ATLS 10 EXAMS TEST BANK , Exams of Nursing

Download ATLS 10 EXAMS TEST BANK and more Exams Nursing in PDF only on Docsity! ATLS 10 EXAMS TEST BANK WITH ACTUAL CORRECT QUESTIONS AND VERIFIED DETAILED RATIONALES ANSWERS| LATEST UPDATE 2024 ALREADY GRADED A+| GUARANTEED PASS 100% Describe the mechanism of injury of severe diffuse hypoxic, ischemic brain injuries: Prolonged shock or apnea occurring immediately after trauma will starve the brain, leading to ischemic injury. Initially, the brain may appear radiographically normal. Over time, cerebral edema will develop leading to loss of gray-white matter distinction. Describe the injury patterns in high-velocity impact or deceleration injuries on the brain: Shearing injuries occur at the border between gray and white matter, which present as multiple punctate hemorrhages throughout the cerebral hemispheres. This pattern is often characterized as diffuse axonal injury, which has variable often poor outcomes. Epidural hematomas occur in about ___ % of patients with brain injuries and __ % of patients with TBI who are comatose. 0.5%, 9% Describe the appearance of epidural hematomas and how they most often occur: Biconvex (lenticular, lens-shaped) as they push the adherent dura away from the inner table of the skull. Most often in the temporal or temporoparietal regions. Most often result from tears of the middle meningeal artery due to fracture. Most often arterial in origin, but can result from major venous sinus hemorrhage, or bleeding from a skull fracture. Describe the classic presentation of epidural hematoma: A lucid interval between the time of injury and neurological deterioration. Subdural hematomas occur in approximately __% of patients with severe brain injuries: 30% Describe the appearance of subdural hematomas and how they most often occur. Crescent-shaped (conforming to the contours of the brain). Develop from shearing of the small surface or bridging blood vessels of the cerebral cortex. Often accompanies severe parenchymal injury. Cerebral contusions occur in approximately __% of patients with severe brain injuries. 20-30% Describe the appearance of cerebral contusions and how they most often occur. Most occur in the frontal and temporal lobes, but can be anywhere in the brain. Over hours–days, contusions evolve to form an intracerebral hematoma or a coalescent contusion. Mass effect can develop, indicating immediate surgical evacuation in about 20% of cases. Common presenting features in mild TBI: Transient loss of consciousness Disorientation Amnesia Often confounded by alcohol or other intoxicants Initial management of mild traumatic brain injury Mechanism Time of injury Initial GCS Confusion Amnestic interval Seizure Headache severity AMPLE history Neurological examination Anticoagulation assessment Secondary management of mild traumatic brain injury Serial examination until GCS 15 and no persistent memory deficit or perseveration. Follow-up CT scan if first is abnormal or GCS remains <15. Consider transfer if neurological status deteriorates. Prognosis of mild traumatic brain injury: Most have uneventful recovery. Approximately 3% unexpectedly deteriorate, potentially resulting in severe neurological dysfunction unless the decline in mental status is detected early. Diagnostic workup for mild traumatic brain injury CT scan (if CT Head rules apply) EtOH and drug screen Admission criteria for mild traumatic brain injury Prognosis of moderate traumatic brain injury: Approximately 10% to 20% of these patients deteriorate and lapse into coma. Common presenting features in severe TBI: Unable to follow simple commands, even after cardiopulmonary stabilization. Confused, somnolent, or comatose Diagnostic workup for severe traumatic brain injury Frequent serial neurological exam including GCS CT scan in all cases once stabilized Type and crossmatch and coagulation studies EtOH and drug screen Evaluate for other injuries and investigations as appropriate Admission criteria for severe traumatic brain injury All severe TBI requires admission and observation in unit capable of close nursing observation and frequent neurological reassessment for at least the first 12 to 24 hours. A follow-up CT scan within 24 hours is recommended if the initial CT scan is abnormal or the patient's neurological status deteriorates. CT scan findings of severe brain injury Midline shift Loss of definition of basal cisterns Severe skull fractures with intrusion Initial management of severe traumatic brain injury Urgent neurosurgical consultation and transfer Primary survey and resuscitation Intubation and ventilation for airway protection Treat hypotension, hypovolemia, and hypoxia Focused neurological exam AMPLE history and secondary survey Secondary management of severe traumatic brain injury Serial examination Neurosurgical consultation. PaCO2 35-40 mmHg Avoid hyperventilation in the first 24 hours as bloodflow may be critically reduced. Mannitol and brief hyperventilation (maintain PaCO2 >25 mmHg) if deteriorates Utilize SjO2 or PbTO2 to monitor and titrate oxygen delivery. Hypertonic saline. Disposition of severe traumatic brain injury Admission and/or transfer to neurosurgery and/or trauma center for serial observation, CT scan, and intervention if needed Priorities for the Initial Evaluation and Triage of Patients with Severe Brain Injuries 1. Primary survey and adhere to ABCDE priorities. 2. Brief neurological examination should be performed before administering drugs for intubation. 3. Once blood pressure normalized, complete a neurological examination including GCS and pupil exam. 4. If hypotension is persistent, perform the neurological exam and record the blood pressure. 