General Principles of Initial Care





Orthopedic injuries are common presentations to the emergency department. Most injuries are traumatic in nature, resulting in pain and deformity. Emergency medicine physicians need to be able to recognize the gravity of the injury and resources needed to take care of the patient. The assessment begins with a thorough history and proceeds with a tailored examination to create a differential diagnosis and generate a treatment plan.


History


As with any medical encounter, the patient’s history is key. Obtaining details such as mechanism, timing, and initial symptoms can be helpful. Some patients may be unable to speak because of their injuries, necessitating the reliance on family, friends, witnesses, and emergency personnel such as paramedics or police officers who accompany the patient to the trauma bay to relay vital information. When obtaining an orthopedic history, the clinician should determine the chief complaint, the events as best recollected, the mechanism of the injury, the energy or speed of injury, timing, function after the injury, neurologic status changes, reductions or manipulations already performed, pain generators, concomitant injuries, and new limitations. The history should also include a complete medical (including allergies and current medications), surgical, and social history. Occupation and prior activity level are important to establish. Aspects of this broader history may alter the treatment plan.


Traumatic Presentation


The history may be very limited in situations where the patient is already intubated and few witnesses are available. Emergency personnel may be the only source of injury information. These personnel should be used to assist in understanding the nature and severity of the injury. Information about the scene and energy of the injury entailed can be approximated by asking questions such as the following: Was it a motor vehicle crash at highway speed or a fender-bender at a local intersection? Was it a fall from a ladder or multiple stories of a building? Did an airbag deploy, and were hydraulic extraction tools needed? Was it a prolonged extrication? What was the penetrating object? What type of gun was used? Is there an open wound and what has been done to it? All of these questions can help the clinician assess the severity of the traumatic situation to establish the diagnostic and treatment pathways to pursue.


Limb-Specific Presentation


Most patients with musculoskeletal injury present to the emergency department in a less emergent fashion with injuries from simple falls, sports-related injuries, or injuries from other low-energy incidents. Common injuries include hip fractures in elderly adults, wrist fractures from a fall on an outstretched hand, and ankle fractures. The complaint is often localized to one limb or joint. A more focused history may be pursued after quickly determining that there are no other injuries. Similar questions may be tailored to the individual’s injury. Determining the mechanism and what currently hurts is the first step. The patient can be asked demonstrate the mechanism with the contralateral extremity if he or she is able to do so. The clinician can ask the following questions: When did the pain begin? Was there associated swelling or numbness? Does either of the adjacent joints hurt? Did you feel a “pop” or a joint dislocate? Has there already been a manipulation or reduction to a dislocated joint? Elderly patients often present from a skilled nursing facility, and dementia may limit the history the clinician is able to obtain from the patient. A quick phone call to a caretaker at the facility may yield information important to the injury.


Spine Presentation


Injuries to the spine are often part of a traumatic presentation. Neck or back pain may be the chief complaint of some patients. Establishing whether there was an acute injury to cause the pain or the pain is a chronic condition is a key beginning point. It is crucial to discover new neurologic deficits. Also, new-onset bowel and bladder dysfunction, which may reflect an emerging cauda equina syndrome, is a crucial diagnostic finding.




Traumatic Presentation


The history may be very limited in situations where the patient is already intubated and few witnesses are available. Emergency personnel may be the only source of injury information. These personnel should be used to assist in understanding the nature and severity of the injury. Information about the scene and energy of the injury entailed can be approximated by asking questions such as the following: Was it a motor vehicle crash at highway speed or a fender-bender at a local intersection? Was it a fall from a ladder or multiple stories of a building? Did an airbag deploy, and were hydraulic extraction tools needed? Was it a prolonged extrication? What was the penetrating object? What type of gun was used? Is there an open wound and what has been done to it? All of these questions can help the clinician assess the severity of the traumatic situation to establish the diagnostic and treatment pathways to pursue.




Limb-Specific Presentation


Most patients with musculoskeletal injury present to the emergency department in a less emergent fashion with injuries from simple falls, sports-related injuries, or injuries from other low-energy incidents. Common injuries include hip fractures in elderly adults, wrist fractures from a fall on an outstretched hand, and ankle fractures. The complaint is often localized to one limb or joint. A more focused history may be pursued after quickly determining that there are no other injuries. Similar questions may be tailored to the individual’s injury. Determining the mechanism and what currently hurts is the first step. The patient can be asked demonstrate the mechanism with the contralateral extremity if he or she is able to do so. The clinician can ask the following questions: When did the pain begin? Was there associated swelling or numbness? Does either of the adjacent joints hurt? Did you feel a “pop” or a joint dislocate? Has there already been a manipulation or reduction to a dislocated joint? Elderly patients often present from a skilled nursing facility, and dementia may limit the history the clinician is able to obtain from the patient. A quick phone call to a caretaker at the facility may yield information important to the injury.




