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Basics of Trauma Care: Primary Management & Identifying the Red Flags

Jan 11 | 3:30 PM

Around the world, injury management is becoming a pressing public health issue. Road accidents, workplace accidents, and home accidents are increasing at an alarming pace - leading to a subsequent rise in injuries and fatalities. Many injured people suffer long-term consequences to their quality of life. Join us live and exclusive on Medflix as Dr. Chetan Pradhan, Head of Trauma at Sancheti Hospital (Pune), discusses the basics of trauma care and how to spot red flags early to avoid post-traumatic morbidity.

[Music] so good evening everyone netflix welcomes you to today's session which on basics of trauma care primary management and identifying the red flags today with us we have this amazing very experienced faculty dr chaitan pradhan he is a renowned consultant orthopedic surgeon and head of trauma at sancheti hospital pune he has almost three decades of experience in the field of orthopedics he pursued his ms orthopedics from university of pune in 1996 along with a brilliant clinical record sarah is also presented at many national and international conferences his areas of expertise include advanced polytrauma and adult reconstructive surgery along with of course today's topic emergency trauma care so sir we welcome you on behalf of netflix and all of our audience so good evening everyone um it's really nice to be with you today and i thank netflix for that i'm dr chaitan pradhan i'm head of trauma for in sanchiti institute for last 25 plus years and i deal with only trauma since um many years now i'm also the associate medical director at century hospital pune so uh today i'm going to discuss with you how do we assess uh victims of trauma in our practice what are the various types of extremity injuries that we should be aware of and as a general practitioner or a treating physician or a surgeon what should be the basic management and first aid that we can actually give to the trauma victim before the definitive management so today the musculoskeletal trauma can be divided into low velocity trauma which consists of domestic falls simple or sports injuries which is obviously never fatal or high velocity trauma which are usually highway accidents or falls from height second floor third floor suicidal falls which we saw a huge number of suicidal injuries in the pandemic lockdown area or train accidents which are often fatal so today road trauma is not only common but it is designated as a killer disease by none other than the who and mind you it affects a very young bread winning age group between the 20 to 50 years which is the most productive population in the country and has a huge impact on the economy of the nation if we do not deal with it properly just to give you indian statistics it costs us more than the cardiac or cancer hospital days in terms of about 5 5 200 crore of rupees are many more seriously disabled patients for life and mind you they are mostly the young patients the bread winners of the family now this is just an old clipping which i have included in the presentation at accident scale about three patients per day in pune it's the city where i live now this is not very surprising because this is what the traffic looks like and it is not really difficult to understand nobody following traffic rules seriously that you end up with a situation like this the the whole spectrum of trauma today is changing initially when i was a resident we used to see very few cases of high velocity accidents previously what used to happen was mostly we used to cater to low velocity injuries and you know one or two road accidents a day but today because of the availability of fast cars good roads we see a lot of high velocity accidents and this is now the era of polytrauma so what is a polytrauma i keep on saying this word again and again polytrauma by definition is an injury to two major systems in the body say like a head injury or an abdominal injury or a chest injury with one long moon fracture or multiple long bone fractures one of which is compound by compound i mean either an open fracture or something which requires a neurovascular intervention or there is severe crushing of extremities now all these are usually high velocity accidents and you need to act aggressively you need to act fast and you need to act decisively in order to save these victims mind you every 30 minute delay in transportation of a polytrauma case results in the mortality to the extent of 30 increase and therefore we have this concept of golden hour all of you know that golden hour is nothing but the very first hour from the injury in which your first 10 minutes are the platinum 10 minutes now what is the importance of this golden hour it is why is this first hour important because after the first hour some irreversible changes start taking place in various systems in the vital organ of the patient and there starts a vicious cycle of progressive deterioration which will lead to not only loss of life but definitely loss of limb so therefore you need to shift such patients to a tertiary trauma care center by tertiary trauma care center i mean place a hospital where you have a multi-speciality trauma team so you have a orthopedic surgeon and a competent anaesthetist a neurosurgeon an abdominal surgeon a cardiothoracic surgeon etc a well-equipped intensive trauma care unit 24x7 