Advanced Trauma Life Support ATLS Student Course Manual 2018

LIMB-THREATENING INJURIES 157
necessary. The patient should be adequately
resuscitated and, if possible, hemodynamically
normal. Wounds may then be operatively debrided,
fractures stabilized, and distal pulses confirmed.
Tetanus prophylaxis should be administered. (See
Tetanus Immunization.)
Pitfall
prevention
n FIGURE 8-6 Example of an open fracture. Open fractures and joint
injuries are prone to problems with infection, healing, and function.
Failure to give timely
antibiotics to patients
with open fractures
• Recognize that infection is
a significant risk in patients
with open fractures.
• Administer weight-based
doses of appropriate
antibiotics as soon as an
open fracture is suspected.
the same limb segment as an associated fracture. At
no time should the wound be probed.
Documentation of the open wound begins during
the prehospital phase with the initial description of
the injury and any treatment rendered at the scene.
If an open wound exists over or near a joint, it should
be assumed that the injury connects with or enters
the joint. The presence of an open joint injury may be
identified using CT. The presence of intraarticular gas
on a CT of the affected extremity is highly sensitive
and specific for identifying open joint injury. If CT
is not available, consider insertion of saline or dye
into the joint to determine whether the joint cavity
communicates with the wound. If an open joint is
suspected, request consultation by an orthopedic
surgeon, as surgical exploration and debridement may
be indicated.
Management
Management decisions should be based on a complete
history of the incident and assessment of the
injury. Treat all patients with open fractures as
soon as possible with intravenous antibiotics using
weight-based dosing. First-generation cephalosporins
are necessary for all patients with open fractures
(n TABLE 8-2). Delay of antibiotic administration
beyond three hours is related to an increased risk
of infection.
Remove gross contamination and particulates from
the wound as soon as possible, and cover it with a moist
sterile dressing. Apply appropriate immobilization
after accurately describing the wound and determining
any associated soft-tissue, circulatory, and neurologic
involvement. Prompt surgical consultation is
Vascular Injuries
In patients who manifest vascular insufficiency
associated with a history of blunt, crushing, twisting,
or penetrating injury or dislocation to an extremity,
clinicians should strongly suspect a vascular injury.
Assessment
The limb may initially appear viable because extremities
often have some collateral circulation that provides
adequate flow. Non-occlusive vascular injury, such
as an intimal tear, can cause coolness and prolonged
capillary refill in the distal part of the extremity, as
well as diminished peripheral pulses and an abnormal
ankle/brachial index. Alternatively, the distal extremity
may have complete disruption of flow and be cold, pale,
and pulseless.
Management
It is crucial to promptly recognize and emergently
treat an acutely avascular extremity.
Early operative revascularization is required to
restore arterial flow to an ischemic extremity. Muscle
necrosis begins when there is a lack of arterial blood
flow for more than 6 hours. Nerves may be even
more sensitive to an anoxic environment. If there is
an associated fracture deformity, correct it by gently
pulling the limb out to length, realigning the fracture,
and splinting the injured extremity. This maneuver
often restores blood flow to an ischemic extremity when
the artery is kinked by shortening and deformity at the
fracture site.
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