Early Management of Severe Trauma (EMST) in Orthopaedic Decision-Making

A comprehensive evidence-based guide for polytrauma patient care

Highlights

Systematic Approach: EMST provides a clear framework from the primary survey to secondary assessments.
Surgical Decision-Making: The critical choice between Early Total Care and Damage Control Orthopaedics is driven by patient stability and injury severity.
Team Coordination: Multidisciplinary integration ensures rapid stabilization, definitive management, and improved outcomes.

1. Core Principles of EMST in Trauma Care

Early Management of Severe Trauma (EMST) offers a systematic, evidence-based approach designed to rapidly identify and stabilize life-threatening injuries within the first one to two hours after trauma. Emphasis is placed on:

Rapid assessment to identify and address life-threatening issues.
Immediate resuscitative measures, including fluid and blood management, to counter shock.
Minimization of further injury through carefully administered interventions and ensuring minimal iatrogenic damage.
Restoration of tissue perfusion to prevent irreversible organ damage.

The guiding philosophy is to protect crucial functions — such as airway patency, breathing, and circulation — thus laying a strong foundation for subsequent orthopaedic management.

2. Primary Survey & Resuscitation: ABCDE Approach in Orthopaedic Trauma

The primary survey under EMST adheres to the universally recognized ABCDE protocol, which serves as the backbone of initial trauma management:

Airway

Ensuring the airway is open and secure is the first priority, with special emphasis on cervical spine stabilization to prevent further injury.

Breathing

Assessment of respiratory function is undertaken to identify and manage conditions such as pneumothorax, hemothorax, or airway obstructions that may compromise breathing.

Circulation

This phase involves controlling bleeding, including hemorrhage from fractures, and initiating volume replacement with fluids or blood products to counter shock.

Disability

A brief neurological evaluation is performed using tools like the Glasgow Coma Scale or AVPU to assess brain function and detect any neurological deficits.

Exposure

The patient is fully undressed to assess for hidden injuries while measures are in place to prevent hypothermia, a common complication in trauma scenarios.

In orthopaedic cases, special attention is given to identifying bleeding sources from long bone or pelvic fractures during the circulation phase, which can have immediate life-threatening implications.

3. Secondary Survey: Identifying & Prioritizing Orthopaedic Injuries

Following the stabilization achieved during the primary survey, the secondary survey provides a detailed head-to-toe clinical examination. This process is critical for identifying the full extent of injuries, including:

Full Physical Examination: A comprehensive evaluation to detect fractures, dislocations, and soft tissue injuries that were not immediately life-threatening.
Imaging Studies: Radiographs, computed tomography (CT) scans, and other imaging modalities are employed, particularly for areas such as the spine, chest, and pelvis, to confirm diagnoses.
Use of Mnemonics: Tools such as the AMPLE mnemonic (Allergies, Medications, Past medical history, Last meal, Events leading to the injury) guide a focused history-taking session that can unearth subtleties impacting overall management.

The secondary survey is instrumental in ensuring no injury is overlooked, and it informs further definitive orthopaedic surgical planning.

4. Decision-Making: Early Total Care (ETC) vs. Damage Control Orthopaedics (DCO)

Central to orthopaedic trauma management is the decision between two primary intervention strategies: Early Total Care (ETC) and Damage Control Orthopaedics (DCO). The decision is primarily based on the patient’s physiological stability, injury severity score, and hemodynamic parameters.

Early Total Care (ETC)

ETC represents the definitive surgical management of fractures early in the treatment process. It is best suited to patients with stable conditions where the overall trauma burden allows for definitive repair. Benefits of ETC include:

Rapid mobilization, which can result in a decreased hospital stay and reduced complications.
Definitive fixation of fractures, leading to improved outcomes and lower rates of non-union or malunion.

