March 2nd Dr Abdulla R2

1. Abdullah Al-abdali
R2 EM

2. Outlines:
• Introduction, physics
• Anatomy
• Management
– Vascular injury
– Nerve injury
– Compartment syndrome
• Antibiotics

3. Introduction
• Penetrating injury: injury produced by
foreign objects that penetrate tissue.
– Low energy : knife or hand-energized missiles
– Medium energy: handguns
– High energy: military or hunting rifles

4. 2
KE= ½ mvs ic s o f
Phy
P e n e tratin g T rau m a
 R e c a ll K in e tic E n e rg<2500 fps
Low velocity y E q u a tio n
High ( weight ) Velocity ( speedfps
Mass
velocity >2500 ) 2
KE
2
 G re a te r th e m a s s th e g re a te r th e e n e rg y
 D o u b le m a s s = d o u b le K E
 D o u b le m a s s = d o u b le K E
 G re a te r th e s p e e d th e g re a te r th e e n e rg y
 D o u b le s p e e d = 4 x in c re a s e K E
 D o u b le s p e e d = 4 x in c re a s e K E
(co n tin u e d )

5. Temporary cavity
• Result of energy exchange b/w moving
missiles & body tissue, caused by shock
wave initiated by impact of the bullet.
• Diameter depends on the velocity
• The max. diameter occurs at the area of
greatest resistance to the bullet.
Tissue damage can occur at some distance
from the bullet track itself.

7. Missiles wounds
• The wound at the point of bullet impact is
determined by:
– Shape of the missile
– Position of the missile relative to the impact site
– fragmentation

8. Sp ec ific W e ap o n
C h aracteristics
 H andguns
 S m all calib er, sh o rt b arrel, m ed iu m -velo city
 S m all calib er, sh o rt b arrel, m ed iu m -velo city
 E ffective at clo s e ran g e
 E ffective at clo s e ran g e
 S e verity o f in ju ry b as ed u p o n o rg an s d am ag ed
 S e verity o f in ju ry b as ed u p o n o rg an s d am ag ed
 R ifle
 H ig h -velo city, lo n g er b arre l, larg e calib er
 H ig h -velo city, lo n g er b arre l, larg e calib er
 In cre as ed a ccu rac y at far d istan c es
 In cre as ed a ccu rac y at far d istan c es
 As s a u lt R ifle s
 L arg e m ag azin e, s em i- o r fu ll-au to m atic
 L arg e m ag azin e, s em i- o r fu ll-au to m atic
 S im ilar in ju ry to h u n tin g rifles
 S im ilar in ju ry to h u n tin g rifles
 M u ltip le w o u n d s
 M u ltip le w o u n d s

9. Anatomy
• 2 guiding principles:
– The major nerves tend to follow the course of
major arteries. Ex.
– Most of extremity musculature is organized
into compartments, which encased by
unyielding fibrous fascia.

16. • A 19 yrs old male, was struck in the R. thigh by stray
bullet, he collapsed. In ED, looks pale, P:120,
BP:100/50, RR:22, O2 sat:95% on 100% O2,on 10
survey, he is alert & without trauma to the head, neck or
chest. Had clear breath sound b/l. on 2nd survey he had,
normal cardiac & abdomen Exam. You found an
entrance wound on his proximal thigh (just distal to
inguinal lig.) which is oozing blood, he has no back
wound, he has a sizable R. thigh hematoma, but there is
no pulsating blood coming from the wound, EMS said it
is same for the last 20min. His R. DP pulse is present.
What Do you want to Do first:
• Take him to OR
• Obtain pelvis and leg x-ray and perform FAST exam.
• Intubate the patient
• Measure compartment pressure

17. Management
o
1 survey
A Go straight to where
the money is
B Extremity Injuries are examined
during the 2nd survey, once
C patient stabilized
D
E

18. • Purpose of the exam:
Has there been an injury to a Major artery or vein?
Has a peripheral nerve been transected?
Is there any evidence of bone or tendon injury?
Is there any evidence of compartment syndrome?

19. What to examine?
• Pulse: compare it with uninjured extremity.
• Hand held Doppler
• API
• Color
• Coolness Careful physical exam
• Sensation and high index of
• Tendons suspicion are most
important !
• Pain

20. Hand held Doppler
• Determine presence/absence of arterial supply
• Assess adequacy of
flow
PRESENCE OF SIGNAL DOES NOT
EXCLUDE ARTERIAL INJURY !