functioning operation theater with trained personal labs and everything else available and the concept of horizontal care so horizontal care is something where all the specialists specialists are available simultaneously what happens in especially in government hospitals today is that the junior most resident sees the patient first uh then he calls his senior then he calls his consultant and you know so that's a vertical chain of care horizontal care is a concept where when you know that there is a polytrauma or when you know that there is a multiple trauma victim coming in all the specialists are available or a trauma team is available in place to simultaneously assess and treat that patient that is what is a tertiary trauma care center so commonly what we see is the standard dilemma especially when you are treating such patients in the periphery should i treat the patient should i shift him how do i shift him if i shift him what are the label legal implications to me if i treat him what are the legal implications to me these are the questions raised and presented to us by quite a few of our colleagues especially when while practicing in the periphery so let me answer most of these in just a bit so let's see a few scenarios so if you see the first scenario a patient is brought to you unconscious on a trolley is gasping on the responsive bleeding mind you not dead but it is a potentially life-threatening situation so what you need to do is manage the abcs first and i'm going to tell you what are abc's but do not be distracted by the extremities so even if you see mangled extremities don't pay any attention to them first manage your abc's typical second scenario patient is brought on a trolley or a stretcher he is conscious responding to commands and questions but he is unable to walk or move now this is not a life threatening situation but it may be limp threatening so this is a patient where you need to do your primary and secondary trauma survey again i'm going to tell you what is that and identify whether there are any limb threatening injuries and the third scenario is when the patient is brought on a wheelchair where he walks in himself he is fully conscious and oriented obviously he is there's no danger to life or lymph now this is where you need to do a focused clinical examination of the injury extremity and give him first aid the most important thing to remember from today's talk is that fractures are rarely life-threatening so it is imperative that when you deal with trauma victims first perform a primary trauma survey to find out whether there are any life-threatening injuries do not be distracted by limb threat the obvious but not life-threatening in extremity injuries like say crushed limbs or mangled extremities be allowed to measure bleeding from extremity injuries and after you have identified the life-threatening injuries then you do your secondary focus trauma survey i'm going to explain to you in a minute what all this is so the primary trauma survey is nothing but your abcde as per the atls guidelines a stands for airway with cervical spine control so see if the patient is breathing well if not do the airway management by extending the neck or putting in a standard oral airway or if required intubating him and then taking control of the airway check whether he is breathing well or if there is a chest injury if there is a paradoxical respiration c stands for circulation and hemorrhage control so you stop obvious sources of bleeding from anywhere d stands for disability of a brief neurological examination whether he is able to move all the four limbs or not and e stands for exposure that is environmental control or hypothermia which is not really relevant in our situation so by the end of your primary trauma survey you come to know whether there are any life-threatening injuries or not the secondary trauma survey is nothing but the detailed evaluation of extremities so in the primary trauma survey you did not look at the extremities at all you just looked at the abcde whereas in the secondary trauma survey you are looking in details at the extremities what do you look at you assess the perfusion you identify open wounds and document on a piece of paper or photograph them you identify the closed wounds or fractures and document them most important thing is to assess whether there is a neuromuscular injury by recording the pulse the motor action and the sensations in all the four limbs at the end of your secondary trauma survey you will come to know whether there are any limb threatening injuries or not so this is just a small mnemonic simple mnemonic which can tell you how to assess the extremities so look for dcap btls which means deformities contusions abrasions penetrations burns tenderness lacerations and swelling so you document all this and mark the pulses on the extremities so after your secondary survey is over you have already identified the life-threatening injuries and you have already identified the limb threatening injuries and you have documented wounds you have documented fractures you have documented the neurovascular status of the limbs and you have photographed the wounds this is what you do as step one when you're managing basic trauma what are the life-threatening injuries i keep on saying identify life threatening so all actual injuries are life threatening injuries so everything in the center of the body so the head the chest the abdomen and the pelvis these