Damage Control Orthopaedics (DCO)

DCO is a staged surgical strategy used in patients who are physiologically unstable. The focus is on temporary stabilization—typically using external fixation—to reduce further trauma and stabilize the patient’s metabolic state prior to a definitive surgical intervention. This method is preferred when:

The patient is at risk of systemic inflammatory response syndrome (SIRS) or multiple organ failure.
There are severe associated injuries requiring urgent attention and stabilization.

Comparison Table of ETC vs. DCO

Characteristic	Early Total Care (ETC)	Damage Control Orthopaedics (DCO)
Patient Condition	Hemodynamically stable	Hemodynamically unstable
Timing of Surgery	Early definitive fixation	Staged approach; initial temporary stabilization
Surgical Impact	Full repair during initial surgery	Minimizes physiological stress in critical patients
Risk of Complications	Lower if patient stability is maintained	Decreased risk of overwhelming systemic response

5. Specific Orthopaedic Trauma Considerations in EMST

Managing orthopaedic injuries in polytrauma patients under EMST involves recognizing the complexity of associated injuries. Key considerations include:

Fracture Management

Immediate stabilization through splinting or external fixation at the injury site is essential to prevent further damage. This prevents additional tissue trauma while reducing pain and minimizing the risk of vascular compromise.

Soft Tissue Injury Care

Concurrent soft tissue injuries, such as lacerations, contusions, or degloving, require prompt and appropriate care to avoid complications like infection. Careful assessment ensures that these injuries are correctly managed alongside bony injuries.

Neurological Assessment

Particularly in cases involving the spine or limb injuries, frequent neurological checks are vital. This helps in early identification of nerve damage or compartment syndrome, which if untreated could lead to permanent deficits.

Additional considerations also involve the risk of fat embolism in long bone fractures and planning for potential embolization in cases with uncontrolled hemorrhage.

6. Coordination with Trauma Teams & Definitive Care Planning

Effective management of polytrauma patients is a team effort requiring constant communication among emergency physicians, anaesthetists, surgeons, orthopaedists, radiologists, and nursing staff. Key strategies include:

Multidisciplinary Meetings: Regular briefings and clear communication pathways ensure that every team member is aware of the patient’s status and the planned interventions.
Role Clarity: Each specialist is responsible for specific aspects of care, ensuring that priorities are managed without delay.
Definitive Care Planning: Once the patient is stabilized, a clear timeline for definitive surgical interventions is established. This mitigates delays and aids in structuring a coordinated pathway from temporary measures to final repairs.

7. Evidence-Based Guidelines & Emerging Trends in EMST for Orthopaedic Trauma

Contemporary trauma management is deeply rooted in evidence-based practice. Clinicians rely on extensive research and clinical outcomes to shape the protocols of EMST. Key trends include:

Individualized Care: Treatment is increasingly tailored to the specific anatomical and physiological needs of the patient, reducing the risk of complications from a one-size-fits-all approach.
Advanced Imaging and Monitoring: Modern imaging techniques such as multi-slice CTs and MRI are integrated into trauma protocols, allowing for early detection of hidden injuries.
Integration of Orthopaedic Surgeons in Trauma Teams: Enhanced collaboration with specialists ensures that orthopaedic interventions are coordinated with overall trauma care, particularly in decisions between ETC and DCO.
Emphasis on Early Appropriate Care: Balancing between early definitive fixation and temporary stabilization, the approach is constantly refined with updated protocols like damage control resuscitation and balanced transfusion strategies.

These trends not only enhance clinical outcomes but also contribute to the evolution of training and continuous education in trauma management, ensuring that teams remain adept in the latest techniques and protocols.

References

Early Management of Severe Trauma (EMST) | RACS - Surgeons
ATLS/ EMST - OrthoFracs
Summary of Early Management of Severe Trauma
Early Total Care versus Damage Control - PMC
Role of Damage Control Orthopaedics and Early Total Care
Current Trends in Orthopaedic Trauma
Early Care vs Damage Control - Arbutus Medical
Orthopaedic Considerations in Polytrauma - JEMS
Study on Early Total Care versus Damage Control
Comprehensive Overview in Orthopaedic Trauma Care