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M. S. Pinzur
Blood Sugar/Hemoglobin A1C
Management of blood glucose is the rst objective when discussing either longitudinal medical management or surgical intervention in diabetic individuals. The level
of glycosylated hemoglobin, that is, Hemoglobin A1C provides the treating physician an estimation of daily blood glucose levels over the past 90 days. The United
States Centers for Disease Control dene levels under 5.7% as normal. Levels in
patients between 5.7–6.4% designate the patient as being pre-diabetic, with values
over 6.5% designating the patient as having clinical diabetes [14]. There is growing
literature that the target for optimal glucose management is 6.5%, and that elective
surgery should be delayed if levels are above 8% [15–18].
Morbid Obesity
The current accepted cutoff for performing elective Orthopaedic surgery is a BMI
of 40. While this value is controversial, the current recommendation for performing
elective Orthopaedic surgery in morbidly obese patients is to develop and institutional methodology to address these patients. Best practice organizations have these
individuals evaluated by a local hyperbaric program. Many of these patients can
achieve signicant weight loss with structured diet. Some will benet from socalled weight loss surgery. There should be a screening process to determine which
patients have made a substantial effort to decrease their BMI, and thus, decrease
their risk for perioperative morbidity. This programming makes the BMI value of 40
as a soft target, allowing for surgery in patients that lower their BMI, albeit even if
they do get attain the hard stop value of 40 [3, 19].
Anemia
Anemia, as dened by a hemoglobin level below 12 g/dL, has been demonstrated to
be associated with less than favorable clinical outcomes, and an increased risk for
perioperative complications in elective Orthopaedic surgery [3, 19, 20]. A local pro-
gram can be developed to use oral iron supplementation, targeted medication and
dietary modication to address this co-morbidity.
Hypertension/Elevated Diastolic Blood Pressure
The nal of the four hard stops is a diastolic blood pressure greater than 110mmHg,
which has been associated with increased perioperative complications [3, 19]. This
value should be addressed before safely proceeding with elective surgery.
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A best practice initiative advises the development of checklists to be utilized dur-
ing all phases of care. The checklist can be even utilized in preparing patients for
emergent or urgent surgery, so that all participating physicians have a clear understanding of the level of co-morbid disease. The checklist can be expanded for patients
undergoing elective surgery to additionally include the so-called soft stops [3, 13].
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The Soft Stops
SOFT stops are medical co-morbidities that can be improved prior to proceeding
with elective Orthopaedic surgery. The degree that one addresses these conditions
will vary with the delay tolerance prior to performing the elective surgery. These
medical co-morbid conditions include smoking cessation, nutrition, and sleep
apnea. When addressing the geriatric population, many patients being evaluated for
treatment have some element of malnutrition. Several investigations have demonstrated that patients with metrics associated with malnutrition are more likely to
develop delayed wound healing and postoperative infection [3, 13, 21–24]. Each
individual health system needs to address how much medical optimization should
be undertaken prior to proceeding with elective reconstructive Orthopaedic surgery.
The Perioperative Period
The modern patient safety movement has demonstrated that organizations that
develop standardization of health care delivery are more likely to delivery improved
metrics of care, lower rates of perioperative complication, and a decreased rate of
hospital re-admission. The application of standardized care is accomplished when
physicians within an organization agree to use in common perioperative checklists
and electronic medical record order sets [3, 13].
Perioperative Glucose Management
Glucose monitoring and control are crucial during the perioperative management of
diabetics. The accepted range should be between 140 and 200mg/dL during the
perioperative period. Blood sugar should be measured and monitored in all
Orthopaedic patients, as up to 25% of patients undergoing Orthopaedic surgery will
experience severe hyperglycemia during the perioperative period, regardless of
whether they carry a pre-operative diagnosis of diabetes [18, 25]. This is likely due
to the high incidence of patients who are pre-diabetic, and only exhibit symptoms
associated with the stress of surgery [5]. Performing surgery on diabetics early in
the day takes advantage of diurnal glucose levels [2, 6]. Careful postoperative
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glucose monitoring is essential, one of the earliest signs of impending surgical site
infection is worsening glycemic control [26].
Known diabetic patients are advised to hold their medications on the day of surgery, with exception of metformin. Patients taking metformin are instructed to stop
taking the medication the evening prior to surgery to decease the development of
lactic acidosis [22]. Oral medications can be re-introduced when blood sugars are
stable within the accepted range.
