During this time, fractures should be adequately immobilised with splints, traction or plaster. In our experience, some patients will have a surprisingly high lactate on presentation, such as the patient with apparently isolated bilateral fractures of the femoral shafts. The lactate level will settle rapidly, but it is those patients who appear physiologically normal and suitable for immediate nailing who may benefit most from lactate-controlled ETC.
All of these physiological indices should be monitored continually during surgery. If they deteriorate the surgeon should be prepared to stop the procedure, perform DCO and transfer the patient to intensive care for further resuscitation. These decisions need to be made in consultation with other members of the trauma team, particularly the anaesthetist and critical care physicians. Considerable research is taking place into the immunological response to severe trauma.
Interleukin-6 IL-6 levels appear to be a good marker for the severity of the initial injury and the remaining immunophysiological reserve of the injured patient.
At present, the physiological markers described above remain the best practical guide to clinical decision-making. It is hoped that future research will allow us to use a combination of physiological and immunological criteria to inform these decisions.
All patients with multiple injuries should have a tertiary survey between 12 and 36 hours after admission. This involves repeating the head to toe examination, checking for bruising and tenderness, and checking each joint for stability. Additional radiographs should be obtained where necessary, and all available radiographs should be reviewed for missed injuries.
The outcome must be documented in the medical records. In summary, trauma care is evolving rapidly. There have been many advances and changes in practice over the past few years. The orthopaedic surgeon has a key role to play in the management of the patient with severe, multiple injuries and must be familiar with the current guidelines for resuscitation and management.
However, it should be emphasised that the treatment of the patient with multiple injuries depends on the expertise, experience and facilities within the local health-care system, and the evidence-based guidelines will need to be adapted to suit the available resources. A number of specialists contributed to these guidelines, and we would like to acknowledge the contributions of Mr D. Esberger and Dr J. Ollerton emergency medicine , Drs J. Haycock and J. Lamb anaesthetics and Mr A. Brooks general surgery.
British volume Vol. Abstract There have been many advances in the resuscitation and early management of patients with severe injuries during the last decade.
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