5. If systolic pressure cannot be raised to >100 mmHg, determine cause of hypotension first rather than neurosurgical evaluation (e.g. FAST, DPL, laparotomy). 6. If clinical evidence of intracranial mass, then diagnostic and therapeutic burr hole or craniotomy can be performed in the OR simultaneously. 7. If systolic pressure is resuscitated to >100 mmHg and there is evidence of intracranial mass, then CT head becomes next priority. 8. If systolic pressure is resuscitated but is trending downward (metastability), consult with trauma surgical and neurosurgical teams about CT scan before or after operative management. Describe how cardiopulmonary success affects mortality in severe brain injury Hypotension at admission doubles mortality rate. Hypoxia in addition to hypotension increases relative risk of mortality by 75%. The purpose of intubation of a comatose (GCS ≤8) patient is to: Prevent hypoxia. In severe TBI, ventilate with ____% oxygen until ____. Maintain an oxygen saturation of ____. 100%, blood gas measurements are available, >98%. In severe TBI, set ventilation parameters to maintain a PCO2 of ____. 35 mmHg Indications for hyperventilation in severe TBI: Acute neurologic deterioration, or Signs of herniation Prolonged hyperventilation with PCO2 of ____ is not recommended. <25 mmHg What oxygen saturation should be targeted in brain injury, if blood gas analysis is not available? 98% When may hypotension be due to brain injury? Terminal stages of medullary failure Concomitant spinal cord injury (neurogenic shock) Maintain systolic blood pressure at ____ for patients ______ years or at ______ for patients ______ years or older than _____ years; this may decrease mortality and improve outcomes. ≥100 mmHg, 50-69 years ≥110 mmHg, 15-49 years or >70 years Goals of treatment in brain injury: Systolic blood pressure Temperature Glucose Hemoglobin INR Na PaO2 PaCO2 pH Platelets Cranial perfusion pressure (CPP) Intracranial pressure (ICP) Partial pressure of brain tissue oxygen (PbTO2) Pulse oximetry ≥100 mmHg 36-38°C 4.4-10 mM/L (80-180 mg/dL) ≥70 g/L (7 g/dL) ≤1.4 135-145 Protamine sulfate idarucizumab (Praxbind) or PCC PCC Describe the relationship between ventilation, PaCO2, and vasoconstriction. Hyperventilation drives down PaCO2 and causes cerebral vasoconstriction. Excessive hyperventilation can lead to cerebral ischemia. If hyperventilation is required, it is preferable to keep PaCO2 at approximately ____. 35 mmHg (low-end of normal) The risk of hyperventilation-associated brain injury is particular high if PaCO2 falls below _____. 30 mmHg Hypercarbia with PaCO2 _____ will cause ____ in the brain. 45 mmHg, vasodilation and increase intracranial pressure. Describe the role of hyperventilation in management of brain injury. Brief periods of hyperventilation, titrated to PaCO2 25-30 mmHg, may be necessary to manage acute neurological deterioration while other treatments are initiated or surgical intervention is performed. The most common preparation of mannitol is: 20% solution (20 g mannitol in 100 mL of solution). Mannitol should not be given in patients with... Hypotension (SBP <90 mmHg), as it does not lower ICP if hypovolemic and is a potent osmotic diuretic. Mannitol is strongly indicated if... Acute neurological deterioration occurs - uncal herniation syndrome (dilated, fixed pupil with contralateral hemiparesis) or loss of consciousness, and the patient is not hypovolemic. The bolus dose of mannitol is... 1 g/kg infused rapidly over 5 minutes for acute neurological deterioration (e.g. uncal herniation). 0.25-1 g/kg to control elevated ICP. Parameters which must be monitored when administering mannitol: ICP Serum osmolality (<320 mOsm) Volume status (urine output, blood pressure >90 mmHg) Typical concentrations of hypertonic saline range from: 3%-23.4% Hypertonic saline may be used in patients with... Elevated ICP, and may be used in patients with hypotension because it is not a diuretic. However, in hypovolemic patients, the effect is minimal. Barbiturates may be effective in ______, though should not be used in the presence of _______ or _______. Reducing ICP refractory to other methods Hypovolemia Hypotension Disadvantages of barbiturates to reduce intracranial pressure: Long half-life delays time in determining brain death. Not preferred agent to induce burst suppression in status epilepticus. Management of a patient with TBI who is seizing when long-acting paralytic wears off: Avoid long-acting paralytic agents, as muscle paralysis confounds the neurologic examination. Use benzodiazepines to acutely manage seizures, as muscle relaxants mask rather than control seizures. Post-traumatic epilepsy occurs in approximately __% of inpatients with closed head injuries and __% of inpatients with severe head injuries. 5%, 15% Three factors linked to a high incidence of traumatic epilepsy are: Seizures occurring within the first week Intracranial hematoma Depressed skull fracture True or false: Early anticonvulsants aid in improving long-term traumatic seizures. False. They do not change long-term seizure outcomes. Disadvantages of anticonvulsants in brain injury: Inhibit brain recovery, so should be used only when absolutely necessary. Anticonvulsants used in the acute phase: Dilantin (phenytoin) Valium (diazepam) Ativan (lorazepam) Cerebyx (fosphenytoin) Dilantin (phenytoin) loading, maintenance, and titration target: 1 g IV at no faster than 50 mg/min, with typical maintenance rate of 100 mg/8 hours, to achieve therapeutic serum levels. Control of continuous seizures may require... General anesthesia (intravenous and inhaled anesthetics) Prolonged seizures lasting _____ may cause secondary brain injury. 