Advanced Trauma Life Support ATLS Student Course Manual 2018
Share Embed Flag
Download ePaper

Advanced Trauma Life Support ATLS Student Course Manual 2018

bakordik
04.12.2017 Views

SECONDARY SURVEY 153 debridement. Remove gross contamination and particulate matter from the wound, and administer weight-based dosing of antibiotics as early as possible in patients with open fractures. (See Appendix G: Circulation Skills.) Qualified clinicians may attempt reduction of joint dislocations. If a closed reduction successfully relocates the joint, immobilize it in the anatomic position with prefabricated splints, pillows, or plaster to maintain the extremity in its reduced position. If reduction is unsuccessful, splint the joint in the position in which it was found. Apply splints as soon as possible, because they can control hemorrhage and pain. However, resuscitation efforts must take priority over splint application. Assess the neurovascular status of the extremity before and after manipulation and splinting. X-ray Examination Although x-ray examination of most skeletal injuries is appropriate during the secondary survey, it may be undertaken during the primary survey when fracture is suspected as a cause of shock. The decisions regarding which x-ray films to obtain and when to obtain them are based on the patient’s initial and obvious clinical findings, the patient’s hemodynamic status, and the mechanism of injury. SecondARy Survey Important elements of the secondary survey of patients with musculoskeletal injuries are the history and physical examination. History Key aspects of the patient history are mechanism of injury, environment, preinjury status and predisposing factors, and prehospital observations and care. Mechanism of Injury Information obtained from the patient, relatives, prehospital and transport personnel, and bystanders at the scene of the injury should be documented and included as a part of the patient’s history. It is particularly important to determine the mechanism of injury, which can help identify injuries that may not be immediately apparent. (See Biomechanics of Injury.) The clinician should mentally reconstruct the injury scene, consider other potential injuries the patient may have sustained, and determine as much of the following information as possible: 1. Where was the patient located before the crash? In a motor vehicle crash, the patient’s precrash location (i.e., driver or passenger) can suggest the type of fracture—for example, a lateral compression fracture of the pelvis may result from a side impact collision. 2. Where was the patient located after the crash— inside the vehicle or ejected? Was a seat belt or airbag in use? This information may indicate certain patterns of injury. If the patient was ejected, determine the distance the patient was thrown, as well as the landing conditions. Ejection generally results in unpredictable patterns of injury and more severe injuries. 3. Was the vehicle’s exterior damaged, such as having its front end deformed by a head-on collision? This information raises the suspicion of a hip dislocation. 4. Was the vehicle’s interior damaged, such as a deformed dashboard? This finding indicates a greater likelihood of lower-extremity injuries. 5. Did the patient fall? If so, what was the distance of the fall, and how did the patient land? This information helps identify the spectrum of injuries. 6. Was the patient crushed by an object? If so, identify the weight of the crushing object, the site of the injury, and duration of weight applied to the site. Depending on whether a subcutaneous bony surface or a muscular area was crushed, different degrees of soft-tissue damage may occur, ranging from a simple contusion to a severe degloving extremity injury with compartment syndrome and tissue loss. 7. Did an explosion occur? If so, what was the magnitude of the blast, and what was the patient’s distance from the blast? An individual close to the explosion may sustain primary blast injury from the force of the blast wave. A secondary blast injury may occur from debris and other objects accelerated by the blast (e.g., fragments), leading to penetrating wounds, lacerations, and contusions. The patient may also be violently thrown to the ground or against other objects by the blast effect, leading to blunt musculoskeletal and other injuries (i.e., a tertiary blast injury). n BACK TO TABLE OF CONTENTS

