Trauma Flashcards
List potential orthopedic emergencies
- Open fracture
- Irreducible dislocations
- Vascular injury
- Amputation
- Compartment syndrome
- Unstable pelvic fracture/ hemodynamic instability
- Multiply-injured patient
- Spinal cord injury
- Displaced femoral neck and talar neck fractures
4 conditions considered vascular injury
- Blood loss
- Progressive ischemia
- Compartment syndrome
- Tissue necrosis
What is the time frame for irreversible damage?
6 hrs
Vascular injury is increased with…
- Proximity of vessels to bone
- Tethering of vessels at joints
- Superficial location of vessels
Clavicle fracture
-artery
subclavian
Shoulder fx/dislocation
-artery
axillary
Supracondylar humerus fx
-artery
brachial
Elbow dislocation
-artery
brachial
Pelvic fx
-artery
gluteal and/or iliac arteries
Femoral shaft fx
-artery
femoral
Distal femur fx
-artery
popliteal
Knee dislocation
-artery
popliteal
Tibial shaft fx
-artery
tibial
Incidence of fracture or dislocation with vascular injury
-uncommon, only 3% of long bone fractures
specific circumstances:
-fractures with GSW (up to 38%) and knee dislocations (16-40%)
Mechanism of injury
Penetrating trauma
- GSW
- Stab
Blunt trauma
- High energy
- Low energy
Iatrogenic
Types of vascular injuries
- Vascular spasms
- Intimal flaps
- Subintimal hematoma
- Laceration
- Transection
- Thrombosis/Occlusion
- A-V fistula
Consequences of vascular injury
- Blood loss
- Ischemia
- Compartment syndrome
- Tissue necrosis
- Amputation
- Death
Prognostic factors
- Level and type of vascular injury
- Collateral circulation
- Shock/hypotension
- Tissue damage (crush injury)
- Warm ischemia time
- Patient factors/medical conditions
What is the most crucial factor to trauma?
SPEED!!
- Rapid resuscitation
- Complete, rapid evaluation
- Urgent surgical treatment
Which protocol fall under the category of immediate treatment?
- Control bleeding
- Replace volume loss
- Cover wounds
- Reduce fractures/dislocations
- Splint
- Re-evaluate
What are the keys to diagnosis?
- Physical exam
- Doppler pressure (Ankle/brachial systolic pressure index (ABI))
- Duplex scanning
- Arteriogram
- Exploration
**careful PE and high suspicion are most important!
What should you be looking for on physical exam of the vasculature?
- Major hemorrhage/hypotension
- Arterial bleeding
- Expanding hematoma
- Altered distal pulses
- Pallor
- Temperature differential between extremities
- Injury to anatomically-related nerve
Which types of pulses warrant further exam??
- Asymmetric pulses warrant doppler examination (determine ABI)
- Absent pulses warrant emergent vascular consultation/surgical exploration
How does ankle brachial index compare to taking a blood pressure?
ABI measures the occlusion pressure whereas BP measures the opening pressure.
Performance of the ABI
-arm
Arm
- Appropriate cuff size
- Doppler over brachial artery
- NOT STETHESCOPE (underestimate SBP)
- NOT OVER RADIAL ARTERY
- Record right AND left arm brachial pressures
Performance of the ABI
-cuff
- Appropriate size
- Appropriate location
- -Lower leg above malleoli
*NOT OVER BULK OF CALF MUSCLES!
Performance of the ABI
-doppler
- Doppler over DP AND PT
* NOT STETHESCOPE
ABI calculation
- Numerator – Ankle pressures
- Higher of the two pedal pressures
- Denominator – Brachial pressure
- Higher of the two arm pressures
- Best reflects aortic pressure
ABI interpretation
> 1.3 = non-compressible
- 00-1.29 = normal
- 91-0.99 = equivocal
- 41-0.90 = mild-mod PVD
- 00-0.40 = severe PVD
What is doppler ultrasound used for?
- Determine presence/absence of arterial supply
- Assess adequacy of flow
NOTE: presence of signal does not exclude arterial injury
What findings would you have on doppler ultrasound for knee dislocation?
- Abnormal ABI < 0.90
- Does not define extent or level of injury
- Abnormal values warrant further evaluation
- ABI > 0.90 can be observed (i.e. no arteriogram)
Why is duplex scanning so valuable?