injuries can kill a patient so you must be able to diagnose these four types of injuries which are potentially life threatening mind you again isolated extremity trauma is really life threatening so even if you see a crushed upper limb or a lower limb that's not going to kill the patient but if the patient is unconscious or the patient is not able to breathe well or he complains of severe pain in the abdomen or he is not able to pass urine then these are these may be life-threatening injuries head injuries can be diagnosed by the patient being either unconscious or he gives history of profuse vomiting he's confused he's not able to remember how he feel down or there is bleeding through your nose etc or there are multiple scalp moons as seen here and this is a serious life-threatening head injury you have to admit this patient do a ct scan of the brain needless to say that such patients should be transported always on a hard board or a spine board if you have one because you must assume cervical spine injuries in all patients of head injuries so your trauma series when you take x-rays must include a skull lateral and a cervical spine when you're suspecting head injuries it must also include a chest and a pelvis with both hips so what are then the limb threatening injuries the most commonest or the most obvious limb threatening injury is something where you have a vascular compromise so you are not able to feel the pulse or there is a compartment syndrome syndrome is something where there is so much swelling of the extremity that it compromises the circulation of the limb how do you diagnose that you it's it's very simple to diagnose so the pain there are five ps how you diagnose the compartment syndrome so pulse is the last thing in that but pain is something which is the first thing that the patient will complain of the pain which is disproportionate to the injury or it does not reduce by immobilization or giving an nsa id so severe pain stretch pain unable to feel the pulses all these are signs of compartment syndrome or severe crushing yeah parastatia etc so five ps but mind you don't be fooled by the pulse a present pulse may not exclude a compartment syndrome in fact when the pulse goes away it is far too late and the patient usually lands up with an amputation so if the patient is complaining of severe pain on passive stretching then this is a compartment syndrome severe soft tissue loss severe bone loss or very rarely what we see today nowadays is gas gangrene so something like this now this is a typical runover accident this is a neurovascular compromise there's no pulse no movements no sensations this can be a potentially limb threatening injury this is uh again our suicidal attempt in front of a train so this is a severe crushing of the entire limb this is the thigh as you can see here and the lower limb this is not going to survive so muscular skill trauma can be divided into soft tissue injuries and bony injuries soft tissue injuries are typically ligament sprains or strains and joint subluxations or dislocations only injuries are fractured at fractures either closed fractures or open fractures where you have wounds mind you both may be associated with neurovascularity so even a soft tissue simple soft tissue injury or a dislocation may be associated with neurovascular compromise or a compartment syndrome how do you diagnose fractures fractures typically have swelling they are severely painful they are deformed they show abnormal moments so movements where there should not be any movements and presence of crepitus how do you manage trauma in especially in a peripheral level dispensary so the first tenet of managing trauma is to manage shock if the patient is in hypoallen the second principle would be to manage the pain third is to splint the extremity or give first aid and then prepare the patient for definitive management by optimizing him for anesthesia in other words prepare the patient for definitive management in the hospital in terms of surgical intervention what should be your first aid the first state should be quick and simple it should take care of the pain it should definitely not do more damage so effectively it means immobilization and pain relief that is what is effective first aid uh when you talk of splinting or immobilization there are again certain principles that you need to follow so you must always visualize the injured part you should not cover it before you immobilize anything check and record the pulsations the motor and sensory movements uh before and after your splinting you may give a gentle inline traction to the extremity to cover to correct the deformities or cover your open cover the open wounds with sterile dressings not handkerchiefs or anything cover them with sterile dressings pad the spins adequately and extend the splint one joint above and below the side of the injury so let's talk about the upper extremity you may have fractures of any bone from the clavicle to the fingers or dislocations of the shoulder elbow and multiple joints in the hand how do you manage them you quickly assess the injury check for pulsations the brachial and the radial artery check the peripheral nerve function of all the three nerves so a simple way is to ask the patient to in an extended risk ask the patient to make a fist and extend it all the fingers and open the fist so that means that all your radial median and on the nose are functioning motor wise you must also document