30-60 minutes The most common cause of infected scalp wounds is: Inadequate cleansing and debridement. Methods to control scalp hemorrhage: Direct pressure Cauterizing Ligating large vessels Sutures, clips, or staples Red flags features of scalp wounds: Skull fracture (open or depressed) Foreign body CSF leakage (dural tear) _____ can be commonly confused with a skull fracture on examination: Subgaleal hematoma Skull fracture can be confirmed or excluded by: Plain X-ray or CT scan For patients with depressed skull fractures, a ____ is an invaluable test because it _______: CT Head Identifies degree of depression Evaluates for intracranial hematoma or contusion Operative criteria for depressed skull fractures: Degree of depression is greater than the thickness of the adjacent skull Fracture is open and grossly contaminated. Less severe depressed skull fractures can often be managed by: Closure of the overlying scalp laceration, if present. Indications for an emergency craniotomy by non-neurosurgeon Rapidly deteriorating patient Austere or remote areas After consultation with a neurosurgeon Definitive neurosurgical care is unavailable The most important ways to limit secondary brain damage and thereby improve a patient's outcome are to: 1. Ensure adequate oxygenation 2. Maintain blood pressure at a level that is sufficient to perfuse the brain. 3. If neurosurgery consultation available, identify any mass lesion that requires surgical evacuation 4. If imaging and neurosurgical consultation available, rapidly obtain a computed tomographic (CT) scan of the head. 5. Transfer to head injury unit once stabilized. When consulting a neurosurgeon about a patient with TBI, communicate the following information: 1. Patient age 2. Mechanism and time of injury 3. Patient's respiratory and cardiovascular status (particularly blood pressure and oxygen saturation) 4. Results of the neurological examination, including the GCS score (particularly the motor response), pupil size, and reaction to light 5. Presence of any focal neurological deficits 6. Presence of suspected abnormal neuromuscular status 7. Presence and type of associated injuries Results of diagnostic studies, particularly CT scan (if available) 8. Treatment of hypotension or hypoxia 9. Use of anticoagulants Because of the scalp's generous blood supply, what complications may arise? Scalp lacerations can result in major blood loss, hemorrhagic shock, and even death. Patients who are subject to long transport times are at particular risk for these complications. What are anatomy and injury implications of the anatomy of the base of the skull? The base of the skull is irregular, and its surface can contribute to injury as the brain moves within the skull during the acceleration and deceleration that occurs during the traumatic event. The anterior fossa houses the _____, the middle fossa houses the _____, and the posterior fossa contains the _______. frontal lobes / temporal lobes / lower brainstem and cerebellum The meninges cover the brain and consist of three layers: Dura mater, arachnoid mater, and pia mater Describe the anatomy and injury implications of the dura mater: Tough, fibrous membrane that adheres firmly to the internal surface of the skull. At specific sites, the dura splits into two "leaves" that enclose the large venous sinuses, which provide the major venous drainage from the brain. The midline superior sagittal sinus drains into the bilateral transverse and sigmoid sinuses, which are usually larger on the right side. Laceration of the venous sinuses can result in massive hemorrhage. Describe the anatomy and injury implications of the meningeal arteries: Meningeal arteries lie between the dura and the internal surface of the skull in the epidural space. Overlying skull fractures can lacerate these arteries and cause an epidural hematoma. The most commonly injured meningeal vessel is the ____, which is located over the ____. An expanding hematoma from injury in this location can lead to rapid deterioration and death. Middle meningeal artery Temporal fossa Epidural hematomas can arise from: Lacerations of the meningeal arteries (rapid, most common) Injury to the dural sinuses (slow) Skull fractures (slow) Most epidural hematomas must be managed as.... Life-threatening emergencies that must be evaluated by a neurosurgeon as soon as possible. Describe the anatomy and injury implications of the arachnoid mater: Beneath the dura mater Thin and transparent A potential space between the dura and the arachoid layers exists (the subdural space) Hemorrhage into the subdural space arises from ____: Bridging veins, which travel from the surface of the brain to the venous sinuses within the dura. Describe the anatomy and injury implications of the pia mater: Firmly attached to the surface of the brain. CSF fills the space between the watertight arachnoid mater and the pia mater (the subarachnoid space) Subarachnoid space cushions the brain and spinal cord. Hemorrhage into the subarachnoid space frequently accompanies brain contusion and injuries to the basal brain. The brain consists of the ____, ____, and ____. Cerebrum, brainstem, and the cerebellum The cerebrum is composed of the _____ and _____ hemispheres, separated by the ________. Left, right, falx cerebri The left hemisphere contains the _______ in all _____ people and ____% of _____ people. language centers, right-handed, >85%, left-handed The frontal lobe controls: Executive function Emotions Motor function Motor speech (dominant side) The parietal lobe controls: Sensory function Spatial orientation The temporal lobe controls: Memory function Olfactory function The occipital lobe controls: Vision The brainstem is composed of: Midbrain Pons Medulla oblongata The midbrain