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1 International Trauma Life Support for Prehospital Care Providers Sixth Edition Patricia M. Hicks, MS, NREMTP Roy Alson, PhD, MD, FACEP Donna Hastings, EMT-P John Emory Campbell, MD, FACEP and Alabama Chapter, American College of Emergency Physicians
2 Courtesy of Bonnie Meneely, EMT-P Extremity Trauma
3 Overview Priority of extremity trauma Major complications and treatment: Fractures Neurovascular injuries Dislocations Sprains and strains Amputations Impaled objects Open wounds Compartment syndrome Estimated blood loss Pelvic and extremity fractures Extremity Trauma - 2
4 Overview Major mechanisms, associated trauma, potential complications, management: Pelvis Femur Hip Knee Tibia/fibula Clavicle/shoulder Elbow Forearm and wrist Hand or foot Extremity Trauma - 3
5 Extremity Trauma Distorted 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 Extremity Trauma - 4
6 Extremity Trauma Extremity injuries Fractures Dislocations Amputations Open wounds Neurovascular injuries Impaled objects Compartment syndrome Courtesy of Roy Alson, MD Extremity Trauma - 5
7 Extremity Injuries Fractures 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 Extremity Trauma - 6
8 Fractures Hemorrhage 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 Extremity Trauma - 7
9 Extremity Injuries Dislocations Neurovascular compromise True emergency though not life-threatening Check PMS distal to major joint dislocations Courtesy of Roy Alson, MD Extremity Trauma - 8
10 Dislocations Management 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 Extremity Trauma - 9
11 Extremity Injuries Amputations Disabling and sometimes life-threatening Potential for massive hemorrhage Most often, bleeding controlled with ordinary pressure Extremity Trauma - 10
12 Amputations Management 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 Extremity Trauma - 11
13 Extremity Injuries Open wounds Remove contamination Gross: remove Smaller: irrigate with normal saline Sterile dressing and bandage Pressure dressing, if necessary Pressure point Tourniquet rare Hemostatic agent Courtesy of Roy Alson, MD Extremity Trauma - 12
14 Open Wounds Obvious exsanguinating hemorrhage only time can change order of ABC to CAB. Extremity Trauma - 13
15 Extremity Injuries Neurovascular injuries Nerves and major vessels run beside each other in flexor area of major joints Distal PMS Assess pulse Assess motor function Assess sensory Extremity Trauma - 14
16 Extremity Injuries Impaled objects Do not remove Airway obstruction exception Apply very bulky padding Transport object in place No unnecessary movement Motion magnified in tissues Extremity Trauma - 15
17 Extremity Injuries Compartment syndrome Forearm and lower leg most common Swelling compresses nerves and vessels Extremity Trauma - 16
18 Compartment Syndrome Early symptoms Pain Paresthesia Late symptoms Pain Pallor Pulselessness Paresthesia Paralysis Extremity Trauma - 17
19 ITLS Patient Assessment Mechanism History Falls landing on feet Sitting position Fall onto wrist Fall onto ankle Shoulder involved Pelvis involved Common Injury Foot, lumbar spine Knee, hip Wrist, elbow Ankle, proximal fibula Shoulder, neck, chest Pelvis, shock Extremity Trauma - 18
20 Extremity Trauma ITLS Primary and Secondary Surveys Major bleeding DCAP-BTLS Instability Crepitation Joint pain Joint movement Distal PMS Extremity Trauma - 19
21 Management Splinting Prevent motion in broken bone ends Eliminate further damage Decrease pain Load-and-go patients Temporary splinting with long backboard Additional splinting during transport Extremity Trauma - 20
22 Splinting Rules 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 Extremity Trauma - 21
23 Extremity Trauma If in doubt, splint possible injury. Extremity Trauma - 22
24 Types of Splints Extremity Trauma - 23
25 Extremity Trauma Spine Extremity Trauma - 24
26 Extremity Trauma Pelvis Courtesy of Sam Splints Extremity Trauma - 25
27 Extremity Trauma Femur Extremity Trauma - 26
28 Extremity Trauma Hip Extremity Trauma - 27
29 Extremity Trauma Knee Extremity Trauma - 28
30 Extremity Trauma Tibula/fibula Extremity Trauma - 29
31 Extremity Trauma Clavicle Extremity Trauma - 30
32 Extremity Trauma Shoulder Extremity Trauma - 31
33 Extremity Trauma Elbow Extremity Trauma - 32
34 Extremity Trauma Forearm and wrist Extremity Trauma - 33
35 Extremity Trauma Hand or foot Extremity Trauma - 34
36 Summary ITLS 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 Extremity Trauma - 35
37 Discussion Craig Jackson/In the Dark Photography Extremity Trauma - 36
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