In message <003401bf4897$f4ed09a0$4aeeabc3@default>, Simon Carley
<[log in to unmask]> writes
>Age 20's. High speed RTA. Lower leg entrapment at scene. 30 mins extrication
>time.
>Specific difficulties:-
>1. Splinting the right shaft of femur was difficult due to the
>flexion/adduction
>of the posterior left hip dislocation. The hip dislocation came across the
>right
>femur encouraging it to externally rotate and displace.
>Any thoughts on other options in the early stages???? I was keen to get some
>traction splintage here to prevent further blood loss, pain etc.
having seen your diag, borrow traction frame from orthopoedic ward, pin
L calcis, traction l lower leg in current position / elevated further,
with support under l knee. This should allow any old splint to be
applied to teh R femur un-incumbered.
Better still: RSI (see below)
>2. Clearly this girl needed to go urgently to theatre for fixation (pelvis,
>femur, tib/fib and hip reduction) but we were understandably worried about the
>abdomen. A passing radiologist did an USS abdo which showed no free fluid and
>no
>evidence of solid organ damage (though we know this is only 95-97% sensitive)
>Question: If the signs are fairly convincing (rigid abdomen) but the USS
>negative would you do the laparotomy anyway or wait and see. We are conscious
>of the fact that an unnecessary laparotomy with this pelvic injury would be a
>bad thing. What would you suggest with your surgical collegues (e.g procede
>anyway, DPL, serial exam though patient about to be put to sleep, serial USS,
>or
>rest easy go somewhere else and let the orthopods get on with it)
If she's stable (though compromised), ?CT pre-theatre (in your dreams!).
If surgical reg / con not there for an hour anyway, why not use that
time.
Displaying my surgical ignorance, would a laparoscopy in theatre be any
good as a less invasive exploratory procedure (CO2 embolus if open
vessels??!).
>3. This girl was clearly at very high risk of developing ARDS. She was also
>difficult to analgese as splintage was difficult and her conscious level was
>already compromised. She was in pain with any movement (though right fem nerve
>block worked very well).
>Question: When would you put this girl to sleep & would early ventilation have
>been of benefit. Soon after coming in or just before theatre? (PRO's - less
>pain, ?less risk of subsequent ARDS???????(has been suggested don't know if
>true) CONS - losing tamponade effect of abdomen from paralysis, lack of further
>clinical information)
Tricky one. Anaesthetists usually need most pursuading, because they
have to pick up the pieces if complications.
She's going to be put to sleep anyway in the near future for orthopods
and I think some gas-board types would elect to ventilate on ITU post-op
for 24 hours anyway with such injuries (?). so would an extra hour pre-
op make any sig diff?
>From humanitarian point of view, if pain uncontrolled with such
injuries, elective vent in A&E would be kind, and might be clinically
beneficial (reduce hip in A&E, allowing better splintage etc.). There's
some yarn about pain causing more metabolic stress on injured bodies
etc.
If loads of opiates required for analgesia, will probably run into
airway / ventilation problems soon anyway.
Once CVS stable and pelvis fixed, could she have an epidural for pain
relief (CVS compromise is a CI)?
Only evidence I remember (!) relating to the question of when to vent or
not in borderline cases suggests monitoring ABGs on regular basis and
venting only if gases sliding wrong way. That study was for chest
injuries (specifically flails / lung contusions) which are high risk
ARDS group. Outcomes were better in "vent on gases" group rater than
"vent everything" group.
Dr G Ray
Staff Grade
A&E
Sussex
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