and upper pons contain: Reticular activating system (alertness) The medulla contains: Cardiorespiratory centers, extending to the spinal cord. The cerebellum is responsible for ____ and connects to _____: Coordination and balance Spinal cord, brainstem, cerebral hemispheres Describe the anatomy and injury implications of the ventricular system: Intracranial lesions (focal, diffuse) List the categories of skull fractures: Cranial vault vs. skull base fractures Linear vs. stellate Open vs. closed Describe the clinical signs of a basilar skull fracture: Periorbital ecchymosis (raccoon eyes) Retroauricular ecchymosis (Battle's sign) CSF rhinorrhea or otorrhea Hemotympanum Cranial nerve VII and VIII palsy (facial paralysis, hearing loss) Basilar skull fractures can be diagnosed using what diagnostic test? CT scan with bone-window settings Describe vascular injuries that can arise from skull fractures, and how they are diagnosed: Fractures can traverse the carotid canals and can cause dissection, pseudoaneurysm, or thrombosis. Diagnosed via CT angiogram (CT-A) or conventional angiogram. What skull fractures provide direction communication between the scalp and the cerebral surface? Open fractures or compound skull fractures, when the dura is torn. What injuries are associated with linear vault fracture? It takes considerable force to fracture the skull. A linear vault fracture in conscious patients increases the likelihood of an ICH 400-fold. List the morphologies of intracranial brain injury categories: Focal (subdural, epidural, intracerebral) Diffuse (concussions, multiple contusions, hypoxic/ischemic, axonal The quickest killer of injured patients is: The inadequate delivery of oxygenated blood to the brain and other vital structures. For example, airway injury, airway occlusion, respiratory arrest, respiratory failure. Maxillofacial trauma that can threaten the airway Hemorrhage into the airway Edema of critical airway structures Dislodged teeth Increased secretions Loss of airway structural integrity and tone Neck trauma that can threaten the airway Hematomas Disruption of the soft tissue structures Hemorrhage into the tracheobronchial tree Laryngeal fractures may present with: Hoarseness Subcutaneous emphysema Palpable fracture with crepitus Immediate management of laryngeal fractures and airway compromise Attempt flexible ETT intubation Attempt emergency tracheostomy (cricothyroidotomy) Operative management for definitive repair Laryngeal fracture is confirmed with what test? Computed tomography (CT) Airway obstruction objective signs Agitation (hypoxia) Obtundation (hypercarbia) Cyanosis (nail beds, circumoral skin) Increased work of breathing (retractions, accessory muscles) Pulse oximetry Abnormal breath sounds (snoring, gurgling, stridor, hoarseness) Risk factors for ventilation compromise Direct trauma to the chest Rib fractures Intracranial injuries Cervical spine injury High cervical spine injuries above ___ will ___ Low cervical spine injuries below ___ will ___, but ___ C3, paralyze the diaphragm. C3, maintain the diaphragm, but paralyze the intercostal and abdominal muscles (diaphragmatic or see- saw breathing) Signs of inadequate ventilation Asymmetric tidal breathing Inadequate chest wall excursion Laboured breathing Decreased or absent breath sounds Tachypnea Pulse oximetry Capnography Altered mental status Symptoms of inadequate ventilation Dyspnea Orthopnea Urge to sit up to breathe Confusion Potential situations causing difficulties in airway maneuvers C-spine injury Severe arthritis of the C-spine Significant maxillofacial or mandibular trauma Limited mouth opening Retrognathia Short, muscular necks Bariatrics Pediatrics LEMON Assessment for Difficult Airway Look externally (e.g. small mouth, large overbite, facial trauma) Evaluate 3-3-2 rule (incisor teeth distance of 3 finger breadths; hyoid bone Mallampati score to evaluate hypopharynx (soft palate) evaluation Obstructions that can make laryngoscopy and ventilation difficult. Neck mobility (C-spine flexion, extension) - obviously cannot be performed in blunt trauma with suspected C-spine injury, also in those with C-spine surgery, Down syndrome, and rheumatoid arthritis. The ATLS airway decision scheme only applies in which scenarios? Acute respiratory distress Apneic patient Immediate airway needed Potentially have C-spine injury Equipment checklist for airway maneuvers Suction Oxygen OPA and NPA Bag-mask Laryngoscope Gum elastic bougie (GEB) Extraglottic devices (LMA, LTA) Surgical or needle cricothyroidotomy kit How to use gum elastic bougie (GEB) 1. Place laryngoscope into the vallecula 2. Pass the GEB blindly beyond the epiglottis with the angled tip facing anteriorly 3. Confirm tracheal placement by feeling clicks or rubs along the cartilaginous tracheal rings. 4. If inserted into the esophagus, no resistance will be encountered. 5. Once placement confirmed, pass a lubricated ETT over the bougie. 