1. Trauma Músculo-Esquelético
O Comitê de Trauma Apresenta
Trauma Músculo-Esquelético
8-1 Title Slide
The instructor should introduce the topic and relate to the students that based on their preparation for the course, a series of questions will be asked throughout the lecture and their active participation and responses are expected.
All slides begin with a header, followed by subheaders, phrases, diagrams, graphics, etc. The instructor must use the slide show to emphasize key points, and accordingly must be familiar with every slide, its sequencing, and the related information in the ATLS® Student Manual. Core content knowledge, and proper sequencing of questions and responses facilitates an interactive presentation.
When the slide first appears on the screen, “Committee on Trauma” types in. The first click of the mouse causes the photograph and lecture title to strip down to the left.
Pressing the down arrow key on the computer keyboard or left-clicking on the mouse initiates the animation on all the slides. For brevity in this dialogue, mouse clicking is referenced. However, either method may be used.
Photograph courtesy of Dr. Ray McGlone, A&E Consultant, Royal Lancaster Infirmary; UK
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2. Objetivos
Estabelecer os princípios da avaliação do paciente com lesões músculo-esqueléticas.
Estabelecer as prioridades de tratamento.
Identificar a importância das lesões músculo-esqueléticas no paciente com trauma múltiplo.
8-2 Objectives
The instructor should review the objectives with the students as provided on the slide.
Each objective appears with a mouse click, and the preceding item dims as the next one appears.
The instructor should relate to the students that pelvic fractures are not discussed in this presentation because of their previous discussion during the abdominal trauma presentation as well as in the skills stations.
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3. Questões-Chave
Qual o impacto das lesões músculo-esqueléticas no exame primário?
Quais são as prioridades?
Quais são os princípios de tratamento?
8-3 Key Questions
The instructor should review these key questions with the students to stimulate their thinking about 1. 2. 3.
Each bulleted item appears with a mouse click, and the preceding item dims as the next one appears.
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4. Impacto no exame primário?B D E
Sangramento externo
8-4 How do musculoskeletal injuries impact on the primary survey?
Dr. Weigelt and Dr. Parks: Need additional narrative for this slide, eg, salient points to make.
The instructor reveals the responses on the slides after the students elicit their responses. The alphabet blocks, A, B, D, and E strip across the screen and then the C block zooms in emphasizing that musculoskeletal injuries have the greatest impact on the ‘C’ (circulation) component of the ABCDEs.
Each bulleted item appears with a mouse click, and the preceding item dims as the next one appears.
While musculoskeletal injuries are not usually addressed during the primary survey, they may have an effect on circulation. This can be with obvious blood loss from open fractures or occult blood loss from closed fractures. Major blood loss from pelvic fractures remains one of the most challenging injuries to manage.
Perda oculta de sangue
Fratura de ossos longos
Fratura de bacia
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5. Tratamento durante o exame primário?
Os 3 S’s
Stop Parar o sangramento!
Splint Imobilizar as extremidades
Stabilize Estabilizar a bacia
8-5 How do I manage musculoskeletal injuries during the primary survey?
Drs. Weigelt and Parks: Need narrative for this slide
The subheading appears and remains on the screen. Each bulleted item then appears with a mouse click, and the preceding item dims as the next one appears.
During the primary survey, controlling blood loss, visible and occult should be the main objective. This may be done by direct pressure, splinting the extremity, or by stabilizing the pelvis. External blood loss is safely managed by direct pressure. Various splints can stabilize fractured extremities. Wrapping the pelvis with a sheet or applying a PASG can stabilize the fractured pelvis.
Stopping movement of broken bones will decrease blood loss and pain.
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6. Qual a utilidade da imobilização?
Impede que ocorra mais perda de sangue e mais lesão
Pode restaurar ou manter a perfusão
Alivia a dor
8-6 Why is splinting useful?
Drs. Weigelt and Parks: Need narrative for this slide.
Each bulleted item appears with a mouse click, and the preceding item dims as the next one appears.
Splinting will stop fracture movement which will decrease blood loss, decrease pain, and help preserve distal perfusion. Distal pulses should always be checked before and after splint application.
Importante durante a avaliação
Imobilizar precocemente
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7. Quais são as primeiras preocupações?
Comprometimento vascular
Fraturas expostas
8-7 What are my early concerns in evaluating a patient with musculoskeletal injuries?
Drs. Weigelt and Parks: Need narrative for this slide
The first mouse click causes the photograph of an open fracture of the tibia and fibula to strip up from the lower right-hand corner of the slide. Each bulleted item appears with a mouse click, and the preceding item dims as the next one appears. The instructor may elect to reveal the slide at the beginning of the discussion or reveal it after the students’ elicit their responses.
Photograph courtesy of Dr. Ray McGlone, A&E Consultant, Royal Lancaster Infirmary; UK
Any fracture can cause vascular injury. Open or closed fractures can cause direct vascular injury with bleeding or distal ischemia. Pulse examination must be done if extremity fractures are suspected. Reducing and splinting a fracture with decreased or absent pulses can return distal perfusion. If distal perfusion does not return then evaluation for immediate surgical intervention must be considered (?need for vascular surgeon)
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8. O que fazer se houver comprometimento vascular?
