1 / 25

Penetrating Trauma to the Extremities

Penetrating Trauma to the Extremities . Steven Issley, MD Emergency Medicine McGill University May 8, 2002. Outline. Ballistics Vascular injury Orthopedic injury Antibiotics Wound care. Ballistics: temporary cavity. Ballistics: energy. E = 1/2 mv 2. Ballistics: energy. E =

omer
Télécharger la présentation

Penetrating Trauma to the Extremities

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Penetrating Trauma to the Extremities Steven Issley, MD Emergency Medicine McGill University May 8, 2002

  2. Outline • Ballistics • Vascular injury • Orthopedic injury • Antibiotics • Wound care

  3. Ballistics: temporary cavity

  4. Ballistics: energy E = 1/2 mv2

  5. Ballistics: energy E = 1/2 mv2 Low velocity <2500 fps High velocity >2500 fps

  6. Ballistics: types of firearms • Handguns: low velocity • 38mm 600-870 fps • 9mm 860 fps • 22mm 1200 fps • Military: high velocity • M16 3250 fps • AK47 2340 fps • Shotguns: low velocity*** • 1100-1500 fps

  7. Ballistics: shotguns

  8. Ballistics: knife wounds • Slash • Stab • No indirect tissue damage

  9. Ballistics: documenting exam • Entrance / exit wounds • How many wounds • Location • Size, depth, shape • Injuries: detailed neurovasc • State of clothes • Identify and keep missiles • write only on base or tip to maintain rifling • DOCUMENT OBJECTIVELY!

  10. Vascular injury: anatomy

  11. Vascular injury: hard signs • Hemorrhage: pulsatile or exsanguinating • Expanding hematoma • Bruit • Thrill • Ischemia (“6 P’s”)

  12. Vascular injury: soft signs • Hx of significant hemorrhage • hematoma: small, non-expanding • Neurologic deficit (non-progressive) • Proximity

  13. Vascular Injury • Complications: • hemorrhage • thrombosis / emoblism • aneurism / pseudoaneurism • compartment syndrome • Venous injury

  14. Vascular: investigations • ???? none • Frykberg ‘ 91: • No sx ’s: D/C home • Proximity+ No sx ’s: obs x 24h • <1% missed; no morbidity • Gonzalez ‘ 99: • Proximity, no hard signs • 24h obs = 1% missed; • no morbidity • Pressure Index: Arterial or Doppler (API, DPI) • sens: 45-95% for wounds requiring OR

  15. Vascular: investigations • Arteriogram • Sens: 98% • Spec: 99% • Too Sens: 4% False Pos --> unecessary OR • Expensive • Thrombosis / allergic reaction • Dupplex • sens: 50-60% (comp. to angio) • sens: 100% (wounds req. OR) • spec: 99-100%

  16. Vascular: investigations • New Kids On The Block: • CT angio • sens: 90% • spec 100% • MRI

  17. Algorithm Hard signs Shotgun II, III *High energy Destruction Soft signs API<0.9 Proximity *Shotgun I *High energy - Sx ’s - Proximity IPA>0.9 Normal exam ±Angio Obs 24h + - Angio/US + - OR Home

  18. Orthopedic injury: bone • Low velocity • Drill Hole • Divot • High Velocity • complicated • comminuted • Fragments act as 2o missiles • Stab wounds

  19. Orthopedic injury • Joints • Lead Toxicity • Nerves

  20. Antibiotics: wound infection • Bacrterial innoculum • Devitalized tissue • Age of wound • Location of wound • Foreign bodies • Immune compromize

  21. Antibiotics • Lacs and Stabs • ???Sterile bullets • GSW • Low energy • High energy • Shotguns

  22. GSW wound care: indications for OR • Hard signs • Progressive neuro deficit • Open fracture • Unstable fracture • Significant soft tissue damage or necrosis • Compartment syndrome • Shotgun II, III • >8h post-injury

  23. Wound care What about the bullet?

  24. Summary • ATLS • Tetanus • Indication for OR? Stable / unstable? • Further investigations? • Wound care • Antibiotics? • Bonjour la visite!

  25. References • Arrillaga A, Nagy K, et al. Practice Management Guidelines forPenetrating Trauma to the Lower Extremity. EAST Trauma Practice Guidelines. http:\\www.east.org . • Barlett CS, Helfet DL. Ballistics and Gunshot Wounds : Effect on Musculoskeletal Tissues. J Am Acad Ortho Surgeons. 8(1) : Jan/Feb 2000. • Dake AD, Stack LS. Penetrating Trauma to the Extremities: Systematic Assessment and Targeted Management of Weapons-Related Injuries. Emergency Medicine Reports. March 31, 1997. • Fesmire FM, Dalsey WC, et al. American College of Emergency Physicians: Clinical Policy for the Initial Approach to Patients Presenting With Penetrating Extremity Trauma. Annals Emerg Med 33(5):612-36. May 1999. • Frykberg ER, Dennis JW. The Reliability of Physical Exam […] Vascular Injury: Results at One Year. J Trauma. 31(4):502-11. Apr 1991. • Gonzalez RP, Falimirski ME. Th Utility of Physical […] Penetrating Extremity Trauma. Am Surg. 65(8): 784-9. Aug 1999. • Leibner EC, Jackimczyk K. Penetrating Extremity Trauma : The Problem of Occult Vascular Injury. Emergency Medicine Reports. Jan 11, 2001. • Rathlev N. Peripheral Vascular Injuries. eMedicine Journal. 2(6): June 22, 2001. • Newton E. Peripheral Vascular Injuries in Rosen `s Emergency Medicine : Concepts and Clinical Practice, 5th Ed. Mosby: 2002. • http:\\www.trauma.org

More Related