SOMEML12 - slides.jsomtc.org

2/17/2016

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Slide 1JSOMTC, SWMG(A)

Musculoskeletal TraumaPFN: SOMEML12

Hours: 1.0

Instructor:


References

Tintinalli’s Emergency Medicine, 7th Edition, 2010

Tactical Trauma Protocols

PHTLS, 7th Edition, 2010


Terminal Learning Objective

Action: Communicate knowledge of musculoskeletal trauma

Conditions: Given a lecture in a classroom environment

Standards: Received a minimum score of 75% on a written exam IAW course standards

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Reason


Agenda

Identify the clinical presentation, and management of rhabdomyolysis

Identify the clinical presentation, and management of compartment syndrome

Identify the clinical presentation, and management of crush injury and crush syndrome


Rhabdomyolysis

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Rhabdomyolysis

Rhabdomyolysis is a serious syndrome due to a direct or indirect muscle injury

It results from the death of muscle fibers and release of their contents into the bloodstream

This can lead to complications such as renal (kidney) failure


RhabdomyolysisCauses

Must think about risk factors because classic signs may be absent in 50% of cases

Extreme muscle strain, especially in someone who is an untrained athlete. This can happen in elite athletes too. And it can be more dangerous if there is more muscle mass to break down

Crush injuries

Long‐lasting muscle compression

Electrical shock injury, burn, heat stroke


RhabdomyolysisCauses

Strenuous exercise or unaccustomed muscular activity (i.e. siezure)

Drug or alcohol abuse

Certain disease processes (i.e. viruses)

Bacterial infections leading to toxins in tissues or the bloodstream (sepsis)

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Clinical Presentation

Muscle pain, especially in the shoulders, thighs or lower back

Muscle weakness or trouble moving arms or legs

Abdominal pain

Nausea or vomiting

Fever, rapid heart rate

Confusion, dehydration, fever, or lack of consciousness



Dark (tea‐colored) urine

Oliguria or anuria

Urine or serum myoglobin

Dipstick + for blood, but no intact RBCs on spun specimen


Complications Early

Hyperkalemia

Hypocalcemia

Hepatic inflammation

Cardiac arrhythmia and/or arrest

Late

Hypercalcemia

Renal failure

DIC

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Complications

Early or late

Compartment syndrome

•May occur after fluid resuscitation. This serious compression of nerves, blood vessels, and muscles can cause tissue damage and problems with blood flow.


Management (TMEP)Aggressive hydration is the cornerstone of

treatment

Normal saline 1 ‐ 2L bolus IV/IO followed by 500 ml ‐1L per hour

Avoid Ringer’s lactate due to the potassium content

Titrate to achieve target urine output of > 200 ml/hour

• Consider urinary alkalinization to achieve urine pH > 6.5 Mix Sodium Bicarbonate 40 mEq (1 ampule/bristojet) in 500 ml normal saline. Run at 100 ml/h


Management (TMEP)

Reassess vital signs and mental status frequently

Foley catheter to facilitate measuring urine output

Utilize cardiac monitoring if available

Electrolyte and metabolic complications can cause dysrhythmias

Urgent evacuation

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Potential Problems/Complications Monitor for signs and symptoms of hyperkalemia (cardiac dysrhythmia)

Administer 1 gm calcium and 40 mEq sodium bicarbonate (1 ampule) IV/IO

Hypocalcemia (provoked by sodium bicarbonate)

Peri‐oral tingling, muscle tetany, increased deep tendon reflexes, QT prolongation on cardiac monitor • Stop sodium bicarbonate infusion

Avoid loop diuretics such as furosemide (Lasix), which may increase myoglobin precipitation in kidneys and provoke acute renal failure


Additional Management

Mannitol

Only use once urinary flow is established

1 to 2 gm/kg at a rate of 5 gm/hr

Don’t exceed 200 gm/24 hrs

Alternate with NS

Forced diuresis

Decompresses edematous muscles

Continue until urine myoglobin has cleared


Compartment Syndrome

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Compartment Syndrome

Occurs when excessive pressure builds up inside an enclosed space in the body

Increased compartment pressure compromises circulation and function of compartment tissues

Prolonged elevation of tissue pressure leads to muscle death and nerve damage


Common Causes

Any mechanism that increases the volume of blood or tissue within the compartment can cause a compartment syndrome

External forces

Tight cast or constrictive dressing

Venous tourniquet

Vascular

Hemorrhage

Ischemic‐reperfusion injury


Common Causes

Orthopedic

Tibial and forearm fractures

Soft tissue injury

Prolonged limb compression

Crush injury

Burns

Envenomation

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The classic “P’s”

Pain

Parasthesia

Poikilothermia

Pallor

Pressure

Paralysis

Pulselessness


Pain

Disproportionate to physical exam findings

Earliest and most consistent sign

Aggravated by passive stretching

Most sensitive sign

Diffuse, deep, unremitting, and poorly localized

Not relieved with immobilization

Often difficult to control with narcotics


Paresthesia

Tingling, burning

Diminished sensation

Two‐point discrimination

Light touch

Sensory disturbance generally precedes motor dysfunction

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Poikilothermia, Pallor, and Pressure

Poikilothermia

Cold distal extremity compared to the contralateral side

Pallor

Pale color

Pressure

Compartment is swollen and firm on palpation

Measurable increase in tissue pressure


Pressure

Compartment pressure can be measured

Commercial kits available

Measure pressure within 5 cm of any fracture


Paralysis and Pulselessness

Paralysis

Late finding from prolonged ischemia

Permanent damage may already be present

Pulselessness

Least reliable sign

CS is a disorder of microvasculature and rarely affects major vessels

Pulses are present in 90% of patients

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Maintain a high index of suspicion with polytrauma patients

