Week 9 - MSK Injuries + Burns Flashcards
What is the old/traditional way we used to classify burns? Why do we no longer use this method to classify burns?
Stage stage 1 - 4 method! - it does not directly describe how much of the epidermis and/or dermis is damaged
-We use the layer of skin method now!!!
What are burn injuries in “lower status/class countries correlated with? Why?
In all countries, lower SE status” is correlated with burns. Less access to 911, no smoke detectors in the home, poor equipment/no safety mechanisms
How do we treat joint injuries?
Treatment:
-Relocate joint (procedural sedation in ER or OR)
-Need to relocate the joint—procedural sedation in ER or possibly to OR (knee dislocation needs Immediate intervention—almost guaranteed nerve involvement)
S+S for pelvic fracture?
Signs and Symptoms:
-pain, hypovolemic shock, hematuria, urethral/vaginal/rectal bleeding
shortened or rotated leg
-Large vessel injuries (shearing), Abdominal organ injuries
Instability/Crepitus
Aortic injuries, other large vessel injuries, abdominal organ injuries causing hemorrhage
Pain
Evidence of hypovolemic shock
Shortening or abnormal rotation of the affected leg, other lower abdominal physical deformity
Genitourinary or intra-abdominal injury
Bruising
hematuria
Urethral, vaginal, or rectal bleeding
What are 5 interventions we can do for the Ongoing care + treatment of burn injures ( these are done AFTER eth Early Care + Treatments of Burn injuries!!)
Ongoing Care + Treatment of Burns:
1.) Patient Moved to Specialized Unit
-Burns ICU, plastics unit, etc.
2.) Skin Grafting + Dressings
-Grafts can be from both the patient and/or donors
3.) Escharotomies
-Procedure where burn tissue is removed to allow for pressure release
4.) Nutrition
-Insertion of NG tube or J tube, patient may receive TPN
5.) Reverse Isolation:
-To protect the patient from us!, Antibiotics may be administered, more likely that antimicrobial dressings will be used if positive cultures come back
How do we diagnose Rhabdomyolysis?
-Myoglobin levels are less reliable because the body breaks it down within 6 hrs – more likely to test urine for blood
-Diagnosis made by clinical history + elevated CK which peak at 24-36hrs (can be in the tens of thousands), which is released by the damaged cells.
-Creatinine will also rise as the body converts creatine to creatinine (plus AKI).
-Blood for myoglobin less reliable because it breaks down within 6 hours. More likely to test the urine for blood but even that has 50% false negatives
What kind of mortality rate does/do pelvic fractures have? (what does it depend on?)
Up to 70% mortality depending on fracture type and promptness of treatment
What are fractures associated with? Why?
Associated with large blood loss because or disruption of arteries or veins in close proximity to bones
-Tibia/Humerus Fracture: 250 - 2000mL blood loss
-Femur Fracture: 500 - 3000mL of blood loss
-Pelvic Fractures: varies but may range from 750 mL – 6000mL of blood loss
What is compartment syndrome? What does/can it result in?
Occurs as pressure increases inside a fascial compartment
Results in impaired capillary blood flow and cellular ischemia
What is the Rule of nines? (what is it commonly used for?/what does it do/give)
Rule of Nines:
-Most common method used in the ER, though not as accurate as some (like the Lund-Brower chart)
-Rule of nines is a rough estimate when there is nothing more accurate available—useful for a first guess of extent of the injury
What specific S+S do pelvic fractures have that are unique to them?
Pelvic fractures: unstable to palpation, shock
What is the initial treatment for fractures? (7 different interventions we can do)
Initial treatment:
-Immobilization and stabilization (splints, slings, pelvic binders, backboard for femurs)
-Cool packs
-Analgesia, muscle relaxants
-Sedation for reduction, then cast and sling
-Backslab and sling for support (non-displaced and stable)
-Surgery if unstable
-External fixation (multiple bone fragments) (cage)
What can electrical injuries cause that makes them kind of unique?
Electrical injuries cause severe internal injuries and cardiac arrest but very little visible external
S+S for Rhabdomyolysis?