Spine Presentation


Injuries to the spine are often part of a traumatic presentation. Neck or back pain may be the chief complaint of some patients. Establishing whether there was an acute injury to cause the pain or the pain is a chronic condition is a key beginning point. It is crucial to discover new neurologic deficits. Also, new-onset bowel and bladder dysfunction, which may reflect an emerging cauda equina syndrome, is a crucial diagnostic finding.




Physical Examination


The orthopedic physical examination of a patient includes assessment of the axial and appendicular skeleton and the pelvis. The extent of the examination depends in part on the awareness of the patient and his or her ability to interact with the clinician. Early examination of a patient involved in trauma is critical to assess the body before soft tissues become distorted from swelling. Evaluation should proceed in a systematic way to minimize chances of missed injuries and maximize efficiency and reproducible results. The trauma bay is a very active place with many different personnel partaking in the care of the patient. This activity may make the physician’s job more difficult, but doing things systematically ensures completeness.


In the trauma setting, all clothing should be removed to perform a complete examination. Obvious open fractures and deformity should prompt immediate orthopedic surgery consultation. Initial examination should adhere to tenets of advanced trauma life support with attention to the ABCs— A irway, B reathing, and C irculation. The musculoskeletal examination can then proceed in a stepwise fashion, as follows:




  • Visual Inspection


    Note deformity, wounds, burns, ecchymosis, sources of bleeding, entry and exit wounds from penetrating trauma, and use or disuse of an extremity by the patient



  • Palpation


    It is critical to palpate all long bones, joints, and areas of wounds to assess for crepitation, false motion, and soft tissue defects such as a quadriceps tendon rupture. This palpation is especially important in an unresponsive patient because abnormal motion is the only way to find an injury and image and treat it appropriately. Pain is produced by this examination, but this is the time to be as complete as possible.



  • Head


    Palpate the face, mandible, and cranium.



  • Cervical Spine


    While maintaining spinal precautions, palpate the cervical midline, noting any pain or stepoffs.



  • Upper Extremity


    Palpate the shoulders, humeri, elbows, forearms, wrists, hands, and each individual finger.



  • Pelvis


    Examine the pelvis with gentle compression of the iliac wings in the anteroposterior plane, mediolateral plane, and on the pubis.



  • Lower Extremity


    Palpate the hips, groin, femora, knees, tibiae, ankles, feet, and each toe.



  • Spine


    Using a coordinated team effort to ensure spinal precautions, logroll the patient and palpate the thoracic, lumbar, and sacral spine feeling for vertebral stepoffs and paraspinal areas of tenderness. While the patient is in this position, you may also palpate the scapulae and any other area of visible trauma.



  • Range of Motion


    Take each limb and its joints through a full range of motion to assess for blockage to movement.



  • Muscle Examination


    The muscular examination may be limited because of pain, but documentation of function is important to guide treatment. Minimal movement or response to a noxious stimulus is enough to assess the presence of volitional muscular function. Obvious trauma to an area warrants a more thorough and specific examination. Grossly, the upper extremity should be tested for the following:




    • Deltoid—axillary nerve



    • Biceps—musculocutaneous nerve



    • Triceps—radial nerve



    • Extensor pollicis longus—radial nerve



    • Flexor pollicis longus—anterior interosseous branch of the median nerve



    • Intrinsics—median and ulnar nerves



    The lower extremity should be tested for the following:




    • Quadriceps—femoral nerve



    • Tibialis anterior—deep peroneal nerve



    • Gastrocnemius and soleus complex—tibial nerve



    • Extensor hallucis longus—deep peroneal nerve



    • Flexor hallucis longus—tibial nerve



    Each muscle can be graded on a numerical scale. This documentation helps in treatment decision making and in rehabilitation. Table 1-1 shows the grading system.



