international trauma life support for emergency care providers chapter seventh edition extremity...
TRANSCRIPT
International Trauma Life Supportfor Emergency Care Providers
CHAPTER
seventh edition
Extremity Trauma
14
International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians
Extremity Trauma
© Pearson
International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians
Overview
• Priority of extremity trauma• Major complications and treatment:
– Fractures– Dislocations– Amputations– Open wounds
International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians
Overview
• Major complications and treatment (cont.):– Neurovascular injuries– Sprains and strains– Impaled objects– Compartment syndrome
• Estimated blood loss – Pelvic and extremity fractures
International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians
Overview
• Major mechanisms, associated trauma, potential complications, management:– Pelvis– Femur– Hip– Knee– Tibia/fibula
International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians
Overview
• Major mechanisms, associated trauma, potential complications, management:– Clavicle/shoulder– Elbow– Forearm and wrist– Hand or foot
International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians
Extremity Trauma
• Distorted or wounded extremities must not distract from life-threatening injuries. – Easy to identify– Disabling but rarely immediately life-
threatening
• Potential danger:– Hemorrhagic shock (very few)– Neurovascular compromise
Distal PMS
International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians
Extremity Trauma
• Extremity injuries– Fractures– Dislocations– Open wounds– Amputations– Neurovascular injuries– Sprains & strains– Impaled objects– Compartment syndrome– Crush injury
Courtesy of Roy Alson, MD
International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians
Extremity Injuries
• Fractures– Open (compound)
Communication to outside Danger of contamination Blood loss outside body
– Closed (simple) No communication to outside No danger of contamination Blood loss inside body
(Photo courtesy of Roy Alson, MD)
International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians
Fractures
• Hemorrhage with fracture– Closed femur fracture
Loss of 1 liter of blood Two closed femur fractures
life-threatening
(Courtesy of ®E. M. Singletary, MD)
International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians
Fractures
• Hemorrhage with fracture– Closed pelvic fracture
Extensive bleeding into abdomen or retroperitoneal
Usually fractures in several places
500 cc of blood loss for each fracture
May lacerate bladder or large pelvic blood vessels
(Courtesy of Sabina Braithwaite, MD)
International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians
Extremity Injuries
• Dislocations– Neurovascular compromise
True emergency though not life-threatening Check PMS distal to major joint dislocations
Courtesy of Roy Alson, MD© Pearson
International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians
Dislocations
• Management– No neurovascular compromise
Splint in position found
– Neurovascular compromise Apply only gentle traction in effort to straighten Often best: pad and splint in most comfortable
position and rapid safe transport
International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians
Extremity Injuries
• Open wounds– Remove contamination
Gross: remove Smaller: irrigate with normal
saline
– Sterile dressing and bandage Pressure dressing, if necessary Pressure point Tourniquet rare Hemostatic agent
(Courtesy of 2010 North American Rescue, LLC)
International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians
Open Wounds
Obviousexsanguinating hemorrhage—
only time can change order of ABC to CABC.