Signs and Symptoms:
-Dark/Red urine, reduced urine output, severe muscle aching, arrhythmias/arrest
Impaired renal function from the massive release of myoglobin—kidneys hate dealing with the molecule in large amounts.
Damages the nephron—ATN. Urine becomes darker (“rhabdo”)
Release of potassium can cause massive increases in vascular space—arrhythmias and arrest (happens in the first few hours)
What is the MOI/what are fractures usually caused by?
Blunt force Trauma
-Typically caused by MVAs, assaults, falls, sports
MOI: motor vehicle crashes, assaults, falls, sports, leisure, or home activities
Treatment for pelvic injuries? (what do we avoid) (think of 5 things)
Treatment:
-avoid catheters if there is urethral trauma
-Stabilization device (Pelvic binder) – slow blood loss/encourage -clotting
-Surgery: internal/external fixation
-Angiography with embolization for bleeding vessels
-Blood/IV Fluid admin
-Tight stabilizing device that can slow blood loss and encourage clotting by direct pressure – they can hurt!
-Surgery to internally or externally fixate unstable fracture
-Angiography with embolization of bleeding vessels
-Blood or iv fluid admin
How do we diagnose pelvic fractures?
Diagnostic: Xrays, FAST to detect bleeding, CT
When diagnosing a joint injury, what non-mechanical/picture taking diagnostic method/tool will help us differentiate a dislocation from a fracture?
Usually clinical history will help us differentiate a dislocation from a fracture (sound of a crack or pop, for example)
How do crush injuries work/what is the patho behind them?
When muscles are crushed (especially for long periods), they become ischemic, then necrotic, then release potassium, myoglobin (protein found in muscles), and creatine kinase (enzyme found in muscles) into the blood:
-This release of potassium can lead to arrhythmias and cardiac arrest (usually within the first few hours)
-Release of myoglobin and creatine kinase (indicator for myoglobin) can cause acute kidney injury or rhabdomyolysis
Why can patient with crush injuries go into shock?
When muscles are crushed (especially for long periods), they become ischemic, then necrotic, then release potassium, myoglobin (protein found in muscles), and creatine kinase (enzyme found in muscles) into the blood:
Fluids leak into third spaces, causing edema and possibly increased compartment pressure
Patients can go into shock from these massive fluid shifts (distributive shock), or from hemorrhage (hypovolemic shock)
What type of injury has a high morbidity in the elder population?
Fractures!!
Elderly at high risk of being hospitalized for an extremity injury (rate of injury in pop)
What do we need to remember with pelvic injuries? (think about extent of injuries)
remember, A LOT of force to cause this, so there might/will be injuries around the pelvis/abdomen too
For fractures what is the average blood loss associated with?
Average blood loss: Associated with large blood loss due to proximity of vessels to bones
Tibia/Humerus Fracture: 250 - 2000mL
Femur Fracture: 500 - 3000mL
Pelvic Fractures: varies bu
How do we diagnose joint injuries?
Diagnosis:
-Clinically (exam) and Xrays
-Usually clinical history will help us differentiate a dislocation from a fracture (sound of a crack or pop, for example), but the deformity is also in the joint instead of along the bone (hips are tricky to distinguish)
-Can often be diagnosed clinically (above picture), may need xrays (lower picture), anything further is quite rare
Treatment for rhabdomyolysis? Why do we do this?
Treatment:
Aggressive IV fluids – dilute blood of myoglobin and other nephrotoxins
Aim for at least 100-200mL urine output/hr
Treatment is aggressive IV fluids—we want 100-200mL urine output per hour minimum. Diluting the blood of myoglobin and other nephrotoxins
How do we treat compartment syndrome?
Treatment:
Elevate the limb to the level of the heart
Fasciotomy is literally cutting into these compartments to release the pressure
What type of fractures do we use external fixation for?
External fixation (multiple bone fragments)
-Typically used with crush injuries!
What are some other factors that contribute to the International Epidemiology of individuals who experience a burn injury?
