With compensated shock, the patient has vital signs that appear normal, however the vital signs are not a sensitive indicator of shock or resuscitation.
The heart and brain are perfused at the expense of other organs, so you have an occult hypo perfusion that cannot be detected by the vital signs. Shock is indicated in the body’s pH, the base deficit, and the serum lactate level. These are very helpful in monitoring resuscitation! The patient may have a normal heart rate, blood pressure, and adequate urine output, but the serum lactate level may be 3, which is considered high. Serum lactate levels should be less than 2.5—some labs consider it abnormal if it is greater than 2.
If the patient has occult hypoperfusion, then you will use damage control first before doing definitive care. In multiple trauma patients, the only time you will rod the femur is if the lactic acid and base deficit are within normal levels. For resuscitation and normalizing the lactate level, you can do early appropriate care, because if you have adequate resuscitation, the patient will be able to tolerate the nailing. You could probably lose up to 1/3 of the total blood volume before the blood pressure will be affected.
Sometimes it is very hard to determine the extent of resuscitation: Is the patient fully resuscitated? Or does the patient have compensated shock? This could be difficult to determine, which is why you would find the base deficit and the serum lactate level. Both are predictive of survival and are used to guide the resuscitation.
If the patient is under resuscitated, you will do damage control orthopaedics. When stabilizing the patient, you will decrease the trauma by initial stabilization followed by staged definitive management. For example, if the trauma involves the pelvis, you will have a sheet, a binder, and traction. Do not leave the sheet or binder in place for more than 24 hours. Once the patient is stable, we will get the chest, abdomen, and pelvic CT scans. If the patient is unstable, you will do angiography and embolization. You will use an external fixator for long bone fractures and splints for the forearm and humerus. There is no significant advantage of the external fixator on the femur more than skeletal traction unless the patient is already in the operating room.
The typical scenario is a huge story about the patient, don’t worry about the details first! Check the patient’s serum lactate level and base deficit. If it is high, you are going to do damage control orthopaedics (DCO).
Although this practice is controversial, you will want to wait at least 5 days before doing definitive treatment, and this has to do with the inflammatory markers. Definitive treatment can be delayed 7-10 days for pelvic fractures and up to 3 week for fractures of the femur to change from an external fixator to an IM rod. About 7-10 days is needed for the tibia to change from external fixator to an IM rod.
In morbid obese polytrauma patients, there will be increased systemic complications with IM nails of the femur with increased ARDS and death. In patients with a head injury, intraoperative hypotension increases the mortality rate.
