< Back Pneumothorax American Thoracic Society- Patient Education | INFORMATION SERIES What is a Spontaneous Pneumothorax? Tube Thoracostomy (Chest Tube) You have a pneumothorax. This happens when your lung collapses and there is air in your chest. This can be spontaneous but is also frequently secondary to trauma. Imagine your lung is a balloon. When there is a hole in the balloon (penetrating wound to the chest, rib fracture, etc), the balloon collapses. When you breath in, the air moves from your airway, into the balloon and then out into your chest, the space around your lung. A chest tube is placed to evacuate the air from your chest and allow your lung (the balloon) to reexpand. As long as the hole in the lung is small, removing the air is generally all that is required. This is because when the lung is stuck back up to the inside of your chest, air stops leaking into the space around your lung. Surgery is infrequently required for management of a pneumothorax. This occurs when the lung fails to reinflate despite placement of a chest tube. It can also be required if there is an “air leak”. An air leak is the result of the ongoing leakage of air from the lung into the chest. The air that moves into the chest continues to be evacuated into the chest tube, and this is seen as bubbles in one window of the chest tube drainage canister. Spontaneous pneumothorax is often due to apical blebs, which are small areas at the lung of your lung that have thinned out and can rupture, with a similar results as a traumatic hole in the balloon that is the lung. Previous Next

< Back Shakshuka- A North African Dish Ingredients 1 large red bell pepper, thinly sliced 1 large yellow bell pepper, sliced 1 red onion, sliced 3-4 garlic cloves, diced ¾ tsp salt cracked pepper to taste 1 tsp cumin 1 tsp sugar ½ tsp smoked paprika ½ tsp chili flakes 3 medium tomatoes diced small ⅓ c white wine or water 1 T fresh basil ribbons or chopped Italian parsley 4 -6 Extra large organic eggs Other optional additions: crumbled feta or goat cheese 1 C browned chorizo ¼ C finely diced spanish style cured Chorizo or Merguez, a North African spiced sausage Instructions 1. Preheat oven to 400F. 2. In a large cast iron skillet, heat the olive oil over medium heat. Add the onion and cook until tender, about 5 minutes. If adding raw chorizo, brown it with the onions. 3. Add the sliced peppers and garlic, and turn heat down to med-low and cook for 5 more minutes, until peppers are tender. If adding the cured spanish chorizo or Merguez sausage, add it now. Add all spices, sugar and salt. Cook for 2 more minutes. Add fresh tomatoes and white wine. 4. Simmer on low for 15 minutes, adding more water if it gets too dry or thick- you want a stew-like consistency. After tomatoes cook down, taste, it should be full flavored- adjust salt and sugar if necessary. Crack 4-6 eggs over the mixture, sprinkling each egg with salt and cracked pepper. Add crumble goat cheese or feta over the top and place in the 400F oven. 5. Bake until egg whites are cooked (about 7 minutes) and yolks are still soft. Remove from oven and top with fresh basil (or Italian parsley). Serve with toast or crusty bread. Veggies sizzling Previous Ready for the oven Yummy! Next

Brain Death and Organ Donation End of Life Issues < Back Brain Death and Organ Donation Death can be uncomfortable and challenging to face/ navigate. Here are some of the situations that can arise surrounding the issue of death and organ donation. - Is resuscitating a patient with a devastating TBI for organ donation preservation justified? It may seem opportunistic and NOT focused on the dignified care of the patient- but it the patient’s desire would be to donate, preserving that option DOES honor their wishes. - If a patient is declared dead, specifically brain dead or death by neurologic criteria, and they previously expressed desire to be an organ donor (such as registration with an OPO or indicating their desires on their drivers license), legally the family can’t prevent the patient from donating. Even if the family opposes it, legally the patient should proceed to donation. But what about the risk of “bad press”? You’re honoring the patients wishes although that fact may be less apparent to the public compared to the anger expressed by the family members that the hospital “stole their loved one’s organs against their wish” or even worse, implying that the hospital “allowed” the patient to die so they could use their organs. - You don't need consent to perform a brain death test. Previous Next

< Back Stomach Ulcers UpToDate Patient Information Patient education: Peptic ulcer disease (Beyond the Basics) Patient education: Helicobacter pylori infection and treatment (Beyond the Basics) Patient education: Upper endoscopy (Beyond the Basics) Patient Information from Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Upper Endoscopy Previous Next

