International Trauma Life Support for Prehospital Care Providers Sixth Edition for Prehospital Care...

International Trauma Life Support

for Prehospital Care ProvidersSixth Edition

Patricia M. Hicks, MS, NREMTPRoy Alson, PhD, MD, FACEP

Donna Hastings, EMT-PJohn Emory Campbell, MD, FACEP

and Alabama Chapter,American College of Emergency Physicians

Patricia M. Hicks, MS, NREMTPRoy Alson, PhD, MD, FACEP

Donna Hastings, EMT-PJohn Emory Campbell, MD, FACEP

and Alabama Chapter,American College of Emergency Physicians

Chapter 14Extremity TraumaChapter 14Extremity Trauma

Extremity TraumaExtremity TraumaCourtesy of Bonnie Meneely, EMT-P

Overview

• Fractures• Dislocations• Amputations• Open wounds

• Neurovascular injuries• Sprains and strains• Impaled objects• Compartment syndrome

Priority of extremity trauma

Major complications and treatment:

Estimated blood loss • Pelvic and extremity fractures

Extremity Trauma -

Overview

• Pelvis• Femur• Hip• Knee• Tibia/fibula

• Clavicle/shoulder• Elbow• Forearm and wrist• Hand or foot

Major mechanisms, associated trauma, potential complications, management:

Extremity Trauma -

Extremity Trauma

Distorted or wounded extremities must not distract from life-threatening injuries. • Easy to identify• Disabling but rarely immediately life-threatening

Potential danger:• Hemorrhagic shock (very few)• Neurovascular compromise

• Distal PMS

5Extremity Trauma -

Extremity Trauma

Extremity injuries• Fractures

• Dislocations

• Amputations

• Open wounds

• Neurovascular injuries

• Impaled objects

• Compartment syndrome

6Extremity Trauma -

Courtesy of Roy Alson, MD

Extremity Injuries

Fractures

• Open (compound)• Communication to outside• Danger of contamination • Blood loss outside body

• Closed (simple)• No communication to outside• Danger of contamination • Blood loss inside body

7Extremity Trauma -

Fractures

Hemorrhage with fracture• Closed femur fracture

• Loss of 1 liter of blood• Two closed femur fractures life-threatening

• Closed pelvic fracture• Extensive bleeding into abdomen or retroperitoneal • Usually fractures in several places • 500 cc of blood loss for each fracture• May lacerate bladder or large pelvic blood vessels

8Extremity Trauma -

Extremity Injuries

Dislocations• Neurovascular compromise

• True emergency though not life-threatening• Check PMS distal to major joint dislocations

9Extremity Trauma -

Dislocations

Management

• No neurovascular compromise• Splint in position found

• Neurovascular compromise• Apply only gentle traction in effort to straighten• No more than 10 pounds of force• Often best: pad and splint in most comfortable

position and rapid safe transport

10Extremity Trauma -

Extremity Injuries

Amputations• Disabling and sometimes life-threatening • Potential for massive hemorrhage

• Most often, bleeding controlled with ordinary pressure

Amputations

Management

• Cover with damp sterile dressing, elastic wrap

• Uniform reasonable pressure across stump

• Tourniquet if bleeding absolutely not controlled • Rarely needed

• Retrieve amputated part• In plastic bag, inside ice water

Extremity Injuries

Open wounds

• Remove contamination• Gross: remove• Smaller: irrigate with normal saline

• Sterile dressing and bandage• Pressure dressing, if necessary• Pressure point• Tourniquet rare• Hemostatic agent

Open Wounds

Obviousexsanguinating hemorrhage—

only time can change order of ABC to CAB.

Obviousexsanguinating hemorrhage—

only time can change order of ABC to CAB.

Extremity Trauma -

Extremity Injuries

Neurovascular injuries• Nerves and major vessels

run beside each other in flexor area of major joints

Distal PMS• Assess pulse• Assess motor function• Assess sensory

Extremity Injuries

Impaled objects

• Do not remove• Airway obstruction exception

• Apply very bulky padding

• Transport object in place

• No unnecessary movement• Motion magnified in tissues

Compartment syndrome• Forearm and lower leg most common• Swelling compresses nerves and vessels

Extremity Injuries

Compartment Syndrome

Early symptoms• Pain

• Paresthesia

Late symptoms

• Pain

• Pallor

• Pulselessness

• Paresthesia

• Paralysis

ITLS Patient Assessment

Mechanism History Common InjuryFalls landing on feet Foot, lumbar spine

Sitting position Knee, hip

Fall onto wrist Wrist, elbow

Fall onto ankle Ankle, proximal fibula

Shoulder involved Shoulder, neck, chest

Pelvis involved Pelvis, shock

Extremity Trauma

ITLS Primary and Secondary Surveys• Major bleeding

• DCAP-BTLS

• Instability

• Crepitation

• Joint pain

• Joint movement

• Distal PMS

Management

Splinting

• Prevent motion in broken bone ends

• Eliminate further damage

• Decrease pain

Load-and-go patients

• Temporary splinting with long backboard

• Additional splinting during transport

Splinting

Rules• Adequately visualize

• Distal PMS before and after splinting• Treat neurovascular compromise

• Cover open wounds with sterile dressing

• Immobilize one joint above and below• Apply on side away from open wound• Pad splint well• Do not attempt to push bone ends under skin

Extremity Trauma

If in doubt, splint possible injury.If in doubt, splint possible injury.

Extremity Trauma -

Types of Splints

Extremity Trauma

Pelvis

Courtesy of Sam Splints

Extremity Trauma

Tibula/fibula

Extremity Trauma

Clavicle

Extremity Trauma

Shoulder

Extremity Trauma

Forearm and wrist

Extremity Trauma

Hand or foot

Summary

ITLS Primary Survey has priority.• Extremity trauma not usually life-threatening• Pelvic, femur fractures can be life-threatening

Proper splinting decreases further injury.

Dislocations of elbows, hips, knees:• Careful splinting and rapid reduction

to prevent severe disability to extremity

Discussion

International Trauma Life Support for Prehospital Care Providers Sixth Edition for Prehospital Care...

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