I Ketut Suyasa

Lecturer Block Emergency

Primary Survey

Secondary
Survey (Head to
Toe)
 ALWAYS BE FOLLOWED IN STRICT ORDER

A. Airway Maintenance with Cervical

Spine Protection

B. Breathing and Ventilation

C. Circulation and Hemorrhage Control

D. Disability/ Neurological Status

E. Exposure/Environmental Control
Clear the oropharynx of blood, mucus, and foreign bodies

Jaw Thrust

Use of oropharyngeal tubes

Intubation  Cricothyroidotomy if needed

C-Spine protection :
• Avoid rough manipulation
• Obtain appropriate radiological evaluation
• Apply semi rigid collar
 Inspect for
Auscultate for
symmetrical
breath sounds
chest
bilaterally
movements

Palpate chest
Palpate trachea
wall for
for deviation
fractures
 Open, sucking
Tension
Flail chest wound in the
pneumothorax
chest wall
Initial decompression
Monitor pulse with needle through
Square gauze
oximetry and blood 2nd or 3rd intercostal
gases taped on 3 sides space anteriorly, mid-
clavicular line
Assess BP, heart rate and evidence of bleeding

Control any external bleeding by direct pressure

Penetrating injuries of the neck, when venous injuries are suspected

 Trendelenburg position (head down) to prevent air embolism

Shock  two large IV lines, bolus fluid resuscitation

 Vascular access
Most common
with two or more
cause
large bore Iv lines

Children < 6 years Initial fluid: 2 L of

: consider intra- RL ( or 20 ml/kg
osseus infusion for children)

Clear indication for

surgery : no time
should be wasted
for fluid
resuscitation
Should be suspected in trauma patients with shock in the
absence of blood loss.

Low Blood pressure, distended neck vein.

Associated with :
• Cardiac tamponade
• Myocardial contusion
• Tension pneumothorax
• Air embolism
• Myocardial infarction
Air embolism may follow injuries to major veins, lungs, or
cardiac chambers.
Result of loss of vascular tone
following cervical cord or upper
thoracic spinal cord injury
 Assess level of
consciousness (
GCS)

Assess pupils
(size,
reactivity)
Undress the patient
completely for
thorough
examination

Keep patient warm

with blankets and
warm IV fluids
A : allergies

M : medications

P : Past medical
history

L : Last food / drink

E : Events leading to
the injury
 OPEN FRACTURES
 ACUTE COMPARTMENT
SYNDROME
 CRUSH INJURY and CRUSH
SYNDROME
 DISLOCATION
 UNSTABLE PELVIC
FRACTURES
 MAJOR ARTERIAL
HEMORRHAGE
 Osseous disruption in which a break
in the skin and underlying soft
tissue communicates directly with
the fracture and its hematoma
 Soft tissue injuries :
◦ Contamination of the wound and
fracture
◦ Crushing, stripping, and
devascularization soft tissue
◦ Destruction or loss of the soft
tissue envelope
Type Wound Level of Soft tissue injury Bone injury
contamination
I <1 cm Clean Minimal Simple, minimal
long comminution
II >1cm Moderate Moderate, some muscle damage Moderate
long comminution
III
A Usually High Severe with crushing Usually comminuted;
>10 cm soft tissue coverage of
long bone possible
B Usually High Very severe loss of coverage; Bone coverage poor;
>10 cm usually requires soft tissue variable, may be
long reconstructive surgery moderate to severe
comminution
C Usually High Very severe loss of coverage plus Bone coverage poor;
>10 cm vascular injury requiring repair; variable, may be
long may require soft tissue moderate to severe
reconstructive surgery comminution
 Type~I of Open Fracture of the Lower Leg

I <1 cm Clean Minimal Simple, minimal

long comminution
 Type~II Open Fracture of the Lower Leg

II >1cm Moderate Moderate, some muscle damage Moderate

long comminution
Type~II Open Fracture of the forearm

II >1cm Moderate Moderate, some muscle damage Moderate

long comminution
 Type~III Open Fracture of the Fore Arm

III
A Usually High Severe with crushing Usually comminuted;
>10 cm soft tissue coverage of
long bone possible
B Usually High Very severe loss of coverage; Bone coverage poor;
>10 cm usually requires soft tissue variable, may be
long reconstructive surgery moderate to severe
comminution
 Type~IIIC Open Fracture of Femur