< Back Anemia...pending Anemia Previous Next

< Back Delirium...what's going on? A 29-year-old male with moderate traumatic brain injury (TBI) remains intubated in the surgical ICU (SICU) due to agitation/ delirium during daily spontaneous awakening and breathing trials (SAT/ SBT). What are the clinical priorities? Rule out acute processes that can cause agitation and delirium, such as anemia, acidosis, hypoxemia, infection, intra-cranial process, fever, and an adverse drug reaction. Other potential causes? Immobility, "lines and tubes." Isolation, disorientation, lack of normal sleep-wake patterns Endocrine or metabolic derangements Organ dysfunction (renal disease, liver disease, etc) Withdrawal from chronic home medications (benzodiazepines, alcohol, psychiatric medication, etc.). What are the treatment principles for agitation and delirium? Treat organic reversible causes (treat infection, minimize unnecessary medication, etc.) Implement non-pharmacology therapy (sleep-wake cycles, lights and stimulation during the day and darkness at night) Pharmacologic agents can be used once reversible causes are remedied and non-pharmacologic therapy has been instituted. After the optimization of non-pharmacologic therapy, the patient was successfully extubated. A few days later on rounds, the patient was sitting up in bed. During our conversation, I noticed that he was drinking a Mountain Dew. His mom told us that he drinks multiple Mountain Dews every day (read- 6 or more). I told her that I suspect this had a significant role in his altered mental status during attempts at ventilator liberation. Management of Agitation and Delirium Definition Agitation is a psychomotor disturbance characterized by excessive motor activity and a feeling of “inner tension”. Delirium is an altered consciousness with reduced focus/ cognitive function. It is abrupt in onset and can have a fluctuating presentation. High prevelance, often misdiagnosed. Classified as hypoactive (most common, worse prognosis, difficult to diagnose), hyperactive (better prognosis) or mixed. Etiologies Acute illness- sepsis , electrolyte/ metabolism disorders, hyperthermia, hypoxia, hypotension, EtOH withdrawal, organ dysfunction, polytrauma, emergency surgery Patient factors- elderly, history of depression/ stroke/ dementia, history of EtOH abuse, tobacco use. Hearing or vision impairment. Iatrogenic- noise, discomfort, pain, sedative/ analgesics, ventilator dyssynchrony. Exacerbated by pain, anxiety, discomfort. Diagnosis [see charts below] Assess consciousness with Richmond Agitation-Sedation Scale (RASS). 10 point scale, ranging from combative to unarousable. Assess for delirium with Confusion Assessment Method for the ICU (CAM-ICU). 1-2 min test, 98% accurate in diagnosing delirium. Assess over 24 hrs to capture nocturnal symptoms. Non-Pharmacologic Treatment of Delirium Diagnose and manage underlying acute illness - Treat sepsis as appropriate- antibiotics, source control, etc. - Correct hypoxia, metabolic disturbances, dehydration, hyperthermia Non-pharmacologic interventions for anxiety/ discomfort[1] Periodic reorientation and reassurance from nursing staff Cognitive stimulation Correction of sensory deficits Management of environment (reassess need for invasive devices) Normalize sleep/wake cycles Minimize iatrogenic factors (sedation) Pharmacologic Therapy for Delirium Typical anti-psychotic- Haloperidol. MIND and HOPE-ICU trial- no difference in duration of delirium.[2,3] AID-ICU trial- no difference in mortality.