Week 9 - MSK Injuries + Burns

Question 1

What is the old/traditional way we used to classify burns? Why do we no longer use this method to classify burns?

Answer 1

Stage stage 1 - 4 method! - it does not directly describe how much of the epidermis and/or dermis is damaged

-We use the layer of skin method now!!!

Question 2

What are burn injuries in “lower status/class countries correlated with? Why?

Answer 2

In all countries, lower SE status” is correlated with burns. Less access to 911, no smoke detectors in the home, poor equipment/no safety mechanisms

Question 3

How do we treat joint injuries?

Answer 3

Treatment:
-Relocate joint (procedural sedation in ER or OR)
-Need to relocate the joint—procedural sedation in ER or possibly to OR (knee dislocation needs Immediate intervention—almost guaranteed nerve involvement)

Question 4

S+S for pelvic fracture?

Answer 4

Signs and Symptoms:
-pain, hypovolemic shock, hematuria, urethral/vaginal/rectal bleeding

shortened or rotated leg

-Large vessel injuries (shearing), Abdominal organ injuries
Instability/Crepitus

Aortic injuries, other large vessel injuries, abdominal organ injuries causing hemorrhage
Pain
Evidence of hypovolemic shock
Shortening or abnormal rotation of the affected leg, other lower abdominal physical deformity
Genitourinary or intra-abdominal injury
Bruising
hematuria
Urethral, vaginal, or rectal bleeding

Question 5

What are 5 interventions we can do for the Ongoing care + treatment of burn injures ( these are done AFTER eth Early Care + Treatments of Burn injuries!!)

Answer 5

Ongoing Care + Treatment of Burns:
1.) Patient Moved to Specialized Unit
-Burns ICU, plastics unit, etc.
2.) Skin Grafting + Dressings
-Grafts can be from both the patient and/or donors
3.) Escharotomies
-Procedure where burn tissue is removed to allow for pressure release
4.) Nutrition
-Insertion of NG tube or J tube, patient may receive TPN
5.) Reverse Isolation:
-To protect the patient from us!, Antibiotics may be administered, more likely that antimicrobial dressings will be used if positive cultures come back

Question 6

How do we diagnose Rhabdomyolysis?

Answer 6

-Myoglobin levels are less reliable because the body breaks it down within 6 hrs – more likely to test urine for blood

-Diagnosis made by clinical history + elevated CK which peak at 24-36hrs (can be in the tens of thousands), which is released by the damaged cells.

-Creatinine will also rise as the body converts creatine to creatinine (plus AKI).

-Blood for myoglobin less reliable because it breaks down within 6 hours. More likely to test the urine for blood but even that has 50% false negatives

Question 7

What kind of mortality rate does/do pelvic fractures have? (what does it depend on?)

Answer 7

Up to 70% mortality depending on fracture type and promptness of treatment

Question 8

What are fractures associated with? Why?

Answer 8

Associated with large blood loss because or disruption of arteries or veins in close proximity to bones

-Tibia/Humerus Fracture: 250 - 2000mL blood loss
-Femur Fracture: 500 - 3000mL of blood loss
-Pelvic Fractures: varies but may range from 750 mL – 6000mL of blood loss

Question 9

What is compartment syndrome? What does/can it result in?

Answer 9

Occurs as pressure increases inside a fascial compartment

Results in impaired capillary blood flow and cellular ischemia

Question 10

What is the Rule of nines? (what is it commonly used for?/what does it do/give)

Answer 10

Rule of Nines:
-Most common method used in the ER, though not as accurate as some (like the Lund-Brower chart)
-Rule of nines is a rough estimate when there is nothing more accurate available—useful for a first guess of extent of the injury

Question 11

What specific S+S do pelvic fractures have that are unique to them?

Answer 11

Pelvic fractures: unstable to palpation, shock

Question 12

What is the initial treatment for fractures? (7 different interventions we can do)

Answer 12

Initial treatment:
-Immobilization and stabilization (splints, slings, pelvic binders, backboard for femurs)
-Cool packs
-Analgesia, muscle relaxants
-Sedation for reduction, then cast and sling
-Backslab and sling for support (non-displaced and stable)
-Surgery if unstable
-External fixation (multiple bone fragments) (cage)

Question 13

What can electrical injuries cause that makes them kind of unique?

Answer 13

Electrical injuries cause severe internal injuries and cardiac arrest but very little visible external

Question 15

S+S for Rhabdomyolysis?