Other factors: occupations, overcrowding, lack of safety measures, medical conditions (e.g. cognitive impairment, epilepsy), fuel sources like kerosene (WHO, 2018)
Such as epilepsy, nerve damage, cognitive impairment, alcohol, smoking). Fuels such as kerosene instead of electric appliances
What fractures are hard to distinguish? Why?
-hips are tricky to distinguish
Hard to distingish because the deformity is also in the joint instead of along the bone
What do half of hospital admissions for trauma include?
Half of all hospital admissions for trauma include a lower limb fracture
What is the Rule of Palms? (what is it useful for? what does it use to represent a portion of the patients body?)
Rule of Palms:
-Useful for smaller burns. The patient’s palm represents 1% of their total body surface area
-The patient’s palm also represents 1% of the BSA—easy way to estimate smaller burns
What are the 4 different thickness that a burn injury can be? (think of the different stages like we learned in pathology!! However, remeber we don’t classify these burns off of stages anymore!)
Thickness can be superficial (sunburn, touching something hot and then reflexively jumping back),
superficial partial (blistered, wet/weeping, pink or red, extremely painful),
deep partial (dryer, paler pink to white, less painful),
or full thickness (leathery, many colours, dry, painless or aching).
What can Joint injuries be complicated by/with?
May be complicated by neurovascular compromise and associated fractures
-Knee dislocation
How do we diagnose fractures?
Diagnosis: Xrays, CT (if xray inconclusive), MRI if soft tissue injury
When testing/diagnosing rhabdomyolysis, what blood test might be less reliable? Why?
-Blood for myoglobin less reliable because it breaks down within 6 hours. More likely to test the urine for blood but even that has 50% false negatives
What is the patho behind a fracture?
Pathophysiology:
Bone/join displacement compresses surrounding tissues and nerves – obstructs arterial blood flow, causing decreased tissue oxygenation
With crush injuries, what does the release of myoglobin and creatine kinase cause?
Release of myoglobin and creatine kinase (indicator for myoglobin) can cause acute kidney injury or rhabdomyolysis
With compartment syndrome, how long does it take before irreversible damage to muscle cells and nerves occurs?
Only takes about 6-8 hours before irreversible damage to muscle cells and nerves occurs
When treating rhabdomyolysis, what is the urine output/hr goal we want to aim for? Why?
Aim for at least 100-200mL urine output/hr
Treatment is aggressive IV fluids—we want 100-200mL urine out put per hour minimum. Diluting the blood of myoglobin and other nephrotoxins
Difference between a stable and unstable pelvic fracture?
Stable: able to withstand normal physiologic forces without abnormal deformation
-(able to stand normal physiologic force without deformity)
Unstable: Pelvic ring is fractured in more than one place resulting in two displacements on the ring
-more than one fracture, resulting in displacement of the pelvic ring)
What are some concurrent injuries that are specially related to burns!
Airway injury due to inhaled smoke
Fatal hypoxia due to carbon monoxide blocking oxygen transport
Electrical injuries can cause fatal arrhythmias - Electrical injuries cause severe internal injuries and cardiac arrest but very little visible external
What are pelvic fractures often accompanied by? (2 things)
Often accompanied by large blood loss and injury to genitourinary system
Why are children at risk for experiencing a burn/thermal injury?
Children also at risk due to Lack of supervision, understanding, or child abuse
Why do Females have slightly higher rates for experiencing a burn/thermal injury?
Females have slightly higher rates - Thought to be due to traditional loose clothings in some countries and more often being the primary cook for the house
What are the 4 classifications of burns? What layer of the skin does each category impact? (think of the current staging method for burns!)
Classification of burns (Cont.)
1.) Superficial Burn:
-Only impacts the epidermis
2.) Superficial-partial thickness Burn:
-Impacts the epidermis + upper portion of dermis
3.) Deep-Partial thickness Burn:
-Impacts/extends deeper into the dermis
4.) Full Thickness Burn
-Destroys the epidermis and entire dermis, extends into subcutaneous fat
What are the 3 zones of a severe burn? What zone can’t we help? Why?
central (coagulation) zone is necrotic,
zone of stasis has impaired blood flow,
and zone of hyperemia has good blood flow.