the sensations of the radial median and the ulnar nerves give gentle traction to correct the deformity if there is one and then immobilize it there are various ways of immobilization but the simplest and commercially available uh immobilizers are these just a simple cuff and collar sling or a universal shoulder immobilizer or if you have the access then you can give an above or a below elbow plaster but even this simple immobilizer which is commercially easily available can take care of most of the upper extremity trauma like this this is a universal shoulder immobilization so it can effectively immobilize most of the fractures in the upper extremity just a word of caution when you give a sling see to it that you are not giving it like this shown on the left side but more than 90 degrees of elbow flexion so that there is no swelling otherwise the surgeon cannot do anything till the swelling reduces what are the danger signals now this is something which is very important if there is a grass deformity if you cannot feel the pulsations of the radial on the regular artery if the limb is cold cyanosed there are no movements no sensations or if the extremity is crushed with open fractures or some traumatic amputations now these are your red flags these are the ones which require urgent transportation to a tertiary level trauma center in the lower extremity you get fractures and dislocation of the hip fracture of any bone right from the hip to the toes you get something which is known as internal derangement of knee which means there is no fracture where there are multiple ligamentous or meniscal injuries the commonest open fractures are those of tb and the fibula and horrible fracture dislocations of the ankle or crush injuries to the lower extremities so these are the spectrum of trauma that you see in the lower extremity again how do you basically manage them you quickly assess the injury primarily the neurovascular status so that is something which you should do as the first thing in your secondary trauma survey whenever you are assessing upper or the lower extremity so first thing is feel the pulses ask the patient to move the limbs if he is conscious enough move the fingers palpate the dorsal aspect is posterity will both check for toe sensations and movements and document it if it is present or absent apply gentle traction immobilize use ice ice packs are now commercially easily available in any medical store and elevate the extremity so lower limb should always always be elevated immobilization can be very effectively done using a thomas splint and this is a splint right from world war ii which has been used historically but it's a great immobilization aid or a great splint which can be used for practically every fracture in the lower limb if available you can use well-paid padded pop slabs or commercially available slabs or a simple knee extension place brace use pillows and sheets under the knee always keep the patient supine with the extremity elevator do not ask him to bear weight there is a common tendency he just see if you can walk around don't do that because all the um fractures lower limb fractures displace under load so unnecessarily if you ask the patient to bear weight you may be displacing an undisplaced fracture so this is an exter an example of a thomas print on the left and a longly extension brace on the right both are commercially available um the thomas flint can be shed uh in on to the extremity like a trouser and just bandaged and it effectively mobilizes practically all the fractures in the lower extremity again dangerous signals absent pulsations or sensations no movements possible cyanosed cold limbs open fractures with bone jutting out and this is very common in the tbl fractures or severe crush injuries hip fractures now something which is very very common in geriatric age group you will see it almost every day in your practice and some of them even [Music] come to you walking with some minimal pain in the hip others with displaced fractures typically come with leg externally rotated referred pain to the knee may be possible but this is a very common situation today where we see a huge amount of geriatric population with domestic falls especially in the bathrooms and mind you they it may well be a terminal event in the life of that patient but the whole scenario is now changing aggressive management of these factors especially surgical management and rapid mobilization out of the bed has excellent outcomes today in all age groups in all geriatric hip fractures no matter what is the medical condition of the patient or what is the fracture today a hip fracture is almost treated like an emergency especially in my institute where we aggressively treat this patient without waiting for too much of surgical medical optimization of that patient and get him out of the bed the only way to keep these geriatric patients alive is to get them out of the bed as soon as possible and it is possible nowadays with better anesthesia techniques regional anesthesia better surgical techniques minimally invasive surgical techniques it is very much possible to get them out of the bed and moving that is really increase their longevity and life expectancy in a big way open woods now this is again a very common scenario what you need to do is control the bleeding with pressure mind you all bleeding stops with pressure if it's a major arterial bleeding that patient will not survive so it will he