Respiratory problems of the seriously injured patient

Pulmonary insufficiency after long bone fractures: significant correlation with the catabolic response

Twelve young men between the ages of 17 and 25 years had their metabolism investigated over the first 5 days after sustaining multiple fractures involving at least one femoral shaft. Five patients developed respiratory distress and three of these required varying periods of ventilatory support. The lowering of arterial oxygen tension following injury was directly proportional to the excretion of urinary urea (a convenient index of protein catabolism). Pulmonary insufficiency was rectilinearly related to the degree of thrombocytopenia. The relationship between hypoxaemia and protein catabolism following long bone fractures has not been reported previously. It is important to appreciate that metabolic alterations are more severe in those patients with overt pulmonary insufficiency and that the metabolic response does not appear to be directly related to the severity of skeletal injury.

[Principles of therapy and priorities in polytrauma (author's transl)]

Immediate assessment of severe injuries, and instant, effective therapy are the fundamentals of getting good results in the emergency management of trauma victims. A schedule for, if possible, early fracture fixation in multiply traumatized patients is recommended to avoid acute complications and irreversible lesions. Yet cautious and individual timing of internal fixation is mandatory especially in seriously injured patients with concomitant severe cranio-cerebral trauma and long-lasting unconsciousness.