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seventh edition International Trauma Life Support for Emergency Care Providers Extremity Trauma CHAPTER 14 Extremity Trauma © Pearson International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Overview • Priority of extremity trauma • Major complications and treatment: – Fractures – Dislocations – Amputations – Open wounds International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Overview • Major complications and treatment (cont.): – Neurovascular injuries – Sprains and strains – Impaled objects – Compartment syndrome • Estimated blood loss – Pelvic and extremity fractures International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Overview • Major mechanisms, associated trauma, potential complications, management: – Pelvis – Femur – Hip – Knee – Tibia/fibula International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Overview • Major mechanisms, associated trauma, potential complications, management: – Clavicle/shoulder – Elbow – Forearm and wrist – Hand or foot International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Extremity Trauma • Distorted or wounded extremities must not distract from life-threatening injuries. – Easy to identify – Disabling but rarely immediately lifethreatening • Potential danger: – Hemorrhagic shock (very few) – Neurovascular compromise Distal PMS International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Extremity Trauma • Extremity injuries – – – – – – – – – Fractures Dislocations Open wounds Amputations Neurovascular injuries Sprains & strains Impaled objects Compartment syndrome Crush injury Courtesy of Roy Alson, MD International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians 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) International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians 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) International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians 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) International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Extremity Injuries • Dislocations – Neurovascular compromise True emergency though not life-threatening Check PMS distal to major joint dislocations © Pearson Courtesy of Roy Alson, MD International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians 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 International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Extremity Injuries • Open wounds – Remove contamination Gross: remove Smaller: irrigate with normal saline – Sterile dressing and bandage (Courtesy of 2010 North American Rescue, LLC) Pressure dressing, if necessary Pressure point Tourniquet rare Hemostatic agent International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Open Wounds Obvious exsanguinating hemorrhage— only time can change order of ABC to CABC. International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians 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 International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Extremity Injuries • Amputation Management – Cover with damp sterile dressing, elastic wrap – Uniform reasonable pressure across stump – Tourniquet if bleeding absolutely not controlled (Courtesy of Stanley Cooper, EMT-P) Rarely needed – Retrieve amputated part In plastic bag, inside ice water International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Extremity Injuries • Neurovascular injuries – Nerves and major vessels run beside each other in flexor area of major joints • Distal PMS Courtesy of Louis B. Mallory, MBA, REMT-P – Assess pulse – Assess motor function – Assess sensory Courtesy of Louis B. Mallory, MBA, REMT-P International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians 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 International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Extremity Injuries • Impaled objects – Do not remove Airway obstruction exception – Apply very bulky padding – Transport object in place – No unnecessary movement © Pearson Motion magnified in tissues © Pearson International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Extremity Injuries • Compartment syndrome – Forearm and lower leg most common – Swelling compresses nerves and vessels International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Compartment Syndrome • Early symptoms – Pain – Paresthesia • Late symptoms – – – – – Pain Pallor Pulselessness Paresthesia Paralysis International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians 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” International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians 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 International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Extremity Trauma • ITLS Primary and Secondary Surveys – Major bleeding – DCAP-BLS-TIC – Instability – Crepitation – Joint pain – Joint movement – Distal PMS International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians © 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 International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians 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 International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Extremity Trauma If in doubt, splint possible injury. International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Types of Splints (Courtesy of Eduardo Romero Hicks, MD) International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians 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) International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Hemostatic Agents • For uncontrollable bleeding • Promote clot formation • Used in conjunction with direct pressure International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Extremity Trauma • Spine Courtesy of Louis B. Mallory, MBA, REMT-P International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Extremity Trauma • Pelvis Courtesy of Louis B. Mallory, MBA, REMT-P Courtesy of Louis B. Mallory, MBA, REMT-P International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Extremity Trauma • Femur Courtesy of Louis B. Mallory, MBA, REMT-P Courtesy of Louis B. Mallory, MBA, REMT-P International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Extremity Trauma • Hip © Pearson © Pearson International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Extremity Trauma • Knee Courtesy of Louis B. Mallory, MBA, REMT-P Courtesy of Louis B. Mallory, MBA, REMT-P International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Extremity Trauma • Tibia/fibula © Pearson International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Extremity Trauma • Clavicle © Pearson International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Extremity Trauma • Shoulder © Pearson International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Extremity Trauma • Elbow Courtesy of Louis B. Mallory, MBA, REMT-P International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Extremity Trauma • Forearm and wrist Courtesy of Louis B. Mallory, MBA, REMT-P Courtesy of Louis B. Mallory, MBA, REMT-P International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Extremity Trauma • Hand or foot Courtesy of Louis B. Mallory, MBA, REMT-P Courtesy of Louis B. Mallory, MBA, REMT-P International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Crush Injuries – Frequent ongoing exams – Alkalizing the blood Fluid resuscitation NaCO3 infusion Osmotic diuretics – Tourniquet use – Contact Medical Command early International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians 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, Seventh Edition John Campbell • Alabama College of Emergency Physicians