M. S. Pinzur
Perioperative Hypertension
Cardio-vascular disease and hypertension are frequently associated with diabetes due
to the deleterious effects at the basement membrane level [4, 5]. When stressed during
the perioperative period, hypertension can be complicated with heart attack and stroke
[17]. Careful monitoring and perioperative management are associated with improved
patient outcomes [27]. The use of regional anesthesia as opposed to general anesthesia
should be considered when feasible and when regional methods prove adequate.
Antibiotic Prophylaxis
Surgical site infection is the leading cause of perioperative complication, increased
length of stay and hospital re-admission in diabetics undergoing Orthopaedic surgery [28–30]. Prophylactic appropriate perioperative antibiotics initiated less than 1
h prior to surgical incision and continued for no more than 24 following surgery
have been demonstrated to decrease the risk of surgical site infection [3, 13].
Venous Thromboembolism (VTE) Prophylaxis
Diabetic individuals are likely at a higher risk for developing perioperative venous
thromboembolism, likely secondary to both biochemical and biomechanical considerations [19, 31–33]. Prophylaxis should combine early ambulation, mechanical
methods (venous compression devices) and some element of chemical prophylaxis.
Building local checklists and electronic medical record order sets allow both standardization of care and the individualization necessary to address the unique needs
of the individual patient [3, 13].
Medical Optimization ofPatients Undergoing Urgent or
Emergent Orthopaedic Surgery
Very few musculoskeletal conditions require emergent surgery. This section will
focus on patients with life or limb-threatening conditions. The most-common condition in this category is the patient with abscess or infection that requires acute
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decompression of the abscess, removal of sepsis-producing infected tissue or amputation. Since the natural history of these conditions lead to death or limb-loss, time
to surgery is of the essence.
A thoughtful collaboration between the Internal Medicine Hospitalist, Infectious
Disease Specialist, Anesthesiologist, and Surgeon should be undertaken to address
the Hard Stops discussed earlier. There should be an attempt to address cardiac
function, and control blood pressure and blood sugar levels as close to the safe range
as possible. Due to the essence of time, medical optimization of co-morbidities
needs to be delayed until the need for surgery has been addressed.
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Medical Optimization ofPatients Undergoing Urgent
Orthopaedic Surgery
The prototype musculoskeletal conditions that require urgent surgical treatment are
geriatric hip and femur fractures. It is now well accepted that those patients who
have surgery within the rst 24 h post injury, have the most favorable clinical outcomes. The mortality rate and incidence of perioperative complications is greatly
increased when surgery is performed greater than 24 h post injury [34]. It appears
that the most favorable clinical outcomes are achieved with the development of
Hospitalist-Orthopaedic co-management practice patterns [12, 34].
Geriatric patients that can be safely prepared for surgery the morning after sustaining a hip or femur fracture, should be admitted to the hospital to a co- management
service that appreciates the urgency of having the patient medically prepared for
surgery the next morning. Those patients with unstable medical co-morbidities that
preclude readiness for surgery the next morning should be admitted to a traditional
medical service, where their unstable medical co-morbidities can be optimized prior
to temporally stabilized prior to undergoing surgery.
The primary co-morbidity that delays the surgical treatment of unstable fractures
is an acute myocardial infarction associated with the fracture or an unstable cardiac
arrhythmia. The goal is to stabilize these conditions as soon as possible, to allow
performing the life-saving surgery.
Blood glucose levels need to be brought down to the previously described safe
range. This often requires consultation among Internal Medicine Hospitalist,
Endocrinologist, and Anesthesiologist. Interdisciplinary co-ordination is often
required to address time constraints.
The next most common impediment to surgical readiness is observed in patients
being treated with anticoagulant medications. Patients managed longitudinally with
warfarin are generally monitored with protime (PT), partial thromboplastin time
(PTT), or a laboratory derived ration, and/or the so-called international normalized
ratio (INR). The effects of the warfarin can be reversed with vitamin K.Depending on
the number of hours before the planned surgery, this reversal can be accomplished by
intravenous, intramuscular, or oral vitamin K.A locally agreed upon algorithm for
normalizing coagulation metrics is associated with timely care that avoids the complications associated with anticoagulation. Many of the modern anticoagulation medications do not have to be stopped prior to safely performing surgery.
