Trauma Flashcards
Management of lower limbs injuries in casualty? (10)
- Assess C spine, Airway, breathing, circulation, disability, exposure according to ATLS principles
- analgesia
- Clexane (enoxaparin LMWH) for DVT prophylaxis
- Assess and note neurovascular Status of limb
- reduce dislocation immediately if present, under sedation
- immobilise limb
- elevate limb
- look for other injuries and fractures of surrounding bones and joints and do general examination
- reassess and note nv status of limb
- refer for definitive treatment
Diagnosis compartment syndrome? (9)
1 paraesthesia (compression of small arteries that supply nerve)
2. Pain out of proportion and not resolving after analgesia and splinting
3. Pain on passive stretch
• lower leg ant compartment affected first- test by flex big toe
• posterior compartment: extend other toes
• upper limb flexor compartment more affected. Test by extending fingers
4. Swollen, tense compartment
5. Suspicious history: elbow sypracondylar, prox forearm, prox tibia most prone
6. Pallor (late sign)
7. Paralysis (late sign)
8. Pulselessness (late sign)
(5 ps)
If unconscious patient where clinical exam unreliable, monitor compartment pressure with catheter. Normal =0. Elevated ≥ 30 mm hg
Management compartment syndrome? (6)
- Decompress threatened compartment promptly.
- cut casts, bandages and dressings (don’t remove, fracture movement will cause more bleeding thus more pressure)
- elevate limb to level of the heart, no more otherwise further decrease in end capillary pressure and aggravate muscle ischaemia
- wait 30 minutes and repeat examination of limb. If not improve…
- urgent fasciotomy (definitive treatment)
- leave the wound open and inspect 2 days later. If muscle necrosis, debride. If none, suture wounds or skin graft
Name 3 complications compartment syndrome
- Volkmann’s ischaemic contracture: ischaemic necrosis of muscle followed by secondary fibrosis and finally calcification, especially after supra condylar #humerus
- Rhabdomyolysis
- renal failure secondary to myoglobinuria
Management of open #? (10)
- ATLS principles and resuscitation as needed
- analgesia: opioid. Not NSAIDs - nephrotoxic
- remove obvious foreign material
- irrigate with normal saline if grossly contaminated
- cover wound with sterile saline soaked dressing
- immediate iv antibiotics!.- first generation cephalosporin first line eg kefzol (cefazolin); allergy:clindamycin. Triple regime for farm/train injury: cloxacillin , flagyl (metronidazole), gentamicin.
- tetanus toxoid if previously immunized, or immunoglobin of not.
- reduce and splint fracture under conscious sedation to stabilise!
- NPo and prepare for theatre (bloods, ECG, cxr)
- operative irrigation and debridement within 6-8h to decrease risk infection! Can repeat until viable.
- external fixation to stabilise #! Internal too high risk infection.
- traumatic wound left open to drain but can use vacuum assisted closure drainage
- delayed closure of wound in 3-7 days
Name and describe the classification for open fractures
Gustilo Anderson classification
Grade 1:
• wound <1 cm
• minimal soft tissue injury and contamination
• simple low energy or minimally comminuted fractures
Grade 2
• wound 1-10cm
• moderate soft tissue injury and contamination with some muscle damage
• moderate comminution fracture
Grade 3a
• wound 1-10 cm
• severe deep contusion, compartment syndrome, adequate ability of soft tissue to cover wound
• high energy fracture patterns, comminuted
Grade 3b
• wound >10 cm
• severe loss soft tissue cover, periosteal stripping and bone exposure
Grade 3c
• wound >10 cm
• vascular injury/compromise
• require soft tissue reconstruction for cover
• give both cefazolin and gentamicin/ceftriaxone for antibiotic prophylaxis
Describe presentation of fat embolism syndrome (5)
- 24-72 hours after injury
- pulmonary: tachypnoea, dyspnoea, cyanosis
- tachycardia and pyrexia
- cerebral: headache, irritable, delirium common. Stupor, coma and convulsions in severe
- cutaneous: petechial rash Axilla, chest, conjunctivae, retinae
Aetiology fat embolism syndrome? (2)
- Mechanical theory: obstruction in pulmonary capillaries from fat emboli
- physiochemical theory: free fatty acids released during trauma or during breakdown of fat in lung, directly affect pneumocytes, resulting in inflammatory response
Spinal vs neurogenic shock? (6)
- Both hypotension
- both bradycardia
- bulbocavernosus reflex absent in spinal shock; variable or independant in neurogenic shock
- motor: flaccid paralysis vs variable or independent
- both 48-72 hours immediately after spinal cord injury
- mechanism peripheral neurons become temporarily unresponsive to brain stimuli vs disruption of autonomic pathway leads to loss sympathetic tone and decreased systemic vascular resistance
Management human bites? (8)
• Copious irrigation with isotonic sodium chloride solution or dilute povidone -iodine (betadine) or dilute hydrogen peroxide with 10 ml syringe and 18 G angiocatheter
• avoid injection of tissues to prevent additional trauma
• debride devitalised tissue
. Don’t close hand wounds, punctures,infected wounds or wounds >12 hours old. Let heal by secondary intention
• Head and neck wounds may be closed if <12 h old and not obviously infected.
• antibiotic prophylaxis if completely penetrate epidermal layer or involve joints or cartilaginous structures, or to hand- co-amoxiclavulanic acid or quinolone, not cephalosporin (E. Corrodens)
• hep B immunoglobulin and accelerated course vaccination
• HIV prophylaxis
Define compartment syndrome
Excessive pressure of myofascial compartments
Name 5 areas that commonly get compartment syndrome
• Proximal radius and ulna • middle and proximal tibia and fibula . Foot, especially lisfranc • scapula • supracondylar