6. Remove the GEB and inflate the cuff of the ETT. 7. Confirm ETT placement. Signs of proper ETT placement Bilateral breath sounds heard. No borygorygmi heard with inspiration. Capnography confirms CO2 detection (excludes esophageal intubation only) Only chest X-ray confirms placement into the trachea. What is the purpose of cricoid pressure i.e. Sellick maneuver? Reduces the risk of aspiration but may reduce the view of the larynx. What is the purpose of laryngeal manipulation, backwards, upwards, rightward pressure (BURP)? To aid direct visualization of the vocal cords. Crash Airway definition: Crash airway refers to patients in cardiopulmonary arrest, deep coma or near death, who can't maintain ventilation and oxygenation. Established as quickly as possible using BVM ventilation and rapidly moving to laryngoscopy without drug assistance. Commonly used induction anesthetic agents and doses in RSI/DAI: ETOMIDATE 0.3 mg/kg (OR 20 mg) KETAMINE 1-2 mg/kg MIDAZOLAM 0.05-0.1 mg/kg PROPOFOL 1.5 (1-2.5) mg/kg FENTANYL 1-2 mcg/kg LIDOCAINE 1.0 mg/kg ATROPINE 0.01 mg/kg (pediatrics) Commonly used neuromuscular blockade i.e. paralyzing agents and doses in RSI/DAI: SUCCINYLCHOLINE 1.5 (1-2) mg/kg (typically 100 mg) ROCURONIUM 1 (0.6-1.2) mg/kg Contraindications to succinylcholine as a paralyzing agent in DAI: Crush injuries (hyperkalemia) Major burns (hyperkalemia) Electrical injuries (hyperkalemia) Renal failure (hyperkalemia) Neuromuscular diseases (exacerbation) Define tracheostomy tube An endotracheal tube produced by surgically creating an entry directly into the trachea e.g. cricothyroidotomy, tracheostomy Indications for surgical airway: Failed airway (can't intubate, can't oxygenate) Glottal edema Laryngeal fracture Severe oropharyngeal hemorrhage Percutaneous transtracheal oxygenation (PTO) using the Seldinger technique (needle cricothyroidotomy) involves: 1. Place large-caliber plastic cannula (12-14G for adults, 16-18G for children) through the cryothyroid membrane into the trachea. 2. Connect cannula to oxygen at 15 L/min (50-60 psi) 3. Use a Y-connector or a site hole cut in the tubing between the cannula and the cannula to intermittently occlude and thereby insufflate the lungs. 4. Use 1 second occlusion (inspiration) and 4 seconds off (expiration) Risks of PTO technique in needle cricothyroidotomy Barotrauma Pulmonary rupture Tension pneumothorax Inadequate ventilation, leading to hypercapnia Surgical Cricothyroidtotomy technique: 1. Horizontal incision through the cricothyroid membrane. 2. Dissect the incision using a curved hemostat or scalpel handle 3. Insert a small ET (5-7 ID) or tracheostomy tube (5-7 OD) At what age should surgical cricothyroidotomy not be considered, and why? Children <12 years of age, due to injury to the cricoid cartilage causing upper airway collapse, as it is the only circumferential support in the pre-adolescent airway. Devices to provide supplemental oxygen in trauma patients: Non-rebreather mask with reservoir (10-15 L/min) Tight-fitting face mask (10 L/min) Nasal catheters (6 L/min) Nasal cannula (<10 L/min) Factors that impact accurate pulse oximetry 1. Patient is severely clamped down (vasoconstriction) leading to poor tissue perfusion 2. Presence of carboxyhemoglobin (CO poisoning) 3. Presence of methemoglobin (drug-induced e.g. trimethoprim, sulfonamides, dapsone, benzocaine, lidocaine, metoclopramide) 4. Profound anemia (Hgb <50) 5. Hypothermia (<30 °C / 86 °F) Approximate PaO2 vs. O2 Saturation Levels SaO2 100%, 90%, 60%, 50% PaO2 ___, ___, ___, ___ 90, 60, 30, 27 mmHg) Bag-mask technique - one vs. two-person technique Bag-mask ventilation with two people is always preferred, as it permits better seal and less relative motion of the cervical spine. Improving mask seal in an edentulous patient Pack the space between the cheeks and gum with gauze to improve mask fit. Considerations for transfer between pre-hospital to hospital care, and interfacility transfers. 1. Assemble equipment and draw up appropriate drugs in advance if drug-assisted intubation is suspected. 2. Coordinate with other specialists (e.g. neurosurgeon, trauma surgeon) Establish roles and who has expertise in difficult airways and challenging injuries. 3. Consider need for early intubation prior to transfer if there is high risk of airway loss during transfer. 4. Transfer early if unable to secure definitive airway in low-resource setting. Helmet removal - Two-person technique One person restricts movement of the cervical spine Second person expands the helmet laterally and removes it First person then supports the weight of the head Second person then takes over restriction of cervical spine motion POV-SIGN Indications for Definitive Airway (non-ATLS) P - Failure to maintain patent airway - despite other means such as an oropharyngeal tube O - Failure to oxygenate - despite supplemental oxygen through a face mask, with evidence of hypoxia V - Failure to ventilate - inability to breath spontaneously, with evidence of respiratory failure S - Failure to protect against secretions - aspiration of blood or vomitus may occur, causing lower airway injury I - Impending compromise of the airway - due to facial trauma or burns, inhalation injury, Describe the effect of the release of endogenous catecholamines on the vital signs: Catecholamines cause systemic vasoconstriction, increasing peripheral vascular resistance and a rise in diastolic blood pressure, and pulse pressure narrows. Catecholamines also cause tachycardia. True or false: The increase in diastolic blood pressure and narrowing of pulse pressure in early hemorrhagic shock improves organ perfusion and tissue oxygenation. False. It does little to improve these parameters. True or false: The contraction of the volume of blood in the venous system in early hemorrhagic shock improves organ perfusion and tissue oxygenation. False. It does little to improve these parameters. What is the most effective method of restoring adequate cardiac output, end-organ perfusion, and tissue oxygenation? Stopping hemorrhage and volume repletion. Why are vasopressors contraindicated in the first-line treatment of hemorrhagic shock? Worsens end-organ tissue perfusion. Fails to address the underlying cause, which can only be corrected by identifying and stopping the bleeding, and repleting blood volume. What interventions should be considered in the trauma patient with hemorrhagic shock? Immediate identification and control of external hemorrhage. Rapid