Pain greater than expected due to the injury alone is your earliest and best clue

Open wounds do not exclude CS

The presence of pulses and normal capillary refill does not exclude CS

CS can develop up to 48 hours after the event


Complications

Rhabdomyolysis

Myoglobinuria

Renal failure

Volkmann contracture


Management

Maintain extremity at heart level ‐

DO NOT ELEVATE

Supplemental oxygen

Fluid resuscitation

Remove constrictive casts or dressings

Evacuate to surgical facility for immediate fasciotomy

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Surgical FasciotomyNot in your scope of practice

Long incisions through the skin and fascia

Allows tissue swelling without pressure elevation

May require delayed grafting

Should be performed immediately after making the diagnosis


Crush Injury and Crush Syndrome


Injury vs Syndrome

Crush INJURY ‐ occurs when a body part is subjected to a high degree of force or pressure

Can produce compartment syndrome

Crush SYNDROME ‐ the systemic manifestation of muscle cell and capillary endothelial damage‐ what happens after the injury occurs

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Crush Syndrome

Major shock and renal failure after a crushing injury to skeletal muscle

Imagine “rhabdomyolysis on steroids”


Reperfusion Syndrome

Devastating systemic effects can occur when the crushing pressure is suddenly released, without proper preparation of the patient

Initiates inflammatory response

Hypovolemia, hypotension, myocardial depression, hyperkalemia, and acidosis

Immediate release of toxins can have catastrophic systemic consequences



MOI

Obvious external signs of crush injury

Lacerations, degloving, deformity, or pain

Compartment syndrome

Rhabdomyolysis, myoglobinuria, and/or renal failure

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Management (TMEP)

Special Considerations

Be aware of development of crush syndrome starting as early as 4 hours post injury

The medications used to treat crush syndrome are not part of the standard ATP aid bag and require development of a separate crush injury kit


Management (TMEP)

Warnings

The principles of hypotensive resuscitation according to TCCC DO NOT apply in the setting of extremity crush injury requiring extrication

In the setting of a crush injury associated with non compressible (thoracic, abdominal, pelvic) hemorrhage, aggressive fluid resuscitation may result in increased hemorrhage


Management (TMEP)

Warnings

With extremity injuries, tourniquets should NOT be applied during Phase 1 unless there is hemorrhage which is not controllable by other means

Be aware of development of cardiac dysrhythmias due to hyperkalemia immediately following extrication

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Management (TMEP)

Management

Broken down into three phases

• Phase 1: Immediate (while attempting extrication)

• Phase 2: Immediately prior to extrication

• Phase 3: Immediately following extrication


Management (TMEP)

Phase 1: Immediate (while attempting extrication)

Maintain patent airway (NPA, OPA, etc.) and adequate ventilation

Monitor O2 sat with pulse ox and administer high flow oxygen if available


Management (TMEP)

Phase 1: Immediate (cont.)

Give initial bolus of 1 to 1.5 L of NS PRIOR to attempts at extrication and continue at 1.5 L/hr

• Ringer’s lactate is not recommended due to the potassium content

Maintain urine output at greater than or equal to 200 cc/hr. If possible, insert Foley catheter.

Assess and reassess mental status

Follow Pain Management Protocol (TMEP)

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Management (TMEP)

Phase 1: Immediate (cont.)

Consider prophylactic antibiotics ‐

• Ertapenem (Invanz) 1 gm IV

Utilize cardiac monitoring if available

Mannitol (administer 1 to 2 gm/kg at a rate of 5gm/hr)

• Ensure urine output has been established prior to using Mannitol


Management (TMEP)

Phase 2: Immediately PRIOR to extrication

Apply tourniquets to crushed extremities, if possible

Sodium Bicarbonate ‐

•1 mEq/kg IV immediately prior to extrication.

• Additional dosing of Sodium bicarbonate may be required if dysrhythmias or cardiac arrest persist after giving calcium chloride or gluconate.


Management (TMEP)

Phase 3: Immediately FOLLOWING extrication

CPR should be initiated if cardiac arrest develops following extrication. DO NOT follow the TCCC guidelines on cardiac arrest.

If extrication is greater then 4 hours OR in the presence of dysrhythmias, administer Calcium Chloride (1 gm, 10 ml of 10% solution) or Calcium Gluconate (1 gm, 10 ml of 10% solution)

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Management (TMEP)

Phase 3: Immediately FOLLOWING extrication

(cont.)

Calcium should not be given in bicarbonate containing solutions due to precipitation of calcium carbonate

Additional dosing of Sodium bicarbonate may be required if dysrhythmias or cardiac arrest persist after giving calcium chloride or gluconate

Following extrication, once the patient is stabilized, be prepared to treat hyperkalemia as tourniquets are released


Questions?


Terminal Learning Objective

Action: Communicate knowledge of musculoskeletal trauma

Conditions: Given a lecture in a classroom environment

Standards: Received a minimum score of 75% on a written exam IAW course standards

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Agenda

Identify the clinical presentation, and management of rhabdomyolysis

Identify the clinical presentation, and management of compartment syndrome

Identify the clinical presentation, and management of crush injury and crush syndrome


Reason

SOMEML12 - slides.jsomtc.org

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