Orthopedic Trauma Anesthesia

Preop Prep - Setting Bones Straight

• Assessment (ABCDE First!):
  • Critical AMPLE history (Allergies, Meds, PMH, Last Meal, Events).
  • Full exam; document limb neurovascular status.
• Investigations:
  • Labs: CBC, Coags (PT/INR, aPTT), Group & X-match.
  • Imaging: X-rays, CT (complex #/polytrauma). FAST scan.
• Stabilization:
  • Resuscitate: 2 large bore IVs, fluids/blood. Target SBP >90 mmHg, MAP >65 mmHg.
  • Hemorrhage control: Pressure, splints, pelvic binder if needed.
  • Pain: Multimodal analgesia. Consider early regional blocks.
  • Prophylaxis: DVT, Tetanus. Prevent hypothermia. NPO status confirmation.

⭐ For open fractures, administer prophylactic antibiotics (e.g., Cefazolin 1-2g IV) ideally within 1 hour of injury to reduce infection risk.

Intraop Anesthesia - Navigating the Nerves

• Regional Anesthesia (RA) Preferred:
  • Benefits: Superior analgesia, ↓blood loss/DVT/PE, ↓opioids, faster rehab.
  • Neuraxial: Spinal (rapid), Epidural (catheter for prolonged pain relief).
  • PNBs (Ultrasound-Guided): Standard for safety & efficacy.
    • Upper Limb: Interscalene, Supraclavicular, Axillary.
    • Lower Limb: Femoral, Sciatic, Popliteal, PENG, Adductor Canal.
• General Anesthesia (GA):
  • Indications: RA C/I, patient refusal, airway control, prolonged/complex surgery. RSI common.
• Key Nerve Safety:
  • Tourniquet: Pain >45-60 min (Max 2 hrs). Monitor for neuropraxia.
  • Positioning: Meticulous padding; avoid nerve stretch/compression.
  • 📌 LAST: Constant vigilance. Have 20% lipid emulsion ready.

⭐ USG for PNBs: Crucial for ↑success, ↓risk (intraneural/vascular injury).

Key Injury Anesthesia - Fracture Focus Fiesta

• Core Principles:

  • • ATLS: Airway, Breathing, Circulation.
  • • DCR for hemodynamically unstable.
  • • Early multimodal pain relief (regional blocks).
  • • VTE prophylaxis.

• Key Fractures & Anesthesia:

  • • Pelvic:
    • • Massive hemorrhage risk (MTP).
    • • Associated visceral/vascular injuries.
    • • 
  • • Femur (Shaft):
    • • Blood loss (1-1.5L). High FES risk.
    • • 📌 FES Triad: Respiratory distress, Neurologic signs, Petechial rash.
    • • Early fixation improves outcomes.
  • • Long Bones (General):
    • • Tourniquet: Max ~2 hrs; monitor pain, hemodynamics.
    • • Compartment syndrome: high suspicion, urgent fasciotomy.
  • • Crush Injury:
    • • Risks: Hyperkalemia ($K^+$↑), rhabdomyolysis, AKI.
    • • Manage: IV fluids, mannitol, $NaHCO_3$.

⭐ > For suspected major pelvic fractures, apply pelvic binder at greater trochanters; avoid log-rolling if unstable (prevents clot dislodgement).

Postop & Problems - Healing Hurdles Help

• Pain: Multimodal (opioids, NSAIDs, regional blocks/PNBs). Aim: early mobilization, prevent CRPS.
• VTE (DVT/PE): High risk. Prophylaxis: LMWH/DOACs, mechanical. Risk-stratify duration.
• Infection (SSI/Osteomyelitis): Asepsis, prophylactic antibiotics. Rx: Debridement, targeted antibiotics.
• Compartment Syndrome: Vigilance! Fasciotomy if pressure > 30 mmHg or ΔP (Diastolic BP - Compartment Pressure) < 20-30 mmHg.
• Fat Embolism Syndrome (FES): Long bone/pelvic #. Gurd's criteria. Supportive. Early fixation ↓ risk.
• Healing Hurdles (Non-union): Address infection, stability, vascularity, smoking.

⭐ For open fractures, antibiotic administration within 1 hour of injury is critical to reduce infection rates, ideally as soon as possible after injury assessment is complete and IV access obtained (Gustilo-Anderson classification influences choice).

High‑Yield Points - ⚡ Biggest Takeaways

• Fat Embolism Syndrome (FES): High risk with long bone/pelvic fractures; watch for hypoxemia, neurological changes, petechial rash.
• Regional Anesthesia: Preferred for pain control & ↓ thromboembolic events if no contraindications (e.g., coagulopathy).
• Damage Control Orthopedics (DCO): Early temporary stabilization in polytrauma, definitive fixation later.
• Tourniquet Management: Max 2 hours inflation; risk of nerve injury, ischemia-reperfusion.
• Tranexamic Acid (TXA): Crucial for ↓ blood loss in major trauma, especially pelvic fractures.
• Hypothermia Prevention: Actively warm to avoid worsening coagulopathy & acidosis.