Point of Wounding: Musculoskeletal trauma

Musculoskeletal Trauma

Musculoskeletal Trauma

Department of Combat Medic TrainingC168W010

Terminal Learning ObjectiveTerminal Learning Objective

Given a casualty who has a suspected musculoskeletal injury,

manage a musculoskeletal injury

IAW Prehospital Trauma Life Support Chapters 12 and 21.

AssessmentAssessment

Consider the MOI and visualize possible primary injuries (most obvious) and secondary injuries (less obvious, but located in the path of

the injury).

Assess and manage any life threatening hemorrhage and injuries that affect the

casualty's airway, breathing and circulation.

AssessmentAssessment

In which three categories can musculoskeletal injuries be placed?

Isolated non life-threatening musculoskeletal trauma Non life-threatening musculoskeletal trauma, but with

multisystem life-threatening trauma Definite musculoskeletal life-threatening injuries.

Bleeding from pelvic fractures can be fatal.

AssessmentAssessment

How does placing musculoskeletal injuries in categories help?

These categories will help you understand the priority of care.

Loss of 1-2 liters of blood can be caused by the fracture of one

femur.

AssessmentAssessment

What signs and symptoms do you expect from musculoskeletal injuries?

Swelling, deformities, crepitus, limited range of motion, and pain.

Once a sign or symptom is found, no additional or repetitive steps should be taken to

reproduce it.That’s just mean….

AssessmentAssessment

When is PMS assessed?Distal to all extremity injuries.

Before and after splinting any extremity.

What do abnormal findings tell you about the extent of the injury?

 Loss of motor and sensory function usually indicates nerve injury.

Loss of motor, sensory and pulse indicate a serious arterial and

nerve injury.

Multisystem TraumaMultisystem Trauma

Life takes precedence over limb. 

Focus on maintaining vital function. Hemorrhage, Airway, Breathing, Circulation

Limited measures should be taken to addressing musculoskeletal injuries of the

extremities.

Amputation and AvulsionsAmputation and Avulsions

How is life threatening hemorrhage of the

extremities controlled?Tourniquet

Amputations may not immediately bleed due to vascular spasms of the

injured vessels. Once the spasms subside,

bleeding will occur.

Compartment SyndromeCompartment Syndrome

Compartment SyndromeCompartment Syndrome

What are the five P’s of compartment syndrome?

PainParesthesias (par·es·the·sia)

(burning, prickling, pins and needles, itching, or tingling of the skin)

Pulselessness

Paralysis

Pallor

Compartment SyndromeCompartment Syndrome

What is the corrective action if compartment syndrome is suspected?

Loosen tightly applied splints or dressings.

Tighten tourniquets or apply a second tourniquet directly above the first until a distal pulse can no

longer be detected.

Crush SyndromeCrush Syndrome

Damaged muscle tissue releases myoglobin and potassium.

Myoglobin can cause damage to the kidneys. This free myoglobin will produce tea or cola colored urine.

Elevated potassium can cause cardiac arrhythmias.

When the casualty is extricated and the injury is reperfused,

new blood washes the old blood with the accumulated toxins into the system.

Crush SyndromeCrush Syndrome

When possible, achieve vascular access and contact a MO

before extrication.

 Provide aggressive fluid resuscitation with

Normal Saline.(Lactate Ringers contains potassium)

Mangled ExtremitiesMangled Extremities

Involves skin, muscle, tendons, bone, vessels, nerves. The focus is life-threatening conditions. Apply tourniquets to control hemorrhage.

Evacuate the casualty as an urgent surgical priority.

Check on your Learning…Check on your Learning…

What is crush syndrome?

Damaged muscle tissue releases myoglobin and potassium.

Myoglobin is a storage site within muscle tissue that stores oxygen. When released from damaged

muscle, it can cause damage to the kidneys. The free myoglobin will produce tea or cola colored urine.

Elevated potassium levels can cause cardiac arrhythmias.

Check on your Learning…Check on your Learning…

What is the most common cause of compartment syndrome in combat casualties?

