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Musculoskeletal 2 > Trauma > Flashcards

Trauma Flashcards

1
Q

List potential orthopedic emergencies

A
  • Open fracture
  • Irreducible dislocations
  • Vascular injury
  • Amputation
  • Compartment syndrome
  • Unstable pelvic fracture/ hemodynamic instability
  • Multiply-injured patient
  • Spinal cord injury
  • Displaced femoral neck and talar neck fractures
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2
Q

4 conditions considered vascular injury

A
  1. Blood loss
  2. Progressive ischemia
  3. Compartment syndrome
  4. Tissue necrosis
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3
Q

What is the time frame for irreversible damage?

A

6 hrs

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4
Q

Vascular injury is increased with…

A
  • Proximity of vessels to bone
  • Tethering of vessels at joints
  • Superficial location of vessels
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5
Q

Clavicle fracture

-artery

A

subclavian

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6
Q

Shoulder fx/dislocation

-artery

A

axillary

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7
Q

Supracondylar humerus fx

-artery

A

brachial

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8
Q

Elbow dislocation

-artery

A

brachial

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9
Q

Pelvic fx

-artery

A

gluteal and/or iliac arteries

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10
Q

Femoral shaft fx

-artery

A

femoral

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11
Q

Distal femur fx

-artery

A

popliteal

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12
Q

Knee dislocation

-artery

A

popliteal

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13
Q

Tibial shaft fx

-artery

A

tibial

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14
Q

Incidence of fracture or dislocation with vascular injury

A

-uncommon, only 3% of long bone fractures

specific circumstances:
-fractures with GSW (up to 38%) and knee dislocations (16-40%)

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15
Q

Mechanism of injury

A

Penetrating trauma

  • GSW
  • Stab

Blunt trauma

  • High energy
  • Low energy

Iatrogenic

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16
Q

Types of vascular injuries

A
  • Vascular spasms
  • Intimal flaps
  • Subintimal hematoma
  • Laceration
  • Transection
  • Thrombosis/Occlusion
  • A-V fistula
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17
Q

Consequences of vascular injury

A
  • Blood loss
  • Ischemia
  • Compartment syndrome
  • Tissue necrosis
  • Amputation
  • Death
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18
Q

Prognostic factors

A
  • Level and type of vascular injury
  • Collateral circulation
  • Shock/hypotension
  • Tissue damage (crush injury)
  • Warm ischemia time
  • Patient factors/medical conditions
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19
Q

What is the most crucial factor to trauma?

A

SPEED!!

  • Rapid resuscitation
  • Complete, rapid evaluation
  • Urgent surgical treatment
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20
Q

Which protocol fall under the category of immediate treatment?

A
  • Control bleeding
  • Replace volume loss
  • Cover wounds
  • Reduce fractures/dislocations
  • Splint
  • Re-evaluate
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21
Q

What are the keys to diagnosis?

A
  • Physical exam
  • Doppler pressure (Ankle/brachial systolic pressure index (ABI))
  • Duplex scanning
  • Arteriogram
  • Exploration

**careful PE and high suspicion are most important!

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22
Q

What should you be looking for on physical exam of the vasculature?

A
  • Major hemorrhage/hypotension
  • Arterial bleeding
  • Expanding hematoma
  • Altered distal pulses
  • Pallor
  • Temperature differential between extremities
  • Injury to anatomically-related nerve
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23
Q

Which types of pulses warrant further exam??

A
  • Asymmetric pulses warrant doppler examination (determine ABI)
  • Absent pulses warrant emergent vascular consultation/surgical exploration
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24
Q

How does ankle brachial index compare to taking a blood pressure?

A

ABI measures the occlusion pressure whereas BP measures the opening pressure.

25
Q

Performance of the ABI

-arm

A

Arm

  • Appropriate cuff size
  • Doppler over brachial artery
  • NOT STETHESCOPE (underestimate SBP)
  • NOT OVER RADIAL ARTERY
  • Record right AND left arm brachial pressures
26
Q

Performance of the ABI

-cuff

A
  • Appropriate size
  • Appropriate location
  • -Lower leg above malleoli

*NOT OVER BULK OF CALF MUSCLES!

27
Q

Performance of the ABI

-doppler

A
  • Doppler over DP AND PT

* NOT STETHESCOPE

28
Q

ABI calculation

A
  • Numerator – Ankle pressures
  • Higher of the two pedal pressures
  • Denominator – Brachial pressure
  • Higher of the two arm pressures
  • Best reflects aortic pressure
29
Q

ABI interpretation

A

> 1.3 = non-compressible

  1. 00-1.29 = normal
  2. 91-0.99 = equivocal
  3. 41-0.90 = mild-mod PVD
  4. 00-0.40 = severe PVD
30
Q

What is doppler ultrasound used for?

A
  • Determine presence/absence of arterial supply
  • Assess adequacy of flow

NOTE: presence of signal does not exclude arterial injury

31
Q

What findings would you have on doppler ultrasound for knee dislocation?

