splinting rules • adequately visualize • distal pms before and after splinting • treat...

International Trauma Life Support

International Trauma Life Support

for Prehospital Care ProvidersSixth Edition

for Prehospital Care ProvidersSixth Edition

Patricia M. Hicks, MS, NREMTPRoy Alson, PhD, MD, FACEP

Donna Hastings, EMT-PJohn Emory Campbell, MD, FACEP

and Alabama Chapter,American College of Emergency Physicians

Patricia M. Hicks, MS, NREMTPRoy Alson, PhD, MD, FACEP

Donna Hastings, EMT-PJohn Emory Campbell, MD, FACEP

and Alabama Chapter,American College of Emergency Physicians

Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJwww.fisiokinesiterapia.biz

Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Extremity TraumaExtremity TraumaCourtesy of Bonnie Meneely, EMT-P

Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Overview

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• Fractures• Dislocations• Amputations• Open wounds

• Neurovascular injuries• Sprains and strains• Impaled objects• Compartment syndrome

Priority of extremity trauma

Major complications and treatment:

Estimated blood loss • Pelvic and extremity fractures

Extremity Trauma -

Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Overview

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• Pelvis• Femur• Hip• Knee• Tibia/fibula

• Clavicle/shoulder• Elbow• Forearm and wrist• Hand or foot

Major mechanisms, associated trauma, potential complications, management:

Extremity Trauma -

Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Extremity TraumaDistorted or wounded extremities must not distract from life-threatening injuries. • Easy to identify• Disabling but rarely immediately life-threatening

Potential danger:• Hemorrhagic shock (very few)• Neurovascular compromise

• Distal PMS

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Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Extremity TraumaExtremity injuries• Fractures• Dislocations• Amputations• Open wounds• Neurovascular injuries• Impaled objects• Compartment syndrome

5Extremity Trauma -

Courtesy of Roy Alson, MD

Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Extremity InjuriesFractures• Open (compound)

• Communication to outside• Danger of contamination • Blood loss outside body

• Closed (simple)• No communication to outside• Danger of contamination • Blood loss inside body

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Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

FracturesHemorrhage with fracture• Closed femur fracture

• Loss of 1 liter of blood• Two closed femur fractures life-threatening

• 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

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Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Extremity InjuriesDislocations• Neurovascular compromise

• True emergency though not life-threatening• Check PMS distal to major joint dislocations

8Extremity Trauma -

Courtesy of Roy Alson, MD

Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

DislocationsManagement• No neurovascular compromise

• Splint in position found

• Neurovascular compromise• Apply only gentle traction in effort to straighten• No more than 10 pounds of force• Often best: pad and splint in most comfortable

position and rapid safe transport

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Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Extremity InjuriesAmputations• Disabling and sometimes life-threatening • Potential for massive hemorrhage

• Most often, bleeding controlled with ordinary pressure

10Extremity Trauma -

Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

AmputationsManagement• Cover with damp sterile dressing, elastic wrap• Uniform reasonable pressure across stump • Tourniquet if bleeding absolutely not controlled

• Rarely needed

• Retrieve amputated part• In plastic bag, inside ice water

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Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Extremity InjuriesOpen wounds• Remove contamination

• Gross: remove• Smaller: irrigate with normal saline

• Sterile dressing and bandage• Pressure dressing, if necessary• Pressure point• Tourniquet rare• Hemostatic agent

12Extremity Trauma -

Courtesy of Roy Alson, MD

Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Open Wounds

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Obviousexsanguinating hemorrhage—

only time can change order of ABC to CAB.

Obviousexsanguinating hemorrhage—

only time can change order of ABC to CAB.

Extremity Trauma -

Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Extremity InjuriesNeurovascular injuries• Nerves and major vessels

run beside each other in flexor area of major joints

Distal PMS• Assess pulse• Assess motor function• Assess sensory

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Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Extremity InjuriesImpaled objects• Do not remove

• Airway obstruction exception

• Apply very bulky padding

• Transport object in place

• No unnecessary movement• Motion magnified in tissues

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Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Compartment syndrome• Forearm and lower leg most common• Swelling compresses nerves and vessels

Extremity Injuries

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Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Compartment SyndromeEarly symptoms• Pain

• Paresthesia

Late symptoms• Pain• Pallor• Pulselessness • Paresthesia • Paralysis

17Extremity Trauma -

Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

ITLS Patient Assessment

Mechanism History Common InjuryFalls landing on feet Foot, lumbar spine

Sitting position Knee, hip

Fall onto wrist Wrist, elbow

Fall onto ankle Ankle, proximal fibula

Shoulder involved Shoulder, neck, chest

Pelvis involved Pelvis, shock

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Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Extremity TraumaITLS Primary and Secondary Surveys• Major bleeding• DCAP-BTLS• Instability • Crepitation• Joint pain• Joint movement• Distal PMS

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Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

ManagementSplinting• Prevent motion in broken bone ends• Eliminate further damage• Decrease pain

Load-and-go patients• Temporary splinting with long backboard• Additional splinting during transport

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Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

SplintingRules• 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

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Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Extremity Trauma

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If in doubt, splint possible injury.If in doubt, splint possible injury.

Extremity Trauma -

Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Types of Splints

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Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Extremity TraumaSpine

24Extremity Trauma -

Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Extremity TraumaPelvis

25Extremity Trauma -

Courtesy of Sam Splints

Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Extremity TraumaFemur

26Extremity Trauma -

Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Extremity TraumaHip

27Extremity Trauma -

Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Extremity TraumaKnee

28Extremity Trauma -

Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Extremity TraumaTibula/fibula

29Extremity Trauma -

Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Extremity TraumaClavicle

30Extremity Trauma -

Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Extremity TraumaShoulder

31Extremity Trauma -

Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Extremity TraumaElbow

32Extremity Trauma -

Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Extremity TraumaForearm and wrist

33Extremity Trauma -

Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Extremity TraumaHand or foot

34Extremity Trauma -

Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

SummaryITLS 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

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Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Discussion

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