TRAUMATIC INJURIES TO EXTREMITIES

Question 1

An individual crushed or trapped with compression to extremities for a prolonged time may develop what?

Answer 1

crush syndrome

Question 2

Crush Syndrome is characterized by

Answer 2

ischemia and muscle damage or death (rhabdomyolysis)

Question 3

Rhabdomyolysis occurs with injury/necrosis to the muscle fiber. Involves leakage of intracellular components such as…..

Answer 3

potassium, Creatine Kinase (CK), myoglobin

Question 4

_________ may result from a combination of nephrotoxic substances from muscle death (myoglobin, uric acid)

Answer 4

Acute Renal Failure (ARF)

Question 5

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

Answer 5

Crush Syndrome

Question 6

crush syndrome:
_______ is an ultimate cause of death from cardiac arrhythmia

Answer 6

Hyperkalemia

Question 7

crush syndrome:
With progression, potassium and CPK increase. Creatinine and Blood Urea Nitrogen will increase due to….

Answer 7

renal failure

Question 8

Crush Syndrome Tx:
Key in improving outcomes is what?

Answer 8

early and aggressive fluid resuscitation

Question 9

When treating a crush pt, when should you initiate fluid resuscitation and why?

Answer 9

before extrication to minimize to toxic effects of myoglobin and potassium before release of the limb

Question 10

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 ______________.

Answer 10

1) ARF
2) IV access in a free arm or leg vein

Question 11

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.

Answer 11

12 hours

Question 12

Crush injury
If you don’t start aggressive iv therapy prior to extraction what can happen?

Answer 12

may go into cardiac arrest during extrication due to sudden release of metabolic acid and potassium

Question 13

What is the dosage for fluids when treating an entrapped pt?

Answer 13

1. 1L/h (short extrication time)
2. maximum of 6-10 L/d in prolonged entrapments
   WITH
   one ampule (50mEq) sodium bicarbonate & 10 g mannitol w/ each L of fluid

Question 14

What is the last resort for entrapped patients?

Answer 14

amputation

Question 15

What is recognized by the development of peaked T waves on cardiac monitor

Answer 15

Hyperkalemia

Question 16

Standard protocol for treatment of hyperkalemia

Answer 16

Sodium Bicarbonate IV Dextrose and insulin

Question 17

Crush injury:
Urine output should be ___ mL/h

Answer 17

output >100 mL/h until pigments have cleared

Question 18

Two most common causes of compartment syndrome

Answer 18

(a) Hemorrhage from fracture
(b) Edema following reperfusion injury

Question 19

Occurs with pressure in the compartment exceeds that of the capillary _______ mmHg pressure increases and subsequently can lead to impaired blood flow

Answer 19

30

Question 20

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

Answer 20

Compartment Syndrome

Question 21

Management of Compartment syndrome

Answer 21

Fasciotomy
–Only basic maneuvers can be performed in the field
–Perform in consultation with SMO/specialist

Question 22

What are the 4 functional components that are evaluated for Trauma to the extremities

Answer 22

(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

Question 23

Extremity trauma
IF a pt has 3 out of the 4 functional components damaged what is it defined as?

Answer 23

Mangled extremity

Question 24

Systemic antibiotics for extremity trauma

Answer 24

1) Ertapenem
2) Cefazolin
3) Cefoxitin

Question 25

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.

Answer 25

2) amputation
3) necrosis
4) Compartment syndrome, fasciotomy

Question 26

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

Answer 26

arterial injury

Question 27

Management External hemorrhage

Answer 27

1) Direct pressure
2) Tourniquet
3) Wound packing with hemostatic agent
4) Elevation/splinting extremity

Question 28

Contraindications to traction femur splint

Answer 28

Suspected pelvic fracture,
femoral neck fracture,
amputation of foot/ankle,
suspected fracture adjacent to knee

Question 29

ANY open wound near a possible fracture site you need to consider it as what?

Answer 29

open and treat it as such.

Question 30

MAnagement for Open FX

Answer 30

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

Question 31

Most common sites for internal hemorrhage from fracture are what?

Answer 31

femur and pelvic fractures

Question 32

________ is the leading cause of death in pelvic fractures

Answer 32

Blood loss

Question 33

What type of pelvic fx typically does not require surgical stabilization

Answer 33

Rami fracture

Question 34

What type of pelvic fx, surgery generally needed to optimize hip function

Answer 34

Acetabular fracture

Question 35

Pelvic ring – classified into 3 types of fx:

Answer 35

a) Lateral compression majority
b) Anterior posterior compression fracture
c) Vertical shear

Question 36

What type of pevlic ring injury tends to have the greatest bleeding?

Answer 36

Vertical shear

Question 37

Management of amputations:

Answer 37

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

Question 38

degloving injury attains more significance in where?

Answer 38

the hand

Question 39

Field Management of avulsion

Answer 39

(1) Preserve as much of the structures as possible
(2) Wound cleaning and debridement
(3) Antibiotics to cover skin flora bacteria (Staph and Strep)

Question 40

Signs of urethral injury

Answer 40

-Classic taught is to evaluate for blood from urethral meatus, high riding prostate and scrotal hematoma

Question 41

urethral injury can be elusive and if highly suspected based on MOI the patient should undergo what?

Answer 41

imaging….

Question 42

What is the common term Common term to describe pelvic ring disruptions

Answer 42

Open book pelvic fracture

Question 43

Unstable injuries such as open book are associated with what?

Answer 43

retroperitoneal bleeding

Question 44

What is the gold standard for management of pelvic fx?

Answer 44

CT scan

Question 45

Initial management of pelvic fx

Answer 45

(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.