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M. S. Pinzur
Medical Optimization ofPatients Undergoing Elective
Orthopaedic Surgery
Modern reconstructive Orthopaedic Surgery often uses techniques that expose patients
to prolonged surgical anesthesia, extensive surgical approach, and levels of blood loss
far greater than seen in a previous era. Modern shared risk-benet decision- making is
necessary when exposing patients to such risks. Unlike the constraints imposed by
emergent or urgent Orthopaedic surgery, time can be taken to medically optimize
patients before exposing them to the risks associated with surgery. Multidisciplinary
medical optimization programs have been demonstrated to decrease the rate of perioperative complication, reduce hospital length of stay (LOS), reduce postoperative
emergency department (ED) visits, reduce the rate of hospital re-admission and
increase the rate of discharge to home following surgery [3, 13, 35].
Patients undergoing elective surgery have the time to effectively address the
Hard Stops associated with surgery. We avoid the term medical clearance, as this
term seems to imply some sort of guarantee. Instead, we attempt to risk stratify,
improving medical conditions when feasible. Patients with cardiac co-morbidities
can be evaluated by a Cardiology consultant, who often has the capacity to initiate
medical therapy or perform a procedure that improves cardiac status, thus decreasing the risk for perioperative cardiac complication. The judicious use of consultant
allows a similar medical optimization with other medical co-morbidities, such as
hypertension, renal failure, or chronic pulmonary disease.
Each organization should develop a local set of guidelines to address elective
musculoskeletal surgery in morbidly obese patients. While a target BMI less than 40
is the accepted standard, many investigations have demonstrated reasonable clinical
outcomes in patients with a BMI greater than 40. That said, it should be understood
that clinical outcomes are improved as we approach the target BMI of 40. A Best
Practice initiative would allow each individual patient to be evaluated by a team,
that includes a physician member of a bariatric program. Patients should be evaluated by this team and demonstrate some effort to improve their risk stratication.
Once the team feels that the patient has made a reasonable effort, risk stratication
and surgical planning can be initiated.
The subtle, but more difcult medical co-morbidities that require addressing are
the Soft Stops
morbidities are smoking and malnutrition. A local strategy should address these
co-morbidities, so that the decision-making is consistent.
that we have discussed earlier. The most difcult of these co-
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M. S. Pinzur
Chapter 11
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Advanced Trauma Life Support
ChristopherR.Parrino, RyanB.Fransman, AndrewJ.Varone,
andSamuelM.Galvagno Jr.
Initial Assessment
Implementing a systematic approach to the initial assessment of a trauma patient
is critical. By following a methodical system, the trauma team may rapidly identify and address immediate life-threatening injuries. If done well, it can also
serve to provide a degree of organization to a frequently chaotic environment. A
successful initial assessment starts before the patient arrives. The team leaders
must identify themselves and begin the room setup and team task allocation. This
includes identifying personnel available to assist, establishing roles and expectations for each role, and ensuring the availability of appropriate equipment for
procedures. Involved personnel often include clinicians to help secure the airway; respiratory therapy personnel; X-ray technologists; and nurses to establish
rapid intravenous (IV) access, obtain vital signs, administer medications, and
document critical events. Additional staff may be useful to assist with cardiopulmonary resuscitation (CPR) or other procedures, if indicated. It is also important
to ensure the room is quiet and that closed loop communication is employed.
Procedural supplies should include difcult airway kits, chest tubes with appropriate drainage systems, large bore central venous access kits, intra-arterial blood
pressure monitoring systems, rapid IV infusers, and blood product availability.
C. R. Parrino · S. M. Galvagno Jr. (*)
Department of Anesthesiology, University of Maryland School of Medicine,
Baltimore, MD, USA
e-mail: Christopher.Parrino@som.umaryland.edu; Sgalvagno@som.umaryland.edu
R. B. Fransman
Department of Surgery, Grady Memorial Hospital, Atlanta, GA, USA
A. J. Varone
Program in Trauma, University of Maryland School of Medicine, Baltimore, MD, USA
e-mail: andrew_varone@brown.edu
Switzerland AG 2024
J. Faintuch, S. Faintuch (eds.), Recent Strategies in High Risk Surgery,
https://doi.org/10.1007/978-3-031-56270-9_11
171© The Author(s), under exclusive license to Springer Nature
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C. R. Parrino et al.