Answer 15

Signs and Symptoms:

-Dark/Red urine, reduced urine output, severe muscle aching, arrhythmias/arrest

Impaired renal function from the massive release of myoglobin—kidneys hate dealing with the molecule in large amounts.
Damages the nephron—ATN. Urine becomes darker (“rhabdo”)
Release of potassium can cause massive increases in vascular space—arrhythmias and arrest (happens in the first few hours)

Question 16

What is the MOI/what are fractures usually caused by?

Answer 16

Blunt force Trauma

-Typically caused by MVAs, assaults, falls, sports

MOI: motor vehicle crashes, assaults, falls, sports, leisure, or home activities

Question 17

Treatment for pelvic injuries? (what do we avoid) (think of 5 things)

Answer 17

Treatment:
-avoid catheters if there is urethral trauma
-Stabilization device (Pelvic binder) – slow blood loss/encourage -clotting
-Surgery: internal/external fixation
-Angiography with embolization for bleeding vessels
-Blood/IV Fluid admin

-Tight stabilizing device that can slow blood loss and encourage clotting by direct pressure – they can hurt!

-Surgery to internally or externally fixate unstable fracture

-Angiography with embolization of bleeding vessels

-Blood or iv fluid admin

Question 18

How do we diagnose pelvic fractures?

Answer 18

Diagnostic: Xrays, FAST to detect bleeding, CT

Question 19

When diagnosing a joint injury, what non-mechanical/picture taking diagnostic method/tool will help us differentiate a dislocation from a fracture?

Answer 19

Usually clinical history will help us differentiate a dislocation from a fracture (sound of a crack or pop, for example)

Question 20

How do crush injuries work/what is the patho behind them?

Answer 20

When muscles are crushed (especially for long periods), they become ischemic, then necrotic, then release potassium, myoglobin (protein found in muscles), and creatine kinase (enzyme found in muscles) into the blood:

-This release of potassium can lead to arrhythmias and cardiac arrest (usually within the first few hours)

-Release of myoglobin and creatine kinase (indicator for myoglobin) can cause acute kidney injury or rhabdomyolysis

Question 21

Why can patient with crush injuries go into shock?

Answer 21

When muscles are crushed (especially for long periods), they become ischemic, then necrotic, then release potassium, myoglobin (protein found in muscles), and creatine kinase (enzyme found in muscles) into the blood:

Fluids leak into third spaces, causing edema and possibly increased compartment pressure

Patients can go into shock from these massive fluid shifts (distributive shock), or from hemorrhage (hypovolemic shock)

Question 22

What type of injury has a high morbidity in the elder population?

Answer 22

Fractures!!

Elderly at high risk of being hospitalized for an extremity injury (rate of injury in pop)

Question 23

What do we need to remember with pelvic injuries? (think about extent of injuries)

Answer 23

remember, A LOT of force to cause this, so there might/will be injuries around the pelvis/abdomen too

Question 24

For fractures what is the average blood loss associated with?

Answer 24

Average blood loss: Associated with large blood loss due to proximity of vessels to bones

Tibia/Humerus Fracture: 250 - 2000mL
Femur Fracture: 500 - 3000mL
Pelvic Fractures: varies bu

Question 25

How do we diagnose joint injuries?

Answer 25

Diagnosis: -Clinically (exam) and Xrays -Usually clinical history will help us differentiate a dislocation from a fracture (sound of a crack or pop, for example), but the deformity is also in the joint instead of along the bone (hips are tricky to distinguish) -Can often be diagnosed clinically (above picture), may need xrays (lower picture), anything further is quite rare

Question 26

Treatment for rhabdomyolysis? Why do we do this?

Answer 26

Treatment: Aggressive IV fluids – dilute blood of myoglobin and other nephrotoxins Aim for at least 100-200mL urine output/hr Treatment is aggressive IV fluids—we want 100-200mL urine output per hour minimum. Diluting the blood of myoglobin and other nephrotoxins

Question 27

How do we treat compartment syndrome?

Answer 27

Treatment: Elevate the limb **to the level of the heart** Fasciotomy is literally cutting into these compartments to release the pressure

Question 28

What type of fractures do we use external fixation for?

Answer 28

External fixation (multiple bone fragments) -Typically used with crush injuries!

Question 29

What are some other factors that contribute to the International Epidemiology of individuals who experience a burn injury?