*We can’t help the coagulation zone, but we can act to keep the zone of stasis from converting to a zone of coagulation (necrotizing)
S+S of fracture?
Signs/Symptoms: depends on location
-Deformity, pain, exposed bone/bleeding, cool to touch, lack of pulse, sensation changes, swelling ,loss of function, bone exposed/bleeding if open, bruising, pallor/cyanosis, cool to touch, lack of a pulse, sensation changes, increase in cap fill time, swelling
Hip/femur fractures specifically: shortening/rotation, unable to weight bear, shock
Pelvic fractures: unstable to palpation, shock
How can compartment syndrome occur/what it its MOI?
May occur by internal or external forces:
-Internal: fractures, crush injuries, hemorrhage, edema
-External: casts, splints, traction
S+S for joint injuries?
Signs and Symptoms:
Pain, joint deformity, edema, inability to move affected joint, abnormal range of motion, reduced pulses and sensation
What are the S+S of compartment syndrome? (think 6P’s!!!)
Pain (disproportionate to injury)
Parestheia (numbness/tingling)
Paralysis (loss of motor function)
Pressures (tense on palpation)
Pallor (late sign)
Loss of pulse (late sign)
Six P’s: pain (disproportionate to the injury), paresthesia (numbness/tingling), paralysis (loss of motor function), pressures (tense on palpation, elevated if measured), pallor (later sign), loss of pulses (late)
What are 5 interventions we can do for the Early Care + Treatment of Burn injuries?
Early Care + Treatment of Burns:
1.) Airway and breathing management!
-Monitor closely! depending on the MOI, there may be inhalation burns or irritants)
-Give O2 and be prepared to intubate patient
2.) Cooling the burn
-Cool the burn with sterile, saline soaked gauze if <10%
-Cover burn with clean sheet if the burn is <10% (risk of hypothermia)!
3.) CVAD + IV Fluids
-Large amounts of IV fluids may be required, especially on the first day!
-Monitor patients urine output closely (catheter) for clues that more fluids are needed
4.) Temperature Control
-Keep the patient’s room warm, this can reduce hypermetabolism, esp in extensive burns!
5.) Analgesic
-Opiods are the primary analgesic used
What are the two late S+S of compartment syndrome?
Pallor (late sign)
Loss of pulse (late sign)
What types of fractures do we use a backslab and sling for support as an intervention?
-Backslab and sling for support (non-displaced and stable)
What is smiling death syndrome?
Smiling Death Syndrome: A phenomenon where a individual, initially appears to be relieved after being rescued from a crush injury, suddenly dies shortly after due to the release of toxins and electrolytes from damaged tissues, leading to a condition called crush syndrome. (Think of the grey’s anatomy episode where the teenage boy comes into the ER after submerging himself in concrete and then
went into cardiac arrest!)
What do we look at for our initial assessment of burns?
Initial Assessments of Burns:
-Assess/look at the thickness (see above)
-Rule of Nines: gives us a rough estimate when there is nothing more accurate available for
us to use—useful for a first guess of extent of the injury
-Rule of Palms: Assessment that is useful for smaller burns! The patient’s palm represents 1%
of their total body surface area!
MOIs/causes of pelvic fractures?
MOI: MVCs, Falls, Cyclist vs Motorcycle vs Pedestrian
-Falls from great height
What do serve burns have?
Severe burns often have a mix of depths. Center is usually the deepest. 1st/2nd/3rd degree burns used less in the medical community than the public
What specific S+S does a hip/femur fracture have that is unique to them?
Hip/femur fractures specifically: shortening/rotation, unable to weight bear, shock
What is one of the main potential problems in crush injuries is related to the kidneys?
One of the main potential problems in crush injuries is related to the kidneys:
-Impaired renal function – damage to nephrons from myoglobin (protein in muscle) = Rhabdomyolysis!
What is a joint injury? What causes them?
A joint may become dislocated when the normal range of motion is exceeded
