emergency lectures - ortho trauma
TRANSCRIPT
Initial Assessment and Management
Loma Linda Medical Center
Musculoskeletal Trauma
Case Scenario
● A wall collapses on a 44-year-old male worker
● BP: 130/75; Pulse: 110; RR: 22
● GCS score: 15
● Painful, bruised, deformed right leg
What are your priorities?Is this life- or limb-threatening?
Objectives
● Describe the principles for assessing patients with musculoskeletal injuries.
● Identify treatment priorities.
● Explain the importance of musculoskeletal injuries in multiply injured patients.
Primary Survey
How do musculoskeletal injuries impact on the primary survey?
Primary Survey
●External bleeding
●Occult blood loss
● Pelvic fractures
● Long bone fractures
How do musculoskeletal injuries impact on the primary survey?
A B D EC
Primary Survey
What are my priorities and management principles?
Primary Survey
●Stop the bleeding! (pressure /
tourniquet)
●Splint the extremity
●Stabilize the pelvis
During the Primary Survey – The 3 S’s
What are my priorities and management principles?
Primary Survey
●Prevents further blood loss and injury
●Can restore or maintain perfusion
●Relieves pain
● Important during evaluation
●Do not delay
Rationale for Splinting
Primary Survey
Stabilization
Secondary Survey
●Look
●Listen
●Feel
Secondary Survey
Look
●Deformity
●Pain
●Tenderness
●Wound(s)
Rationale for Splinting
Listen
●Doppler signals
●Bruit
Feel
●Crepitus
●Skin flaps
●Neurologic deficit
●Pulses
Secondary Survey
●Preinjury status and predisposing factors
●Mechanism of injury
●Time of injury
●Associated factors (eg, environment)
●Prehospital observations and care
Key Information
Secondary Survey
●Vascular compromise
●Open fractures
Early Concerns
Secondary Survey
●Reduce fracture(s)
●Splint fracture(s)
●Assess by Doppler
●Obtain surgical consult Time is critical!
●Consider angiography
Assess and Manage Vascular Compromise
Secondary Survey
●Apply appropriate splint
●Cleanse / debride (now or later)
●Consider time factor
●Obtain orthopedic consult
●Antibiotic / tetanus status
Managing Open Fractures
Secondary Survey
●What x-rays do I need?
●Any suspected area
●One joint above and below
●When do I obtain them?
●Patient is hemodynamically normal
X-Ray Studies
Secondary Survey
●When should I delay getting x-rays?
● If life-threatening injuries take priority
● If patient transfer will be delayed
X-Ray Studies
Compartment Syndrome
What injuries can cause compartment syndrome?
Compartment Syndrome
What injuries can cause compartment syndrome?●Tibia and forearm
fractures
●Vascular and bony injuries
●Injuries immobilized in tight dressings or casts
●Severe crush injuries to muscle
●Burns
Compartment Syndrome
How do I recognize compartment syndrome?
Compartment Syndrome
●Pain
●Disproportionate
●Passive stretch
●Tense compartments
●Asymmetry
●Paresthesia
●Tissue pressures > 35 to 45 mm Hg
How do I recognize compartment syndrome?
● Altered sensation
● Compartment syndrome
● Vascular injury
● Crush injuries / myoglobinuria
● Occult fractures / soft tissue injuries
● Coagulation disorders
Pitfalls
Pitfalls
Summary
●Manage life-threatening injuries first
●Stop the bleeding!
●Reduce and immobilize fractures and dislocations
●Recognize vascular compromise
●Consider compartment syndrome
Thank you everyone!