12 musculoskeletal injuries 9/19/2016 - munson healthcare presentation.pdf12_musculoskeletal...

12_Musculoskeletal Injuries 9/19/2016

STN E-Library 2012 1

Nursing Grand Rounds Trauma Lecture

Shamarie Regenold, FNP‐BC

Elizabeth Erickson, PA‐C

Musculoskeletal Injuries

Objectives

At the conclusion of this presentation the participant will be able to:

• Identify the initial assessment for patients with musculoskeletal injury

•Describe upper extremity, lower extremity and pelvic musculoskeletal traumatic injuries and implications for nursing care

•Explain indications and strategies for open and closed reduction of fracture/dislocations

•Discuss the prevention, recognition and interventions for compartment syndrome and rhabdomyolysis



Resuscitation

A diagnosis of Musculoskeletal Injury may not occur initially, until there is significant blood loss causing

hemodynamic instability.

The Primary Survey in ATLS/ATCN does not include a thorough assessment of musculoskeletal injuries

unless gross bleeding causes a concern.

Radiography may/will confirm musculoskeletal injuries.

Prehospital information can help raise the index of suspicion.

Mechanism of Injury (MOI)

How’s

What’s

Where’s

When’s

Injury Facts

• Injury: The Leading Cause of Death Among Persons ages 1‐44

•800,000 EMT’s in our country significantly impact on the outcomes of trauma victims

•Field Triage is a process whereas the level of injury is determined, medical management is provided, and the right Trauma Center is identified



2011 Field Triage Decision Scheme

Step One:• Glasgow Coma Scale score of 13 or lower (change from <14),

• Systolic blood pressure of less than 90 mm Hg, or

• Respiratory rate of fewer than 10 or more than 29 breaths/minute (<20 breaths/minute in infants aged <1 year) or need for ventilatory support (criterion added).

Field Triage Decision Scheme

Step Two:• All penetrating injuries to head, neck, torso, and extremities proximal to elbow or knee

• Chest wall instability or deformity (e.g., flail chest)

• 2 or more proximal long‐bone fractures;• Crushed, degloved, mangled, or pulseless extremity • Amputation proximal to wrist or ankle

• Pelvic fractures• Open or depressed skull fractures; or• Paralysis

Step Three MOI Criteria

•Falls •High‐risk auto crash•Automobile vspedestrian/bicyclist thrown, run over, or with significant (>20 miles/hour) impact

•Motorcycle crash faster than 20 miles/hour



Step Four: Special Considerations

• Older Adults

• Children

• Anticoagulants

• Bleeding disorders

• Burns

• Pregnancy

Initial Management

Blood loss hypovolemia

Pain

Infection

Neurovascular damage

The four priorities of care

Blood Loss Hypovolemia



Petit Tourniquet ‐ Savigny 1798

Tourniquets

Pelvic Binder



Covert Blood Loss

•Blood Loss Associated with Fracture in Adults•Fracture site amount of blood loss in mL

•Radius and ulna 150–250•Humerus 250

•Tibia and fibula 500 •Femur 1000

•Pelvis 1500–3000

Blood Loss Hypovolemia

CLASS I CLASS II CLASS III CLASS IV

BloodLoss (ml)%

<75015%

750-150015%-30%

1500-200030-40%

>2000>40%

HR <100 >100 >120 >140

BP normal normal decrease decrease

PP normal decrease decrease decrease

RR 14-20 20-30 30-40 >35

UOP >30 20-30 5-15 negligible

CNS slightlyanxious

mildlyanxious

anxiousconfused

confusedlethargic

Acute Pain from Traumatic Injury

• Leads to stress response that increases heart rate and blood pressure

• Limits recovery

• Improves clinical outcome when managed well



Pain Assessment

• Numeric Scale

• Visual Analogue Scale

• Faces Pain Scale

Pain Management‐General Rules

Analgesics should be prescribed with a constant concern for detail

Dosing of pain medication should be adapted to the individual

Analgesics should be prescribed according to pain intensity as evaluated by a scale of intensity of pain

Analgesics should be given at regular intervals

Appropriate route for administration of analgesics

Prehospital

Pain starts at the point of injury (POI) and must be controlled from that initiating event

Prehospital practitioner has the first and perhaps only opportunity to break the pain cascade.

