Penetrating Extremity Trauma March 2nd

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March 2nd Dr Abdulla R2

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Penetrating Extremity Trauma March 2nd

  1. 1. Abdullah Al-abdali R2 EM
  2. 2. Outlines: • Introduction, physics • Anatomy • Management – Vascular injury – Nerve injury – Compartment syndrome • Antibiotics
  3. 3. Introduction • Penetrating injury: injury produced by foreign objects that penetrate tissue. – Low energy : knife or hand-energized missiles – Medium energy: handguns – High energy: military or hunting rifles
  4. 4. 2 KE= ½ mvs ic s o f Phy P e n e tratin g T rau m a  R e c a ll K in e tic E n e rg<2500 fps Low velocity y E q u a tio n High ( weight ) Velocity ( speedfps Mass velocity >2500 ) 2 KE 2  G re a te r th e m a s s th e g re a te r th e e n e rg y  D o u b le m a s s = d o u b le K E  D o u b le m a s s = d o u b le K E  G re a te r th e s p e e d th e g re a te r th e e n e rg y  D o u b le s p e e d = 4 x in c re a s e K E  D o u b le s p e e d = 4 x in c re a s e K E (co n tin u e d )
  5. 5. Temporary cavity • Result of energy exchange b/w moving missiles & body tissue, caused by shock wave initiated by impact of the bullet. • Diameter depends on the velocity • The max. diameter occurs at the area of greatest resistance to the bullet. Tissue damage can occur at some distance from the bullet track itself.
  6. 6. Missiles wounds • The wound at the point of bullet impact is determined by: – Shape of the missile – Position of the missile relative to the impact site – fragmentation
  7. 7. Sp ec ific W e ap o n C h aracteristics  H andguns  S m all calib er, sh o rt b arrel, m ed iu m -velo city  S m all calib er, sh o rt b arrel, m ed iu m -velo city  E ffective at clo s e ran g e  E ffective at clo s e ran g e  S e verity o f in ju ry b as ed u p o n o rg an s d am ag ed  S e verity o f in ju ry b as ed u p o n o rg an s d am ag ed  R ifle  H ig h -velo city, lo n g er b arre l, larg e calib er  H ig h -velo city, lo n g er b arre l, larg e calib er  In cre as ed a ccu rac y at far d istan c es  In cre as ed a ccu rac y at far d istan c es  As s a u lt R ifle s  L arg e m ag azin e, s em i- o r fu ll-au to m atic  L arg e m ag azin e, s em i- o r fu ll-au to m atic  S im ilar in ju ry to h u n tin g rifles  S im ilar in ju ry to h u n tin g rifles  M u ltip le w o u n d s  M u ltip le w o u n d s
  8. 8. Anatomy • 2 guiding principles: – The major nerves tend to follow the course of major arteries. Ex. – Most of extremity musculature is organized into compartments, which encased by unyielding fibrous fascia.
  9. 9. • A 19 yrs old male, was struck in the R. thigh by stray bullet, he collapsed. In ED, looks pale, P:120, BP:100/50, RR:22, O2 sat:95% on 100% O2,on 10 survey, he is alert & without trauma to the head, neck or chest. Had clear breath sound b/l. on 2nd survey he had, normal cardiac & abdomen Exam. You found an entrance wound on his proximal thigh (just distal to inguinal lig.) which is oozing blood, he has no back wound, he has a sizable R. thigh hematoma, but there is no pulsating blood coming from the wound, EMS said it is same for the last 20min. His R. DP pulse is present. What Do you want to Do first: • Take him to OR • Obtain pelvis and leg x-ray and perform FAST exam. • Intubate the patient • Measure compartment pressure
  10. 10. Management o 1 survey A Go straight to where the money is B Extremity Injuries are examined during the 2nd survey, once C patient stabilized D E
  11. 11. • Purpose of the exam: Has there been an injury to a Major artery or vein? Has a peripheral nerve been transected? Is there any evidence of bone or tendon injury? Is there any evidence of compartment syndrome?
  12. 12. What to examine? • Pulse: compare it with uninjured extremity. • Hand held Doppler • API • Color • Coolness Careful physical exam • Sensation and high index of • Tendons suspicion are most important ! • Pain
  13. 13. Hand held Doppler • Determine presence/absence of arterial supply • Assess adequacy of flow PRESENCE OF SIGNAL DOES NOT EXCLUDE ARTERIAL INJURY !