International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians
Extremity Injuries
• Amputations– Disabling and sometimes life-threatening – Potential for massive hemorrhage
Most often, bleeding controlled with direct pressure
© Edward T. Dickinson, MD © Edward T. Dickinson, MD
International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians
• Amputation Management– Cover with damp sterile
dressing, elastic wrap– Uniform reasonable pressure
across stump – Tourniquet if bleeding
absolutely not controlled Rarely needed
– Retrieve amputated part In plastic bag, inside ice water
(Courtesy of Stanley Cooper, EMT-P)
International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians
Extremity Injuries
• Neurovascular injuries– Nerves and major vessels
run beside each other in flexor area of major joints
• Distal PMS– Assess pulse– Assess motor function– Assess sensory
Courtesy of Louis B. Mallory, MBA, REMT-P
Courtesy of Louis B. Mallory, MBA, REMT-P
International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians
Extremity Injuries
• Sprain– Injury to ligaments of a joint– Pain & swelling– Treat like a fracture
• Strain– Injury of musculotendinous unit– Pain & swelling– Treat like a fracture
International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians
Extremity Injuries
• Impaled objects– Do not remove
Airway obstruction exception
– Apply very bulky padding– Transport object in place– No unnecessary movement
Motion magnified in tissues
© Pearson
© Pearson
International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians
Extremity Injuries
• Compartment syndrome– Forearm and lower leg most common– Swelling compresses nerves and vessels
International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians
Compartment Syndrome
• Early symptoms– Pain– Paresthesia
• Late symptoms– Pain– Pallor– Pulselessness – Paresthesia – Paralysis
International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians
Extremity Injuries
• Crush injury– Pressure on extremities for extended time
Anaerobic metabolism
– Pressure released Blood flow to crushed tissue reinstated Toxins distributed throughout entire body
• a.k.a. “Crush or Compression Syndrome”
International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians
ITLS Patient Assessment
• Mechanism history– Falls landing on feet– Sitting position– Fall onto wrist– Fall onto ankle– Shoulder involved– Pelvis involved
• Common injury– Foot, lumbar spine– Knee, hip– Wrist, elbow– Ankle, proximal fibula– Shoulder, neck, chest– Pelvis, shock
International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians
Extremity Trauma
• ITLS Primary and Secondary Surveys– Major bleeding– DCAP-BLS-TIC– Instability – Crepitation– Joint pain– Joint movement– Distal PMS
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International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians
Management
• Splinting– Prevent motion in broken bone ends– Eliminate further damage– Decrease pain
• Load-and-go patients– Temporary splinting with long backboard– Additional splinting during transport
International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians
Splinting
• Rules– Adequately visualize– Distal PMS before and after splinting
Treat neurovascular compromise
– Cover open wounds with sterile dressing– Immobilize one joint above and below
Apply on side away from open wound Pad splint well Do not attempt to push bone ends under skin
International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians
Extremity Trauma
If in doubt, splint possible injury.
International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians
Types of Splints
(Courtesy of Eduardo Romero Hicks, MD)
International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians
Tourniquets
• Common in military and tactical settings• Regaining use in civilian use• Not without complications• Label patients who have tourniquets
(Courtesy of 2010 North American Rescue, LLC)
International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians
Hemostatic Agents
• For uncontrollable bleeding• Promote clot formation• Used in conjunction with direct pressure
International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians
Extremity Trauma
• Spine
Courtesy of Louis B. Mallory, MBA, REMT-P
International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians
Extremity Trauma
• Pelvis
Courtesy of Louis B. Mallory, MBA, REMT-P Courtesy of Louis B. Mallory, MBA, REMT-P
International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians
Extremity Trauma
• Femur
Courtesy of Louis B. Mallory, MBA, REMT-PCourtesy of Louis B. Mallory, MBA, REMT-P
International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians
Extremity Trauma
• Hip
© Pearson
© Pearson
International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians
Extremity Trauma
• Knee
Courtesy of Louis B. Mallory, MBA, REMT-PCourtesy of Louis B. Mallory, MBA, REMT-P
International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians
Extremity Trauma
• Tibia/fibula
© Pearson
International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians
Extremity Trauma
• Clavicle
© Pearson
International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians
Extremity Trauma
• Shoulder
© Pearson
International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians
Extremity Trauma
• Elbow
Courtesy of Louis B. Mallory, MBA, REMT-P
International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians
Extremity Trauma
• Forearm and wrist
Courtesy of Louis B. Mallory, MBA, REMT-P Courtesy of Louis B. Mallory, MBA, REMT-P
International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians
Extremity Trauma
• Hand or foot
Courtesy of Louis B. Mallory, MBA, REMT-P Courtesy of Louis B. Mallory, MBA, REMT-P
International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians
Crush Injuries
– Frequent ongoing exams– Alkalizing the blood
Fluid resuscitation NaCO3 infusion
Osmotic diuretics
– Tourniquet use– Contact Medical Command early
International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians
Summary
• ITLS Primary Survey has priority– Extremity trauma not usually life-threatening– Pelvic, femur fractures can be life-threatening
• Proper splinting decreases further injury• Dislocations of elbows, hips, knees:
– Careful splinting and rapid reduction to prevent severe disability to extremity