establishment of intravenous access. Administration of blood, blood products, and crystalloids. Early surgical or interventional involvement to stop internal hemorrhage. Clinical and vital sign manifestations of shock: Tachycardia Low systolic blood pressure High or (late) low diastolic blood pressure Narrowed pulse pressure Thready pulse Tachypnea or bradypnea Skin pallor (cutaneous vasoconstriction) Coolness to extremities (exception: distributive shock) Tachycardic heart rate ranges based on age: Infants >160 bpm Preschool-aged children >140 bpm School aged - pubescent children >120 bpm Adolescent and adults >100 Geriatric (variable) Cardiogenic shock causes: Blunt cardiac injury (myocardial contusion) Cardiac tamponade Air embolus Myocardial infarction Drug intoxication (e.g. cocaine) Cardiac tamponade is best managed by... Formal operative intervention, as pericardiocentesis is at best only a temporizing maneuver. Tension pneumothorax is best managed by... Immediate needle or finger decompression, followed by placement of a chest tube using appropriate sterile technique. Neurogenic shock is caused by... Brainstem or spinal cord injury. Isolated intracranial injury does not cause neurogenic shock. The classic presentation of neurogenic shock is: Hypotension Absence of tachycardia Absence of vasocontriction Absence of narrowed pulse pressure Failure to respond to fluid resuscitation Septic shock in trauma patients should be suspected if... Delayed presentation (hours) Penetrating abdominal injuries Elderly patients with secondary trauma to septic shock Early septic shock signs: Normal circulating volume Modest tachycardia Warm skin Normal or near-normal blood pressure Wide pulse pressure Fever Blood loss and initial lab values (hemoglobin, hematocrit, lactate and base deficit): Hematocrit - may only be slightly decreased in early blood loss Hemoglobin - may only be slightly decreased in early blood loss Lactate and/or base deficit - often elevated early All labs can be trended serially, as this is often most helpful. Initial assessment for causes of hemorrhagic shock may include: Primary survey Chest X-ray Pelvic X-ray FAST DPL Bladder catheterization Common compartments of hemorrhage: On the floor, plus four more External hemorrhage (i.e. on the floor) Intrathoracic space (e.g. hemothorax) Intraabdominal cavity (e.g. splenic rupture, mesenteric artery rupture) Pelvis and retroperitoneum (e.g. open book fracture, aortic disruption) Major long bones and soft tissues (e.g. femoral and humeral fractures) Normal adult blood volume is approximately __% of ideal body weight. 7% (e.g. 70 kg male ~ 5 L) Normal pediatric blood volume is approximately ___% of body weight. 8-9% (70-80 mL/kg) Class I Hemorrhagic Shock The condition of an individual who has donated 1 unit of blood and requires no intravenous fluid resuscitation. Class II Hemorrhagic Shock Uncomplicated event that will likely only require crystalloid infusion. Class III Hemorrhagic Shock Complicated event that will require at least crystalloid infusion, and almost certainly blood products. Class IV Hemorrhagic Shock Pre-terminal event, will die within minutes without intervention. Approximate blood loss, heart rate, blood pressure, pulse pressure, respiratory rate, urine output, GCS, base deficit, and need for blood and/or crystalloid transfusion for Class I Hemorrhagic shock. EBVL: <15% Poiseuille's law states the rate of flow is proportional to the fourth power of the radius, and inversely related to its length. Alternatives to peripheral intravenous access: Intraosseous lines Central venous lines (femoral, internal jugular, subclavian) Initial fluid resuscitation volumes in shock for adults and children: For adults, 1 L of warmed isotonic fluid bolus For children, 20 mL/kg if under 40 kg Acid-base disorders in initial management of hemorrhagic shock: Initial respiratory alkalosis is common, due to tachypnea. Delayed, compensatory metabolic acidosis is common and self-resolves if shock is managed. Persistent metabolic acidosis is caused by shock until proven otherwise. Management of metabolic acidosis in hemorrhagic shock: Fluids or blood products to restore end-organ perfusion. Surgical or interventional treatment to limit blood loss. Do not treat with sodium bicarbonate. How long does cross-matching blood typically take? Most blood banks will take 1 hour to complete the crossmatching process. When might universal blood (O-) and/or universal plasma (AB+) be preferable to type-specific or cross- matched blood? Multiple unidentified casualty event with simultaneous administration of blood products, to prevent inadvertently administering type-specific blood to the wrong patient. How can intravenous fluids and blood products be kept warm, and at what temperature? The target fluid temperature is 39°C (102.2 °F) before infusion. Crystalloids can be stored in a warmer or infused through high-flow, warming pumps. Blood products cannot be stored in a warmer but they can be heated by high-flow, warming pumps. Define massive transfusion protocol, and a balanced transfusion protocol: MTP: >10 units of pRBC within first 24 hours of admission, or >4 units in 1 hour. Balanced (hemostatic, damage-control) transfusion: 1:1:1 ratio of pRBC to platelets to plasma. Management of failure to respond to initial crystalloid fluid bolus Consider unaccounted sources of ongoing blood loss Consider non-hemorrhagic shock (e.g. neurogenic, obstructive) Consider interventional or surgical consultation Consider blood and blood product replacement Rapid response to initial fluid resuscitation (vital signs, TBV, need for blood, blood preparation, need for surgical consultation, and management). Vital