IIIC Usually High Very severe loss of coverage Bone coverage poor;
>10 cm plus vascular injury requiring variable, may be
long repair; may require soft tissue moderate to severe
reconstructive surgery comminution
1. Treat as an emergency
2. Evaluation of life threatening
injury
3. Adequate Antibiotics
4. Debridement and irrigation
5. Fracture stabilization
6. Wound coverage and closure
7. Cancellous bone grafting if
needed
8. Amputation
9. Compartment syndrome
10. Rehabilitation of the patient
 Grade I, II : first-generation cephalosporin (Cefacetrile,
cephalexin, cephalotin, cephaloridine, cephapirin, cefatrizine,
cefazedone, cefazolin, cephradine, cefroxadine, ceftezole)
 Grade III: add an aminoglycosides
 Immunization dT TIG
history
The current dose of toxoid is 0.5
mL; for immune globulin, the Incomplete (<3 + -
doses) or not
dose is 75 U for patients <5 years known
of age, 125 U for those 5 to 10
years old, and 250 U for those >10
years old. Complete/>10 + -
years since last
dose

Complete/<10 - -
years since last
dose
 Irrigation, debridement and
remove foreign bodies
 Fracture stabilization
 Soft tissue coverage and bone
grafting
 Limb salvage
 provides protection from
additional soft tissue injury,
 maximum access for wound
management,
 maximum limb and patient
mobilization
In Gustilo Gr III, immediate or early
amputation indicated if:
 The limb is nonviable: irreparable
vascular injury, warm ischemia
time >8 hours, or severe crush
with minimal remaining viable
tissue.
 After revascularization the limb
remains so severely damaged
 The patient presents with an injury
severity score (ISS; of >20)
Increased pressure within a closed fascial spaces of the arm, leg
or other extremity, most often due to injury, exceeds the perfusion
pressure (enough to occlude capillary blood flow) and results in
muscle and nerve ischemia.
Etiologies of CS
◦ Decreased Compartment Size:
 Crush syndrome
 Closure of fascial defect
 Tight dressing or cast
 External pressure(PASG or direct pressure)
◦ Increased Compartment Content:
 Bleeding
 Edema
 Postischemic swelling
 Exercise
 Trauma
 Burn
 Intra arterial drug
 Orthopaedic surgery or trrauma
 Venous obstruction
 Energy is
Injury dissipated into the
muscle

Increased pressure,
intracellular
within the closed swelling
space

circulatory Ischemia and tissue

embarrassment damage
1. Pain
2. Pallor
3. Pulselessness
4. Paresthesia
5. Poikilothermy
6. Paralysis
The earliest, most consistent, and most reliable
sign is deep, unrelenting, vague but progressive
PAIN that is out of proportion to the injury and
not responsive to normal doses of pain
medication.
 Non Surgical
 Elevation of the affected limb
 Release the closure of fascial defect
 Release of the tight dressing or cast
 Release the External pressure(PASG or direct pressure)
 Observation of distal neurovascular
 Vascular repair and fasciotomy
Fasciotomy of the Upper Extremity
Fasciotomy of the Lower Leg
 Crush injurycompression of
extremities and body parts that causes
muscle swelling and/or neurological
disturbances in the affected parts of the
body
 Crush syndromelocalized crush
injury with systemic manifestations.
Systemic effects caused by a traumatic
rhabdomyolysis and the release of
toxic muscle cell components and
electrolytes into the circulation
Synonym : Bywaters’ Syndrome
 Prolonged Compression of Limb

