood of MOSF or ARDS and an increased risk of mortality. It is theorized that a major surgical intervention prior to full resuscitation may be such a “second hit.”1 Certain systemic indicators are useful in determining whether a prolonged surgical reconstruction is likely to result in further systemic compromise.

A protocol for “Early Appropriate Care” demonstrated lower pulmonary and overall complication rates ...

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