MSK Injuries II Flashcards
High risk injuries r/t compartment syndrome include?
Forearm & tibial fx’s
Immobilized injuries in constrictive dressings/casts
Severe crush injuries
Localized, prolonged external pressure
Increased capillary permeability from reperfusion of ischemic muscle
Burns
Excessive exercise
Compartment S/Sx’s include?
Swollen, tense extremity
4P’s - 1st symptoms occur with nerve compression
1. Paresthesia - w/n 30 min can have numbness & tingling
2. Pain - out of proportion to injury
3. Pallor - cyanosis early, pallor late
4. Pulseless - unreliable & late sign
Hypoesthesia (late sign)
Paresis (late sign)
Compartment syndrome management includes
Release constrictive dressings & monitor for 30-60 min
Fasciotomy for pressure > 35mmHg
Untreated muscle death & amputation
Crush Injury Complications Hyperkalemia
ECG?
Progressive increase in what? leads to what?
How high can K+ rise to an hour after extrication?
Elevated K+ & peaked T waves, prolonged PR & QRS intervals
QRS widens to V dysrhythmias
7 or higher
Hyperkalemia management includes?
Stabilize myocardium with what?
Shift K into cells with what?
Promote K excretion with what?
CaGluconate 10ml 10% solution; CaChloride 5ml 10% solution
NaHCO3 1mEq/kg; Albuterol 5mg/3ml inhalation; Regular insulin 10u IV with 1amp D50W
Lasix 20-40mg IV; Kayexalate 25-50gm po/pr; Lokelma 10gm po TID
Crush injury complications Hypocalcemia
Depostion of Ca+2 salts where?
Cell membrane injury leads to?
Ca+2 influx overloads what?
Usually doesn’t require what?
in necrotic muscle & binds w/ phosphate
Na/K pump malfunction & cant pump out Ca+2
mitochondria to further reduce ATP production
repletion & will correct as fluid shifts occur post injury
Rhabdomyolysis
Multiple causes include?
final common pathway resulting in muscle injury & necrosis is direct myocyte injury or energy supply failure in muscle cell
Rhabdomyolysis
Normally Na/K pump & Na/Ca exchanger on what? maintain what?
sarcoplasmic membrane
low IC sarcoplasmic Na, Ca & high K concentration in resting muscle
Rhabdomyolysis
Muscle contraction is active prosses in using ATP; excess Ca influx into sarcoplasm results in what?
Any insult that disrupts ATP, ion channels, & plasma membrane results in what?
actin myosin linkage.
loss of IC electrolyte equilibrium
Be suspicious of Rhabdo in patients with?
traumatic injuries
Multiple orthopedic injuries
Crush injury to any part of body
laying on limb for long period of time - patient found down
Lengthy surgery
brown urine
Rhabdo Diagnosis
Classic triad?
S/Sx?
Electrolyte abnormalities include?
Elevated what?
brown urine, muscle pain & weakness
Hypovolemia, shock
increased K, Low Ca, acidemia upon reperfusion
Creatinine
Rhabdo: CK levels how high above normal with risk factors or symptoms?
Check serial what?
Should peak when? then decrease how much/day?
If not decreasing after 2-3 days, suspect what?
5-10x’s, > 5000 correlated with AKI
CK levels q6-12 hrs
w/n 24hrs; 30%/day
further injury or compartment syndrome
Rhabdo stats
5-35% of pts develop what?
8-15% of what is caused by Rhabdo in US?
Mortality rate for those that develop this complication is what?
AKI
AKI
3-50%
Rhabdo management
what is the cornerstone of treatment?
IV access?
Urine output goal of what by using what?
urine alkalization to keep pH > what?
Monitor/manage what?
Use what to encourage UO?
hydration with isotonic crystalloid
Large bore
IVF for UO goal of > 100ml/hr
6.5
electrolyte abnormalities
mannitol or lasix
Abdominal Compartment Syndrome (ACS)
Organ dysfunction due to what?
definition of this problem?
ACS occurs if sustained IAP > what? & what other qualifier?
Intra-abdominal HTN
sustained or repeated pathological elevation of intrabdominal pressure (IAP) of 12 mmHg or more
Sustained IAP > 20mmHg & new organ dysfunction or failure
Abdominal Compartment Syndrome
Grade I =
Grade II =
Grade III =
Grade IV =
IAP 12-15
16-20
21-25
>/= 25
Abdominal Compartment Syndrome Categories/Causes?
Primary or acute?
Secondary?
Chronic?
Intra-abdominal pathology is directly responsible
when no visible intra-abdominal injury is present but injuries otuside abdomen cause fluid accumulation
presence of cirrhosis & ascites or related disease states, often in later stages of disease
ACS causes
Primary
blunt/penetrating trauma
liver transplant
ruptured AAA
RP hemorrhage
bowel obstruction
post-op tension
bleeding pelvic fx
ACS causes
secondary/chronic
severe intra-abd infection
large volume resuscitation
ascites
pancreatitis
ileus
sepsis
burns
morbid obesity
pregnancy
ACS System by system
Renal IAP of >/= what associated w/ what?
Pulm: IAP pushes diaphragm up; how much IAP is dispersed across diaphragm affecting what?
15mmHg associated w/ renal impairment
~50%; respiration/ventilation (decreased VT, hypercarbia, acidosis, compression atelectasis)
ACS System by system
CV: IAP compresses what? resulting in what?
Fictitiously elevated what?
CO affected by waht?
heart & major vessels; tamponade-like picture
CVP & PAWP
decreased preload, contractility, & increased pulmonary vascular resistance
ACS System by System
CNS: IAP can impair what?
drainage of CNS d/t increased intrathoracic pressure
ACS S/Sx?
Increased abdominal girth
difficulty breathing
High peak/plateau pressures, difficulty ventilating
decreased UOP (unresponsive to IVF/pressor)
Syncope
Melena
N/V
ACS Workup includes
CMP
CBC
amylase/lipase
coag studies
cardiac markers
Lactate
ABG
CT scan
Bladder pressure if >/= 2 risk factors
Lift Foley tubing
ACS diagnosis
Transducer Or manometer via?
sustained IAP > what? & what other qualifier?
Abdominal perfusion pressure = what?
Goal APP?
Foley
20mmHg & new organ dysfunction
MAP - IAP
> 60mmHg
ACS management includes?
Judicious use of IVF
Diuretics
General Surgery
Decompression for IAP > 25mmHg
early closure
pressors or inotropes if IVF do not increase APP
Goal: IAP < 15 mmHg, APP> 60 mmHg, Prevent ACS
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