  14. 14. API SBP is obtained by inflating a blood pressure cuff proximal to the injury, and using the Doppler distal to the injury to determine the SBP • Ratio of 0.9 or less, abnormal • 0.9 to 0.99 observe for 12-24Hs • sens: 45-95% for wounds requiring OR
  15. 15. Vascular injury • 3 Qs. – When dose the Pt need to go to OR? – When dose the Pt need angiography? – When can the Pt simply observed and discharge home?
  16. 16. Extremity Wound Open Wound (larger lacerations): Penetrating wound: -can bleed profusely. HARD SIGNS OF -Small wound **1 st step is to stop bleeding. ARTERIAL INJURY -external bleed is minimal •Direct pressure •Tourniquet •Don’t ligate blindly. Doesn't exclude significant arterial injury.
  17. 17. Hard Vs Soft signs: HARD SIGNS: SOFT SIGNS: • Pulsatile bleeding • Large non-pulsatile • Expanding or pulsatile hematoma hematoma • Isolated nerve injury • Palpable thrill or • Proximity injury audible bruit • Palpable, but • Ischemia 5P’s diminished pulse
  18. 18. • The incidence of arterial injury in the presence of any one of hard signs is >90%. • 35% of patients with soft finding had positive angiographic studies. • Vascular injury occurs in 8-45% of cases of penetrating nerve injury.
  19. 19. Diagnostic strategies • Non • X-ray • Ultrasound • Arteriography • CTA
  20. 20. X-ray: • Detect fracture • Joint penetration • Foreign bodies – The position of metallic bodies – The presence of fragments of a bullet which has broken up.
  21. 21. Ultrasound • Duplex US (B-mode + US) • Non-invasive, portable • Sn 83 – 100% • Sp 99 – 100% • Operator dependent • Not always 24 h available.
  22. 22. Arteriography • It has been the gold standard for Dx. – Sens: 98% – Spec: 99% • Problems: – The cost – Need to leave the ED – Small complication of arterial cannulation – Difficult in children. – 5% FP, 5% FN when compare to surgical exploration
  23. 23. CTA • Less invasive • Much more readily available • Less time consuming • Replacing angiography in many indications.
  24. 24. CT angiography effectively evaluates extremity vascular trauma. Peng PD, Spain DA, Tataria M, Hellinger JC, Rubin GD, Brundage SI. This study supports CTA as an effective alternative to Conventional arteriography in assessing extremity vascular trauma. Am Surg. 2008 Feb;74(2):103-7. Division of Trauma and Surgical Critical Care, Department of Surgery, Stanford University Medical Center, Stanford, California, USA
  25. 25. CONCLUSIONS: With acceptable injury detection, rapid availability, and a favorable cost profile, our results suggest that CTA may replace arteriography as the diagnostic study of choice for vascular injuries of the extremities. J Trauma. 2009 Aug;67(2):238-43; discussion 243-4.
  26. 26. Manage ABCs Axillary or Hard Signs Inguinal Yes CTA/arterio + NO Wound? OR Present Yes NO • ED exploration vascular study open • Irrigate thoroughly first if wound Injury type - Primary closure laceration - Tetanus location unclear simple Shotgun Arterial injury SW or GSW sharpnel OR • observe, irrigate, tetanus •X-ray for GSW OR CTA/arterio •Consider AP/US •Consider CTA/angio + AP/US •Loose closure for SW + OR + CTA/arterio
  27. 27. Manage ABCs Axillary or Hard Signs Inguinal Yes CTA/arterio + NO Wound? OR Present Yes NO • ED exploration vascular study open • Irrigate thoroughly first if wound Injury type - Primary closure laceration - Tetanus location unclear simple Shotgun Arterial injury SW or GSW sharpnel OR • observe, irrigate, tetanus •X-ray for GSW OR CTA/arterio •Consider AP/US + AP/US •Consider CTA/angio + •Loose closure for SW + OR + CTA/arterio
  28. 28. GSW indication for OR – Hard signs – Progressive neuro deficit – Open fracture – Unstable fracture – Significant soft tissue damage or necrosis – Compartment syndrome
  29. 29. Complications Blood loss Ischemia Compartment syndrome Tissue necrosis Amputation Death
  30. 30. Nerve injury • Difficult to asses in trauma patient. • Neuropraxia – Contusion of the nerve – Normal function returns in weeks to months • Axonotmesis – Injury to nerve fibers occurs within their sheath. – Spontaneous healing is possible but slow? Why? • Neurotmesis – Is the severing of nerve – Usually require surgical repair
  31. 31. Examination • Examine sensation and muscle power • Two-points discrimination is a more sensitive examination. • Testing for sympathetic nerve function using the O’Riain wrinkle test may be helpful.