[4] Atypical anti-psychotic- Quetiapine, Ziprasidone MIND-USA trial- no difference in delirium duration with either agent [5] Dexmedetomidine MENDS and SEDCOM trials- ↓ mechanical ventilation and ↓ delirium vs benzos [6,7] MIDEX and Prodex trial- non-inferior compared to benzos/ Propofol [8] DahLIA trial- quicker and more sustained resolution of delirium vs placebo [9] SPICE III Trial- similar mortality and similar number of delirium-free days [10] MENDS II Trial- similar number of delirium-free days vs Propofol.[11] Melatonin Pro-MEDIC Trial- prophylactic melatonin didn't decrease delirium prevalence[12] Assessment for Caffeine Withdrawal Obtaining a detailed patient history, or even a focused history of the most pertinent diagnoses or medication (blood thinners, cardiac disease) is often challenging in traumatically injured parents who may have decreased mental status due to injury or intoxication. Documenting daily caffeine intake is not typically a key component in a surgical history. However, caffeine is readily available and is the most commonly used drug in the world.[13] Unfortunately, it has significant systemic effects. Along with nicotine, it is gaining more attention as a potential etiology of altered mental status or other symptoms that would typically prompt extensive work-up. If a patient has persistent altered mental status after evaluating typical causes, consider the possibility that the patient could be missing their usual caffeine fix. "Withdrawal symptoms caused by people abruptly stopping smoking or drinking tea and coffee can include nausea, vomiting, headaches, and delirium and can last for up to two weeks."[14] References Faustino TN et al. Effectiveness of combined non-pharmacological interventions in the prevention of delirium in critically ill patients: A randomized clinical trial. J Crit Care. 2022;68:114-120. MIND Trial. Girard TD et al. Feasibility, efficacy, and safety of antipsychotics for intensive care unit delirium: The MIND randomized, placebo-controlled trial. Crit Care Med. 2010;38(2):428-437. HOPE-ICU Trial. Page VJ et al. Effect of intravenous haloperidol on the duration of delirium and coma in critically ill patients (Hope-ICU): a randomised, double-blind, placebo-controlled trial. Lancet Resp Med. 2013;1(7):515-523. AID-ICU Trial. Andersen-Ranberg NC et al. Haloperidol for the Treatment of Delirium in ICU Patients. N Engl J Med. Published online October 26, 2022. MIND-USA Trial. Girard TD et al. Haloperidol and Ziprasidone for Treatment of Delirium in Critical Illness. N Engl J Med. 2018;379(26):2506-2516. MENDS Trial. Hughes CG et al. Dexmedetomidine or Propofol for Sedation in Mechanically Ventilated Adults with Sepsis. N Engl J Med. 2021;384(15):1424-1436. SEDCOM Trial. Riker RR et al. Dexmedetomidine vs Midazolam for Sedation of Critically Ill Patients: A Randomized Trial. JAMA. 2009;301(5):489. MIDEX and PRODEX Trials. Jakob SM et al. Dexmedetomidine vs Midazolam or Propofol for Sedation During Prolonged Mechanical Ventilation: Two Randomized Controlled Trials. JAMA. 2012;307(11):1151. DahLIA Trial. Reade MC et al. Effect of Dexmedetomidine Added to Standard Care on Ventilator-Free Time in Patients With Agitated Delirium: A Randomized Clinical Trial. JAMA. 2016;315(14):1460. SPICE III Trial. Shehabi Y et al. Early Sedation with Dexmedetomidine in Critically Ill Patients. N Engl J Med. 2019;380(26):2506-2517. MENDS II Trial. Hughes CG et al. Dexmedetomidine or Propofol for Sedation in Mechanically Ventilated Adults with Sepsis. N Engl J Med. 2021;384(15):1424-1436. Pro-MEDIC Trial. Wibrow B et al. Prophylactic melatonin for delirium in intensive care (Pro-MEDIC): a randomized controlled trial. Intensive Care Med. 2022;48(4):414-425. Caffeine: The chemistry behind the world’s most popular drug Stephenson J. Nicotine and caffeine withdrawal may affect ICU patients. Nursing Times. June 2019 . RASS for Agitation Assessment CAM-ICU For Delirium Assessment Previous Next