Early, effective pain control is essential to successful outcomes after traumatic injury



Current Acute Care Practice

Severe pain

Moderate Pain

Mild Pain

Strongest Opioid

Stronger Opioid

Mild Opioid

Postoperative Pain

2. Unless contraindicated, patients should receive an around the-clock regimen of NSAIDs, COXIBs, or acetaminophen

1. Epidural or intrathecal opioids, systemic opioid PCA, and regional techniques

Procedural Medications

Etomidate Midazolam

Propofol Ketamine

Fentanyl



Pain

Standardize medications

Keep airway resuscitative equipment

nearby

Frequent sensory &

motor assessments

Prevent Infection

Sample of Proprietary Wound Irrigation Systems

Bionixmed.com Irrimax.com

ortho.smith-nephew.com

Infection

Antibiotics are often necessary in the prophylaxis and treatment of orthopedic

infections post-operatively

The characteristics of implantable materials makes them a generous host

for bacterial colonization



Prophylaxis and Surgical Infections

• Staphylococci

• Pseudomonas Aeruginosa

• Klebsiella

• Acinetobacter baumani

Assessment

•What is baseline status?

•Are splints applied correctly

•Past Medical History

Diagnostic Studies

• Plain films

• CT, CT angio

• MRI

• Angiography



3 Views of the Pelvis

AP View Inlet View Outlet View

Anterior‐Posterior (AP) View of the Pelvis

Oblique’s “Judet”



AP View of Acetabulum

Selected Injuries

Types of Fractures

Wikimedia.com



Drdavidgeier.com

Non-displaced Displaced

Types of Fractures

Skeletal Traction

• Indications• Unstable patient (damage control)

• Preparation for surgery

AO Foundation.org

Traction & Immobilization



Reduction

•Reduction is a medical procedure to restore a fracture or dislocation to the correct alignment. For the fractured bone to heal without any deformity the bony fragments must be re‐aligned to their normal anatomical position

Dislocations

• Shoulder

• Knee

• Hip

• Shoulder

• Knee

• Hip

Knee Dislocation



Hip Dislocation

Classic presentation

of hip dislocation

Types of Surgical Treatments for Fractures

Intramedullary Nails vs. Screws and Plates



Gamma Nail in Femoral Head Intramedullary Nail in Femoral Shaft

Screw Holds Intramedullary Nail in Place to Avoid Migration

Open Reduction Internal Fixation (ORIF)



External Fixation

• Indications

• Nursing Responsibilities

• Indications

• Nursing Responsibilities

Pelvic Fractures

Classification of Pelvic Fractures: Young vs. Tile



Diastasis Symphysis Pubis

Associated Injuries in Order of Frequency

•Closed head injury• Long bone fractures•Peripheral nerve injury•Thoracic injury•Bladder•Spleen• Liver•GI tract•Kidney, Urethra, Mesentery, Diaphragm

Pelvic Fracture Treatment Protocol

Trauma.org



Angiographic Embolization

Blush

Complex Open Fractures

•Gustilo I : <1 cm wound over Fx

•Gustilo II: >1cm wound over Fx

•Gustilo III: A) Extensive soft tissue

injury

B) Periosteal stripping

C) Arterial injury needing repair

Gustilo Type 1 & Type 2



Mangled Extremity

Popliteal Artery and Vein Shunted



Identify the Zone of Injury



Compartment Syndrome

Capillary Perfusion Pressure- 25 mm Hg

Interstitial Pressure 4-6 mm Hg

http://www.hughston.com/

Compartment Syndrome

Ischemia

Myoglobin Release

Necrosis

Increase Interstitial Edema and Intravascular Viscosity

Increase Permeability

Endothelial Cell Damage

Vasodilatation



Etiology

Increased Fluid Content in Interstitial Space

Decreased Compartment Size

Signs and Symptoms

•Pain disproportionate to injury!