Answer 29

Other factors: occupations, overcrowding, lack of safety measures, medical conditions (e.g. cognitive impairment, epilepsy), fuel sources like kerosene (WHO, 2018) Such as epilepsy, nerve damage, cognitive impairment, alcohol, smoking). Fuels such as kerosene instead of electric appliances

Question 30

What fractures are hard to distinguish? Why?

Answer 30

-hips are tricky to distinguish Hard to distingish because the deformity is also in the joint instead of along the bone

Question 31

What do half of hospital admissions for trauma include?

Answer 31

Half of all hospital admissions for trauma include a lower limb fracture

Question 32

What is the Rule of Palms? (what is it useful for? what does it use to represent a portion of the patients body?)

Answer 32

Rule of Palms: -Useful for smaller burns. The patient’s palm represents 1% of their total body surface area -The patient’s palm also represents 1% of the BSA—easy way to estimate smaller burns

Question 33

What are the 4 different thickness that a burn injury can be? (think of the different stages like we learned in pathology!! However, remeber we don't classify these burns off of stages anymore!)

Answer 33

Thickness can be superficial (sunburn, touching something hot and then reflexively jumping back), superficial partial (blistered, wet/weeping, pink or red, extremely painful), deep partial (dryer, paler pink to white, less painful), or full thickness (leathery, many colours, dry, painless or aching).

Question 34

What can Joint injuries be complicated by/with?

Answer 34

May be complicated by neurovascular compromise and associated fractures -Knee dislocation

Question 35

How do we diagnose fractures?

Answer 35

Diagnosis: Xrays, CT (if xray inconclusive), MRI if soft tissue injury

Question 36

When testing/diagnosing rhabdomyolysis, what blood test might be less reliable? Why?

Answer 36

-Blood for myoglobin less reliable because it breaks down within 6 hours. More likely to test the urine for blood but even that has 50% false negatives

Question 37

What is the patho behind a fracture?

Answer 37

Pathophysiology: Bone/join displacement compresses surrounding tissues and nerves – obstructs arterial blood flow, causing decreased tissue oxygenation

Question 38

With crush injuries, what does the release of myoglobin and creatine kinase cause?

Answer 38

Release of myoglobin and creatine kinase (indicator for myoglobin) can cause acute kidney injury or rhabdomyolysis

Question 39

With compartment syndrome, how long does it take before irreversible damage to muscle cells and nerves occurs?

Answer 39

Only takes about 6-8 hours before irreversible damage to muscle cells and nerves occurs

Question 40

When treating rhabdomyolysis, what is the urine output/hr goal we want to aim for? Why?

Answer 40

Aim for at least 100-200mL urine output/hr Treatment is aggressive IV fluids—we want 100-200mL urine out put per hour minimum. Diluting the blood of myoglobin and other nephrotoxins

Question 41

Difference between a stable and unstable pelvic fracture?

Answer 41

Stable: able to withstand normal physiologic forces without abnormal deformation -(able to stand normal physiologic force without deformity) Unstable: Pelvic ring is fractured in more than one place resulting in two displacements on the ring -more than one fracture, resulting in displacement of the pelvic ring)

Question 42

What are some concurrent injuries that are specially related to burns!

Answer 42

Airway injury due to inhaled smoke Fatal hypoxia due to carbon monoxide blocking oxygen transport Electrical injuries can cause fatal arrhythmias - Electrical injuries cause severe internal injuries and cardiac arrest but very little visible external

Question 43

What are pelvic fractures often accompanied by? (2 things)

Answer 43

Often accompanied by large blood loss and injury to genitourinary system

Question 44

Why are children at risk for experiencing a burn/thermal injury?

Answer 44

Children also at risk due to Lack of supervision, understanding, or child abuse

Question 45

Why do Females have slightly higher rates for experiencing a burn/thermal injury?

Answer 45

Females have slightly higher rates - Thought to be due to traditional loose clothings in some countries and more often being the primary cook for the house

Question 46

What are the 4 classifications of burns? What layer of the skin does each category impact? (think of the current staging method for burns!)

Answer 46

Classification of burns (Cont.) 1.) Superficial Burn: -Only impacts the epidermis 2.) Superficial-partial thickness Burn: -Impacts the epidermis + upper portion of dermis 3.) Deep-Partial thickness Burn: -Impacts/extends deeper into the dermis 4.) Full Thickness Burn -Destroys the epidermis and entire dermis, extends into subcutaneous fat

Question 47

What are the 3 zones of a severe burn? What zone can't we help? Why?