will not come to you but most of the arterial bleeds stop because arteries have muscle in their walls so it goes into a spasm the bleeding that you usually see is venous bleeding and all venus bleeding stops with pressure so you need to give sustained pressure for more than 10 minutes to stop it of course when you see bleeding check for distal pulses motor and sensations don't apply a tourniquet unless you are yourself accompanying the patient to the hospital because the nikkei usually remains in place and causes critical ischemia so as soon as you see the wounds you document the site size depth and see whether there is an associated fracture below and the contamination avoid the temptation to suture we see so many wounds brought in from the periphery which are sutured now unless you surgically debride a wound especially a deep wound and thoroughly lavage it with normal saline it is not correct to suture them because you are exposing them to infection or making it prone to infection so control the bleeding with pressure bandage keep the pressure bandage in place don't poke your fingers or instruments to see what is down below you explore the whole wound in a proper operation theater setup do not forget to give an iv antibiotic especially second generation cephalosporin to all patients with sizable wounds impaired objects so many times you find foreign bodies impilled in the wounds you usually stabilize them in the position form don't try to remove it except in the operation theater because it might cause severe bleeding so only exceptions to this are when you have an objects in the cheek which you cannot uh close the mouth or you cannot control the major breeding vessel with object in place these are the only two exceptions otherwise you you stabilize the the same object with a sticking tape as it was and then shift the patient to the operation theater as soon as possible hand and foot injury is very common in industrial zones often very disabling if not treated properly very very rarely life threatening splint the hand in a position of function so splinted in 10 to 15 degrees of dorsiflexion or splint the foot in plantigrate position and what is required is a quick debridement especially when the first four to six hours and external fixation or internal fixation and can really salvage even grossly horrible looking crushed and of feet so which trauma is an emergency which are the patients which you need to load and go or shift asap to major centers so all pelvic fractures are emergencies bilateral femoral fractures are emergencies and may be potentially life threatening any open fracture is an emergency all dislocations are emergencies and badly crushed extremities are emergencies just to give you a brief recap about blood loss from fractures pelvis about 500 cc for each break in the pelvis and it may lacerate major vessels so fracture pelvis is a fatal injury usually if the patient reaches you alive you need to be really really aggressive every femur loses about 1000 species of blood internally so even if you don't see any source of bleeding assume that he has lost about a liter of blood in the thigh and multiple fractures therefore can produce severe hypoallemia which may not be visible so you need to be very careful about shock so which injuries are lymph threatening all open fractures traumatic impute amputations compartment syndromes and rarely gas gangrene gas gangrene is very rarely seen nowadays but it is possible in farmyard contamination or several contaminated woods something like this now this is a great 3b open fracture of the femur you can see the gravel and the contamination this is a potentially limb threatening injury [Music] fracture pelvis like i told you is one of the fatal orthopedic emergencies frequently because of severe hypoallemia or internal organ damage what you need to do is quickly assess so you do a compression distraction test of the pelvic of the eyelid crests if you see blood at external urethral metas it means there is a ruptured urethra if you say camous is around the genitalia then that is a sign of fractured pelvis or the patient is unable to pass the urine or you've done everything and the blood pressure is still not responding that means something is going wrong and something needs to be aggressively done what is done a whiteboard iv line plasma expanders oxygen pelvic strapping now this can be very easily done even in a dispensary so you just strap the entire pelvis with a bed sheet or a sticking tape monitor the vitals and transport the patient in the hospital usually blood is given and pelvis is stabilized by an external fixator a suprapubic systolostomy is done or an exploratory laparotomy with repair of the bladder tear or at times as a last resort ligation of the internal eyelid arches so this is a example of an open book fracture of the pelvis you can see that there is a diastasis of the pubic symphysis and this requires immediate external fixation like this to prevent internal blood loss and imminent death all dislocations are emergencies they should be reduced immediately irrespective of the time of the day or night because only then you can preserve the joint function of course needless to say that all dislocations are extremely painful and they should be pain relief should be the prime first head that you give this patient but mind you the pain will never reduce unless you reduce that dislocation and therefore it should be done as an emergency