3. Primary survey
Airway and C-spine
able to talk, no tracheal shift, no c-spine tender
Breathing
Equal breath sound both sound both lungs,
clear, no rib stepping
Circulation
BP 134/85mmHg, PR 97 bpm
Disability and neurologic status
E4V5M6 pupil 2mm RTLBE
Exposure/Environment control
Laceration wound 5cmx6cm at Right dorsal
ankle, able move toes, not able to move ankle
7. Secondary survey
Allergy : Penicillin Allergy (Rash)
Medication : No current medication
Past history : No underlying disease
Last meal : 11Hr PTA(12:00)
9. Secondary survey
GA: Thai male, good consciousness, well co-operative
V/S: T 37.2C,BP 134/85mmHg, PR97bpm, RR20
HEENT: Not pale conjunctivae, no icteric sclerae
Heart: full regular pulse, normal S1S2, no murmur
Lungs: clear and equal breath sound both lungs
Abdomen: normoactive bowel sound, soft, not tender
Extremities: laceration wound at right dorsal ankle, size
5x6cm, deep to subcutaneous tissue, no ankle
deformities,
Posterior tibialis pulse 2+ both feet,
Dorsalis pedis pulse 2+ both feet
Skin: no rash, no petechiae
10.
11.
12. Adjunct to Secondary survey
1.Film Right ankle AP
Lateral
Mortise
2.Film Right Foot AP
Oblique
3.Film Right leg AP
Lateral
29. Management in the Emergency Room
1.Initial trauma survey and resuscitation
2.Antibiotics
initiate early IV antibiotics and update tetanus prophylaxis as
indicated
3.Control bleeding
-direct pressure will control active bleeding
-do not blindly clamp or place tourniquets on damaged extremities
4.Assessment
-soft-tissue damage
-neurovascular exam
5.Dressing
-remove gross debris from wound
-place sterile saline-soaked dressing on the wound
6.Stabilize
splint fracture for temporary stabilization
decreases pain, further injury from bone ends, and disruption of clots
30. Management in the Emergency Room
In this case
1.Initial trauma survey and resuscitation
2.Antibiotics
Gentamycin 240g iv od x3 days
Clindamycin 600mg iv q8hr
3.Control bleeding
-Venous suture มาจากที่โรงพยาบาลเอกชน
4.Assessment
-soft-tissue damage :deep to subcutaneous
-neurovascular exam :intact
5.Dressing
-remove gross debris from wound : ส่งไปทาใน OR ทันที
-place sterile saline-soaked dressing on the wound
6.Stabilize
-on short leg slab มาจากโรงพยาบาลเอกชน
31. Management in the operating room
1.Aggressive debridement and irrigation
- thorough debridement is critical to prevention of deep
infection
- low and high pressure lavage are equally effective in
reducing bacterial counts
- saline shown to be most effective irrigating agent
- bony fragments without soft tissue attachment can be removed
2.Fracture stabilization
- can be with internal or external fixation, as indicated
3.Early soft tissue coverage or wound closure is ideal
- timing of flap coverage for open tibial fractures remains
controversial
- increased risk of infection beyond 7 days
4.Can place antibiotic bead-pouch in open dirty wounds
- beads made by mixing methylmethacrylate with heat-stable
antibiotic powder
32. Management in the operating room
In this case
1.Debridement and Irrigation with Normal Saline
2.Repair extensor digitorum longus muscle
3.Place Drainage
4.Suture wound with Nylon 3-0
5.On short leg slab
35. Antibiotics treatment
Gustilo Type I and II
-1st generation cephalosporin
-clindamycin or vancomycin can also be used if allergies exist
Gustilo Type III
-1st generation cephalosporin and aminoglycoside
Farm injuries or possible bowel contamination
-add penicillin for anaerobic coverage (clostridium)
Duration
-initiate as soon as possible
studies show increased infection rate when antibiotics are delayed for
more than 3 hours from time of injury
-continue for 24 hours after initial injury if wound is able to be
closed primarily
-continue until 24 hours after final closure if wound is not –
closed during initial surgical debridement
36. Antibiotics treatment
In this case
Gustilo Type IIIA
-1st generation cephalosporin and aminoglycoside
So
-Gentamycin 240mg iv od x 3days
-Clindamycin 600mg iv q8hr