154 CHAPTER 8 n Musculoskeletal Trauma n FIGURE 8-4 Impact points vary based on vehicle and individual, i.e., height of bumper and patient's age and size. 8. Was the patient involved in a vehicle-pedestrian collision? Musculoskeletal injuries follow predictable patterns based on the patient’s size and age (n FIGURE 8-4). Environment When applicable, ask prehospital care personnel for the following information about the postcrash environment: 1. Did the patient sustain an open fracture in a contaminated environment? 2. Was the patient exposed to temperature extremes? 3. Were broken glass fragments, which can also injure the examiner, at the scene? 4. Were there any sources of bacterial contamination, such as dirt, animal feces, and fresh or salt water? This information can help the clinician anticipate potential problems and determine the initial antibiotic treatment. Preinjury Status and Predisposing Factors When possible, determine the patient’s baseline condition before injury. This information can enhance understanding of the patient’s condition, help determine treatment regimen, and affect outcome. An AMPLE history should be obtained, including information about the patient’s exercise tolerance and activity level, ingestion of alcohol and/or other drugs, emotional problems or illnesses, and previous musculoskeletal injuries. Prehospital Observations and Care All prehospital observations and care must be reported and documented. Findings at the incident site that may help to identify potential injuries include •• The time of injury, especially if there is ongoing bleeding, an open fracture, and a delay in reaching the hospital •• Position in which the patient was found •• Bleeding or pooling of blood at the scene, including the estimated amount •• Bone or fracture ends that may have been exposed •• Open wounds in proximity to obvious or suspected fractures •• Obvious deformity or dislocation •• Any crushing mechanism that can result in a crush syndrome •• Presence or absence of motor and/or sensory function in each extremity •• Any delays in extrication procedures or transport •• Changes in limb function, perfusion, or neurologic state, especially after immobilization or during transfer to the hospital •• Reduction of fractures or dislocations during extrication or splinting at the scene •• Dressings and splints applied, with special attention to excessive pressure over bony prominences that can result in peripheral nerve compression or compartment syndrome •• Time of tourniquet placement, if applicable n BACK TO TABLE OF CONTENTS

154<br />

CHAPTER 8 n Musculoskeletal <strong>Trauma</strong><br />

n FIGURE 8-4 Impact points vary based<br />

on vehicle and individual, i.e., height of<br />

bumper and patient's age and size.<br />

8. Was the patient involved in a vehicle-pedestrian<br />

collision? Musculoskeletal injuries follow<br />

predictable patterns based on the patient’s size<br />

and age (n FIGURE 8-4).<br />

Environment<br />

When applicable, ask prehospital care personnel<br />

for the following information about the postcrash<br />

environment:<br />

1. Did the patient sustain an open fracture in a<br />

contaminated environment?<br />

2. Was the patient exposed to temperature extremes?<br />

3. Were broken glass fragments, which can also<br />

injure the examiner, at the scene?<br />

4. Were there any sources of bacterial<br />

contamination, such as dirt, animal feces, and<br />

fresh or salt water?<br />

This information can help the clinician anticipate<br />

potential problems and determine the initial<br />

antibiotic treatment.<br />

Preinjury Status and Predisposing Factors<br />

When possible, determine the patient’s baseline<br />

condition before injury. This information can enhance<br />

understanding of the patient’s condition, help<br />

determine treatment regimen, and affect outcome.<br />

An AMPLE history should be obtained, including<br />

information about the patient’s exercise tolerance<br />

and activity level, ingestion of alcohol and/or other<br />

drugs, emotional problems or illnesses, and previous<br />

musculoskeletal injuries.<br />

Prehospital Observations and Care<br />

All prehospital observations and care must be reported<br />

and documented. Findings at the incident site that may<br />

help to identify potential injuries include<br />

••<br />

The time of injury, especially if there is ongoing<br />

bleeding, an open fracture, and a delay in<br />

reaching the hospital<br />

••<br />

Position in which the patient was found<br />

••<br />

Bleeding or pooling of blood at the scene,<br />

including the estimated amount<br />

••<br />

Bone or fracture ends that may have been exposed<br />

••<br />

Open wounds in proximity to obvious or<br />

suspected fractures<br />

••<br />

Obvious deformity or dislocation<br />

••<br />

Any crushing mechanism that can result in a<br />

crush syndrome<br />

••<br />

Presence or absence of motor and/or sensory<br />

function in each extremity<br />

••<br />

Any delays in extrication procedures or transport<br />

••<br />

Changes in limb function, perfusion, or neurologic<br />

state, especially after immobilization or<br />

during transfer to the hospital<br />

••<br />

Reduction of fractures or dislocations during<br />

extrication or splinting at the scene<br />

••<br />

Dressings and splints applied, with special<br />

attention to excessive pressure over bony<br />

prominences that can result in peripheral nerve<br />

compression or compartment syndrome<br />

••<br />

Time of tourniquet placement, if applicable<br />

n BACK TO TABLE OF CONTENTS

logo

products

Resources

Company

Terms of service
Privacy policy
Cookie policy
Cookie settings
Imprint
Change language
Made with love in Switzerland
© 2024 Yumpu.com all rights reserved

Hooray! Your file is uploaded and ready to be published.

Saved successfully!

Ooh no, something went wrong!