21. API
SBP is obtained by inflating a blood pressure
cuff proximal to the injury, and using the
Doppler distal to the injury to determine the
SBP
• Ratio of 0.9 or less, abnormal
• 0.9 to 0.99 observe for 12-24Hs
• sens: 45-95% for wounds requiring OR

22. Vascular injury
• 3 Qs.
– When dose the Pt need to go to OR?
– When dose the Pt need angiography?
– When can the Pt simply observed and
discharge home?

23. Extremity Wound
Open Wound (larger lacerations): Penetrating wound:
-can bleed profusely. HARD SIGNS OF -Small wound
**1 st step is to stop bleeding.
ARTERIAL INJURY -external bleed is minimal
•Direct pressure
•Tourniquet
•Don’t ligate blindly. Doesn't exclude significant
arterial injury.

24. Hard Vs Soft signs:
HARD SIGNS: SOFT SIGNS:
• Pulsatile bleeding • Large non-pulsatile
• Expanding or pulsatile hematoma
hematoma • Isolated nerve injury
• Palpable thrill or • Proximity injury
audible bruit • Palpable, but
• Ischemia 5P’s diminished pulse

25. • The incidence of arterial injury in the
presence of any one of hard signs is
>90%.
• 35% of patients with soft finding had
positive angiographic studies.
• Vascular injury occurs in 8-45% of cases
of penetrating nerve injury.

26. Diagnostic strategies
• Non
• X-ray
• Ultrasound
• Arteriography
• CTA

27. X-ray:
• Detect fracture
• Joint penetration
• Foreign bodies
– The position of metallic bodies
– The presence of fragments of a bullet which
has broken up.

28. Ultrasound
• Duplex US (B-mode + US)
• Non-invasive, portable
• Sn 83 – 100%
• Sp 99 – 100%
• Operator dependent
• Not always 24 h available.

29. Arteriography
• It has been the gold standard for Dx.
– Sens: 98%
– Spec: 99%
• Problems:
– The cost
– Need to leave the ED
– Small complication of arterial cannulation
– Difficult in children.
– 5% FP, 5% FN when compare to surgical exploration

30. CTA
• Less invasive
• Much more readily available
• Less time consuming
• Replacing angiography in many
indications.

31. CT angiography effectively evaluates extremity vascular trauma.
Peng PD, Spain DA, Tataria M, Hellinger JC, Rubin GD, Brundage SI.
This study supports CTA as an effective
alternative to Conventional arteriography in
assessing extremity vascular trauma.
Am Surg. 2008 Feb;74(2):103-7.
Division of Trauma and Surgical Critical Care, Department of Surgery,
Stanford University Medical Center, Stanford, California, USA

32. CONCLUSIONS: With acceptable injury detection, rapid availability,
and a favorable cost profile, our results suggest that CTA may replace
arteriography as the diagnostic study of choice for vascular injuries of
the extremities.
J Trauma. 2009 Aug;67(2):238-43; discussion 243-4.

33. Manage ABCs
Axillary or
Hard
Signs
Inguinal
Yes CTA/arterio
+
NO Wound? OR
Present
Yes NO
• ED exploration
vascular study open • Irrigate thoroughly
first if wound Injury type - Primary closure
laceration - Tetanus
location unclear
simple
Shotgun Arterial injury
SW or GSW
sharpnel
OR • observe, irrigate, tetanus
•X-ray for GSW OR
CTA/arterio •Consider AP/US
•Consider CTA/angio + AP/US
•Loose closure for SW
+ OR + CTA/arterio

34. Manage ABCs
Axillary or
Hard
Signs
Inguinal
Yes CTA/arterio
+
NO Wound? OR
Present
Yes NO
• ED exploration
vascular study open • Irrigate thoroughly
first if wound Injury type - Primary closure
laceration - Tetanus
location unclear
simple
Shotgun Arterial injury
SW or GSW
sharpnel
OR • observe, irrigate, tetanus
•X-ray for GSW OR
CTA/arterio •Consider AP/US
+ AP/US
•Consider CTA/angio +
•Loose closure for SW
+ OR + CTA/arterio

35. GSW
indication for OR
– Hard signs
– Progressive neuro deficit
– Open fracture
– Unstable fracture
– Significant soft tissue damage or necrosis
– Compartment syndrome

36. Complications
Blood loss
Ischemia
Compartment
syndrome
Tissue necrosis
Amputation
Death

37. Nerve injury
• Difficult to asses in trauma patient.
• Neuropraxia
– Contusion of the nerve
– Normal function returns in weeks to months
• Axonotmesis
– Injury to nerve fibers occurs within their sheath.
– Spontaneous healing is possible but slow? Why?
• Neurotmesis
– Is the severing of nerve
– Usually require surgical repair

38. Examination
• Examine sensation and muscle power
• Two-points discrimination is a more
sensitive examination.
• Testing for sympathetic nerve function
using the O’Riain wrinkle test may be
helpful.