< Back Cardiac Physiology Cardiovascular Physiology Oxygen Delivery Adequate cardiovascular function is vital to maintaining perfusion to the organs and tissues in the body. Perfusion drives oxygen delivery (O2) and removal of byproducts of cell metabolism (CO2). The amount of oxygen that is delivered (DO2) is a function of cardiac output (CO; the volume of blood ejected from the heart every minute) and the arterial oxygen content (amount of oxygen in the blood). Cardiac output is determined by the volume of blood the heart pumps out into the body with each heartbeat (stroke volume, SV) and the frequency of the heartbeat (heart rate, HR). Stroke volume depends on preload (blood volume returned to the heart), contractility (effectiveness of cardiac muscle activity), and afterload (pressure in the peripheral vasculature that the heart has to overcome to eject blood). Arterial oxygen content (CaO2) is the amount of O2 in the blood that is ejected from the heart. This is determined by dissolved O2 + O2 bound to hemoglobin. Hemoglobin carries O2, and the percentage of Hgb molecules that are saturated (bound) with O2 is determined by arterial blood gas (SaO2, arterial oxygen concentration) or pulse oximetry (SpO2, peripheral arterial oxygen concentration). Pulse oximetry is non-invasive and is a reliable surrogate (as long as SaO2 >90%). The O2 carrying capacity of one gram of hemoglobin is 1.38 (this is a constant in the equation). So this is the first part of the equation: the number of hemoglobin molecules x the % of those molecules that are saturated with O2 x how much O2 saturated hemoglobin can carry . The second part of the equation is the dissolved oxygen (partial pressure of arterial oxygen, PaO2, reported as mmHg). This value is multiplied by the constant 0.003, which is the mL of O2 dissolved per mmHg plasma. This number is infinitesimally small relative to the other half of the equation and it is typically ignored when determining oxygen concentration. This means that the significant modifiable factor in CaO2 is Hgb. Oxygen has to have something to bind to (Hgb) because dissolved oxygen has minimal oxygen-carrying capacity. Oxygen delivery (DO2)= CO x CaO2 Cardiac Output (CO)= heart rate (HR) x SV Stroke volume (SV)= the volume of blood ejected from the heart each heartbeat. Arterial oxygen concentration (CaO2)= [1.38 x Hgb x SaO2] + [PaO2 x 0.003] How can oxygen delivery be increased? One of the components of the equation has to be adjusted. Increase cardiac output. Increase SV- use of an inotropic agent (* medication that increases the strength of the heart contraction), ensure adequate preload (volume resuscitation). Increase HR- use of a chronotropic agent (* medication that increases heart rate). Increase arterial oxygen content Increase blood hemoglobin concentration *See pharmacology below Oxygen Consumption Oxygen consumption (VO2) is determined by how much oxygen the peripheral tissues extract and use. It is the difference between oxygen delivery (DO2) and oxygen return(ed) (SvO2). Oxygen consumption (VO2)= DO2 - SvO2. Oxygen consumption is calculated by subtracting SvO2 or ScVO2 from the amount of oxygen delivered. Venous oxygen saturation (SvO2 or ScVO2)- concentration of oxygen in the blood returning to the heart. Measured with a central venous catheter. *See below under CV monitoring for more details. Cardiovascular Monitoring There are several techniques for monitoring cardiovascular parameters, ranging from non-invasive to maximally invasive. Non-invasive methods include telemetry, pulse oximetry, and blood pressure monitoring. The benefit of these devices is their simplicity of use and interpretation. But these are error-prone, and regarding blood pressure, it doesn't provide continuous monitoring. For more info, see lecture entitled " Hemodynamics ". Arterial lines can be placed to provide continuous cardiac monitoring. The arterial waveform can indicate specific pathology (see Edwards Quick Guide to Cardiovascular Care ). In addition, an arterial line can report stroke volume variation. Stroke volume variation (SVV) is a surrogate of arterial pressure changes with inspiration/ expiration. If the change in pressure with respiratory cycles is >10-15%, it suggests the patient is fluid responsive, meaning they are likely to improve their preload (and cardiac output and blood pressure) with IV fluid administration. Central venous catheters can be placed to deliver intravenous medication as well as provide cardiac monitoring. A central venous catheter can measure the pressure of the blood returned to the right atrium (central venous pressure, CVP), which is a crude measurement of preload and right heart function. In addition, the oxygenation of the blood returning to the right heart (from the head and upper body) is reported as Central venous oxygenation saturation (ScVO2). ScVO2 reflects the balance between oxygen delivery and consumption. Arterial lines and central venous catheters are considered "minimally invasive". A pulmonary artery (PA) catheter is the most invasive device for cardiac monitoring. Similar to a central venous catheter, a PA catheter can determine the oxygenation of the blood returning to the right heart, which is the mixed venous oxygen saturation (SvO2). However, in contrast to the central venous catheter which is located in the superior vena cava (proximal to the right atria), this device is measuring blood oxygenation in the pulmonary artery (from the right ventricle), so it accounts for the blood from the entire body (unlike the ScVO2). Cardiac Pharmacology Vasoactive medications are frequently used in the ICU for the management of shock, heart failure, and other acute pathology. There are several key receptors, and understanding the function of each receptor is the key to using these different agents correctly. Receptors * α (alpha) 1- vasoconstriction * α2- inhibit norepinephrine release from presynaptic neurons * β (beta) 1- chronotrope (↑HR), inotrope (↑Ca in cardiac myocytes ↑contractility), dromotrope (↑cardiac impulse conduction velocity) * β2- vasodilation * Dopa 1- vasodilation * Dopa 2- neurotransmitter release Pharmacologic Agent Classification Each medication has a specific physiologic effect based on its particular mechanism of action. Agents may stimulate or inhibit receptors (see above) or alter the concentration of a key substance (cAMP, calcium, potassium, nitric oxide (NO)). Previous Next