Reduzir as fraturas
Imobilizar as fraturas
Doppler
Consultar o especialista (o tempo é crítico)
Considerar a possibilidade de fazer angiografia
8-8 How do I assess and manage vascular compromise?
Drs. Weigelt and Parks: Need narrative for this slide
Each bulleted item appears with a mouse click, and the preceding item dims as the next one appears.
See my last slide narrative.
Also
Angiography should be considered if pulse exam is not normal after reduction and splinting of the fracture. Angiography is appropriate if abnormal pulses with distal perfusion is present. However, if pulses do not return and there is no evidence of tissue perfusion then immediate surgical intervention is indicated.
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9. Informações úteis na avaliação?
Mecanismo de trauma
Energia envolvida
Fatores associados
Tempo decorrido desde o trauma
Local lesado
8-9 What information do I need to aid me in my assessment of the patient with musculoskeletal trauma?
Drs. Weigelt and Parks: Need narrative for this slide
Each bulleted item appears with a mouse click, and the preceding item dims as the next one appears.
Information that could help my assessment and treatment plan for the patient with musculoskeletal injuries would include
Blunt or penetrating injury
2. Force applied which could be a crush injury from a mechanical device or a deceleration force with lower extremity fractures.
3. Injury patterns such as pelvic fractures and diaphragmatic rupture.
4. Time from injury to presentation especially for open fractures and trying to get them to operative therapy within 6 hours to decrease infectious complications.
5. Injury location could provide a risk assessment for infectious complication, such as in dirt versus pavement (barnyard might be used)
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10. O que fazer com as fraturas expostas?
Imobilização adequada
Limpeza / debridamento (agora ou mais tarde)
Considerar o fator tempo
Consultar o ortopedista
8-1- How do I manage open fractures?
Drs. Weigelt and Parks: Need narrative for this slide.
Each bulleted item appears with a mouse click, and the preceding item dims as the next one appears.
Open fractures should be splinted and irrigated with a saline. Using a dressing that can be easily removed for inspection by consultants is helpful in reducing fractures manipulation which only increases tissue damage, bleeding and pain. All attempts should be made to provide definitive care of an open fracture within 6 hours.
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11. Exame Secundário O quê? Observar Sentir Escutar ACS
8-11 Secondary Survey
Drs. Weigelt and Parks: Ibid
This slide appears to be a lead in in which the instructor would relate to the students that nonlife-threatening musculoskeletal injuries are evaluated during the secondary survey by using the tools of look, feel, and listen. The instructor then asks the students, “For what am I looking, feeling, and listening?
The photograph strips down from the upper, right-hand corner with the first mouse click. Each bulleted item then appears with a mouse click, but the items do not dim as the next one appears. The fourth mouse click reveals the question and the instructor proceeds to the next slide.
Not sure that anything else is needed.
Photograph courtesy of Dr. Ray McGlone, A&E Consultant, Royal Lancaster Infirmary; UK
O quê?
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12. O quê? Olhar / Observar Sentir / Palpar Escutar Deformidades
Dor
Dor à palpação
Ferimento(s)
Crepitação
Retalhos de pele
Déficit neurológico
Pulsos
8-12 For what do I look, feel, and listen when evaluating musculoskeletal injuries?
Drs. Weigelt and Parks: Ibid.
The instructor reveals the responses to each of the subheadings (in yellow type) after eliciting responses from the students. Each bulleted item appears with a mouse click, and the preceding item dims as the next one appears.
Look for a deformity, bruising, or any wounds.
Feel for crepitus, pain on palpation, neurologic deficit, distal pulses, thrill.
Listen for a bruit especially with penetrating injuries close to major vascular structures. If pulses are not palpable, but the extremity is not ischemic, then using a doppler to detect arterial flow is appropriate. Care must be taken not to allow the doppler evaluation to take “center stage” in the secondary survey of the extremities.
Escutar
Sinais de Doppler
Sopros
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13. Exame Secundário Que radiografias são necessárias?
Qualquer área suspeita
Uma articulação acima e uma abaixo
Quando fazer as radiografias?
8-13 Secondary Survey
Drs. Weigelt and Parks: Ibid.
The questions appear with a mouse click and remain highlighted. Only the answers dim.
Note: I changed the some of the responses and questions as noted herein from those originally provided.
Added “any suspected area” in response to the first question.
Changed “stable” to hemodynamically normal in response to the 2nd question since this is the phrase used primarily throughout the manual.
These can be changed to whatever is best.
I like your versions. Again I do not think much narrative is needed here.
Quando o doente estiver hemodinamicamente normal
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14. Exame Secundário Quando esperar para fazer as radiografias?
Se houver lesões com risco de vida, que devem ter prioridade
Se as radiografias forem retardar a transferência do doente
8-14 Secondary Survey
See previous notations for slide 8-13
I changed this question from when can I to when should I, I will change it back it you prefer.