Instances found in combat casualties are commonly caused when arterial blood flow continues into an

extremity, but venous flow is restricted from returning to the system.

 What are the five “P”s of compartment

syndrome?

Pain, Paresthesias, Pulselessness, Pallor and Paralysis

Manage Musculoskeletal InjuriesManage Musculoskeletal Injuries

Assess and manage any life threatening hemorrhage and injuries that affect the

casualty's airway, breathing and circulation.

If the tactical situation and the casualty's condition allows, splint suspected

musculoskeletal injuries.

In a hostile environment, there may not be time to splint an injury.

Manage Musculoskeletal InjuriesManage Musculoskeletal Injuries

Why do we splint musculoskeletal injuries?

Prevent motion in the broken bone ends.Not only decreases pain but also eliminates further damage to muscles, nerves, and blood vessels and

helps to control hemorrhage.

Splinting ConsiderationsSplinting Considerations

Expose if the tactical situation allows.

Check PMS before and after splinting.If distal pulses are absent, apply gentle traction

in an attempt to realign it.

Splints must be long enough to immobilize the joint above and the joint below the injury and

rigid in order to keep the bone from moving.

Splinting ConsiderationsSplinting Considerations

If possible, use at least four ties (two above and two below the fracture) with nonslip knots to secure the

splints.

If splinting material is not available, then swathes or a combination of swathes and slings can be used to immobilize an extremity with an anatomic splint.

Splinting MaterialSplinting Material

Splinting MaterialSplinting Material

BackpackBackpack MagazineMagazine

EverythingEverything CardboardCardboard

AnythingAnything

Splinting MaterialSplinting Material

When using improvised material, what are some general rules to follow and why?

If raw materials are not available, anatomical splints may be utilized.

 Splints should be padded.

Narrow materials should not be used to secure a splint.

Pain ManagementPain Management

Splinting the injury will greatly reduce the pain.

Pharmaceutical pain management includes Morphine or Fentanyl

When are analgesics recommended?Isolated joint and limb injuries.

When are analgesics NOT recommended?Casualties with serious multisystem trauma.

AntibioticsAntibiotics

If the casualty is conscious and able to swallow, direct them to take their combat

pill pack. 

If necessary and available, provide IV antibiotics

Check on your Learning…Check on your Learning…

How should musculoskeletal trauma be treated in the following circumstances:

If the tactical situation and the casualty's condition allows?

Splint suspected musculoskeletal injuries.

In a life-threatening situation?Injuries may be splinted while the casualty is being

transported.

In a hostile environment? There may not be time to splint an injury.

Check on your Learning…Check on your Learning…

When treating a musculoskeletal injury of an extremity, you find the distal pulse is absent.

What is the next step?Apply gentle traction in an attempt to realign it. If resistance is encountered, splint the extremity in the

position found. 

When should pain management be considered for musculoskeletal injuries?

Analgesics are recommended for isolated joint and limb injuries, but not for casualties with serious

multisystem trauma.

SplintingSplinting

Demonstration and

Practical Exercise

SummarySummary

Musculoskeletal injuries can be placed in one of three categories. What are they?

Isolated non life-threatening musculoskeletal trauma. (isolated limb fractures)

Non life-threatening musculoskeletal trauma, but with multisystem life-threatening trauma.

(life-threatening injuries with limb fractures)

Definite musculoskeletal life-threatening injuries. (pelvic and femur fractures with life-threatening blood

loss)

How would you treat each one?

SummarySummary

When should a neurological assessment (PMS) be completed?

Distal to any extremity injury.Complete before and after splinting any extremity.

 What do abnormalities indicate?

Loss of motor and sensory function usually indicates a nerve injury.

Loss of motor, sensory and pulse indicate a serious arterial and nerve injury.

SummarySummary

What is the correct length and consistency of a splint?

Splints must be long enough to immobilize the joint above and the joint below the injury and rigid in order to keep the bone from moving.

Questions???Questions???