•Pain with passive stretching

•Neuro compromise

•Tenseness•Unilateral size increase

Wiki.org

High level of suspicion



Interventions

• Supplemental O2

• Level extremity

• Routine trauma resuscitation

• Extra vigilance in some patients

• Hydration

• Diuresis

• Alkalinization of urine

• Supplemental O2

• Level extremity

• Routine trauma resuscitation

• Extra vigilance in some patients

• Hydration

• Diuresis

• Alkalinization of urine

Delta P+ Diastolic Pressure - Compartment Pressure

Compartment >45 Delta P <40

Measurement Compartment Pressures

Fasciotomy

•Definitive Treatment with limb saving results

•Extends hospital length of stay as it turns a closed injury into an open injury

•Threshold for compartment pressure remains ~ 30 mmHg



Rhabdomyolysis

Muscle destruction

Adverse drug

reactions

Toxic effects

What is Myoglobin

Iron containing pigment found in skeletal muscle

Especially in those specialized for sustained contraction

Pathophysiology

• Direct toxicity

• Cast formation

• Mechanical obstruction

• Acid urine causes myoglobin to form a gel

• Hypoperfusion from hemorrhage and fluid shifts

• Reperfusion fluid shifts

• Further hypoperfusion



Causes of Rhabdomyolysis

Rhabdomyolysis

Precipitation is exacerbated by acidic pH of the urine

Myoglobin in the glomerular filtrate precipitates in the tubules and obstructs flow

Results in release of free myoglobin

Breakdown of muscle tissue

Treatment of the Effect of Rhabdomyolysis• Prevent Acute Renal Failure from the effects of myoglobinuria

• Monitor CPK, serum and urine myoglobinuria

• Ensure fluid resuscitation

• Ensure hyperdynamic urine output

• Ensure alkaline urine

• May diurese for mechanical lavage

• Carbonic anhydrase inhibitor



Key Point

Patient must be adequately volume resuscitated for appropriate “pushing pressure”

Before administering diuretics and mannitol to exert a “pulling pressure”

Propofol Infusion Syndrome (PRIS)

• Adverse drug event with high doses

• Not recommended for infusions > 48 hrs

• Signs of PRIS: hyperkalemia, metabolic acidosis, lipemia, renal failure, cardiovascular collapse, hepatomegaly, rhabdomyolysis

Case Study

• 60 yo Female MVC

• Medical HX: HTN, borderline COPD

• Injuries identified on admission:• Right rib fx: 9‐10

• Left rib fx: multiple

• Large pneumomediastinum

• Herniation of liver through the 9th and 10th ribs

• Scapula fx



• Left highly comminuted open displaced fracture of the distal tibia

• Left fibula fx

• Left distal radius and ulnar open fx

• Right closed bimalleolar fx

Admission Labs

BUN 22 Cr 1.3

Serum myoglobin 3018 ng/ml

CK completed on PTD# 2: 4516

Diagnosis

Precipitating Factor

Serum myoglobin

Urine myoglobin >15 mg/l

+heme in absence of RBC in yellow urine

CPK >5000 u/l incidence of ARF becomes significant



Hospital Course

• PTD 5 BUN 60 Cr 5.4 despite aggressive hydration, avoidance of nephrotoxic medications as much as possible, and diuresis

• Dialysis begins on 8/11/16

• Pt. will require ongoing HD post discharge

Early Dialysis

•ARF pts who require RRT have increased morbidity and mortality

•Averting continued rises in creatinine might improve outcome in critically injured trauma patients

•ARF pts who require RRT have increased morbidity and mortality

•Averting continued rises in creatinine might improve outcome in critically injured trauma patients

Deep Vein Thrombosis

Incidence

Signs

Diagnosis

Prophylaxis



Ongoing Assessments

Traction does move out of place

Pins migrate away from initial sites

Patients re-bleed after surgery

Immobilization does cause pneumonia and deep vein thrombosis.

Neurovascular status changes without warning

Injuries Associated with Musculoskeletal Trauma

Injury Missed/Associated Injury

Clavicular fractureScapular fractureFracture and/or dislocation of shoulder

Major thoracic injury, esp. pulmonary contusion and rib fractures

Displaced thoracic spine fracture Thoracic aortic rupture

Spine fracture Intraabdominal injury

Fracture/dislocation of elbow Brachial artery injuryMedian, ulnar, and radial nerve injury

Femur fracture Femoral neck fracturePosterior hip dislocationIntraabdominal injuries

Posterior knee dislocation Femoral fracturePosterior hip dislocation

Knee dislocation or displaced tibial plateaufracture

Popliteal artery and nerve injuries

Calcaneal fracture Spine injury or fractureFracture dislocation of hind footTibial plateau fracture

Open fracture 70% incidence of associated nonskeletal injury

Summary

•Trauma care begins with standard process for care and destination protocol for pre‐hospital personnel

