management musculoskeletal trauma - · pdf filemanagement musculoskeletal trauma ......
TRANSCRIPT
![Page 1: Management Musculoskeletal Trauma - · PDF fileManagement Musculoskeletal Trauma ... Secondary Survey ... –One cavity above/below entrance/exit wounds](https://reader031.vdocuments.site/reader031/viewer/2022022503/5ab040c57f8b9a59478e63e6/html5/thumbnails/1.jpg)
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Management
Musculoskeletal
Trauma
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Musculoskeletal Trauma
Common, occasionally life-threatening
Major musculoskeletal injuries often
indicate other injuries
Hemorrhage, compartment syndrome
Crush syndrome, fat embolism are life-
and limb threatening problems
Continued reevaluation !
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Trauma is not
rocket science!
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ABCDEF
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Initial Assessment: Primary
Survey
• A = Airway
• B = Breathing
• C = Circulation
• D = Disability
• E = Exposure
• F = Fracture
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• Clear & establish a good airway
– Consider intubation for coma, shock, and thoracic injuries
• C-spine stabilization
Initial Assessment: Airway
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Initial Assessment: Breathing
• Chest excursion & breath sounds
– Flail chest
• Pneumothorax
– Open
– Tension
• Massive Hemothorax
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Initial Assessment: Circulation
• Perfusion (mental status, skin, pulse)
• Control bleeding with pressure
• Pericardial Tamponade
– Beck’s Triad
• Establish 2 large bore (16G or larger) IV’s
in upper extremity peripheral veins
• Resuscitate with Lactated Ringers
– After 4 L think about resuscitation with blood
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Initial Assessment: Disability
• Neurologic status
– Glasgow Coma Scale
• Eye
• Motor-best predictor of long term outcome
• Verbal
– Spinal Cord Injury
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Initial Assessment: Exposure
• Remove clothes
• Temperature
– warm blankets
• Finger and tube in every orifice
• Maintain full spine precautions
– Log Roll
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Initial Assessment: Fracture
• Stabilize Fractures
• Relocate dislocated joints
• Reassess pulses
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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 soft-tissue injury
Apply splint early, but avoid delay in
resuscitation
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Primary Survey/ Resuscitation
Adjuncts : x-rays
Determined by patient’s condition
Obtain AP pelvis early if
hemodynamically abnormal and
no obvious source of bleeding
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Secondary Survey
• Patient history
• Head to toe physical exam
• Radiography
– Lateral C-spine, C-xray, pelvis
– One cavity above/below entrance/exit wounds
– FAST
• Urinary bladder drainage
• NGT
• Blood sampling/monitoring
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Secondary Survey
History
Mechanism of injury
Environment
AMPLE history
Prehospital care
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Secondary Survey
Physical Examination
Expose / avoid hypothermia
Goal: Identify life- and limb-threatening,
and occult injuries
Examine
• Skin
• Circulation
• Neuromuscular
• Skeletal
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Secondary Survey
Look
• Bleeding deformity, color
• Posteriorly using modified log roll
• Spontaneous movement
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Secondary Survey
Feel
• Temperature, tenderness, crepitus
• Sensation
• Joint stability
• Back and pelvis: Tenderness, gap
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Secondary Survey
Circulatory Evaluation
Color, temperature
Pulse pressure, capillary refill
Paresthesia
Doppler: Ankle / arm ratio
Bruit / thrill
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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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Management :
stabilization
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Stabilization for transport
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Operative procedures
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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
Compartment syndrome
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 pressure
Nerve / muscle ischemia → necrosis
Pain, paresthesia, paresis, swelling
Release constricting devices
Suspect in tibial, forearm fracture, after
revascularization, in unconscious patient
Early surgical consult
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Neurologic Injury
Due to fracture / dislocation
• Posterior shoulder : Axillary nerve
• Posterior hip : Sciatic nerve
Recognize injury and immobilize
Early surgical consult
Careful reduction, if possible, → reassess and splint
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Traksi
Upaya pengobatan atau rehabilitasi pada
kelainan dan atau cedera sistem
muskuloskeletal dengan menggunakan
traksi (tarikan) padanya secara terus
menerus
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Traksi
• Pada Tulang (Traksi Skeletal)
• Pada Kulit (Traksi Kulit)
• Traksi Menetap (Fixed Traction)
• Traksi Berimbang (Balanced Traction)
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Tujuan Traksi
• Reposisi (pada fraktur / dislokasi)
• Imobilisasi (setelah reposisi)
• Mengkoreksi deformitas (mis. kontraktur)
• Mengurangi nyeri (Coxitis/Gonitis TB)
• Mencegah deformitas (Coxitis/Gonitis TB,
post poliomielitis)
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Prinsip Traksi
• Ada tarikan dan ada kekuatan yang
melawan tarikan (Traksi-Kontra traksi),
kontra traksi yang digunakan biasanya
adalah gravitasi / berat badan pasien
• Traksi-Kontra traksi mengikuti hukum alam
• Traksi-Kontra traksi tidak menimbulkan
komplikasi
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Komplikasi Traksi
• Komplikasi akibat tarikannya
– Spasmus pembuluh darah
– Kelumpuhan saraf
– Iskhemi kulit
• Komplikasi akibat perangkat traksi
– Infeksi akibat tusukan kawat/pin
– Alergi plester
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Traksi Kulit
Alat : Skin Traction Kit pediatrik, adult
Jenis : plester dengan perekat
foam rubber tanpa perekat
Indikasi : Traksi < 10 lbs ( < 5 Kg )
Kontra indikasi : alergi plester, peny. Kulit
Komplikasi : dermatitis, gangguan
neurologis, gangg. vaskuler
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Traksi Kulit
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Traksi Tulang
Alat : Skrup/screw
Pin
Wire
Indikasi : traksi waktu lama
beban tarikan besar
Kontra indikasi relatif : anak-anak
Komplikasi : Infeksi, Kerusakan lempeng
pertumbuhan, gangguan neurologis
dan gangguan vaskuler
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Traksi Tulang
• Bohler stirrup dg
Steinmann pin
• Denham pin
• Kirschner wire
strainer
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Traksi menetap (fixed traction) • Traksi dg bidai Thomas (Thomas splint)
• Keseimbangan bersifat statik
• Digunakan pada transportasi/evakuasi
Arah
tarikan
Bag proksimal
terfiksasi pada paha
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Traksi menetap (fixed traction)
Sliding Traction
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Traksi Berimbang (balanced traction)
• Ada keseimbangan dinamik antara traksi dengan
kontra traksi
Traksi berimbang dengan bidai Thomas
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Traksi berimbang dengan bidai Bohler
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Traksi berimbang dengan Traksi Kulit
Bryant Traction
Umur < 2tahun
Berat badan 35-40 lbs
(15,9 – 18,2 Kg)
Komplikasi : gangguan
vaskuler
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Traksi berimbang dengan traksi kulit
Buck Extension Traction
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Traksi berimbang dengan traksi kulit
Hamilton Russel Traction
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Olecranon Traction Dunlop Traction
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Spinal Traction
Canvas Head Halter Crutchfield Tongs
Skull Traction
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Pitfalls
Occult injuries
Occult blood loss
Compartment syndrome
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Summary
Primary Survey : Identify life-threatening
injuries
Secondary Survey : Identify limb-
threatening injuries
Mechanism of Injuries : History important
Surgical consult
Early immobilization