TRAUMATIC INJURIES TO EXTREMITIES Flashcards
An individual crushed or trapped with compression to extremities for a prolonged time may develop what?
crush syndrome
Crush Syndrome is characterized by
ischemia and muscle damage or death (rhabdomyolysis)
Rhabdomyolysis occurs with injury/necrosis to the muscle fiber. Involves leakage of intracellular components such as…..
potassium, Creatine Kinase (CK), myoglobin
_________ may result from a combination of nephrotoxic substances from muscle death (myoglobin, uric acid)
Acute Renal Failure (ARF)
What issue?
Hx: An individual crushed or trapped with compression to extremities for a prolonged time
PE:
Extremities:
1) Initially, may appear normal just after extrication.
2) Edema develops and extremity becomes swollen, cool, and tense.
3) Pain out of proportion with examination.
4) May mimic a spinal cord injury with flaccid paralysis but there will be normal bowel and bladder function.
5)Trunk/Buttocks: May have severe pain out of proportion with examination intense compartments
Crush Syndrome
crush syndrome:
_______ is an ultimate cause of death from cardiac arrhythmia
Hyperkalemia
crush syndrome:
With progression, potassium and CPK increase. Creatinine and Blood Urea Nitrogen will increase due to….
renal failure
Crush Syndrome Tx:
Key in improving outcomes is what?
early and aggressive fluid resuscitation
When treating a crush pt, when should you initiate fluid resuscitation and why?
before extrication to minimize to toxic effects of myoglobin and potassium before release of the limb
Crush injury, Treat while on scene and trapped.
1) Primary goal is to prevent _____. Suspect, recognize, and treat rhabdomyolysis.
2) Initiate therapy ASAP and establish ______________.
1) ARF
2) IV access in a free arm or leg vein
Crush injury:
A delay in fluid resuscitation, results in renal failure in 50% of patients, a delay of _____ or more produces renal failure in almost 100% of patients.
12 hours
Crush injury
If you don’t start aggressive iv therapy prior to extraction what can happen?
may go into cardiac arrest during extrication due to sudden release of metabolic acid and potassium
What is the dosage for fluids when treating an entrapped pt?
- 1L/h (short extrication time)
- maximum of 6-10 L/d in prolonged entrapments
WITH
one ampule (50mEq) sodium bicarbonate & 10 g mannitol w/ each L of fluid
What is the last resort for entrapped patients?
amputation
What is recognized by the development of peaked T waves on cardiac monitor
Hyperkalemia
Standard protocol for treatment of hyperkalemia
Sodium Bicarbonate IV Dextrose and insulin
Crush injury:
Urine output should be ___ mL/h
output >100 mL/h until pigments have cleared
Two most common causes of compartment syndrome
(a) Hemorrhage from fracture
(b) Edema following reperfusion injury
Occurs with pressure in the compartment exceeds that of the capillary _______ mmHg pressure increases and subsequently can lead to impaired blood flow
30
S/s of what?
(a) Paresthesia’s (most common)
(b) Pain (most common) pain often described as out of proportion
(c) Pulselessness – uncommon, late finding
(d) Pallor
Compartment Syndrome
Management of Compartment syndrome
Fasciotomy
–Only basic maneuvers can be performed in the field
–Perform in consultation with SMO/specialist
What are the 4 functional components that are evaluated for Trauma to the extremities
(a) Nerves
(b) Vessels
(c) Bones (long, short, flat sutural bones, sesamoid etc.…)
(d) Axial vs appendicular skeleton (appendicular comprises bones of the extremities)
(e) Soft tissue
Extremity trauma
IF a pt has 3 out of the 4 functional components damaged what is it defined as?
Mangled extremity
Systemic antibiotics for extremity trauma
1) Ertapenem
2) Cefazolin
3) Cefoxitin
Electrical extremity injuries – special consideration.
1) Soft tissue damage can occur between entrance and exit wound.
2) 40 percent of these injuries will require ________.
3) Areas should be monitored for _____ and vascular thrombosis.
4) ________ should be anticipated with high voltage injuries and consultation for emergent _______ should be made.
2) amputation
3) necrosis
4) Compartment syndrome, fasciotomy
These are hard signs of what?
1) Active hemorrhage
2) Expanding or pulsatile hematoma
3) Bruit or thrill over wound
4) Absent distal pulses
5) Extremity ischemia
arterial injury
Management External hemorrhage
1) Direct pressure
2) Tourniquet
3) Wound packing with hemostatic agent
4) Elevation/splinting extremity
Contraindications to traction femur splint
Suspected pelvic fracture,
femoral neck fracture,
amputation of foot/ankle,
suspected fracture adjacent to knee
ANY open wound near a possible fracture site you need to consider it as what?
open and treat it as such.
MAnagement for Open FX
1) Irrigation and debridement
2) Fixation/splinting
3) Antibiotic prophylaxis –
-a) Cefoxitin
-b) Cefazolin
-c) Ertapenem
-d) Or appropriate regimen in consultation with MO. Pill pack
Most common sites for internal hemorrhage from fracture are what?
femur and pelvic fractures
________ is the leading cause of death in pelvic fractures
Blood loss
What type of pelvic fx typically does not require surgical stabilization
Rami fracture
What type of pelvic fx, surgery generally needed to optimize hip function
Acetabular fracture
Pelvic ring – classified into 3 types of fx:
a) Lateral compression majority
b) Anterior posterior compression fracture
c) Vertical shear
What type of pevlic ring injury tends to have the greatest bleeding?
Vertical shear
Management of amputations:
1) Hemorrhage control of limb
2) Clean amputated part by rinsing with LR
3) Wrap the part in sterile moist LR solution and place in bag/container
4) Label bag/container and place in container of ice (if possible)
5) Transport with patient to the closest facility
degloving injury attains more significance in where?
the hand
Field Management of avulsion
(1) Preserve as much of the structures as possible
(2) Wound cleaning and debridement
(3) Antibiotics to cover skin flora bacteria (Staph and Strep)
Signs of urethral injury
-Classic taught is to evaluate for blood from urethral meatus, high riding prostate and scrotal hematoma
urethral injury can be elusive and if highly suspected based on MOI the patient should undergo what?
imaging….
What is the common term Common term to describe pelvic ring disruptions
Open book pelvic fracture
Unstable injuries such as open book are associated with what?
retroperitoneal bleeding
What is the gold standard for management of pelvic fx?
CT scan
Initial management of pelvic fx
(a) Stabilize ABCs
(b) FAST exam
(c) Plain radiographs
(d) CT scan
(c) hemodynamic instability – transfusion with 1:1:1 or FWB,transfer to surgical trauma facility
(f) pelvic fracture remains hemodynamically unstable, the pelvis should be “wrapped” with either a sheet or a commercial pelvic binder.
