Basic Guide to Suturing


The folks over at LifeintheFastLane have released a series of great posts on Trauma assessment and management. What I've provided here is a collated version of a selection of these posts, along with relevant resources from other sources, to create The Ultimate Guide to Trauma for Junior Doctors and Medical Students.

Most of the posts are done in a Q&A style so you can put your knowledge to test. In Part One we covered the basics (BLS & ALS, initial assessment & management), one step further (major haemorrhage, transfusions and intubation), considered abdominal and genitourinary trauma, chest trauma and trauma in pregnancy. In Part Two, we covered central nervous trauma, eye trauma and general radiology. In Part Three we cover Musculoskeletal / Orthopaedic Injuries, particularly looking at life and limb threatening injuries.

General Principles

Primary Survey
Use the ATLS ABCDE approach to help guide your assessment, identifying and correct issues as found. Bear in mind that life-threatening haemorrhage (though traditionally thought as part of Circulation) is considered a simultaneously priority. People will and have died from exsanguination from pelvic and long bone fractures, whilst people are still focusing on the Airway.

Another approach adapted from the Military is MARCH which may be applicable at times.

  • M assive Haemorrhage (4 D's)
    • Detect: find the source of the bleeding.
    • Direct pressure: hold pressure on the source of the bleeding until the clot forms.
    • Devices: if necessary, use equipment such as tourniquets, hemostatic gauze and pressure bandages to supplement direct pressure.
    • Don’t dilute: use the concept of hypotensive resuscitation to avoid thinning the blood or pumping established clots. Saline does not carry oxygen.
  • A irway Control
  • R espiratory Support
  • C irculation
  • H ead Trauma / Hypothermia

Adequate imaging is a must - Xray first. CT should be delayed until stabilisation has been accomplished.
Fracture Immobilisation & Stabilsation.

Secondary Survey
Further assessment of core and limb musculoskeletal structure is often conducted during the secondary survey. The suggested approach below is adapted from the ATACC Manual.

AMPLE Hx
Look
  • wounds, laceration, contusions
  • deformity
  • colour, perfusion 
Feel
  • assess neurovascular status (e.g. pulses)
  • tenderness
  • crepitis
  • temperature
Move
  • joint stability
  • abnormal or limited movement
Assess for associated injuries
Reduce fracture and/or dislocation


Life Threatening Injuries
  • Pelvic Disruption with Haemorrhage
  • Major Arterial Haemorrhage
  • Crush Syndrome


Limb Threatening Injuries
  • Open Fractures / Joint Injuries
  • Long Bone Fractures
  • Vascular Injuries
  • Compartment Syndrome

Surgical Intervention
As per OrthoBullets.com there are select number of conditions that may require prompt surgical intervention.
  • unstable pelvic fracture
  • compartment syndrome
  • fractures with vascular injuries
  • unreduced dislocations
  • traumatic amputations
  • unstable spine fractures
  • cauda equina syndrome
  • open fractures

Compartment Syndrome

Compartment syndrome is a limb-threatening condition, that causes compression of vessels, muscles and nerves within a fascial compartment. The three key symptoms are pain out of proportion to injury, persistent deep ache or burning pain and parathesia in a peripheral nerve distribution (typical onset 30 minutes to 2hrs).

Management includes relieving external pressure (e.g. remove constrictive dressings or casts), analgesia, supplementary oxygen, followed by internal pressure relief (e.g. surgical Fasciotomy).

6 P's for Critical Limb Ischaemia
Pain, Paresthesia, Paresis, Pallor, Pulselessness, Poikilothermia

Compartment Syndrome by Katelyn Hanson, DO. Fullsize on ALEIM

Paediatric Fractures

The Royal Children's Hospital Clinical Guidelines provide a nice clear overview of Fracture Management in children.



Hip/Pelvis

Pelvic trauma is important as the mortality and morbidity associated with these injuries is high.
Injuries mechanisms include potential for massive haemorrhage, neurovascular compromise and associated soft tissue and abdominal injuries.

Hip Dislocation

Acetabular Fracture
Read more on OrthoBullets: www.orthobullets.com/trauma/1034/acetabular-fractures


Pelvic Fractures I - Initial Workup and Classification
A fractured Pelvic Ring fracture can be difficult to diagnose in Trauma. Assessment includes the usual look, feel and a very cautious approach to the move component. In the literature there is mention of avoiding distracting the pelvis all together given the availability of plain radiography. The rectum (PR Exam), perineum and genetilia, lower limbs and abdomen also need to be examined in the initial workup for any associated injuries.

Two common classifications systems are used often in conjunction in Pelvic Trauma.

Tile: is about stability
  • a stable
  • b partial unstable  (e.g. b1 open book #)
  • c unstable


Young-Burgess: is about mechanism


Be aware FAST can be negative, retroperitoneal bleed.

Read more on Phsyiopedia: www.physio-pedia.com/Pelvic_Fractures
Read more on Radiopedia: radiopaedia.org/articles/pelvic-fractures
Read more on OrthoBullets: www.orthobullets.com/trauma/1030/pelvic-ring-fractures

Pelvic Fractures II - Management and Complications
Management of Pelvic fractures is about maintenance of ABCDE, early stabilisation of the fracture, and minimisation of complications. The patient's haemodynamic stability will also guide management efforts. ALIEM provides a succint overview of management of Major Pelvic Trauma including a section on the use of REBOA.


Compression and Pelvic Binders



Complications
  • Associated injuries
    • Urologic
    • Neurologic
    • Gynaecologic
    • Gastrointestinal
  • Hypovolaemia / Shock
  • Infection in open fractures
RCH: Early management of pelvic injuries in children

Upper Limb

Brachial Plexus
Read more on OrthoBullets: Brachial Plexus Injuries

Shoulder / Humerus
LITFL: https://lifeinthefastlane.com/a-funny-fracture/
Flashcards (Blunt dissection)
Read more on OrthoBullets:

Elbow
Flashcards (Blunt dissection)
Read more on OrthoBullets:


Forearm / Wrist
LITFL: https://lifeinthefastlane.com/bone-and-joint-bamboozler-003/
Flashcards (Blunt dissection)
Read more on OrthoBullets:

Lower Limb

Flashcards (Blunt dissection)

Femur
ACI NSW Health: How to put on a femur splint
Read more on OrthoBullets:

Leg
Read more on OrthoBullets:


Ankle & Hindfoot
LITFL: https://lifeinthefastlane.com/bone-and-joint-bamboozler-001/
Read more on OrthoBullets:


References / Resources

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