7 - Management of the Injured Lower Extremity Flashcards
(36 cards)
What to memorize
o Memorize severity scale of glasow coma scale, RTS and MESS – not exact points for each
o Memorize the tetanus algorithm
Trauma care system
- Prevention
- Resuscitation
- Acute care
- Rehabilitation
Trauma Care System and Development Act (2007)
- Inclusive trauma system integrated with Emergency Medical System (EMS)
- Trauma Designation
o Level I
o Level II
o Level III
o Level IV &V
Level I Trauma
- Regional resource trauma center
- Provide complete care of trauma patient
- Provide trauma prevention and rehabilitation
- Education, research, and systems development leadership
- Surgery residency required
- Admits a minimum required annual volume of severely injured patients
- Required to have a certain number of surgeons, emergency physicians and anesthesiologists on duty 24 hours a day at the hospital
- Prompt availability of other specialties
- Increased survival of seriously injured person by an estimated 20-25%
Level II Trauma
- Initial definitive care of trauma patients
- Ability to transfer complex patients to Level I
- Clinical capabilities similar to Level I except for extent of surgical subspecialties
- General surgeon may be out of house but readily available
- Education and prevention programs
- Research not essential
- Surgical residency not required
Level III Trauma
- Immediate assessment, resuscitation, emergency operations, and stabilization
- Prearranged transfer protocols with Level I or II trauma centers
- Prompt availability of general surgeon
- Includes rural and community hospitals
Level IV & V
- Provide advanced trauma life support prior to transfer to higher levels of care
- Trauma trained nurse immediately available and physicians are available upon patient arrival to the ED
Acute Trauma Care
- ATLS (Advanced Trauma Life Support) protocol
- ABC
- Fluid/blood replacement
- Examination
- Tetanus
- IV Antibiotics
- Gross debridement/irrigation “washout”
- Reduce/Stabilize (splint/ex fix)
- Serial debridement/irrigation as needed until definitive decision made
General trauma evaluation
- NOTE: must use a systematic and thorough approach without compartmentalization
- 1 = Assess severity of injury
- 2 = Cardio-Pulmonary Resuscitation (Intubation/Ventilation, hemodynamics/Shock, Control hemorrhage, Replace fluids)
- 3 = Physical examination
- Primary Survey
- Secondary Survey
- Tertiary Survey
General trauma evaluation (see CDC sheet)
Glasgow coma scale (GCS) for brain injury – scale from 3-15
o 8 or lower: severe head injury, patient in coma
o 9 to 12: moderate head injuries
o 13 to 15: minor head injury
A = Eye opening
o 4 = spontaneous
o 3 = to voice
o 2 = to pain
o 1 = none
B = verbal response
o 5 = oriented o 4 = confused o 3 = inappropriate o 2 = incomprehensible o 1 = none
C = motor response
o 6 = obeys o 5 = purposeful o 4 = withdraws o 3 = flexion o 2 = extension o 1 = none
General trauma evaluation
- Revised trauma score (RTS) = physiologic scoring system
- Directs triage and evaluates patient outcomes
- Scale from 0 to 12 (A + B + C)
o
Primary survey
o ABCDE: life threatening injuries are identified and addressed until the patient is stable
o Airway - Secure, C-Spine protection
o Breathing - Provide necessary intervention
o Circulation - Hemorrhage control & prevent shock
o Disability - Neurological exam, GCS
o Exposure or Environmental Control - Head to toe exam – remove any remaining detrimental agents or correct temperature derangements
Secondary survey
o Complete head to toe evaluation with definitive diagnosis and treatment of injuries
o Repeat vital signs
o Extensive testing is performed (radiographs, CT, ultrasound, angiography)
Anatomical Assessment
- Cranial, neck, thoracic
- Abdominal
- Retroperitoneal
- Genitourinary
- Musculoskeletal
Tertiary survey
o Repeat head to toe evaluation with reevaluation with laboratory and advanced studies
o Comprehensive review of medical record, including repetition of the primary and secondary surveys, review of labs, and review of radiographic studies
o Changes in patient condition are promptly evaluated and treated
o New findings missed in initial evaluations investigated further (Minor fractures, Lacerations, Traumatic brain injury)
Life threatening complications
- Hypovolemic shock
- Rhabdomyolysis
- Acute Renal Failure
- SIRS (Systemic Inflammatory Response Syndrome)
- Sepsis/Septic Shock
- ARDS (Acute respiratory distress syndrome)
- MODS (multi organ dysfunction)
- Reperfusion Injury
- Arrhythmias
- See article on Sepsis/Shock* Singer et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016. February 23;315(8):801-810.
MESS
MEMORIZE CHART
- > 7 high risk of amputation: good specificity, poor sensitivity for amputation
- Concerns: age, hard to get score > 7 if vascular intact, even if soft tissue, bone damage extensive
MESS and other scores
- ***Scores can help guide decision, but cannot be used in isolation
- Salvage does not always = function
- Improvements in medicine = greater ability to save OR
- Excitement for new techniques lead to more morbidity and mortality with secondary amp
- Article: Schiro et al. Primary amputation vs limb salvage in mangled extremity: a systematic review of the current scoring system. BMC MD 2015.
Is the limb salvageable?
Possible scenarios:
o Immediate amputation
o Attempted salvage with early amputation
o Successful salvage
o Unsuccessful salvage with late amputation
When to consider salvage
- Anatomically intact tibial nerve
- Can reconstruct vascular supply: promixal injury, warm ischemia
Diagnostic studies
- Laboratory Data
- CBC with Differential (H&H)
- Full chemistry panel (Chem-7, BMP)
- Type and Cross Match
- Urinary analysis
- Occult hematuria
- Source of infection causing leukocytosis
- Radiographs
- AP Chest – pneumonia, atelectasis
- Spine, fractures
- Gas (diabetic foot infection, necrotizing fasciitis)
- EKG
- Computed Tomography (CT)
o Complicated fractures (Calcaneal fractures, LisFranc fractures, Tri-plane pediatric fracture)
o Unequivocal radiographs - MRI (soft tissue damage (tendon ruptures/lacerations))
- Joint Aspiration (septic joint)
- Angiography
- Compartment pressures
Compartment syndrome
Why pressure monitoring in the foot is a vital part of diagnosis?
o Symptoms are not “typical” in many cases.
o Confusion is created by the compact anatomy of the foot leading to overlap of those symptoms due to direct tissue damage, and those caused by compartment syndrome.
o This makes pressure monitoring vital for diagnosis of CS in the foot.
