MSK Trauma Flashcards
What is the best way to achieve hemorrhage control of an actively bleeding extremity injury?
Direct pressure!
-can also appropriately splint the fractures to significantly decrease bleeding - this reduces motion and enhances the tamponade effect of muscle and fascia
How do you measure an ABI?
Ankle-Brachial Index:
-Ankle SBP of injured leg/Brachial SBP of uninjured arm = if ABI < 0.9, this is concerning for an ischemic/vascular injury, need to get imaging
What is the stepwise approach to controlling arterial bleeding? (4)
- Manual pressure to the wound
- Apply a pressure dressing using a stack of gauze held in place by a circumferential elastic bandage to concentrate pressure over the injury
- If bleeding persists, apply manual pressure to the artery proximal to the injury
- If bleeding continues, apply a manual tourniquet or a pneumatic tourniquet directly to the skin. Tighten the tourniquet until the bleeding stops (a properly applied tourniquet MUST occlude arterial inflow since occluding only the venous system can increase hemorrhage and result in a swollen, cyanotic extremity
***Be sure to document the time the tourniquet was applied. In these cases immediate surgical consultation is essential and transfer ASAP to trauma center
What is the maximum length of time a tourniquet can stay on for before you risk losing the limb?
Approximately 1 hour - if time to operative intervention is longer than 1 hour, a single attempt to deflate the tourniquet MAY be considered in an otherwise stable patient.
-the risks of tourniquet use increases with time so if a tourniquet must remain in place for a prolonged period to save a life, the choice of life over limb must be made
True or false: Application of vascular clamps into bleeding, open wounds in the ED is not advised.
True!
-can consider this ONLY if a superficial vessel is clearly identified
When would replantation of a limb be considered in cases of traumatic amputation?
-if replantation is possible, how should you transport the amputated limb?
Would only be considered for UPPER extremity injuries and the patient has to be stable with no other injuries (ie. has an isolated upper extremity injury)
-if this is possible, wash the amputated part in isotonic solution and wrap it in moist sterile gauze. Then place the part in a similarly moistened sterile towel, place in a plastic bag, and transport with the patient in an insulated cooling chest with crushed ice
True or false: Bilateral femur fractures result in a significantly increased risk of complications and death (significant blood loss, severe associated injuries, pulmonary complications, multiple organ failure, etc).
True!
What is the management for rhabdomyolysis secondary to crush injury?
- Aggressive IV fluid therapy to protect the kidneys and prevent renal failure from ATN
What is your management for open fractures?
- Provide inline traction, gently pulling the exposed bone back into the wound by straightening the extremity (pull the limb out to length), and apply immobilization
- Remove gross contamination and particulate matter from the wound and cover with a moist sterile dressing
- Administer weight based dosing of antibiotics as early as possible (Ancef)
- Surgical consultation ASAP
- Give Tetanus booster
***Overall: do NOT forget Ancef and Tetanus
In vascular injuries to an extremity, after what time frame does muscular necrosis begin if there is no arterial blood flow?
-what is your management if you suspect a fracture deformity that is impeding arterial flow to an extremity?
6 hours
Management:
- Gently pull the limb out to length
- Realign the fracture
- Splint the injured extremity
-this maneuver often restores blood flow to an ischemic extremity when the artery is kinked by shortening and deformity at the fracture site
What tests may be required for vascular injuries to extremities?
CT angiograms
In a patient with an anaphylactic penicillin allergy, what antibiotic can you use for an open fracture instead of ancef?
Clindamycin
What antibiotics should you use for open fractures of the following circumstances:
- severe soft tissue damage and substantial contamination with associated vascular injury?
- farmyard/soil or standing water
- severe soft tissue damage/substantial contamination with associated vascular injury: Ancef + Gentamicin
- farmyard/soil or standing water: Pip-Tazo for pseudomonas coverage
What is compartment syndrome?
Develops when increased pressure within a musculofascial compartment causes ischemia and subsequent necrosis
-can occur wherever muscle is contained within a closed fascial space
What type of injuries are at high risk for compartment syndrome?
- Tibia and forearm fractures
- Injuries immobilized in tight dressings or casts
- Severe crush injury to muscle
- Localized, prolonged external pressure to an extremity
- Increased capillary permeability secondary to reperfusion of ischemic muscle resulting in edema
- Burns
- Excessive exercise