39. Compartment syndrome
• It is a complication of arterial or venous injury.
• A rise in pressure with a compartmentalized group of tissues leading
to impaired perfusion, ischemia and necrosis of muscles within the
compartment.

40. Pathophysiology
• Increased compartment contents
• Decrease compartment volume
• External pressure

41. Clinical presentation
• Pain that is disproportionate to the injury.
• Pain is deep, burning and difficult to
localized.
• Pain on passive stretching of the muscle
groups.
• Hypoesthesias & paresthesias

42. Diagnosis & treatment
Fasciotomy to fully decompress
all involved compartments is the
definitive treatment for ACS in
the great majority of cases
•Capillary blood flow becomes compromised at 20 mmHg.
•Pain develops at pressures between 20 and 30 mmHg.
•Ischemia occurs at pressures above 30 mmHg.

43. Antibiotics
• Pt going to OR broad spectrum IV antibiotics
• Hand & Foot & high velocity short course antibiotics
with one dose IV.
• Other site single IV dose to cover skin flora.
• For immunocompromised patient.
J Am Acad Orthop Surg, Vol 14, No 10, September 2006, S98-S100.
© 2006 the American Academy of Orthopaedic Surgeons

44. 195 patients
ceftriaxon cefoxitin
TID x3 days
There was no significant different in the infection rate and no patient
Developed deep tissue infection requiring surgical intervention by
Post-trauma day 10
Schmidt et al, Chemotherapy 2002;45: 1621-1626

45. • While you are waiting for the result of x-rays, he
becomes tachypneic, and BP drops to 70/40 with P:160,
oxygen sat. probe is not picking up a reading. A repeat
1o survey reveals an intact airway & clear breath sounds
& his thigh looks the same, you look at the back & axilla
again to assure you didn’t miss any injury:
What is a possible explanation for his
deterioration?
• Occult Pneumothorax that has become a tension Pneumothorax.
• Anemia from ongoing occult bleeding
• Fat embolism from a femur fracture
• Missile embolism to the pulmonary vasculature.

46. Missile embolism
• The travel of foreign bodies from penetrating trauma through blood
stream.
• Can be arterial or venous:
– Arterial: distal obstruction & distal ischemia
– Venous: travel through R. heart to P. arterial system PE
• Arterial emboli can be removed either with arteriotomy or balloon
catheter embolectomy.
• All centrally located, symptomatic venous emboli, need to be
removed.
• Some surgeon will leave asymptomatic missiles in place, which has
been shown to be safe.

47. Tetanus

48. Summary
• ATLS
• Indication for OR? Stable /
unstable?
• Further investigations?
• Don’t miss nerve injury
• Compartment syndrome
• Antibiotics?
• Tetanus

50. Compartments of the lower leg
• Anterior compartment- most • Deep Posterior Compartment
frequently affected – Muscles: tibialis posterior, the
– Muscles- tibialis anterior, flexor digitorum longus & FHL
extensors of the toes (EHL – Test: Toe flexion
and EDL) – Nerves: Tibial nerve
– Test: Extension of the 1st toe – Test: Sole of foot (heel too)
– Nerves- Deep peroneal nerve – Vascular: Posterior tibial artery
– Test: Web space of 1st toe – Test: Posterior tibial pulse
– Vascular- Anterior tibial artery • Superficial Posterior
– Test: Dorsalis pedis pulse compartment
• Lateral Compartment – Muscles: Gastrocnemius and,
– Muscles- Preens longus and the soleus muscle
brevis – Test: Plantar flexion
– Test: Foot eversion – Nerve: Sural nerve.
– Nerves: Superficial peroneal – Test: Lateral aspect of 5th toe
nerve
– Test: Dorsum of foot
– No artery