3. Primary survey
A : Airway patent ,can talk ,can move neck ,not tender along C spine
B : no chest wound ,no dyspnea ,no accessory muscle used ,trachea in
midline ,clear and equal breath sound both lungs ,no adventitious sound
C :BP 134/87 mmHg ,PR 80 / min,no external bleeding
D : E4V5M6 ,pupil 3 mm RTLBE ,
E :laceration wound 3 cm deep to bone at left 5th toe
6. Secondary survey
Allergy : no history of drug or food allergy
Medication : no current medication
Past history : no known u/d
Last meal :ประมาณ 21.00 น. 24/7/60
Event : ตาม present illness
Refer จากรพ.เอกชน
7. Physical examination
GA : A Thai middle age man ,good consciousness
Vital sign : BP 134/87 mmHg ,PR 96 bpm ,RR 20/min
HEENT :not pale conjunctivae ,anicteric sclerae
Skin : abrasion wound 3*3 cm at left lower lip
Heart :normal S1,S2 ,no murmur , full and symmetrical pulse all exts.
Lung no accessory muscle used ,trachea in midline ,normal breath sound ,no adventitious sound
Abdomen : not distend ,soft ,not tender
Extremities : Laceration wound 3 cm deep to bone,limit ROM
,capilary refill time <2sec,decrease pinprick sensation on lateral side of left 5th toe
14. Diagnosis : Opened fracture proximal phalange of Lt 5th
toe with extensor tendon injury
15. Management
Initial management
-NPO
-Cefazolin 1 g iv q 6 h with stat
-Tramol 50 mg iv prn q 6 h
- On buddy splint
- Preoperative lab
- dT 0.5 mL IM
Definite management
-Admit for surgery (DB with k-wire fixation with
repair tendon)
17. Management at ER
Fracture management begins after initial trauma survey and resuscitation is
complete
Antibiotics
initiate early IV antibiotics and update tetanus prophylaxis as indicated
Control bleeding
direct pressure will control active bleeding
do not blindly clamp or place tourniquets on damaged extremities
Assessment
soft-tissue damage
neurovascular exam
18. Management at ER
Dressing
remove gross debris from wound
place sterile saline-soaked dressing on the wound
Stabilize
splint fracture for temporary stabilization
-> decreases pain, further injury from bone ends, and disruption of clots
19.
20. Gustillo Grade I and II
1st generation cephalosporin
Gustillo Grade III
1st generation cephalosporin + aminoglycoside
traditionally recommended, but there is no evidence in the literature to
support its use
With farm injury / bowel contamination
1st generation cephalosporin + aminoglycoside + PCN
add PCN for clostridia
21. Duration
initiate as soon as possible
increased infection rate when antibiotics are delayed > 3 hours
time of injury
continue for 72 hours after I&D
48 hours after each procedure
22. Management in OR
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
on average, 3L of saline are used for each successive Gustilo type
Type I: 3L
Type II: 6L
Type III: 9L
bony fragments without soft tissue attachment can be removed
23. Management in OR
Fracture stabilization
can be with internal or external fixation, as indicated
Staged debridement and irrigation
perform every 24 to 48 hours as needed
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