Fluid Increased
Extravasation Compartment Pressure

Hypovolemia Rhabdomyolisis

Acute Tubular Necrosis

Renal Failure
Hypotension  acute hypovolemia

Renal failure  rhabdomiolisis releases myoglobin, potassium,

phosporus and creatinine into blood circulation

Metabolic abnormalities 
•calcium flow into muscle cell through leaky membranes systemic hypocalcemia
•Potassium released from ischemic muscle into systemic circulationhyperkalemia
•Lactic acid released from ischemic muscle into systemis circulationmetabolic acidosis
•Imbalance of potassium and calciumcardiac arrhytmiascardiac arrest
 Diagnosis criterias of
crush syndrome
• Crushing injury to a
large mass of skeletal
muscle
• The sensory and
motor disturbances,
tense and swollen
• Myoglobinuria and/or
hematuria
• Peak creatine kinase
 ABC
 Hypotension  Rapid fluid replacement
 Renal failure
◦ Prevent renal failure through appropriate hydration
◦ Maintain diuresis 300cc/hr with IV fluids and Mannitol 1-2 g/kgBw
in the 1st 4 hours as 20% solution)
◦ If necessary, hemodialysis was
 Metabolic abnormalities
◦ Urine alkalinisation
 (IV Sodium Bicarbonate 8.4% 50 mL, 50-100 meq/l until urine pH reach 6,5)
  maintain urine output at least 8 L per day (300 mLs per hour)
◦ Hyperkalemia/Hypocalcemiaadminister calcium, sodium bicarbonate, insulin/D5%
◦ Cardiac arrhytmiasclose monitoring

 Apply adequate antibiotic and antitetanus

 Analgesia (Intravenous analgesia i.e. opiate, benzodiazepine)
 Hyperbaric oxygen therapy
 Locally
◦ Apply pressure dressing to gross arterial bleeding
◦ Don’t attempt blind clamping of bleeding vessels.
◦ Correct gross misalignment of extremities by gentle
application and repositioning of extremity to better
approximate normal anatomy.
◦ Flood open wounds with sterile saline solution and
cover with antiseptic soaked gauze dreesings.
◦ Apply splinting material to immobilize the injured
extremity
◦ Surgical Management
 Remember damage control principal
 Wound debridement
 Temporary vascular shunting (for vascular injury)
 Fasciotomy (Controversial)
 External fixation
 Amputation
UNSTABLE PELVIC FRACTURE
 Fracture of the pelvic ring accompanied
by Disruption of the posterior osseus-
ligamentous (sacroiliac, sacrospinous,
sacrotuberous)
 Unstable injury characterized by the type
of displacement as:
◦ Rotationally unstable
◦ Vertically unstable
 Initial survival depend on prevention of
death from hemorrhage
adequate replacement for blood
lost, and control ongoing bleeding
 ABCs (airway, breathing, circulation)
 MOI.
 Destot sign
◦ (superficial hematoma above the inguinal
ligament, over the scrotum or perineum, or in
the upper thigh)
 Look for a rotational deformity of the
pelvis or lower extremities.
 Leg Length Discrepancy may also present
with pelvic fractures.
 Lower extremities must undergo a
thorough neurovascular examination
 Unexplained hypotension may be the only indication of
major pelvic disruption
 Physical signs: progressive flank, scrotal, perianal swelling
and bruising
 Mechanical instability, is test by manual manipulation
(should be performed only once!)
 Sign of instability:
◦ Leg length discrepancy or rotational deformity usually external
◦ Open wound in flank, perinium, rectum
Plain radiography
 Unstable fractures characterized by
◦ Hemipelvic cephalad
displacement that exceeds 0.5
cm SI diastasis that exceeds 0.5
cm.
◦ Findings suggestive of pelvic
instability include cephalad
hemipelvic displacement less
than 1 cm and/or a diastatic
fracture of the sacrum or ilium
less than 0.5 cm.
Hemodynamically unstable aggressive resuscitation
and prevention of further hemorrhage.
External fixation is indicated in a hemodynamically
unstable patient with an unstable pelvic fracture.

