International Trauma Life Support for Emergency Care Providers CHAPTER seventh edition Extremity Trauma 14.

International Trauma Life Supportfor Emergency Care Providers

CHAPTER

seventh edition

Extremity Trauma

14

International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians

Extremity Trauma

© Pearson


Overview

• Priority of extremity trauma• Major complications and treatment:

– Fractures– Dislocations– Amputations– Open wounds


Overview

• Major complications and treatment (cont.):– Neurovascular injuries– Sprains and strains– Impaled objects– Compartment syndrome

• Estimated blood loss – Pelvic and extremity fractures


Overview

• Major mechanisms, associated trauma, potential complications, management:– Pelvis– Femur– Hip– Knee– Tibia/fibula


Overview

• Major mechanisms, associated trauma, potential complications, management:– Clavicle/shoulder– Elbow– Forearm and wrist– Hand or foot


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


Extremity Trauma

• Extremity injuries– Fractures– Dislocations– Open wounds– Amputations– Neurovascular injuries– Sprains & strains– Impaled objects– Compartment syndrome– Crush injury

Courtesy of Roy Alson, MD


Extremity Injuries

• Fractures– Open (compound)

Communication to outside Danger of contamination Blood loss outside body

– Closed (simple) No communication to outside No danger of contamination Blood loss inside body

(Photo courtesy of Roy Alson, MD)


Fractures

• Hemorrhage with fracture– Closed femur fracture

Loss of 1 liter of blood Two closed femur fractures

life-threatening

(Courtesy of ®E. M. Singletary, MD)


Fractures

• Hemorrhage with fracture– 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

(Courtesy of Sabina Braithwaite, MD)


Extremity Injuries

• Dislocations– Neurovascular compromise

True emergency though not life-threatening Check PMS distal to major joint dislocations

Courtesy of Roy Alson, MD© Pearson


Dislocations

• Management– No neurovascular compromise

Splint in position found

– Neurovascular compromise Apply only gentle traction in effort to straighten Often best: pad and splint in most comfortable

position and rapid safe transport


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

(Courtesy of 2010 North American Rescue, LLC)


Open Wounds

Obviousexsanguinating hemorrhage—

only time can change order of ABC to CABC.


Extremity Injuries

• Amputations– Disabling and sometimes life-threatening – Potential for massive hemorrhage

Most often, bleeding controlled with direct pressure

© Edward T. Dickinson, MD © Edward T. Dickinson, MD


• Amputation 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

(Courtesy of Stanley Cooper, EMT-P)


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

Courtesy of Louis B. Mallory, MBA, REMT-P



Extremity Injuries

• Sprain– Injury to ligaments of a joint– Pain & swelling– Treat like a fracture

• Strain– Injury of musculotendinous unit– Pain & swelling– Treat like a fracture


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

© Pearson

© Pearson


Extremity Injuries

• Compartment syndrome– Forearm and lower leg most common– Swelling compresses nerves and vessels


Compartment Syndrome

• Early symptoms– Pain– Paresthesia

• Late symptoms– Pain– Pallor– Pulselessness – Paresthesia – Paralysis


Extremity Injuries

• Crush injury– Pressure on extremities for extended time

Anaerobic metabolism

– Pressure released Blood flow to crushed tissue reinstated Toxins distributed throughout entire body

• a.k.a. “Crush or Compression Syndrome”


ITLS Patient Assessment

• Mechanism history– Falls landing on feet– Sitting position– Fall onto wrist– Fall onto ankle– Shoulder involved– Pelvis involved

• Common injury– Foot, lumbar spine– Knee, hip– Wrist, elbow– Ankle, proximal fibula– Shoulder, neck, chest– Pelvis, shock


Extremity Trauma

• ITLS Primary and Secondary Surveys– Major bleeding– DCAP-BLS-TIC– Instability – Crepitation– Joint pain– Joint movement– Distal PMS

© Pearson


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


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


Extremity Trauma

If in doubt, splint possible injury.


Types of Splints

(Courtesy of Eduardo Romero Hicks, MD)


Tourniquets

• Common in military and tactical settings• Regaining use in civilian use• Not without complications• Label patients who have tourniquets

(Courtesy of 2010 North American Rescue, LLC)


Hemostatic Agents

• For uncontrollable bleeding• Promote clot formation• Used in conjunction with direct pressure


Extremity Trauma

• Spine



Extremity Trauma

• Pelvis

Courtesy of Louis B. Mallory, MBA, REMT-P Courtesy of Louis B. Mallory, MBA, REMT-P


Extremity Trauma

• Femur

Courtesy of Louis B. Mallory, MBA, REMT-PCourtesy of Louis B. Mallory, MBA, REMT-P


Extremity Trauma

• Hip

© Pearson

© Pearson


Extremity Trauma

• Knee

Courtesy of Louis B. Mallory, MBA, REMT-PCourtesy of Louis B. Mallory, MBA, REMT-P


Extremity Trauma

• Tibia/fibula

© Pearson


Extremity Trauma

• Clavicle

© Pearson


Extremity Trauma

• Shoulder

© Pearson


Extremity Trauma

• Elbow



Extremity Trauma

• Forearm and wrist



Extremity Trauma

• Hand or foot



Crush Injuries

– Frequent ongoing exams– Alkalizing the blood

Fluid resuscitation NaCO3 infusion

Osmotic diuretics

– Tourniquet use– Contact Medical Command early


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

International Trauma Life Support for Emergency Care Providers CHAPTER seventh edition Extremity Trauma 14.

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