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International Trauma Life Support
International Trauma Life Support
for Prehospital Care ProvidersSixth Edition
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
Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ
Chapter 14Extremity TraumaChapter 14Extremity Trauma
Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ
Extremity TraumaExtremity TraumaCourtesy of Bonnie Meneely, EMT-P
Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ
Overview
3
• 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 -
Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ
Overview
4
• Pelvis• Femur• Hip• Knee• Tibia/fibula
• Clavicle/shoulder• Elbow• Forearm and wrist• Hand or foot
Major mechanisms, associated trauma, potential complications, management:
Extremity Trauma -
Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ
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 -
Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ
Extremity Trauma
Extremity injuries• Fractures
• Dislocations
• Amputations
• Open wounds
• Neurovascular injuries
• Impaled objects
• Compartment syndrome
6Extremity Trauma -
Courtesy of Roy Alson, MD
Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ
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 -
Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ
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 -
Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ
Extremity Injuries
Dislocations• Neurovascular compromise
• True emergency though not life-threatening• Check PMS distal to major joint dislocations
9Extremity Trauma -
Courtesy of Roy Alson, MD
Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ
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 -
Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ
Extremity Injuries
Amputations• Disabling and sometimes life-threatening • Potential for massive hemorrhage
• Most often, bleeding controlled with ordinary pressure
11Extremity Trauma -
Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ
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
12Extremity Trauma -
Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ
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
13Extremity Trauma -
Courtesy of Roy Alson, MD
Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ
Open Wounds
14
Obviousexsanguinating hemorrhage—
only time can change order of ABC to CAB.
Obviousexsanguinating hemorrhage—
only time can change order of ABC to CAB.
Extremity Trauma -
Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ
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
15Extremity Trauma -
Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ
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
16Extremity Trauma -
Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ
Compartment syndrome• Forearm and lower leg most common• Swelling compresses nerves and vessels
Extremity Injuries
17Extremity Trauma -
Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ
Compartment Syndrome
Early symptoms• Pain
• Paresthesia
Late symptoms
• Pain
• Pallor
• Pulselessness
• Paresthesia
• Paralysis
18Extremity Trauma -
Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ
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
19Extremity Trauma -
Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ
Extremity Trauma
ITLS Primary and Secondary Surveys• Major bleeding
• DCAP-BTLS
• Instability
• Crepitation
• Joint pain
• Joint movement
• Distal PMS
20Extremity Trauma -
Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ
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
21Extremity Trauma -
Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ
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
22Extremity Trauma -
Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ
Extremity Trauma
23
If in doubt, splint possible injury.If in doubt, splint possible injury.
Extremity Trauma -
Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ
Types of Splints
24Extremity Trauma -
Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ
Extremity Trauma
Spine
25Extremity Trauma -
Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ
Extremity Trauma
Pelvis
26Extremity Trauma -
Courtesy of Sam Splints
Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ
Extremity Trauma
Femur
27Extremity Trauma -
Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ
Extremity Trauma
Hip
28Extremity Trauma -
Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ
Extremity Trauma
Knee
29Extremity Trauma -
Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ
Extremity Trauma
Tibula/fibula
30Extremity Trauma -
Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ
Extremity Trauma
Clavicle
31Extremity Trauma -
Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ
Extremity Trauma
Shoulder
32Extremity Trauma -
Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ
Extremity Trauma
Elbow
33Extremity Trauma -
Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ
Extremity Trauma
Forearm and wrist
34Extremity Trauma -
Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ
Extremity Trauma
Hand or foot
35Extremity Trauma -
Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ
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
36Extremity Trauma -
Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ
Discussion
37Extremity Trauma -
© Craig Jackson/In the Dark Photography