traumatic amputations now these are quite common in industrial beds or crush injuries sometimes we see them as food chopper chopper injuries etc or even in runover accidents these are potentially salvageable extremities especially if it's a clean cut wound but you need to do urgent microvascular reconstruction in these cases so timing is a priority and you must treat these patients within the first four to six hours from the time of injury microvascular repairs are nowadays possible the implantations are possible and so what you need to do is keep those extremities of fingers and plastic bag which should be kept in eyes so many times we see patients getting the amputated digit or the hand directly in contact with ice now this causes harmonic necrosis of the tissue and we cannot do any reconstruction either microvascular or otherwise of course don't forget to control the bleeding at the parent side wash the wounds take all due precautions to prevent infection and reach a trauma center asap within first four hours usually this is what is to be done so something like this now this is a bilateral traumatic amputation and it can be quite effectively salvaged with micro vascular repairs something like this now this is the right hand and this is the left so to summarize isolated musculoskeletal trauma rarely kills as a treating doctor always do primary and secondary trauma survey as a protocol in the primary trauma survey identify all the limb threat life-threatening injuries which are usually the actual injuries meaning head cervical spine chest abdomen and pelvis in the secondary trauma survey identify limb threatening injuries limb threatening injuries are usually those which have either neurovascular compromise or severe crushing severe soft tissue loss or severe bone loss this is mandatory mind you as doctors intelligent management can definitely save the life definitely save the limb and definitely save the function of the limb if done especially within the golden arm but then a rapid transport to a proper trauma center and make a huge difference in somebody's life and live thank you very much and i'll be happy to answer questions yes sir thank you so much that was a great session i liked the last line intelligent management can save that's very true that's and that's what's needed in an emergency case so that was amazing i think we can move on to the questions now there's a question is ivf ringer lactate contraindicated in head injury no it's not contraindicated but nowadays we prefer to give crystallites than uh colloids and uh in a head injury [Music] i would before having a ct scan in my hand i would just give plain normal session a normal saline without resorting to anything else so simple normal saline as a basic management of head injury give an anti-convulsant loading dose of either phenytoin or liver or whatever you are using and iv fluids nasal oxygen do not give steroids because nowadays they are not advised and antibiotic which is something which we usually forget and get a ct brain asap all right there's a question by dr porika can injection tramadol be given for pain and if not then in which cases it is recommended yes it can very safely be given tramadol is a safe analgesic in fact it can be very safely given in almost all the age groups except the children dr praveen would like to ask please advise on the post-op as well as the pre-op pain management so pre-op pain management is it depends on the age of the patient you in pediatric age group we tend to use only paracetamol and at times naproxen uh in adult age group anything from diclofenac which is one of the best analgesics for acute pain relief to narcotics in patches are very commonly used in the geriatric age group we use iv paracetamol local pain patches but nowadays what we do as a protocol is in our casualty we give a lot of regional anesthesia and post-operatively definitely we are more in favor of using regional anesthesia or pain blocks to prevent the use overuse of nsaids in this age group so post-op pain management is primarily first 24 hours regional blocks uh iv paracetamol and then uh again local patches like fentanyl uh buprenorphine etc as indicated usually stop 48 hours later you don't require too much of pain control next question is how to control fat embolism well that's an excellent question now that's a very common thing in young obese males especially with long bone fractures the the best way to control fat embolism or you know the best thing about fat embolism is to prevent it so don't shift the patient without adequate immobilization such a patient if you must shift a sharp femur or a shaft tbr adequately immobilize either in a thomas flint or a plaster um treatment wise the sooner you stabilize that fracture lesser are the chances of fat embolism so nowadays intra metal nailing is the standard of care for all long bone fractures especially female and tibia so the sooner you do it the better and if at all your patient lines up with fat embolism then you treat him like any other ards patient so positive pressure ventilation [Music] anticoagulation you diagnose it by doing a ct pulmonary angiography positive pressure ventilation something like like saying etc therapeutic doses stabilizing the fracture with the same um so what we do is we put intubate and put the patient on a ventilator we operate on that ventilator and then give him adequate oxygen and anticoagulation till he stabilizes but mind you the moment