You are called to see a 65 year old male tourist who has been admitted to your emergency department after being hit by a car while attempting to cross a busy street. He is unconscious and has obvious chest and limb injuries.

Please discuss your plan for his definitive care (including fixation of long bone fractures etc.).

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College Answer

This patient has major trauma with head, limb and chest injuries, and should be managed in a centre that is experienced in trauma care.   If this hospital is not able to provide sufficient services then early communication with a receiving hospital is essential, and plans made for expedient transfer.

Specific neurosurgery may be necessary if intracranial haemorrhage is detected and should be performed within the first few hours.  Thoracic surgery is rarely required (eg. dependent on amount of bleeding from intercostal tubes), but surgery will be required for long bone fractures.  Compound fractures should be dealt with early (hours), as should injuries with vascular compromise.  Other operations are less urgent and the role of early fixation of fractures is controversial.  In the absence of significant  respiratory  compromise  it is probably reasonable  to progress to early fixation.   If instead there is concern about respiratory status then external fixation rather than internal fixation may be preferable on the first day, followed by more specific management a few days later.

Discussion

This question would benefit from a systematic response.

Thus:

  • Definitive airway/ventilation management
    • The patient may remain intubated.
    • If this patient has had a severe traumatic brain injury, a tracheostomy may be required. If the C-spine is unstable this is best performed surgically, rather than percutaneously.
  • Definitive hemostasis
    • This should be achieved by surgical repair of fractures, wounds, and organ damage. External fixation of long bone fractures is a valid alternative.
      • Early repair of contaminated wounds or compound fractures
      • Delayed closure of laparotomy wounds
      • Vac-dressing for abdominal defects
  • Definitive neurological/neurosurgical management

References

References

ATLS student course manual, 8th edition (Chapter 5) - American College of Surgeons Committee on Trauma