< Back Colorectal Disease UpToDate Patient Education Patient education: Diverticular disease (Beyond the Basics) . Also known as diverticulosis. If associated with an acute episode of infection, this is reference to as diverticulitis. Patient education: Constipation in adults (Beyond the Basics) Patient education: High-fiber diet (Beyond the Basics) Patient education: Colonoscopy (Beyond the Basics) Patient Information from Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Colonoscopy American College of Surgeons: Division of Education Colonoscopy Prep Form Golytely®, Colyte®, Nulytely®, Trilyte® Source: UpToDate Images: Colon and Rectum Patient Info- Constipation .pdf Download PDF • 54KB Previous Next

< Back Who Is Our Patient Population? We take care of critically ill and injured patients. Here are just a few examples of the different patient scenarios we manage. We are available 24 hours a day, 7 days a week. Therefore, we often receive consults for various other surgical disease processes outside of what is listed here. Trauma Penetrating wounds from gunshot wounds, stabs, or assaults from any material that breaks the skin and causes bleeding or significant tissue damage Blunt injuries from falls (roof, ladders, etc.), motor vehicle accidents, bicycle accidents, pedestrians struck by vehicles. Non-accidental injuries (abuse, inter-personal violence) Surgical Critical Care Critically ill trauma or emergency general surgery patients. Patients undergoing complex or high-risk surgical procedures or requiring intensive care unit (ICU) admission. Complications from procedural interventions. Intra-abdominal catastrophes. Airway emergencies- patients who are unable to be intubated and require a surgical airway. Emergency General Surgery Appendicitis, Cholecystitis, Diverticulitis. Bowel ischemia or bowel obstruction. Soft tissue infection- necrotizing soft tissue infection. Surgical airway or enteral access- tracheostomy for ventilator dependency and percutaneous endoscopic gastrostomy (PEG). Previous Next

< Back Vent Mgmt #4: All Together Choosing a mode Controlled- patients who aren't generating breaths. PC, VC. Most common mode at initiation of MV. SIMV- patient generating some breaths, but still needs significant mechanical support. Spontaneous- not frequently used at initiation, but can be used for patients with airway obstruction and preserved lung function. How to set initial parameters TV (6-8 mL/ kg predicted body weight) [lung protective ventilation] RR 10-14 FiO2 often start at 100%, but quickly weaned unless severely hypoxic Inspiratory:expiratory ratio typically 1:2 Flow- typically set @ 60L/min, can increase if the patient is in distress or has a high minute ventilation How to adjust parameters based on arterial blood gas results Low PaO2 (low arterial oxygen content)- increase FiO2, increase mean airway pressure Markedly elevated PaO2 (hyperoxia)- decrease FiO2 Low PaCO2 (low arterial carbon dioxide concentration)- decrease TV or RR High PaCO2 (high arterial carbon dioxide concentration)- increase TV or RR *For more details, check out these resources: Lectures: Critical Care: Respiratory Failure Lectures: Critical Care: Vents Other principles of mechanical ventilation VAP bundle- elevated head of bed, oral care Daily awakening and spontaneous breathing trials Previous Next

< Back Chicken Enchiladas in Sour Cream Sauce Ingredients 10 small soft flour tortillas 3 Tbsp flour 2 c chicken broth 1 c sour cream 2.5 c shredded cooked chicken 3 c shredded Monterey Jack cheese 3 Tbsp butter 4 oz can diced green chillies Instructions 1. Preheat oven to 350 degrees 2. Combine shredded chicken and 1 cup of cheese. Fill tortillas with the mixture above and roll each one then place in a greased 9x13 pan. 3. Melt butter in a pan over medium heat. Stir flour into butter and whisk for 1 minute over heat. 4. Add broth and whisk together. Cook over heat until it's thick and bubbles up 5. Take off heat and add in sour cream and chilies. Be careful it's not too hot or the sour cream will curdle. 6. Pour mixture over enchiladas and add remaining cheese to top. 7. Bake in oven for 20-23 minutes then you will want to broil for 3 minutes to brown the cheese. The roux, with sour cream and green chilies added Previous Enchiladas covered with sauce Cooked and broiled to brown the cheese Next