you stabilize the fracture he immediately comes out so that's the treatment of fat steroids again are of doubtful role all right just with the same question dr sanket would like to ask in fat emboli iv slow molecular weight dextran can can it be used yes it has been empirically used but there's no um molecular weight paren is [Music] more used than than dextra so there's not enough level one literature support for molecular weight dextron in fat embolism uh dr jahangir uh was asking interested more in the facial fractures so if you could just summarize a bit about the facial factors facial fractures are never an emergency unless they are causing respiratory obstruction so we usually take the help of our maxillofacial surgeons who keep the airway patent and once the swelling reduces when you have only four two three injuries they need internal fixation as a first aid what you can do is enter dental wiring or bracing but i think you would be the right person to talk about it that's true next question times when you have a segmental fracture of the mandible or maxilla it can really you know cause a lot of strider and i have had a couple of cases where i had to do a tracheostomy to keep them breathing you know that that can become a problem because you can't really do it you can't even intubate them yeah yes yes that's that's true even while going for the wiring of the mandible and maxilla you need to likely apply a lot of pressure to open the jaws dr krishnan would like to ask how to give cpr in suspected spine injury well so you need to stabilize the cervical spine so you need two people if you don't have um appliances if you you should actually have a cervical collar to put on a heart or a philadelphia collar should be put on as a immediate maneuver and then a cpr can be given but when it comes to giving a cpr i think the life takes precedence or the spine so quickly immobilize the spine with the cervical collar once you've done your airway management and then start the cpr uh next question if you don't have a caller then you will have to have a colleague who is supporting the cervical spine while you're doing the cpr next question is by dr sameer what is the preferred first dose of antibiotics in limb trauma so if it's an open trauma we give a triple antibiotic so we give one for gram positive one for gram negative and one for anaerobe so what we usually give is a second generation cephalosporin and anamikasan and metronidazole if it is a closed trauma then just as a broad spectrum cephalosporin like cepheroxine is good enough next question by dr shravan to what extent neurological function is restored in amputated and reattached paths well in re-implantations you do a neurological reanistomosis also so there is about 50 to 60 recovery of the neurological function there's a next question a host of pelvic fracture cases after how many days patient needs to undergo physiotherapy it depends on the fracture union so if you fix that fracture pelvis or the acetabulum after six weeks you can mobilize the patient effectively but in-bed physiotherapy starts immediately if you have fixed it all right out of the bed six weeks later in pelvic fractures ct is recommended right away or its initial x-rays are to be done initially only x-rays that to portable fracture pelvis is an emergency so you need to resuscitate the patient you may require an external fixator before you do a ct scan or something so the priority goes to resuscitating on the basis of x-rays and once the patient is stable so once your systolic bp is stable at 100 you have a urine output coming um there's no danger to life then you do a ct scan okay uh doctor raja is asking can perio cardio synthesis be done in er well that's that's a dangerous thing to do in here unless you have a depression theater ready for it synthesis is quite an invasive procedure so i would prefer doing it in a theater right there are two three like similar questions that cpr in case of spine injuries or rib fracture so a bit guidance about that ignore the rib fractures if you if it comes to giving cpr because there the life is at risk right right but don't cause a rib fracture while giving a sepia dr sandeep would like to ask in gas gangrene cases is there other treatment we can do without cutting that infected part yes so if you if the patient has reached you immediately you can give anti-gas gangrene serum uh and penicillins work very well in gas gangrene not even cephalosporins so adequate debridement rapid debridement so you have to take the patient straight to the operational theater and debride as radically as possible under the cover of cephalosporins of penicillins and you have to give anti-gas gangrene serum as well okay right dr nishant would like to ask role of skeletal traction in hip fractures when the patient is fit for surgery well nisha definitely scheduled attraction is helpful to get the basic alignment but if it's a geriatric hip i would rather post him the next day rather than spending time on traction etc but if the patient is not operable then he has scale retraction does have a rule but as far as hip fractures are concerned the standard of care today is to aggressively fix them and get them out of the bed asap next question is any guidelines to provide cpr and pregnancy of around six to seven months having a rib fracture cpr guidelines are the same world over it is irrespective of the pregnancy or any other injury so you can go through current cpr