What are the key considerations in preoperative planning for traumatology?

Key Considerations in Preoperative Planning for Traumatology

Preoperative planning in traumatology should prioritize patient risk stratification, timely intervention, and a systematic approach to hemorrhage control to minimize morbidity and mortality.

Initial Patient Assessment and Risk Stratification

The first critical step in preoperative planning is comprehensive risk assessment using validated parameters:

• Hemodynamic Status: Categorize patients as stable, intermediate, or unstable based on 1:

  • Vasopressor requirements (severe: norepinephrine >4 mg/h)
  • Blood transfusion needs (severe: ≥5 units PRBC)
  • Lactate levels (severe: >4 mmol/L)

• Coagulation Status: Assess for coagulopathy severity 1:

  • Mild: PTr <1.2, fibrinogen >1.5 g/L, platelets >100,000/mm³
  • Moderate: PTr 1.2-1.5, fibrinogen 1-1.5 g/L, platelets 50-100,000/mm³
  • Severe: PTr >1.5, fibrinogen <1 g/L, platelets <50,000/mm³

• Associated Injuries: Evaluate using injury severity scores 1:

  • Low risk: ISS <25, mild TBI (GCS 13-15)
  • Intermediate risk: ISS >25 or injury AIS=4, moderate TBI (GCS 9-12)
  • High risk: ISS >40 or injury AIS=5, severe TBI (GCS <9)

Time-Critical Interventions

• Minimize Time to Operation: For patients requiring urgent surgical bleeding control, minimize the time between injury and operation 1. More than 50% of trauma fatalities occur within 24 hours of injury, emphasizing the critical nature of rapid intervention.

• Tourniquet Use: For uncontrolled arterial bleeding from extremity injuries, apply tourniquets in the pre-surgical setting 1. Ensure tourniquets remain in place until surgical control is achieved but minimize application time to prevent complications.

Surgical Strategy Based on Patient Risk

Based on the initial assessment, determine the appropriate surgical approach 1:

1. Low-Risk Patients: Proceed with early definitive orthopaedic surgery

   • Stable circulatory status without vasopressors
   • No significant coagulopathy
   • Mild associated injuries

2. Intermediate-Risk Patients: Initial resuscitation and temporary stabilization with prompt individualized management (PRISM)

   • Moderate circulatory shock (norepinephrine 2-4 mg/h)
   • Moderate coagulopathy
   • Intermediate risk associated injuries

3. High-Risk Patients: Damage-control orthopaedics with mid-term stabilization followed by delayed definitive surgery

   • Severe circulatory shock (norepinephrine >4 mg/h)
   • Severe coagulopathy
   • High-risk associated injuries

Neurosurgical Considerations

For patients with traumatic brain injury 1:

• Airway Management: Control ventilation through tracheal intubation and end-tidal CO₂ monitoring to prevent secondary brain injury

• Intracranial Pressure Management:

  • Consider external ventricular drainage for persistent intracranial hypertension
  • Decompressive craniectomy may be indicated for refractory intracranial hypertension

• Urgent Neurosurgical Indications:

  • Removal of symptomatic extradural hematoma
  • Removal of significant acute subdural hematoma (>5 mm thickness with >5 mm midline shift)
  • Drainage of acute hydrocephalus
  • Closure of open displaced skull fractures

Perioperative Antibiotic Prophylaxis

• For contaminated or potentially contaminated procedures, administer prophylactic antibiotics 2, 3:
  • Cefazolin 1 gram IV 30-60 minutes before surgery
  • For lengthy procedures (>2 hours), consider additional 500 mg-1 gram during surgery
  • Continue for 24 hours postoperatively in standard cases
  • For high-risk procedures (e.g., open-heart surgery, prosthetic arthroplasty), consider extending prophylaxis for 3-5 days

Common Pitfalls and How to Avoid Them

1. Delayed Surgical Intervention: Establish clear protocols for rapid transfer to operating theater for patients with ongoing hemorrhage

2. Inadequate Risk Assessment: Use structured assessment tools to objectively categorize patient risk and guide surgical strategy

3. Inappropriate Surgical Strategy: Match surgical approach to patient risk level - avoid extensive definitive procedures in high-risk patients

4. Overlooking Associated Injuries: Perform systematic secondary survey to identify all injuries requiring intervention

5. Inadequate Perioperative Monitoring: Maintain vigilant monitoring of hemodynamics, coagulation, temperature, and end-organ perfusion throughout perioperative period

By systematically addressing these key considerations in preoperative planning for trauma patients, clinicians can optimize outcomes and reduce morbidity and mortality in this challenging patient population.