7 - Management of the Injured Lower Extremity Flashcards
What to memorize
o Memorize severity scale of glasow coma scale, RTS and MESS – not exact points for each
o Memorize the tetanus algorithm
Trauma care system
- Prevention
- Resuscitation
- Acute care
- Rehabilitation
Trauma Care System and Development Act (2007)
- Inclusive trauma system integrated with Emergency Medical System (EMS)
- Trauma Designation
o Level I
o Level II
o Level III
o Level IV &V
Level I Trauma
- Regional resource trauma center
- Provide complete care of trauma patient
- Provide trauma prevention and rehabilitation
- Education, research, and systems development leadership
- Surgery residency required
- Admits a minimum required annual volume of severely injured patients
- Required to have a certain number of surgeons, emergency physicians and anesthesiologists on duty 24 hours a day at the hospital
- Prompt availability of other specialties
- Increased survival of seriously injured person by an estimated 20-25%
Level II Trauma
- Initial definitive care of trauma patients
- Ability to transfer complex patients to Level I
- Clinical capabilities similar to Level I except for extent of surgical subspecialties
- General surgeon may be out of house but readily available
- Education and prevention programs
- Research not essential
- Surgical residency not required
Level III Trauma
- Immediate assessment, resuscitation, emergency operations, and stabilization
- Prearranged transfer protocols with Level I or II trauma centers
- Prompt availability of general surgeon
- Includes rural and community hospitals
Level IV & V
- Provide advanced trauma life support prior to transfer to higher levels of care
- Trauma trained nurse immediately available and physicians are available upon patient arrival to the ED
Acute Trauma Care
- ATLS (Advanced Trauma Life Support) protocol
- ABC
- Fluid/blood replacement
- Examination
- Tetanus
- IV Antibiotics
- Gross debridement/irrigation “washout”
- Reduce/Stabilize (splint/ex fix)
- Serial debridement/irrigation as needed until definitive decision made
General trauma evaluation
- NOTE: must use a systematic and thorough approach without compartmentalization
- 1 = Assess severity of injury
- 2 = Cardio-Pulmonary Resuscitation (Intubation/Ventilation, hemodynamics/Shock, Control hemorrhage, Replace fluids)
- 3 = Physical examination
- Primary Survey
- Secondary Survey
- Tertiary Survey
General trauma evaluation (see CDC sheet)
Glasgow coma scale (GCS) for brain injury – scale from 3-15
o 8 or lower: severe head injury, patient in coma
o 9 to 12: moderate head injuries
o 13 to 15: minor head injury
A = Eye opening
o 4 = spontaneous
o 3 = to voice
o 2 = to pain
o 1 = none
B = verbal response
o 5 = oriented o 4 = confused o 3 = inappropriate o 2 = incomprehensible o 1 = none
C = motor response
o 6 = obeys o 5 = purposeful o 4 = withdraws o 3 = flexion o 2 = extension o 1 = none
General trauma evaluation
- Revised trauma score (RTS) = physiologic scoring system
- Directs triage and evaluates patient outcomes
- Scale from 0 to 12 (A + B + C)
o
Primary survey
o ABCDE: life threatening injuries are identified and addressed until the patient is stable
o Airway - Secure, C-Spine protection
o Breathing - Provide necessary intervention
o Circulation - Hemorrhage control & prevent shock
o Disability - Neurological exam, GCS
o Exposure or Environmental Control - Head to toe exam – remove any remaining detrimental agents or correct temperature derangements
Secondary survey
o Complete head to toe evaluation with definitive diagnosis and treatment of injuries
o Repeat vital signs
o Extensive testing is performed (radiographs, CT, ultrasound, angiography)
Anatomical Assessment
- Cranial, neck, thoracic
- Abdominal
- Retroperitoneal
- Genitourinary
- Musculoskeletal
Tertiary survey
o Repeat head to toe evaluation with reevaluation with laboratory and advanced studies
o Comprehensive review of medical record, including repetition of the primary and secondary surveys, review of labs, and review of radiographic studies
o Changes in patient condition are promptly evaluated and treated
o New findings missed in initial evaluations investigated further (Minor fractures, Lacerations, Traumatic brain injury)
Life threatening complications
- Hypovolemic shock
- Rhabdomyolysis
- Acute Renal Failure
- SIRS (Systemic Inflammatory Response Syndrome)
- Sepsis/Septic Shock
- ARDS (Acute respiratory distress syndrome)
- MODS (multi organ dysfunction)
- Reperfusion Injury
- Arrhythmias
- See article on Sepsis/Shock* Singer et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016. February 23;315(8):801-810.
MESS
MEMORIZE CHART
- > 7 high risk of amputation: good specificity, poor sensitivity for amputation
- Concerns: age, hard to get score > 7 if vascular intact, even if soft tissue, bone damage extensive
MESS and other scores
- ***Scores can help guide decision, but cannot be used in isolation
- Salvage does not always = function
- Improvements in medicine = greater ability to save OR
- Excitement for new techniques lead to more morbidity and mortality with secondary amp
- Article: Schiro et al. Primary amputation vs limb salvage in mangled extremity: a systematic review of the current scoring system. BMC MD 2015.
