Trauma Flashcards
(44 cards)
What is a fracture?
Soft tissue injury associated with break in the continuity of the bone
How do you manage a peripheral nerve injury 2o to trauma?
Follow BOAST guidelines
Key is identifying early
Reducing joint if dislocation
Release compressive bandages
Check for expanding haematoma
Get formal advice (Plastics vs PNI unit) if:
Penetrating injury- within 24 hours
If non operative management of #- within 24 hours
Prior to surgery
Immediately if noticed post op/during surgery
How do you manage arterial injury associated with a fracture?
Follow BOAST guidelines
Involve Vascular + Plastics + Ortho
Control Haemorrhage- direct pressure/tourniquet +- MHP
Reduce/realign limb- document NVI pre/post
CT post scan + CTA
Revascularisation within 4 hours of injury
Attempt definitive repair- if fails Use arterial shunts whilst skeletal stabilisation occurs
Then for venous grafting
Aim for definitive repair/interposition grafts over bypass grafting
Consent for amputation
Think prophylactic fasciotomies
From time of arterial injury within what time should you revascularise the limb?
4 hours
What is compartment syndrome?
Where raised pressure in a closed fascial compartment leads to comprimised microcirculation, ischaemia, hypoxia and soft tissue death- downward spiral
What is the compartment syndrome downward spiral?
Injury leads to soft tissue swelling
Increased compartment pressure
Decreased perfusion pressure
Local hypoxia
Cell membrane damage
And so on
What are the symptoms of Compartment syndrome?
5Ps- pain, pain, pain, pain, pain
Stretch test
paraesthesia often early
Tight compartments
pH/lactate
Differential Dx for compartment syndrome?
DVT
Post op swelling
Peripheral oedema
How do you diagnose compartment syndrome?
Clinical diagnosis
Adjuncts for patients in ICU/intubated
compartment pressure monitoring
<30 mm Hg between diastolic and compartment pressure
> 40mm Hg
BOAST guidelines advise continous pressure monitoring better for Dx
How do you treat Compartment syndrome?
Normal BP
Elevate limb to level of heart
Take off circumferential dressings
Adequate analgesia
Review in 30 mins
If persistent pain then pre for theatre
NBM
Mark + consent
Alert NOK
Bloods, ECG< 2x G&S
CEPOD, theatre team/anaesthetist
Operation within 1 hour of decision made
Prep and brief for theatre
If fracture not fixed could consider external vs internal fixation
Abx if fracture/metalwork
TXA
No tourniquet
supine
Standard surgical set
Prep to above knee
VAC needed
How do you perform the operation for Lower limb compartment syndrome?
2 incision 4 compartment decompressive fasciotomy as per BOA/BAPRAS guidelines
Anterolateral incision to release anterior and lateral compartment
2 cm lateral to tibial crest between the tibial crest and fibula. Extend for 15-20cm. Identify SPN 10cm proximal to lateral malleolus
Posteromedial incision to release posterior compartments- 1-2c medial to posteromedial boarder of tibial and extend distally 15-20cm. Retract saphenous vein and artery out of the way. Be wary of the anterior perforators at 10/15cm from medial malleolus. Ensure you get access to deep posterior compartment- take down soleus origin on posteromedial aspect of tibia. Post tibial NVI run in between the two compartments so be careful.
Debride dead tissue
VAC dressing
Re look in 48 hours +- plastics
Which blade you using for skin incision?
10 blade
What is in Pack A and B?
In my local unit:
4 units RBC
4 units FFP
Pack B
4 units RBC/FFP
1 unit platelets
What is TXA?
Tranexamic acid
Antifibrinolytic
Prevents clot breakdown
How much circulating volume in an adult?
5 litres
Grades of haemorrhagic shock?
1: 0-15, <750mls lost. Nil
2: 15-30, 750-1500mls. Tachycardia, narrow pulse pressure, decrease UO
3: 30-40, 1500-2000mls. Tachy, BP drop, UO down down
4: >40, >2l, ++ tach/hypotensive, UO nothing
What is the blood supply to bone?
Nutrient artery
Periosteal blood supply
Metaphseal-epiphyseal system (at the end of bone)
How to manage an open fracture?
BOAST guidelines!!
IV abx within 1 hour(local guidelines, co-amox/clinda)
Tetanus
Photo
Plastics
Reduce
Gross contamination removed
Saline soaked gauze and occlusive dressing
1st stage
2nd stage
When do open fractures need to be managed at Major trauma centre?
Fracture of long bones/midfoot/hindfoot
Patients with hand, wrist, forefoot or digit injuries may be managed locally following similar principles.
When do you go to theatre for an open fracture
Immediately if vascular compromise (compartment syndrome or vascular injury leading to ischaemia)
Or high contamination- agricultural, sewage or aquatic
Within 12 hours- high energy injuries
Within 24 hours- low energy injuries
How to do your 1st stage for an open fracture
Following BOAST/BAPRAS guidelines- Plastics/Ortho consultant present
Adhere to fasciotomy lines- avoid perforators for potential further soft tissue coverage.
Excise degloved/dead tissue back to bleeding tissue
Shotgun leg
Remove dirt/contaminant- 5L of wash
Remove dead bone? Tug test
Careful of nerves/vessels- great saphenous often cut
In fix vs ex fix
VAC
When and how to do second stage
Within 72 hours
Orthoplastic list
Fix as per ortho
Soft tissue coverage as per plastics
Free flap over #- lower infection rates
How and when do you classify open fractures?
Gustillo anderson classification
At 1st stage post debridement
1-<1cm and clean
2->1cm no extensive damage
3a- extensive soft tissue damage + high energy trauma
3b- periosteal stripping + bone exposure + contamination
3c- arterial injury or repair required
When do you primarily close open fractures?
Small defect
Low energy
No contamination
Low demand/comorbid patient