A, B, C, D, E
The most widely used trauma initial assessment includes a primary and secondary
survey. The primary survey is encapsulated by the mnemonic “ABCDE” (Airway,
Breathing, Circulation, Disability, Exposure); however, massive exsanguination
should be controlled immediately when identied. Particularly for those who do not
routinely perform trauma assessments, it is important to address each step sequentially rather than in parallel to ensure nothing is missed. An axiom during the primary survey is “resuscitate rst.” For instance, in a severely hypotensive patient
who requires denitive airway management, blood transfusions should occur before
and during airway management. The primary survey can and should be repeated
whenever deemed necessary, given any clinical change or deterioration. Once the
primary survey is complete, the team can perform a secondary survey which
includes a thorough history and head-to-toe physical examination, complemented
by appropriate imaging modalities.
Primary Survey
It is important to note that while basic life support (BLS), advanced cardiovascular
life support (ACLS), and some military trauma programs now prioritize circulation
and massive exsanguination over airway and breathing, current algorithms for
advanced trauma life support (ATLS®) still maintain the traditional “ABCDE”
pathway [1].
Airway management is addressed in a subsequent section of this chapter. Once
the airway has been secured, evaluation of breathing demands assessment of the
patient’s ability to ventilate. Assessment includes the visual inspection of breathing,
respiratory rate and effort, and auscultation of bilateral breath sounds. If hemodynamically unstable patients are found to have diminished or absent breath sounds in
the appropriate setting, this should prompt concern for tension pneumothorax and
may indicate the need for rapid decompression. Chest decompression should involve
placement of a needle, nger, or tube thoracostomy in the fourth or fth intercostal
space in the anterior axillary line. Several studies have demonstrated higher success
of needle decompression with the anterior axillary position compared to the previously accepted second intercostal space in the midclavicular line [2–4].
Shock Prevention
The priority is establishing the patient’s vital signs and rapidly identifying potential
shock states. If found to be in shock, hemorrhagic shock should be considered and
resuscitation with blood products should commence as soon as possible. Up to 1L
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of crystalloid in 500mL increments is still an acceptable starting point, particularly
if non-hemorrhagic causes of shock are still being considered; however, these uids
have often already been administered in the eld. If a patient remains hypotensive
after initial crystalloid resuscitation, blood product transfusion should be considered. If available, whole blood may be superior to traditional low-ratio 1:1:1 (1 unit
of packed red blood cells [PRBCs] to 1 unit of fresh frozen plasma [FFP] to 1 unit
of platelets) resuscitation and should also be considered for patients in hemorrhagic shock.
Large bore IV access should be rapidly obtained. If unable to obtain peripheral
IV access efciently, central access should not be delayed. Any external hemorrhage must also be identied and controlled. Peripheral pulses should be evaluated
in each extremity and discrepancies between the extremities noted and appropriately evaluated during the secondary survey.
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Glasgow Score
Disability refers to prompt evaluation of the patient’s neurologic status, to identify
time-sensitive traumatic brain or spinal cord injuries. A Glasgow Coma Scale (GCS)
score should be obtained on presentation. If possible, it is preferred to obtain a full
GCS prior to administration of paralytics and sedation to identify a baseline and any
need for urgent osmotic therapy or time sensitive imaging.
Exposure involves removal of the patient’s clothing and a full body inspection.
This is particularly important in penetrating trauma patients who may have hidden
wounds in their skin folds, axilla, or perineum that could drastically alter subsequent management. The patient should be rolled and their back as well as cervical
spine examined for posterior injuries.
Imaging Procedures
In critically ill or hemodynamically unstable patients, it may be important to obtain
adjunct testing immediately after completion of the primary survey, to help identify
the potential source of their current clinical status. These tests are often essential to
help guide surgical planning and exploration (i.e., which body cavity to enter), particularly in the setting of blunt trauma with an unknown source of hemorrhage.
These adjuncts include chest X-ray; Focused Assessment with Sonography for
Trauma (FAST) examination or Extended-FAST (e-FAST), which includes a pleural assessment; and pelvic X-ray. In addition to allowing rapid identication of lifethreatening pneumothorax or hemothorax and position of invasive lines or tubes,
chest X-rays also provide insight into the mediastinum and aortic knob and sometimes may indicate aortic injury and associated mediastinal hematoma.
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