guidelines in the acls websites or any other certified websites and you can get the standard cpr guidelines anywhere nowadays yes sir i'll just go through once if we haven't missed out on anything there are many repetitive which we have taken there's a question by dr sanket can you please say our resource citation to patient with flail gist so again it's about refractures and flail just [Music] if you're talking of resuscitation by meaning cpr then again it's the same when it comes to giving a cpr you're not bothered about any other injury for that matter you're just bothered about keeping that patient alive the flail chest part will come later on now the management of flinches today is to have a bilateral uh chest drain and give positive pressure ventilation the second way of doing it nowadays is to fix the rip fracture so you have small rib plates wherein you can stop the paradoxical movement of the ribs or the chest or there are rib you know splints so there are small titanium plates which act as rip splints and that prevents the paradoxical movement of the chest and the patient comes out very soon uh dr yeah singh is asking can we give diclofenac in head injury in a young patient yes but in a patient who is say beyond 50 years old we do not know his renal function so i would not you know risk a dichlorophage has a lot of nephrotoxicity and nylophonic also has a potential um allergic reaction so you may have allergy to diagnosing you may have had severe allergic reactions to diagnose so the safest bit is to give paracetamol or even tramadol dr suhail is asking is xylocard emergency drug yes it is used in cardiac emergencies for arrhythmias etcetera [Music] but xylocart is safe enough to you to be used as a local anesthetic because it does not require testing all right dr saeed is asking what would be the preferred implant for a 10 year old fracture of the femur titanium elastic yes doctor thawker is saying anti-platelet activity of dichlophone can prove uh fatal like in geriatric patient it might be of concern right right yeah post-op long bone fracture is it mandatory or is there any guideline for the anti-platelet drugs if the patient is on some anti-platelet drug so it depends you have to assess the risk profile of anticoagulation or if he has a dvd pro if he requires a long term dvd profile access so there are a lot of charts a lot of scores which tell you whether this patient is going to require a long term dvd prophylaxis but by and large if you are mobilizing that patient out of bed just simple aspirin is good enough what we do is as long as the patient is in bed i use um no molecular weight in something like like saying or an oxypane or something like that and if the patient is mobilized then simple aspirin is good enough but this is a very controversial topics there are um a lot of papers for and against using hardcore anticoagulation in long bone fractures so anticoagulation in trauma is not yet standardized [Music] so the way we have sir consultants and practicing physicians we also have some very budding doctors with us in netflix one of them is doctor he is asking which is better md emergency medicine or fcps medicine according to your opinion and why md md emergency medicine definitely because it's universally recognized yeah right uh the one more question is difference between tracheostomy and cricothyrodictomy brachiostomy is an open procedure because hierarchy is a percutaneous quick first aid procedure okay well that was the those were the questions for today a very very nice and very interesting session i would like to thank you yes on behalf of medford this was uh this was really very basic yeah i mean i could go hours talking about trauma and individual fractures as such i understand that this was very very basic for especially for orthopedic surgeons but this was to be an overview of primary care and trauma so thank you netflix yes and we do have amazing comments that amazing session and all yes so this was basic so we are obviously hoping to have a series from you on trauma care with which where we can you know go in so we like our audience would benefit a lot from that because trauma care and emergency care is the most i would say feared department when it comes to doctors because whenever there is a emergency department posting most of them are scared that no i'll stay in pediatrics i'll stay here there's nothing nothing to be feared or i mean afraid of i i hope i have alleviated at least a bit of here from from the yes audience it's it's just basic management yes yeah so like i said so we would definitely love to have you here i hope you enjoyed our platform uh this was yes this great um opportunity thank you for that opportunity and uh it was a pleasure yes so obviously we do do have a comment that it helps a lot for foreign students who are staying in foreign and study so this this has been very helpful for them every we need another trauma session you already have once more sir i will be very happy to do it yes definitely yes yes we'll definitely schedule it again so i would like to thank you sir again

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dr. Chetan Pradhan

Dr. Chetan Pradhan

Consultant Orthopaedic Surgeon, Assitant Medical Director- Sancheti Hospital

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dr. Chetan Pradhan

Dr. Chetan Pradhan

Consultant Orthopaedic Surgeon, Assitant Medi...

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