A
  • Abnormal ABI < 0.90
  • Does not define extent or level of injury
  • Abnormal values warrant further evaluation
  • ABI > 0.90 can be observed (i.e. no arteriogram)
32
Q

Why is duplex scanning so valuable?

A
  • noninvasive
  • safe
  • rapid
33
Q

What is duplex scanning reliable for?

A
  • Injury to arteries and veins
  • A-V fistulas
  • Pseudoaneurysms
34
Q

What does duplex scanning require?

A

technician and scanner availability

*not all surgeons will operate based on duplex information alone

35
Q

Functions of angiography

A
  • Locates site of injury
  • Characterizes injury
  • Defines status of vessels proximal and distal
  • May afford therapeutic intervention
36
Q

What are the cons of angiography?

A
  • Expensive
  • Time-consuming
  • Difficult to monitor/treat trauma patient in angiography suite
  • Procedural risks
37
Q

What are the procedural risks of angiography?

A
  • Renal burden from dye
  • Possibility of anaphylaxis
  • Injury to proximal vessels
38
Q

When would you choose CT Angiography?

A
  • Alternative to conventional angiography
  • Good sensitivity and specificity
  • Costs much more
39
Q

When is angiography not indicated?

A

**ANGIOGRAPHY WILL DELAY REVASCULARIZATION

-it is not indicated in cases with absent pulses/complete transection, which should go immediately to surgery

40
Q

What is operative angiography? What does it detect?

A
  • Single view in operating room
  • Rapid
  • Excellent for detecting site of injury
41
Q

When is immediate surgical exploration indicated?

A
  • Obvious arterial injury on exam
  • No doppler signal
  • Site of injury is apparent
  • Prolonged warm ischemia time
42
Q

What is your next step if pt comes in with no pulse?

A

If injury obvious - surgery

If multilevel injury - angiography or duplex, then surgery

43
Q

What is your next step if pt comes in with asymmetric pulse?

A

Doppler

If < 0.9, angriography or duplex then surgery

If > 0.9, observation

44
Q

What is your next step if pt comes in with normal exam?

A

observation

45
Q

When should vascular evaluation occur?

A
  • vascular injuries are dynamic, so evaluation should continue after the initial injury or surgery
  • additional debridement and/or fixation undertaken after successful revascularization
46
Q

Key parts to continued evaluation?

A
  • circulation
  • neurologic function
  • compartment pressures (via Stryker needle, MC)
47
Q

What surgical considerations should be on your mind?

A
  • Who goes first?
  • Temporary shunts
  • Fracture stabilization
  • Salvage vs amputation
  • Fasciotomies
48
Q

Oklahoma’s trauma system evolved after…

A

story on Dateline in 1996 titled “`Dateline’ Report Blasts State’s Lack of System to Handle Trauma “

49
Q

Which physician is credited with development of the trauma system?

A

Dr. Roxie Albrecht Trauma Surgeon, Trauma Director at OU Medical Center started and developed Trauma system in Oklahoma August 2001

50
Q

What are the keys to the trauma system?

A
  • Coordinated system of care for injured patients
  • Injured patients to appropriate care in ‘right’ amount of time
  • Reduce preventable morbidity and mortality
  • Built around available resources
  • Quality assurance and improvement
51
Q

What are the components of the trauma system?

A

Administration, Hospitals, EMS, Physicians, EMT’s, Law Enforcement, Data, Research, Education

52
Q

What is trauma level I?

A

comprehensive trauma care, extensive physician specialist support immediately available, teaching and research requirements

53
Q

What is trauma level II?

A

similar to a level I without teaching and research requirements

54
Q

What is trauma level III?

A

24/7 physician level provider in the emergency department, general surgery and orthopedics

55
Q

What is trauma level IV?

A

typically stabilization and transfer, not required to have 24/7 physician level provider in the emergency department

56
Q

What is the mission statement of the Oklahoma regional trauma plan?

A

“In support of the statewide system, create a regional system of optimal care for all trauma patients, to ensure the right patient goes to the right place, receiving the right treatment, in the right amount of time. “

57
Q

Trauma Triage at the Scene of Injury

A
  • Based on readily observable or measurable factors
  • Patient-related – obvious injuries, age, vital signs
  • Scene-related – distance to appropriate hospital, traffic, weather, extrication, multiple patients, etc.
58
Q

When was Helicopter Emergency Medical Transport (HeMS) first used?

A
  • in times of military conflict; Korea, Vietnam
  • importance in the setting of remote locations, limited roadways, and hostile forces is easily recognizable
  • introduced to U.S. civilian use in the early 1970’s
  • effectiveness for civilian transport has been a subject of debate since introduction
59
Q

HEMS Transport Debate

A
  • Costs, Crashes, and Conflicting results
  • Charges for HEMS transport many times that of a ground EMS transport of similar distance
  • Expansion of HEMS services brought increased numbers of helicopter crashes
  • Questions remain regarding effectiveness of HEMS in reducing mortality
  • ‘Over-utilization’– scarce resource used for patients with non-life threatening injuries

Musculoskeletal 2 (14 decks)

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