Operative indications

• diastases of pubic symphysis greater than 2.5 cm,

• sacroiliac joint dislocations,
• displaced sacral fractures,
• crescent fractures,
• posterior or vertical displacement of the hemipelvis (>1 cm),
• rotationally unstable pelvic ring injuries,
• sacral fractures in patients with unstable pelvic ring injuries
that require mobilization, and displaced sacral fractures with
neurologic injury
Management
◦ Hemorrhage control
and rapid fluid
resuscitation
◦ Pelvic C-clamp
◦ Longitudinal skin or
skeletal traction
◦ Pelvic sling
◦ PASG
◦ Open pelvic
fracture packing
the open wound
 Injury:
◦ Penetrating wound
◦ Blunt trauma
 Assessment:
◦ Loss of palpable pulse/changes in pulse quality
◦ Change in Doppler quality
◦ Cold, pale, pulseless
◦ Rapidly expanding hematoma
Management
◦ Application of direct pressures to
the open wound
◦ Aggressive fluid resuscitation
◦ Pneumatic torniquet
◦ Vascular clamp is not
recommended unless superficial
vessel is clearly identified
◦ If a fracture is associated with an
open hemorrhaging wound,
fracture should be realignment
and splinting
 One of the most serious inflammatory disorder of the
musculoskeletal system
 Trauma may determine the site of infection
 Causal organism:
◦ Stap. Aureus (90%)
◦ Strep. Pyogenes
◦ H.influenza  under 4 yrs
 Predilection: metaphysis
Decrease of limb
function
Psychological &
Social dysfunction

Increased cost
Pathology  varies: age, site of
infection, virulence of organism
& host response
1. Inflammation
2. Suppuration
3. Necrosis
4. New Bone
Formation
5. Resolution
 Increased
Vascularity
Inflammation
Edema

After 2-3 days, Ischemia with

Entry of thrombosis bone necrosis
Microbe
Extends to
medullary cavity,
periosteum, and
adjacent tissues

Bone abscess Chronic

Sequestrum Involucrum
formation Osteomyelitis
infants children
Clinical feature
• Pain: severe and constant near the end of the involved long bone
• Fever
• Inflammation
• Acute tenderness
Imaging
• Plain: normal (10 days)
• Ultrasound
• Scintigraphy
• MRI
Investigation
1. WBC
2. ESR
3. Blood culture
4. Antistaphylococcal antibody
titer
Diff Diagnosis
1. Cellulitis
2. Acute septic arthritis
3. Acute Rheumatism
 Plain x-ray

• Sensitivity 43-75%
• Specificity 75-83%
• Soft tissue swelling
48hrs
• Periosteal reaction
5-7 days
• Osteolysis 10 days
 Tc99

•Bone aspiration
DOES NOT give
false +ve
•Decreased uptake in
early phase due to
increased pressure
•“cold” scan up to
100% PPV
MRI

• Sensitivity 83-100%
• Specificity 75-100%
• PPV = Tc99
Marrow and soft tissue
swelling

Good in spine and pelvis

T1
•Best for acute
infection
•Gadolinium helps
•Changes similar to
•Fracture
•Infarct
•Bruise
•Tumor
•Post surgical
CT
◦ Gas
◦ sequestrum
(Cierny-
I: II:

Mader)
1985

III: IV:
A-Host: Good immune system &
delivery
B-Host:
L
Compromised host
B : locally compromised
S
B : systemically compromised
C
B : combined

C-Host: Requires suppressive or no Tx

Minimal disability
Tx worse than disease, not a surgical candidate
Anatomic Type
+
Clinical Stage
Physiologic Class
Example: IV B tibial osteomyelitis = diffuse tibial lesion in a
systemically compromised host
Treatment:
1. Supportive: pain, dehydration- IVFD, blood transfusion
2. Splintage or traction
3. Antibiotic parenterally – 2 weeks, continued min.4 weeks
4. Surgical Drainage, if local and systemic manifestations not
improved after 24 hours
Complication
1. Death from septicemia
2. Metastasis Infection
3. Abscess
4. Septic Arthritis
5. Altered Bone Growth
6. Chronic Osteomyelitis
Prognosis
1. Time interval between onset of infection and the
institution of treatment
2. Effectiveness of antibiotic
3. Dosage of antibiotic
4. Duration
Inflammation of a synovial membrane with purulent effusion
into the joint capsule, often due to bacterial infection

Organisms invade the joint by

• direct inoculation,
• by contiguous spread from infected periarticular tissue,
• via the bloodstream (the most common route).
Stap.aureus (Neonates and infant< 6
months)

