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Emergency Med > 7 - Management of the Injured Lower Extremity > Flashcards

7 - Management of the Injured Lower Extremity Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

What to memorize

A

o Memorize severity scale of glasow coma scale, RTS and MESS – not exact points for each
o Memorize the tetanus algorithm

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2
Q

Trauma care system

A
  • Prevention
  • Resuscitation
  • Acute care
  • Rehabilitation
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3
Q

Trauma Care System and Development Act (2007)

A
  • Inclusive trauma system integrated with Emergency Medical System (EMS)
  • Trauma Designation
    o Level I
    o Level II
    o Level III
    o Level IV &V
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4
Q

Level I Trauma

A
  • 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%
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5
Q

Level II Trauma

A
  • 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
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6
Q

Level III Trauma

A
  • 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
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7
Q

Level IV & V

A
  • 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
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8
Q

Acute Trauma Care

A
  • 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
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9
Q

General trauma evaluation

A
  • 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
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10
Q

General trauma evaluation (see CDC sheet)

A

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

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11
Q

A = Eye opening

A

o 4 = spontaneous
o 3 = to voice
o 2 = to pain
o 1 = none

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12
Q

B = verbal response

A 
o	5 = oriented 
o	4 = confused
o	3 = inappropriate 
o	2 = incomprehensible 
o	1 = none
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13
Q

C = motor response

A 
o	6 = obeys 
o	5 = purposeful 
o	4 = withdraws 
o	3 = flexion 
o	2 = extension 
o	1 = none
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14
Q

General trauma evaluation

A
  • Revised trauma score (RTS) = physiologic scoring system
  • Directs triage and evaluates patient outcomes
  • Scale from 0 to 12 (A + B + C)
    o
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15
Q

Primary survey

A

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

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16
Q

Secondary survey

A

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
17
Q

Tertiary survey

A

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)

18
Q

Life threatening complications

A
  • 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.
19
Q

MESS

A

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
20
Q

MESS and other scores

A
  • ***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.
21
Q

Is the limb salvageable?

A

Possible scenarios:
o Immediate amputation
o Attempted salvage with early amputation
o Successful salvage
o Unsuccessful salvage with late amputation

22
Q

When to consider salvage

A
  • Anatomically intact tibial nerve

- Can reconstruct vascular supply: promixal injury, warm ischemia

23
Q

Diagnostic studies

A
  • 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
24
Q

Compartment syndrome

A

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.

25
Q

Tetanus (Clostridium tetani)

A
  • 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)
26
Q

Tetanus symptoms and treatment

A

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

27
Q

Summary guide to tetanus prophylaxis

A

KNOW THIS = on handout

28
Q

Tetanus wound managemetn

A
    • 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
29
Q

IV antibiotics

A
  • 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
30
Q

Gross debridement and “washout”

A
  • 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
31
Q

Initial stabilization/reduction

A
  • Performed after patient is stabilized
  • Important to address neurovascular compromise
  • Decrease trauma to soft tissue
  • Prevent 2nd Hit
  • **Damage Control Principles
  • **Pilon Fracture Lecture
32
Q

Initial reduction goals

A
  • 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
33
Q

Reduction in detail

A
  • 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
34
Q

Damage control principles

A

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)

35
Q

“Second hit” concept

A

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

36
Q

Case studies

A

Look at handout***

Emergency Med (14 decks)

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