Answer 47

central (coagulation) zone is necrotic, zone of stasis has impaired blood flow, and zone of hyperemia has good blood flow. *We can’t help the coagulation zone, but we can act to keep the zone of stasis from converting to a zone of coagulation (necrotizing)

Question 48

S+S of fracture?

Answer 48

Signs/Symptoms: depends on location -Deformity, pain, exposed bone/bleeding, cool to touch, lack of pulse, sensation changes, swelling ,loss of function, bone exposed/bleeding if open, bruising, pallor/cyanosis, cool to touch, lack of a pulse, sensation changes, increase in cap fill time, swelling Hip/femur fractures specifically: shortening/rotation, unable to weight bear, shock Pelvic fractures: unstable to palpation, shock

Question 49

How can compartment syndrome occur/what it its MOI?

Answer 49

May occur by internal or external forces: -Internal: fractures, crush injuries, hemorrhage, edema -External: casts, splints, traction

Question 50

S+S for joint injuries?

Answer 50

Signs and Symptoms: Pain, joint deformity, edema, inability to move affected joint, abnormal range of motion, reduced pulses and sensation

Question 51

What are the S+S of compartment syndrome? (think 6P's!!!)

Answer 51

Pain (disproportionate to injury) Parestheia (numbness/tingling) Paralysis (loss of motor function) Pressures (tense on palpation) Pallor (late sign) Loss of pulse (late sign) Six P’s: pain (disproportionate to the injury), paresthesia (numbness/tingling), paralysis (loss of motor function), pressures (tense on palpation, elevated if measured), pallor (later sign), loss of pulses (late)

Question 52

What are 5 interventions we can do for the Early Care + Treatment of Burn injuries?

Answer 52

Early Care + Treatment of Burns: 1.) Airway and breathing management! -Monitor closely! depending on the MOI, there may be inhalation burns or irritants) -Give O2 and be prepared to intubate patient 2.) Cooling the burn -Cool the burn with sterile, saline soaked gauze if <10% -Cover burn with clean sheet if the burn is <10% (risk of hypothermia)! 3.) CVAD + IV Fluids -Large amounts of IV fluids may be required, especially on the first day! -Monitor patients urine output closely (catheter) for clues that more fluids are needed 4.) Temperature Control -Keep the patient's room warm, this can reduce hypermetabolism, esp in extensive burns! 5.) Analgesic -Opiods are the primary analgesic used

Question 53

What are the two late S+S of compartment syndrome?

Answer 53

Pallor (late sign) Loss of pulse (late sign)

Question 54

What types of fractures do we use a backslab and sling for support as an intervention?

Answer 54

-Backslab and sling for support (non-displaced and stable)

Question 55

What is smiling death syndrome?

Answer 55

Smiling Death Syndrome: A phenomenon where a individual, initially appears to be relieved after being rescued from a crush injury, suddenly dies shortly after due to the release of toxins and electrolytes from damaged tissues, leading to a condition called crush syndrome. (Think of the grey’s anatomy episode where the teenage boy comes into the ER after submerging himself in concrete and then went into cardiac arrest!)

Question 56

What do we look at for our initial assessment of burns?

Answer 56

Initial Assessments of Burns: -Assess/look at the thickness (see above) -Rule of Nines: gives us a rough estimate when there is nothing more accurate available for us to use—useful for a first guess of extent of the injury -Rule of Palms: Assessment that is useful for smaller burns! The patient’s palm represents 1% of their total body surface area!

Question 57

MOIs/causes of pelvic fractures?

Answer 57

MOI: MVCs, Falls, Cyclist vs Motorcycle vs Pedestrian -Falls from great height

Question 58

What do serve burns have?

Answer 58

Severe burns often have a mix of depths. Center is usually the deepest. 1st/2nd/3rd degree burns used less in the medical community than the public

Question 59

What specific S+S does a hip/femur fracture have that is unique to them?

Answer 59

Hip/femur fractures specifically: shortening/rotation, unable to weight bear, shock

Question 60

What is one of the main potential problems in crush injuries is related to the kidneys?

Answer 60

One of the main potential problems in crush injuries is related to the kidneys: -Impaired renal function – damage to nephrons from myoglobin (protein in muscle) = Rhabdomyolysis!

Question 61

What is a joint injury? What causes them?

Answer 61

A joint may become dislocated when the normal range of motion is exceeded