Haem influenza: infant > 6 months

Streptococcus
Predisposing Chronic disorder
Factors
RA

IV Drug Abuse

Immunosupressive drug theraphy

AIDS
 If infection
untreated:
cartilage spread to
eroded and bone,
Exudation, destroyed abscess,
pannus large sinuses
acute formation effusion
inflammatory
reaction
Haematogenous
infection (synovial
membrane)
Complete resolution

Partial loss of cartilage and fibrosis of joint

Loss of cartilage and bony ankylosis

Bone destruction and permanent deformity

History, pay attention to the following symptoms:

Acuteness of onset of the joint pain

Previous history of joint disease or trauma

The presence of extra-articular symptoms : fever

Underlying joint disease, especially rheumatoid arthritis.

Recent injury to the joint or penetrating or blunt trauma

History of needle aspiration of the joint or injections of corticosteroids into the joint
The triad of
1. fever (40-60% of cases),
2. pain (75% of cases),
3. impaired range of motion.

1. Newborn Infant
◦ Septicaemia > joint pain
◦ Irritable
◦ Fever
2. Children
◦ Acute pain in a single large joint
◦ ‘Pseudoparesis’
◦ Ill
◦ Fever
3. Adult
◦ Superficial joint: knee, ankle, wrist
◦ Painful, swollen, inflamed
Joint Fluid Analysis and Culture
• Infected  yellow-green due to elevated levels of nucleated cells.
• Culture  the only definitive method
Blood Cultures

Polymerase Chain Reaction

• detection of bacterial DNA
• cannot be used to distinguish between live and dead organisms
• susceptible to contamination.
Radiologic Studies
• Radiography and ultrasonography
• CT scanning, MRI, and radionuclide scanning
 CT scanning & MRI more sensitive
for distinguishing osteomyelitis,
periarticular abscesses, and joint
effusions.
 MRI is preferred because of its
greater ability to image soft tissue.
 Radionuclide scans (ie, technetium-
99m [99m Tc], gallium-67 [67 Ga],
indium-111 [111 In] leukocyte scans)
used to nonspecifically localize areas
of inflammation.
Acute Osteomyelitis
Trauma; synovitis;haemarthrosis
Irritable joint
Haemophilic Bleed
Rheumatic fever
Gout and Pseudogout
Bone destruction

Cartilage destruction

Growth disturbance
1. Supportive
2. Splintage
3. Antibiotic
4. Drainage (arthrotomy)
5. After care:
reconstructive,
arthrodesis
 Male, 17 years old, came to ER after traffic
accident, BP : 105/70 mmHg; HR : 100x/ mt;
RR 24 x/mt with deformity and difficulty to
move his right leg. On physical examination,
crepitation on right leg (+), painfull and
severe swollen. Passive stretch test (+) and
pulselessness over the a. dorsalis pedis
◦ What’s your clinical assessment ?
◦ How to manage ?
 Male, 23 years old came to ER after traffic
accident with chest pain, cyanotic condition,
RR : 40 x/mt; BP : 90/60 mmHg; HR :
110x/mt, tracheal deviation and unilateral
absence of breath sound
◦ According ATLS, List the problem, What yours
clinical assessment ?
◦ How to manage ?
 Female, 21 years old, traffic accident, came to ER
with severe damage in Left lower leg; BP : 90/60,
HR : 116 x/ mt; RR : 28 x/mt, Bone exposed with
severe muscle damage. Urine production was
decreased, the urine showing blood with absence
Red Blood Cells. On laboratory investigation
decreased of Renal function Test, Hypercalemia
and hypocalcemia
◦ What’s your assessment ?
◦ How to manage ?
 Male 27 years old, came to out patient clinic with
pain full, tenderness and swollen on the right knee
joint since 3 days ago, The patient had been right
knee joint injured 2 weeks a go, febris condition t :
38.5° C , BP : 120/80 mmHg; HR ; 90 X/mt; RR :
24X/ mt. On Physical examination of the Right
knee : Hyperemia, swollen and tenderness,
decreased range of motion right knee joint.
◦ How to work up diagnosis ?
◦ What’s your diagnosis ?
◦ How to manage ?