  32. 32. Compartment syndrome • It is a complication of arterial or venous injury. • A rise in pressure with a compartmentalized group of tissues leading to impaired perfusion, ischemia and necrosis of muscles within the compartment.
  33. 33. Pathophysiology • Increased compartment contents • Decrease compartment volume • External pressure
  34. 34. Clinical presentation • Pain that is disproportionate to the injury. • Pain is deep, burning and difficult to localized. • Pain on passive stretching of the muscle groups. • Hypoesthesias & paresthesias
  35. 35. Diagnosis & treatment Fasciotomy to fully decompress all involved compartments is the definitive treatment for ACS in the great majority of cases •Capillary blood flow becomes compromised at 20 mmHg. •Pain develops at pressures between 20 and 30 mmHg. •Ischemia occurs at pressures above 30 mmHg.
  36. 36. Antibiotics • Pt going to OR broad spectrum IV antibiotics • Hand & Foot & high velocity short course antibiotics with one dose IV. • Other site single IV dose to cover skin flora. • For immunocompromised patient. J Am Acad Orthop Surg, Vol 14, No 10, September 2006, S98-S100. © 2006 the American Academy of Orthopaedic Surgeons
  37. 37. 195 patients ceftriaxon cefoxitin TID x3 days There was no significant different in the infection rate and no patient Developed deep tissue infection requiring surgical intervention by Post-trauma day 10 Schmidt et al, Chemotherapy 2002;45: 1621-1626
  38. 38. • While you are waiting for the result of x-rays, he becomes tachypneic, and BP drops to 70/40 with P:160, oxygen sat. probe is not picking up a reading. A repeat 1o survey reveals an intact airway & clear breath sounds & his thigh looks the same, you look at the back & axilla again to assure you didn’t miss any injury: What is a possible explanation for his deterioration? • Occult Pneumothorax that has become a tension Pneumothorax. • Anemia from ongoing occult bleeding • Fat embolism from a femur fracture • Missile embolism to the pulmonary vasculature.
  39. 39. Missile embolism • The travel of foreign bodies from penetrating trauma through blood stream. • Can be arterial or venous: – Arterial: distal obstruction & distal ischemia – Venous: travel through R. heart to P. arterial system PE • Arterial emboli can be removed either with arteriotomy or balloon catheter embolectomy. • All centrally located, symptomatic venous emboli, need to be removed. • Some surgeon will leave asymptomatic missiles in place, which has been shown to be safe.
  40. 40. Tetanus
  41. 41. Summary • ATLS • Indication for OR? Stable / unstable? • Further investigations? • Don’t miss nerve injury • Compartment syndrome • Antibiotics? • Tetanus
  42. 42. Compartments of the lower leg • Anterior compartment- most • Deep Posterior Compartment frequently affected – Muscles: tibialis posterior, the – Muscles- tibialis anterior, flexor digitorum longus & FHL extensors of the toes (EHL – Test: Toe flexion and EDL) – Nerves: Tibial nerve – Test: Extension of the 1st toe – Test: Sole of foot (heel too) – Nerves- Deep peroneal nerve – Vascular: Posterior tibial artery – Test: Web space of 1st toe – Test: Posterior tibial pulse – Vascular- Anterior tibial artery • Superficial Posterior – Test: Dorsalis pedis pulse compartment • Lateral Compartment – Muscles: Gastrocnemius and, – Muscles- Preens longus and the soleus muscle brevis – Test: Plantar flexion – Test: Foot eversion – Nerve: Sural nerve. – Nerves: Superficial peroneal – Test: Lateral aspect of 5th toe nerve – Test: Dorsum of foot – No artery

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