•The initial management of the patient consists of a thorough assessment of the type and degree of injury, and the need for damage control surgery to maintain homeostasis

•Pain management is a critical aspect in the care of the patient with musculoskeletal injury



Summary continued…

• The trauma nurse must be familiar with the types of radiographic studies performed and the need for follow studies in certain situations

•Multi‐orthopedic injuries require different treatment strategies: traction, and open or closed reduction

• The nurse must identify limb‐threatening compartment syndrome and patients at risk for rhabdomyolysis

• The nurse must protect the patient from infection, which may progress to osteomyelitis

Drug and Alcohol Abuse in the Trauma Patient

Objectives

• Identifying the patient at risk for withdrawal

• Differentiating withdrawal from head injury symptoms

• Management of the trauma patient during withdrawal from drugs and alcohol



Breadth of the Issue

CDC. (2015)Prevalence of binge drinking among adults. http://www.cdc.gov/alcohol/data-stats.htm

• 5 or more drinks per occasion in men

• 4 or more drinks per occasion in women

• 15 or more drinks per week for men and 8 or more drinks per week for women

• Binge and Heavy Alcohol use sharply rises in ages 18‐20 and peaks in ages 21‐25 years and slowly tapers off after that

• Illicit drug use began to rise in 2010 with a peak in ages 18‐20



• SAMHSA and the ACS advocate for mandatory screening methods on every trauma patient

• Screening and Brief intervention are required for Level I and II trauma centers

• Alcohol and Drug levels are ordered on all Level I and II trauma activation patient

CDC. (2016) Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention

• AUDIT‐C• Standardized screening tool

• 3 item screening tool about alcohol consumption

AUDIT‐C

http://cqaimh.org/pdf/tool_auditc.pdf



12 fl oz ofregular beer

5 fl oz oftable wine

1.5 fl oz shot of80-proof spirits("hard liquor")

• There may need to be follow up questions if your patient has a positive screen

• This will assist you in assessing the risk of withdrawal in your patient

• “When was your last drink?” Mild symptoms usually begin 6‐48 hours after the last drink

• “Have you ever been treated for alcohol withdrawal before?”

• People who have experienced withdrawal symptoms are usually attentive to their bodies signals and can tell you what symptoms they generally experience.

• “Have you ever had an alcohol withdrawal seizure?”Withdrawal can occur even with an elevated BAL (blood alcohol level)



Adolescents and Children

• CRAFFT‐ score of 1= medium risk, brief intervention, 2+ = high risk, brief intervention and referral

• C ‐ Have you ever ridden in a CAR driven by someone (including yourself) who was "high" or had been using alcohol or drugs?

• R ‐ Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in?

• A ‐ Do you ever use alcohol/drugs while you are by yourself, ALONE?

• F ‐ Do you ever FORGET things you did while using alcohol or drugs?

• F ‐ Do your family or FRIENDS ever tell you that you should cut down on your drinking or drug use?

• T ‐ Have you gotten into TROUBLE while you were using alcohol or drugs?

• CIWA used here at Munson

• Currently in the process of being reviewed

• Future changes to come

TBI Patients

• An estimated 36‐51% of patients who sustained a TBI are using substances when this occurs

• Interestingly, the more severe TBI patients had less drug and alcohol use than the population with nothing in their system

Andelic, N. et al. (2010). Effects of acute substance use and pre-injury substance abuse on traumatic brain injury severity in adults admitted to a trauma centre. Journal of Trauma Management & Outcomes, 4;6.



•Neuroprotective effect of alcohol on the brain•Alcohol causes a blunting of the sympathetic response, causing activation of the stress response after major injury

•The surge in catecholamines causes massive systemic increase in metabolism, leaving less oxygen and glucose for the brain

Assessment for withdrawal in the TBI patient

•TBI patients are typically agitated at times and it is nearly impossible to ascertain the reason

•Benzodiazepines are the preferred treatment for signs and symptoms of withdrawal‐ inhibits nerve‐cell excitability in the brain

• Intubated TBI patients are on heavy sedation and pain management already

• An important consideration in these patients is the initiation of thiamine

• Thiamine helps the brain cells produce energy from sugar.

Martin, P. et al (2004). The role of thiamine deficiency in alcoholic brain disease. http://pubs.niaaa.nih.gov/publications/arh27-2/134-142.htm



References

Advanced Trauma Life Support For Doctors. 8th ed. New York, New York: American College of Surgeons, 2008.