< Back Mangled Extremity- Keep or Cut? A 42-year-old male was struck by a vehicle as he was crossing the street. He was brought in by EMS. He had a depressed GCS and unequal pupils, and he was intubated for concern for airway compromise. He had a significant injury to the right lower extremity with diffuse bleeding, but no active arterial bleeding. Compressive dressings were applied. He had fluid in the LUQ window of his FAST. He was hemodynamically unstable. Initial evaluation and management? Imaging? Poly-trauma patients demand prioritization and quick decision making, and the simple step-wise algorithms designed for each injury in isolation are less helpful. Patients with blunt abdominal trauma and hemodynamic instability require emergent operative intervention. Patients with a depressed GCS and an abnormal pupil exam require emergent CT imaging to define the severity of their head injury and consultation with neurosurgery. Patients with a mangled extremity require a CT scan to define the vascular injury. In the setting of blunt abdominal trauma, a positive FAST and hemodynamic instability, he was transported to the OR emergently. If there was an option for a rapid CT en route to define his TBI, that would have been ideal. But hypotension is associated with worse outcomes for TBI patients, so the priority is stopping the bleeding. We performed a midline laparotomy, splenectomy, and repaired a diaphragm injury. We placed a temporary abdominal closure. Intraoperative Image What do we do about his mangled lower extremity? Consult vascular or ortho? Ex-fix? Amputate? There are several important tasks. Assessment of injury to neuromuscular structures is vital. If possible, rapid restoration of arterial blood flow is beneficial. However, it is vital to evaluate the need for amputation. This decision requires consideration of current physiologic status, co-morbidities, and baseline functional status. It's sometimes a question of life versus limb. Orthopedic and vascular specialists can be consulted, but it is important not to lose sight of the patient's overall clinical status. A brief temporizing procedure to restore blood flow with a shunt, stabilize bony structures, and preserve any remaining soft tissue may be appropriate, but a lengthy vascular repair and bony fixation are likely not ideal. The patient's baseline functional status, social support, and co-morbidities were unknown. Based on the severity of his extremity injury, high injury burden, and need for urgent head CT, my recommendation was for immediate amputation. This decision requires weighing the risks/ benefits of limb salvage (prolonged time in the operating room for stabilization, risk of ongoing tissue ischemia leading to systemic complications) vs amputation (limb loss). Our orthopedic specialists felt they could salvage his limb, and give him a chance to be an active participant in the decision-making. We agreed to a time limit to minimize operative time, so the limb was stabilized temporarily with a plan for ongoing evaluation of the limb viability. Managment of the Mangled Extremity WTA Algorithm Management of patients with mangled extremities remains controversial. Severe scoring systems have been created, with variable success in predicting who requires amputation. In the acute setting, the trauma surgeon must weigh the risks and benefits of limb salvage versus immediate amputation. If the limb injury is devastating (perhaps only hanging on by a small skin bridge), and the patient has other injuries that require immediate intervention, rapid amputation can be life-saving. If the decision to amputate is less clear, a second opinion from a colleague and orthopedics should be elicited. There have been remarkable advances in the ability to restore function to mangled extremities, and discussion with specialties can be very helpful. "Therapeutic advances in the treatment of vascular, orthopedic, neurologic, and soft tissue injuries have reduced the diagnostic accuracy of the MESS in predicting the need for amputation. There remains a significant need to examine additional predictors of amputation following severe extremity injury." Loja, Melissa N et al. “The mangled extremity score and amputation: Time for a revision.” J Trauma Acute Care Surg. 2017;82(3):518-523 The trauma surgeon must maintain perspective on the whole patient- spending hours doing meticulous vascular or nerve dissection/ repair or extensive orthopedic manipulation can be an intolerable burden on a patient with multiple other injuries. 1. Control active hemorrhage. 2. Restore anatomic limb alignment. 3. Assess distal arterial flow→ evidence of vascular injury→ CTA to characterize injury. 4. Assess neurologic function. Unable to control active hemorrhage or there is hemodynamic instability→ proceed to OR. Assess for the need for immediate amputation. Factors to consider: Complex, segmental, severely comminuted fracture. Large circumferential soft tissue loss or massive soft tissue necrosis. Compartment syndrome with myonecrosis. Nerve disruption. Massive contamination. Prolonged warm ischemia >6 hours. Poor distal anastomosis options. No immediate amputation→ intraluminal shunt to re-establish perfusion. Then assess bony and nerve injury. Evaluate risks/ benefits of limb-preservation. Previous Next