Is the limb salvageable?
Possible scenarios:
o Immediate amputation
o Attempted salvage with early amputation
o Successful salvage
o Unsuccessful salvage with late amputation
When to consider salvage
- Anatomically intact tibial nerve
- Can reconstruct vascular supply: promixal injury, warm ischemia
Diagnostic studies
- Laboratory Data
- CBC with Differential (H&H)
- Full chemistry panel (Chem-7, BMP)
- Type and Cross Match
- Urinary analysis
- Occult hematuria
- Source of infection causing leukocytosis
- Radiographs
- AP Chest – pneumonia, atelectasis
- Spine, fractures
- Gas (diabetic foot infection, necrotizing fasciitis)
- EKG
- Computed Tomography (CT)
o Complicated fractures (Calcaneal fractures, LisFranc fractures, Tri-plane pediatric fracture)
o Unequivocal radiographs - MRI (soft tissue damage (tendon ruptures/lacerations))
- Joint Aspiration (septic joint)
- Angiography
- Compartment pressures
Compartment syndrome
Why pressure monitoring in the foot is a vital part of diagnosis?
o Symptoms are not “typical” in many cases.
o Confusion is created by the compact anatomy of the foot leading to overlap of those symptoms due to direct tissue damage, and those caused by compartment syndrome.
o This makes pressure monitoring vital for diagnosis of CS in the foot.
Tetanus (Clostridium tetani)
- Obligate, anaerobic, endospore forming, gram + rod
- Found commonly in soil contaminated with animal fecal waste
- Produces 2 exotoxins: tetanolysin and tetanospasmin - Tetanospasmin is a neurotoxin (one of the most potent toxins known)
Tetanus symptoms and treatment
Symptoms caused by potent neurotoxin (tetanospasmin)
o Incubation period- 8 days (3-21d)
o Restlessness, headache, and irritability are common
o Blocks relaxation pathways to muscles
o Jaw muscles affected early -“Lockjaw” or “trismus”
o Death from respiratory muscle spasm
o Spasms continue for 3-4 weeks
o Complete recovery can take months
Treatment = Antitoxin
Summary guide to tetanus prophylaxis
KNOW THIS = on handout
Tetanus wound managemetn
- Vaccine produces immune response that allows recipient to make their own antibodies which takes several months the first time and up to a week for subsequent doses
- Immunoglobulin is immediate but temporary protection
IV antibiotics
- Based on:
o Severity
o Timing
o Contamination (dirty, clean, farm, etc.)
o Medical co-morbidities
o Contra-indications
o Duration based on the above and clinical signs of infection
o *Gustilo and Anderson- Open Fracture Lecture
Gross debridement and “washout”
- Performed after patient is stabilized
- Initially gross irrigation, not definitive
- Remove all debris and foreign material
- Decrease bacterial burden
- Care taken to not create additional neurovascular damage
- **Timing? Golden Period?
- **Gustilo & Anderson-Open Fracture Lecture
Initial stabilization/reduction
- Performed after patient is stabilized
- Important to address neurovascular compromise
- Decrease trauma to soft tissue
- Prevent 2nd Hit
- **Damage Control Principles
- **Pilon Fracture Lecture
Initial reduction goals
- Reduction techniques must be gentle and atraumatic in nature
- They must preserve the vascularity of the soft-tissue envelope and of any remaining tissue attachments to bone fragments
- Only viable tissue can undergo repair
- Bone healing will be delayed or come to a stop if the mechanical or biological environment is critically disturbed
- Attempt to get the fracture fragments, length, axial, and rotational alignment established as anatomic as possible
- To decrease pain, to prevent later deformity, and to encourage healing and normal use of the bone and limb
Reduction in detail
- SLIGHTLY EXAGGERATE THE DEFORMITY
- TRACTION - Relaxes and lengthens the muscles
- MANIPULATION - After proper amount of traction the bone will usually slip back in place, but may also need manipulative traction as well
- Apply a splint, cast, or frame to hold this newly achieved position*
- *Dependent on energy of trauma, soft tissue compromise
Damage control principles
Damage Control General Surgery
o Penetrating trauma
o Damage control for survival
o Surgical second hit (Systemic SIRS and CARS)
Damage Control Orthopedics
o Poly Trauma
o Damage control for survival
o Surgical second hit (Systemic SIRS and CARS)
Extremity Damage Control
o Extremity Trauma
o Damage control applied to reduce local morbidity
o Surgical second hit (Local soft tissue damage, Infection)
“Second hit” concept
First Hit
o Trauma activates SIRS
o Soft tissue and bone trauma
Second Hit
o Surgery in the early phase accelerates SIRS
o Surgery causes increased local soft tissue damage
Lag Period
o Surgery just past the peak of SIRS may be at a time of relative immune-suppression
o Surgery may overwhelm soft tissues already damaged by trauma
Case studies
Look at handout***