    TABLE 1-1

    Muscle Grading System



























    5 Normal Complete range of motion against gravity with full resistance
    4 Good Complete range of motion against gravity with some resistance
    3 Fair Complete range of motion against gravity
    2 Poor Complete range of motion with gravity eliminated
    1 Trace Evidence of contractility; no joint motion
    0 Zero No evidence of contractility



  • Neurologic Examination


    Further neurologic assessment beyond motor function involves sensory testing of major nerves and dermatomes, including the C5-T1 dermatomes and distal sensation in the median, radial, and ulnar distributions in the hand. In the lower extremity, the L2-S2 dermatomes and femoral, sural, saphenous, tibial, and deep and superficial peroneal distributions are assessed. Perianal sensation is assessed during the rectal examination. Reflexes to test include the biceps, triceps, brachioradialis, patellar tendon, and Achilles tendon. Other reflexes directed more at the spinal examination include the Babinski reflex, perianal “wink,” and bulbocavernosus reflex. Classification systems to assess head injury in trauma patients are available. The best-known classification is the Glasgow Coma Scale (GCS); the GCS score ranges from 3 to 15 and is made up of three individual scores for eye opening, verbal response, and motor response ( Table 1-2 ). A score of 8 or less requires intubation to secure the airway.



    TABLE 1-2

    Glasgow Coma Scale






















































    Eye Opening
    Spontaneous 4
    To voice 3
    To pain 2
    None 1
    Verbal Response
    Oriented 5
    Confused 4
    Inappropriate words 3
    Incomprehensible sounds 2
    None 1
    Motor Response
    Obeys command 6
    Localized pain 5
    Withdraws to pain 4
    Flexion to pain 3
    Extension to pain 2
    None 1



  • Special Consideration


    In female patients, when pelvic trauma is suspected or visualized on pelvic radiographs, a vaginal examination is warranted to rule out occult open fracture into the vagina.


    Patients with more routine limb or spine injuries and a nontraumatic presentation still should have a complete examination from the cervical spine to the toes because the main injury may distract from another, less painful area of injury. All examinations of upper extremity injury should begin with the cervical spine to rule that out as a possible cause of injury.





Resuscitation


Resuscitation of a trauma patient is carried out under the guiding principles of the American College of Surgeons Committee on Trauma, including the primary, secondary, and tertiary survey. The primary survey can be easily remembered as ABCDE :




  • A irway and cervical spine precautions



  • B reathing and ventilation



  • C irculation with hemorrhage control



  • D isability/dysfunction



  • E xposure/environmental control (prevent hypothermia)




  • Airway


    The cervical spine should be stabilized manually or with a cervical collar while the airway is evaluated and secured. Clear any obstructions to the airway, and use a chin lift or jaw thrust to help establish an airway; do not manipulate the cervical spine. An oropharyngeal or nasopharyngeal airway may be placed or definitive endotracheal or nasotracheal intubation may be established for patients with a GCS score less than 8, combative patients with an altered mental status, or patients who are hemodynamically unstable. If an airway cannot be established, a surgical airway may need to be created by performing a cricothyroidotomy and placing a tracheostomy tube. After an airway is established, supplemental oxygen can be started to help normalize physiologic status.



  • Breathing


    Adequate ventilation not only provides oxygen to the tissues but also expels carbon dioxide waste products. If a patient is not breathing on his or her own, bag-valve ventilators or ventilation machines can be used to deliver oxygen. A trauma surgeon, if available, should evaluate the patient’s chest. Monitor chest wall rise, respiratory rate and depth, use of accessory muscles, and presence of cyanosis to assess breathing. Special attention should be paid to:




    • Tension pneumothorax—immediate needle thoracostomy and chest tube placement needed



    • Open pneumothorax—three-sided occlusive dressing and chest tube needed



    • Flail chest and pulmonary contusion—loss of chest wall integrity from multiple rib fractures



    • Massive hemothorax




  • Circulation


    Hypotension after trauma is primarily hypovolemic in nature owing to blood loss and fluid shifts. Monitor the patient closely because mental status, coloration, and pulses are good indicators of hemodynamic status. Open fractures, especially of long bones, are often sources of significant blood loss. Apply direct pressure to bleeding sources, and elevate the extremity if possible. A tourniquet may be needed until more definitive management can address the problem. Pelvic fractures or pelvic and abdominal trauma creating internal hemorrhage can hide a significant amount of blood causing hemodynamic instability. Either of these situations can result in hemorrhagic shock. Table 1-3 provides a classification of hemorrhagic shock. Shock needs to be dealt with expeditiously. Two large-bore intravenous catheters are placed in both antecubital fossae. A central line may be needed for rapid volume infusion. Resuscitation is undertaken beginning with 2 L of lactated Ringer solution or normal saline. If the patient is still unstable, blood should be infused, and ongoing monitoring should be continued to re-evaluate the hemodynamic status. Loss of hemodynamic stability requires continued searching for a bleeding source. Ideally, crossmatched blood is given, but often the trauma situation is more emergent and life-threatening mandating use of universal donor O− blood.


Sep 30, 2019 | Posted by in ORTHOPEDIC | Comments Off on General Principles of Initial Care
Premium Wordpress Themes by UFO Themes