Más contenido relacionado Similar a 6fe8a745.pptx (20) 1. International Trauma Life Support
for Emergency Care Providers
eighth edition
International Trauma Life Support for Emergency Care Providers, Eighth Edition
John Campbell • Alabama Chapter, American College of Emergency Physicians
Extremity Trauma
CHAPTER14
3. Objectives
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• Prioritize extremity trauma in the
assessment and management of life-
threatening injuries
• Discuss the major immediate and short-
term complications and treatment of:
– Amputations
– Crush injuries
– Dislocations
– Fractures
— Impaled objects
— Neurovascular injuries
— Open wounds
— Sprains and strains
4. Objectives
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• Discuss the pathophysiology of
compartment syndrome and which
extremity injuries are most likely to
develop this complication
• Describe the potential amount of blood
loss from pelvic and femur fractures
5. Objectives
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• Discuss major mechanisms of injury,
associated injuries, potential
complications, and management of
injuries to:
– Clavicle and shoulder
– Elbow
– Forearm and wrist
– Hand
– Pelvis
– Hip
— Femur
— Knee
— Tibia and fibula
(including
ankle)
— Foot
6. Extremity Trauma
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• 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
7. Extremity Trauma
• Extremity injuries
– Fractures
– Dislocations
– Open wounds
– Amputations
– Neurovascular injuries
– Sprains and strains
– Impaled objects
– Compartment
syndrome
– Crush injury
Courtesy of Roy Alson, MD
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8. 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)
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9. 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)
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10. 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)
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11. Extremity Injuries
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• Dislocations
– Neurovascular compromise
True emergency though not life-threatening
Check PMS distal to major joint dislocations
Courtesy of Roy Alson, MD
© Pearson
12. Dislocations
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• 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
13. Extremity Injuries
• Open wounds
– Remove contamination
Gross: remove
Smaller: irrigate with
normal saline
– Sterile dressing and
bandage
Pressure dressing, if
necessary
Tourniquet
Hemostatic agent
(Courtesy of 2010 North American Rescue, LLC)
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14. Open Wounds
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Obvious exsanguinating
hemorrhage—only time can
change order of ABC to CABC
15. 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
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16. Extremity Injuries
• 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)
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17. 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
Courtesy of Louis B. Mallory, MBA, REMT-P
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18. Extremity Injuries
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• Sprain
– Injury to ligaments of a joint
– Pain and swelling
– Treat like a fracture
• Strain
– Injury of musculotendinous unit
– Pain and swelling
– Treat like a fracture
19. 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
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© Pearson
20. Extremity Injuries
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• Compartment syndrome
– Forearm and lower leg most common
– Swelling compresses nerves and vessels
21. Compartment Syndrome
• Early symptoms
– Pain
– Paresthesia
• Late symptoms
– Pain
– Pallor
– Pulselessness
– Paresthesia
– Paralysis
• Pain progressive
and out of
proportion to
exam
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22. Extremity Injuries
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• 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”
23. ITLS Patient Assessment
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• 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
24. Extremity Trauma
• ITLS Primary and Secondary Surveys
– Major bleeding
– DCAP-BLS-TIC
– Instability
– Crepitation
– Joint pain
– Joint movement
– Distal PMS
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25. Management
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• 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
26. Splinting
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• 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
29. Tourniquets
• Common in military and tactical
settings
• Improved survival
• Regaining use in civilian population
• Minimal complications
• Label patients who have tourniquets
(Courtesy of 2010 North American Rescue, LLC)
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30. Hemostatic Agents
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• For uncontrollable bleeding
• Promote clot formation
• Used in conjunction with direct
pressure
32. Extremity Trauma
• Pelvis
Courtesy of Louis B. Mallory, MBA, REMT-P Courtesy of Louis B. Mallory, MBA, REMT-P
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33. Extremity Trauma
• Femur
Courtesy of Louis B. Mallory, MBA, REMT-P
Courtesy of Louis B. Mallory, MBA, REMT-P
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35. Extremity Trauma
• Knee
Courtesy of Louis B. Mallory, MBA, REMT-P
Courtesy of Louis B. Mallory, MBA, REMT-P
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40. Extremity Trauma
• Forearm and wrist
Courtesy of Louis B. Mallory, MBA, REMT-P Courtesy of Louis B. Mallory, MBA, REMT-P
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41. Extremity Trauma
• Hand or foot
Courtesy of Louis B. Mallory, MBA, REMT-P
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Courtesy of Louis B. Mallory, MBA, REMT-P
42. Crush Injuries
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• Frequent ongoing exams
• Treatment of hyperkalemia
– Fluid resuscitation
– Calcium gluconate
• Alkalizing the blood
– Fluid resuscitation
– NaCO3 infusion
– Osmotic diuretics
• Tourniquet use
• Contact Medical Command early
43. Summary
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• 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
