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Trauma Management:

- Advanced Cardiac Life Support (ACLS)
    - ACLS
    - Iowa Family Practice Handbook
    - AHCPR Guidelines
    - eMedicine Online Text

- Advanced Trauma Life Support (ATLS) 
     - Assessment of Perfusion/Shock: damage control orthopaedics
              - blood pressure (systolic), heart rate, urine output (≥30 mL/hr) body temperature;
              - labs: base deficit, bicarbonate, and lactate
     - fluid management: (in the trauma patient)
     - immobilization:
               - patients should be transported to the ER with the neck immobilized in C-collar and head taped between two sandbags (or equivalent);
               - pediatric cervical spine
                     - children are immobilized so that the shoulders are raised on a folded sheet (which counteracts tendency for the C-spine to
                     be flexed on the trauma board - due to the child's larger head size);
               - without exception, trauma patients need to be taken off the trauma board ASAP to prevent decubiti;
                     - while moving one assistant controls the head while the others help turn, check the scalp and back for lacerations and deformities,
                                and then help to transfer to a padded mattress;
          - references:
                     - Emergency transport and positioning of young children who have an injury of the cervical spine. The standard backboard may be hazardous.
                     - Pediatric cervical spine immobilization: achieving neutral position?   
                     - Reduced time on the spinal board-effects of guidelines and education for emergency department staff.

    - orthopaedic assessment:
          - cervical spine and spine:
                 - management of the spine injured patient
                 - cervical radiographs:
                        - even in the emergent situation (such as knee dislocation with vascular comprimise), a lateral radiograph (or swimmer's view) from occiput down to T1 is manditory;
                               - while some unstable cervical spine injuries can be surgically managed on a delayed basis (if cord compression is not present) other injuries
                                         such as a bilateral facet dislocation usually need to be managed acutely (hence cross table lateral view is required in the ER); 
                 - references:
                        - Lumbar transverse process fractures: A sentinel marker of abdominal organ injuries.
                        - Skeletal fracture demographics in spinal cord-injured patients
          - pelvis:
                 - radiographs: AP view will help diagnose open book pelvic injuries, femoral neck frx, or verticle shear injuries;
          - extremities:
                 - fractures
                 - dislocations
                 - compartment syndromes
                 - vascular injuries note: it is difficult to assess for vascular injuries when the SBP is less than 90 mm Hg;
                 - mangled extremity severity score
    - generalized assessment:
          - neuro and head injury (see Glasgow)
          - cranio-maxillo-facial
          - spine
          - pulmonary:
                 - pulmonary contussion 
                 - pneumothorax
          - cardiac
          - renal
          - abdominal assessment:
          - coagulation 

- Initial Orders for the Trauma Patient:
       - NPO p Midnight x Meds
       - fluids: IVF D5W LR at 100 ml/hr (in stable patients use D5W 1/2 NS w/ 20 KCl)
       - 2 large bore IV
       - foley
       - monitoring;
                - EKG and/or Continuous Cardiac Monitoring;
                - Continuous Pulse Ox monitoring;
       - preOp labs:
                - Type & Cross 2-4 units pRBC and/or FFP
                - musculoskeletal labs 
                - urinalysis
       - meds (trade names)
               - prophylactic ATB
               - DVT prophylaxis
               - steroids:
                     - for spinal cord injured patient;
                     - for FES prophylaxis
               - DVT prophylaxis
               - zantac
               - morphine
               - tetanus or pneumovax if appropriate;
                     - insulin:
                           - in the report by Van Den Berghe G, et al (2001), the authors examined whether normalization of blood glucose levels with
                                   insulin therapy improves prognosis for critically ill patients;
                                   - patients were randomly assigned to recieve intensive insulin therapy (keeping blood glucose levels between 80-110 mg per dl) versus keeping levels below 215;
                                   - out of 1548 patients, intensive insulin therapy reduced mortalility from 8 % to 4.6 %;
                                   - intensive insulin therapy reduced blood stream infections by 41%;
       - traction: (Buck's vs. skeletal)
       - decubiti prophylaxis:  egg crate / pillow and turn 20 deg q2hr
       - hiboclens shower and Bactroban to nares q12 hrs until OR
       - cleocin solution 300 mg per 100 ml NS q6hr as mouth wash 
                                   - Intensive insulin therapy in critically ill patients.
- Outside links:
    - Iowa Family Practice Handbook
    - A History of Resusitation

Prevention of Medical Complications in Orthopedic Trauma.

General principles in the prevention of surgical complications in orthopedic surgery.

Vascular Complications in Orthopedic Surgery.

Free-Tissue Transfers for Limb Salvage Utilizing in Situ Saphenous Vein Bypass Conduit as the Inflow.

Limb Reconstruction by Free-Tissue Transfer Combined With the Ilizarov Method.

The Metabolic Response to Injury: Mechanisms and Clinical Implications.

Spine Trauma and Associated Injuries.

Management of severe forearm injuries.

Use of a subfascial pocket on the contralateral calf for salvage of an avulsed foot.

Free composite groin flap and vascularized external oblique aponeurosis for traumatic avulsion injuries of the foot.

The futility of predictive scoring of mangled lower extremities.

The use of drugs in emergency airway management in pediatric trauma.

Treatment of chronic traumatic bone wounds. Microvascular free tissue transfer: a 13-year experience in 96 patients.

Limb salvage versus traumatic amputation. A decision based on a seven-part predictive index.

Initial assessment and stabilization of the pediatric trauma patient.       

Value of superoxide dismutase for prevention of multiple organ failure after multiple trauma.

Objective criteria accurately predict amputation following lower extremity trauma.

The mangled extremity syndrome (M.E.S.): a severity grading system for multisystem injury of the extremity.

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