Responses were not provided for this question so these are the ones I inserted. I may well be totally off base.
At times an obvious fracture may need to have definitive evaluation and treatment delayed because the patient has more life threatening injuries present. If the patient remains hypotensive despite proper fluid resuscitation and an obvious hemoperitoneum is present on FAST or DPL, then urgent surgical exploration is indicated. X-ray evaluations should be delayed in these cases although the fractures should be reduced and splinted.
At all times, if x-ray studies will delay transfer, they should not be done.
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15. Que lesões podem causar síndrome compartimental?
8-15 What injuries may cause a compartment syndrome?
Drs. Weigelt and Parks: Ibid.
I changed this question from “How do I recognize compartment syndrome?” to as stated on the slide because the responses did not seem to be directly related.
The photograph strips down from the left with a mouse click after the instructor asks the question. The next mouse click causes the photograph to disappear and then each bulleted item appears with a mouse click, and the preceding item dims as the next one appears.
Photograph courtesy of John Fildes, MD, FACS
Almost any type of musculoskeletal injury has a potential for causing a compartment syndrome. Swelling from bleeding, fluid resuscitation, or direct crush injury may all produce the a compartment syndrome. The fascial compartments of the leg are most commonly considered, but compartment syndromes can occur in the arm, forearm, and thigh as well.
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16. Que lesões podem causar síndrome compartimental?
Fraturas de tíbia e do antebraço
Lesões vasculares e ósseas
Lesões imobilizadas com curativos ou gesso muito apertados
Esmagamentos musculares graves
Queimaduras
8-15 What injuries may cause a compartment syndrome?
Drs. Weigelt and Parks: Ibid.
I changed this question from “How do I recognize compartment syndrome?” to as stated on the slide because the responses did not seem to be directly related.
The photograph strips down from the left with a mouse click after the instructor asks the question. The next mouse click causes the photograph to disappear and then each bulleted item appears with a mouse click, and the preceding item dims as the next one appears.
Photograph courtesy of John Fildes, MD, FACS
Almost any type of musculoskeletal injury has a potential for causing a compartment syndrome. Swelling from bleeding, fluid resuscitation, or direct crush injury may all produce the a compartment syndrome. The fascial compartments of the leg are most commonly considered, but compartment syndromes can occur in the arm, forearm, and thigh as well.
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17. Como reconhecer a síndrome compartimental?
Dor (Pain)
Parestesia
Palidez
Paralisia
Pulso ausente (tardio)
8-16 How do I recognize compartment syndrome?
Drs. Weigelt and Parks: Ibid.
Each bulleted item appears with a mouse click, and the preceding item dims as the next one appears. The photograph strips down from the right with the next mouse click.
Note: I changed the last bullet from measure compartment pressures to that listed above, based on the question. Measuring compartment pressures did not seem to fit with the question
Photograph courtesy of John Fildes, MD, FACS
The “P’s” are always mentioned when the compartment syndrome is discussed. The problem is that these “P’s” really describe a lack of perfusion to the extremity and are just as likely to arise from a vascular injury. A pulse loss is always a late sign of a compartment syndrome. A high index of suspicion must be held if an extremity is swollen, firm or even hard to palpation. Tissue pressures should be measured and if elevated a fasciotomy should be done. (Do you want to talk about how to do a tissue measurement?)
Pressão tecidual > 35 to 45 mm Hg
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18. Quais são as ciladas? Fraturas ocultas Lesão vascular
Síndrome compartimental
Pequenas lesões
Anticoagulação
Alteração do nível de consciência
8-17 What pitfalls might I encounter when assessing and managing the patient with musculoskeletal injuries?
Drs. Weigelt and Parks: Ibid.
The instructor reveals the responses on the slide after eliciting the students responses and summarizes the discussion.
Each bulleted item appears with a mouse click, and the preceding item dims as the next one appears.
The more distal an extremity fracture is the more likely, the fracture will be over-looked. Careful examination of the entire extremity will detect most injuries. A patient with altered sensorium should also be carefully examined for any bruising, discoloration, swelling or deformity of the extremities. Pain in these patients will not be a reliable finding. Compartment syndrome should always be considered in a swollen extremity. Patient’s on anticoagulants will always be at risk for excessive bleeding and early correction of abnormal coagulation parameters should be done. Distal pulses should be assessed and if not normal further evaluated.
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19. ?
8-18 Questions
The instructor asks for questions from the students and then pauses, allowing the students adequate time to form and ask their questions.
The question mark spirals in with a mouse click.
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20. Resumo Cuidar primeiro das lesões com risco de vida
Parar o sangramento!
Reduzir e imobilizar fraturas e luxações
Reconhecer o comprometimento vascular
Não perder tempo
8-19 Summary
Drs. Weigelt and Parks: Ibid.
The instructor summarizes the presentation with these salient points. Each bulleted item appears with a mouse click, and the preceding item dims as the next one appears.
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