- noninvasive
- safe
- rapid
What is duplex scanning reliable for?
- Injury to arteries and veins
- A-V fistulas
- Pseudoaneurysms
What does duplex scanning require?
technician and scanner availability
*not all surgeons will operate based on duplex information alone
Functions of angiography
- Locates site of injury
- Characterizes injury
- Defines status of vessels proximal and distal
- May afford therapeutic intervention
What are the cons of angiography?
- Expensive
- Time-consuming
- Difficult to monitor/treat trauma patient in angiography suite
- Procedural risks
What are the procedural risks of angiography?
- Renal burden from dye
- Possibility of anaphylaxis
- Injury to proximal vessels
When would you choose CT Angiography?
- Alternative to conventional angiography
- Good sensitivity and specificity
- Costs much more
When is angiography not indicated?
**ANGIOGRAPHY WILL DELAY REVASCULARIZATION
-it is not indicated in cases with absent pulses/complete transection, which should go immediately to surgery
What is operative angiography? What does it detect?
- Single view in operating room
- Rapid
- Excellent for detecting site of injury
When is immediate surgical exploration indicated?
- Obvious arterial injury on exam
- No doppler signal
- Site of injury is apparent
- Prolonged warm ischemia time
What is your next step if pt comes in with no pulse?
If injury obvious - surgery
If multilevel injury - angiography or duplex, then surgery
What is your next step if pt comes in with asymmetric pulse?
Doppler
If < 0.9, angriography or duplex then surgery
If > 0.9, observation
What is your next step if pt comes in with normal exam?
observation
When should vascular evaluation occur?
- vascular injuries are dynamic, so evaluation should continue after the initial injury or surgery
- additional debridement and/or fixation undertaken after successful revascularization
Key parts to continued evaluation?
- circulation
- neurologic function
- compartment pressures (via Stryker needle, MC)
What surgical considerations should be on your mind?
- Who goes first?
- Temporary shunts
- Fracture stabilization
- Salvage vs amputation
- Fasciotomies
Oklahoma’s trauma system evolved after…
story on Dateline in 1996 titled “`Dateline’ Report Blasts State’s Lack of System to Handle Trauma “
Which physician is credited with development of the trauma system?
Dr. Roxie Albrecht Trauma Surgeon, Trauma Director at OU Medical Center started and developed Trauma system in Oklahoma August 2001
What are the keys to the trauma system?
- Coordinated system of care for injured patients
- Injured patients to appropriate care in ‘right’ amount of time
- Reduce preventable morbidity and mortality
- Built around available resources
- Quality assurance and improvement
What are the components of the trauma system?
Administration, Hospitals, EMS, Physicians, EMT’s, Law Enforcement, Data, Research, Education
What is trauma level I?
comprehensive trauma care, extensive physician specialist support immediately available, teaching and research requirements
What is trauma level II?
similar to a level I without teaching and research requirements
What is trauma level III?
24/7 physician level provider in the emergency department, general surgery and orthopedics
What is trauma level IV?
typically stabilization and transfer, not required to have 24/7 physician level provider in the emergency department
What is the mission statement of the Oklahoma regional trauma plan?
“In support of the statewide system, create a regional system of optimal care for all trauma patients, to ensure the right patient goes to the right place, receiving the right treatment, in the right amount of time. “
Trauma Triage at the Scene of Injury
- Based on readily observable or measurable factors
- Patient-related – obvious injuries, age, vital signs
- Scene-related – distance to appropriate hospital, traffic, weather, extrication, multiple patients, etc.
When was Helicopter Emergency Medical Transport (HeMS) first used?
- in times of military conflict; Korea, Vietnam
- importance in the setting of remote locations, limited roadways, and hostile forces is easily recognizable
- introduced to U.S. civilian use in the early 1970’s
- effectiveness for civilian transport has been a subject of debate since introduction
HEMS Transport Debate
- Costs, Crashes, and Conflicting results
- Charges for HEMS transport many times that of a ground EMS transport of similar distance
- Expansion of HEMS services brought increased numbers of helicopter crashes
- Questions remain regarding effectiveness of HEMS in reducing mortality
- ‘Over-utilization’– scarce resource used for patients with non-life threatening injuries