American Society of Anesthesiologists Task Force on Acute Pain Management. Practice guidelines for acute pain management in the perioperative setting: an updated report. Anesthesiology. 2012; 116(2): 248‐73.

Anterior Pelvic Injuries. Wheeless' on line Web site. http://www.wheelessonline.com/ortho/pelvic_fractures. Updated September 21, 2012. Accessed November 16, 2012.

Bowman, WJ, Nesbitt, ME, and Therian, SP. The effects of standardized trauma training on prehospital pain control: Have pain medication administration rates increased on the battlefield? J Trauma Acute Care Surg. 2012; 73(2 Supp 1): 42‐48.

Brandt, MM, Falvo, AJ, Rubinfield, IS, et al. Renal dysfunction in trauma: even a little costs a lot. J Trauma 2007; 62(6): 1362‐1364.

Dries, DJ. Initial Evaluation of the Trauma Patient e‐Medicine Web site. http://emedicine.medscape.com/article/434707‐overview. Updated September 20, 2012. Accessed November 16, 2012.

Cutts, S, Prempeh, M, and Drew, S. Anterior Shoulder Dislocation. Ann R Coll Surg Engl. 2009 January; 91(1): 2–7.

Davenport, M. Joint Reduction, Hip Dislocation, Posterior e‐Medicine Web site. http://emedicine.medscape.com/article/109225‐overview. Updated February 28, 2012. Accessed November 16, 2012

Fractures of the Pelvis and Acetabulum. OA Centers for Orthopaedics Web site. http://www.orthoassociates.com/SP11B26/ . Updated September 26, 2011. Accessed November 16, 2012.

Gonzalez, D. Crush Syndrome. Critical Care Medicine. 2005; 33(1): S34‐41.

Graf, K. Unstable Pelvic Fractures e‐Medicine Web site. http://emedicine.medscape.com/article/1247426‐overview. Updated August 15, 2011. Accessed November 16, 2012.

Kelleher, HB. Knee Dislocation in Emergency Medicine e Medicine Web site. http://emedicine.medscape.com/article/823589‐overview. Updated January 11, 2011. Accessed November 16, 2012.

Krost,W, Mistovich, J, and Limmer, D. Beyond the Basics: Crush Injuries and Compartment

Syndrome EMSWorld Web site. http://www.emsworld.com/article/10321291/beyond‐the‐basicscrush‐

injuries‐and‐compartment‐syndrome. February 1, 2008. Accessed November 16, 2012.

Malchow, RJ, and Black, IH. The evolution of pain management in the critically ill trauma

patient: Emerging concepts from the global war on terrorism. Crit Care Med. 2008; 36(7 Suppl):

S 346‐357.

McQuillan, KA, Von Rueden, KT, Hartsock, RL, et al. Trauma Nursing: From Resuscitation

Through Rehabilitation (4th ed). W.B. Saunders Co., Philadelphia; 2009.

Sahjian, M, and Frakes, M. Crush Injuries: Pathophysiology and Current Treatment. Advanced

Emergency Nursing Journal. 2007; 29(2): 145‐150.

Tactical Combat Casualty Care Guidelines. http://links.lww.com/TA/A139). Updated August 8,

2011. Accessed November 16, 2012.

The clinical and economic implications of using multi‐modal strategies for postsurgical pain

management. Website. https://www.premierinc.com/advisorlive/Presentations/may‐10‐postsurgical‐

pain‐management‐advisor‐live‐final.pdf . Accessed November 16, 2012.

Vargas‐Schaffer, G. Is the WHO analgesic ladder still valid? Twenty‐four years of experience.

Canadian Family Physician. 2010; 56(6): 514‐517.

Andelic, N. et al. (2010). Effects of acute substance use and pre‐injury substance abuse on traumatic brain injury severity in adults admitted to a trauma centre. Journal of Trauma Management & Outcomes, 4;6.

Martin, P. et al (2004). The role of thiamine deficiency in alcoholic brain disease. http://pubs.niaaa.nih.gov/publications/arh27‐2/134‐142.htm



CDC. (2016) Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention

CDC. (2015)Prevalence of binge drinking among adults. http://www.cdc.gov/alcohol/data‐stats.htm

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