CHAPTER 08 Ekstrem

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Objectives

Recognize and describe the significance of

Musculoskeletal injuries.

Outline assessment priorities to identify

Life and limb-thereatening injuries.

Outline principles of management. Demonstrate ability to assess, assign

Priorities to, and initially manage injuries.


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Musculoskeletal Trauma Common, occasionally life -threatening

Major musculosekeletal injuries often

indicate other injuries

Hemorrhage, compartment syndrome,

Crush syndrome, fat embolism are life-

andlimb threatening problems

Continued reevaluation !


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Primary Survey/ Resuscitation Recognize and control hemorrhage

Direct pressure

Splint fractures

Aggressive fluid resuscitation


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Primary Survey Resuscitation

Adjuncts : Fracture immobilization

Goals

Hemorrhage control Pain relief

Prevent further softtissue injury

Apply splaint early,but avoid delay in

resuscitation


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Primary Survey/ ResuscitationAdjuncts : x-rays

Determinited by patient,s condition

Obtain AP pelvis early if hemodynamically

Abnormal and no obvious source of

bleeding


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Secondary SurveyHistory

Mechanism of injury

Environment

AMPLE history

Prehospital Care


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Secondary SurveyPhysical Examination

Expose / avoid hypothermia

Goal: Identify life-and limb-threatening,

and occult injuries

Examine Skin

Circulation

Neuromuscular

Skeletal


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Secondary SurveyLook

Bleeding deformity, color

Posteriorly using modified log roll

Spontaneous movement


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Secondary SurveyFeel

Temperature,tendernees,crepitus

Sensation

Joint stability

Back and pelvis: Tendernees, gap


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Secondary SurveyCirculatory Evaluation

Color, temperature

Pulse pressure, capillary refill

Paresthesia

Doppler: Ankle arm ratio Bruit / thril


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Secondary Survey

X-ray

Guided by clinical findings

Joint above and below

Obtain 2 views

Delay x-rays if: Vascular compromise

Impending skin breakdown


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Life- Thereatening Injuries

Major pelvic disruption with hemorrhage

Major arterial hemorrhage

Crush syndrome (rhabdomyolysis)


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Major Pelvic Disruption

Posterior pelvic structures disrupted

Pelvis open : vessels, nerves,rectum, skin

Mechanism of injury

Motorcycle

Pedestrian Crush

Falls > 12 feet (3.6 meters)


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Major Pelvic Disruption

Assessment and Management

Hemorrhage occurs rapidly, identify early

Unexplained hypotension

Open wounds, meatal blood, high prostate,

expanding hematoma

Palpable Motion of pelvic ring

Hemorrhage control, fluid resuscitation


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Major Arterial Hemorrhage Penetrating / blunt injury in close

proximity to artery

Hemorrhage ,hematoma,hypotension

Ischemic extremity

Stop the bleeding ! Immediate surgical consult


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Crush Syndrome Myoglobinuria

Metabolic acidosis, K ,Ca and

coagulopathy

Compartment syndrome

IV fluids,alkalization of urine


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Limb- Threatening Injuries

Open fracture and joint injuries

Vascular injuries


Neurologic injury


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Open Fractures, Joint Injuries Wide- spectrum of soft-tissue injuries

Open wound = open fracture

Treatment

Splint sterile dressing tetanus

Immediate surgical consult

Tetanus prophylaxis

Antibiotics?


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Vascular Injury, Amputation Variable presentation : Assess pulses

Associated with fracture/dislocations

Realign

Check pulses after splinting

Immediate surgical consult


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Compartment Syndrome

Crush Injury with Compartment Syndrome


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Compartment Syndrome

Compartment preesure

Nerve/muscle ischemia necrosis Pain, paresthesia, paresis, swelling

Release constricting devices

Suspect in tibial, forearm fracture afterrevascularization inunconsciouspatient

Early surgical consult


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Neurologic Injury Due to fracture /dislocation

Posterior shoulder : Axillary nerve

Posterior hip : Seciatic nerve

Recognize injury and immobilize

Early surgical consult

Careful reduction, if possible, reassess

and splint


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Pitfalls

Occult injuries

Occult blood loss



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Summary

Primary Survey :Indentify life-thereatening

Injuries

Secondary Survey :Indentify limb-

threatening injuries

Mechanism of Injuries :History important

Surgical consult

Early immobilization


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Question

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CHAPTER 08 Ekstrem