signs return to normal. EBVL is <15% and stable. Need for blood is low Typed and crossmatched blood is adequate. Surgical consultation needed, operative management possible. Slow fluids to maintenance rates after response achieved and sustained. Transient response to initial fluid resuscitation (vital signs, TBV, need for blood, blood preparation, need for surgical consultation) Vital signs transiently improve but tachycardia and decreased blood pressure or narrow pulse pressure returns. EBVL is 15-40% and ongoing. Need for blood is moderate-high Typed blood is adequate. Surgical consultation needed, operative management likely. Continue fluid resuscitation but search for other causes of shock. Consider MTP. Minimal or no response to initial fluid resuscitation (vital signs, TBV, need for blood, blood preparation, need for surgical consultation) Vital signs remain abnormal. EBVL is >40% and ongoing. Need for blood is immediate. Emergency blood release (O-) Surgical consultation needed and STAT operative management. Consider non-hemorrhagic shock as it is common due to injury severity. Explain "permissive hypotension" in acute hemorrhagic shock: Also called controlled resuscitation, balanced resuscitation, and hypotensive resuscitation. Control of bleeding is prioritized over fluid or blood replacement. Overly aggressive crystalloid infusion may worsen likelihood of rebleeding. A bridged strategy to definitive surgical or interventional control of hemorrhage. What factors may confound urinary output assessment as a marker of tissue perfusion? Underlying kidney injury Hyperglycemia Administration of diuretics Adequate urinary output for adults, children, and infants, respectively: Adults - 0.5 mL/kg/h Children - 1 mL/kg/h Infants - 2 mL/kg/h Urinary markers of reduced renal perfusion: Reduced urinary output Elevated specific gravity Why does coagulopathy develop in severely injured patients? Severe injury with massive endothelial disruption and hemorrhage consumes coagulation factors. Massive fluid resuscitation further dilutes platelets and clotting factors. Hypothermia and acidosis impairs platelet aggregation and the coagulation cascade. How common is coagulopathy in severely injured patients? About 30% of all admitted patients with severe trauma, in the absence of pre-existing anticoagulant use. How can coagulopathy be monitored in trauma patients? Prothrombin time and INR (PT/INR), activated partial thromboplastin time (aPTT), platelet count. Thromboelastography (TEG) and Rotational Thromboelastometry (ROTEM) can guide administration of blood components to correct the deficiency. Fibrinogen level. What is the dose of tranexamic acid in the prehospital setting? When jurisdictions allow, TXA can be administered within the first 3 hours of injury. The first dose is 1 g infused over 10 minutes. The second dose is an infusion of 1 g over 8 hours. What agents can be administered to correct coagulopathy? Antifibrinolytics (e.g. tranexamic acid i.e. Cyclokapron) Platelets Cryoprecipitate (CP) Fresh frozen plasma (FFP) Prothrombin Complex Concentrate (PCC, i.e. Octaplex) Idarucizumab (Praxbind; for dabigatran) Reversal agents (e.g. Vitamin K, protamine sulfate) What is the role of calcium administration in hemorrhagic shock? Hypocalcemia can be seen in those receiving massive transfusion. Most patients receiving blood transfusions do not need calcium supplements. When necessary, calcium administration should be guided by measurement of ionized calcium. Excessive, supplemental calcium can be harmful. Special considerations: Elderly patients anterior and posterior longitudinal ligaments pedicles vertebral canal (i.e., the lamina) facet joints, interspinous ligaments, and paraspinal muscles The cervical canal is wide from the _______ to the lower part of ____. foramen magnum C2 Approximately ______ of patients with upper cervical spine injuries (i.e., injury above _____) die at the scene from ______. one-third C3 apnea caused by loss of central innervation of the phrenic nerves. A child's cervical spine is markedly different from that of an adult's until approximately __ years of age. These differences include: The differences decline steadily until approximately ___ years, when the cervical spine is more similar to an adult's. - 8 years - more flexible joint capsules and interspinous ligaments - flat facet joints - vertebral bodies wedged anteriorly and tend to slide forward with flexion. - 12 years Vertebral column injuries in the cervical spine are much more likely to cause spinal cord injuries below ____. C3 When a fracture-dislocation in the thoracic spine does occur, it almost always results in a _______ because of the _______ complete spinal cord injury relatively narrow thoracic canal. Most thoracic spine fractures are _______ that are not associated with spinal cord injury. wedge compression fractures The spinal cord originates at the caudal end of the _________, at the ________ in the skull. In adults, it usually ends near the ______ as the _______. Below this level is the _______, which is somewhat _______ resilient to injury. medulla oblongata at the foramen magnum L1 bony level conus medullaris cauda equina more Only three spinal cord tracts can be readily assessed clinically: 1. lateral corticospinal tract 2. spinothalamic tract 3. dorsal columns. Complete spinal cord injury: When a patient has no demonstrable sensory or motor function below a certain level, he or she is said to have a complete spinal cord injury. Incomplete spinal cord injury: One in which some degree of motor or sensory function remains; in this case, the prognosis for recovery is significantly better than that for complete spinal cord injury. Corticospinal tract (location, function, test) In the anterior and lateral segments of the cord Controls motor power on the same side of the body By voluntary muscle contractions or involuntary response to painful stimuli Spinothalamic tract (location, function, test) In the anterolateral aspect of the cord Transmits pain and temperature sensation from the opposite side of the body By pinprick Dorsal columns (location, function, test) In the posteromedial aspect of the cord Carries position sense (proprioception), vibration sense, and some light-touch sensation from the same side of the body By position sense in the toes and fingers or vibration sense using a tuning fork Key spinal nerve segments and areas of innervation C5–C8 C5 Area over the deltoid C6 Thumb C7 Middle finger C8 Little finger Key spinal nerve segments and areas of innervation T4, T8, T10, T12 T4 Nipple T8 Xiphisternum T10 Umbilicus T12 Symphysis pubis Key spinal nerve segments and areas of innervation L4, L5, S1, S3, S4-5 L4 Medial aspect of the calf L5 Web space between the first and second toes S1 Lateral border of the foot S3 Ischial tuberosity area S4 and S5 Perianal region A dermatome is: the area of skin innervated by the sensory axons within a particular segmental nerve root. The sensory level of a SCI is the: lowest dermatome with normal sensory function and can often differ on the two sides of the body. The _______ nerves (C2 through C4) provide sensory innervation to the region overlying the _________. The presence of sensation in this region may confuse examiners when they are trying to determine the sensory level in patients with lower cervical injuries. supraclavicular pectoralis muscle (cervical cape) The _______ worksheet, published by the _______, can be used to document the motor and sensory examination. International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) American Spinal Injury Association (ASIA) lateral bending distraction Upper cervical spine injuries in children (C1-C4) are _______ as common as lower cervical spine injuries. twice Atlanto-occipital dislocation - findings, mechanism, prognosis - orthopedic decapitation, or internal decapitation, and describes ligamentous separation of the spinal column from the skull base. - result from severe traumatic flexion and distraction, including shaken baby syndrome - most die due to brainstem destruction and apnea or have profound neurological impairments (e.g., ventilator dependence and quadriplegia/tetraplegia). - may survive if they are promptly resuscitated at the injury scene. The most common C1 (_____) fracture is a _______ fracture (______ fracture). The typical mechanism of injury is ________. They involve ________ in the skeletal anatomy. The fracture is best seen with ________. They are managed by: atlas / burst / Jefferson / axial loading - disruption of the anterior and posterior rings of C1 with lateral displacement of the lateral masses. - an open-mouth (odontoid) view of the C1 to C2 region and axial computed tomography (CT) scan. - rigid cervical collar initially, until examined by a neurosurgeon or orthopedic surgeon. Fractures of the atlas represent approximately ___% of acute cervical spine fractures, and up to ___% of atlas fractures are associated with fractures of the axis (C2). 5% / 40% The C1 rotary subluxation injury is also known as _____, and is most often seen in which patient demographic? It can occur by with which mechanisms or risk factors? It presents with what key clinical finding? How is it managed? - Atlanto-axial rotatory subluxation (AARS) - children - spontaneously, after major or minor trauma, with an upper respiratory infection and secondary retropharyngeal inflammation (Grisel Syndrome), or with rheumatoid arthritis. - persistent rotation of the head (torticollis). - do not force the patient to overcome the rotation, but restrict motion with him or her in the rotated position and refer for further specialized treatment. Acute fractures of C2 (___) represent approximately ___% of all cervical spine injuries. - Axis - 18% Approximately ___% of C2 fractures involve the ________, a peg-shaped bony protuberance that projects upward and is normally positioned in contact with the _______. It is held in place primarily by the _________. 60% / odontoid process anterior arch of C1 transverse ligament - Type I odontoid fractures typically involve the ____________ - Type II odontoid fractures occur through the __________ and are the most common odontoid fracture. - Type III odontoid fractures occur at the _________. tip of the odontoid (dens) base of the dens, not extending into the body base of the dens, extending into the body In children younger than _____ years of age, the epiphysis (growth plate) of the odontoid may be prominent and resemble a fracture at this level. 6 Posterior Element (________) Fracture of C2 is also known as ________, and should be initially managed with __________. Pars interarticularis / Hangman's Fracture Ensure that patients with this fracture are maintained in properly sized rigid cervical collar until specialized care is available. The area of greatest flexion and extension of the cervical spine occurs at _______ and is thus most vulnerable to injury. In adults, the most common level of cervical vertebral fracture is ___, and the most common level of subluxation is _______ C5-C6 C5 C5 on C6 Thoracic spine fractures may be classified into four broad categories: 1. anterior wedge compression injuries 2. burst injuries 3. Chance fractures 4. fracture-dislocations Simple thoracic wedge compression fractures are usually (stable / unstable) and managed with ________. stable rigid brace Thoracic spine burst fractures are (stable / unstable) and are usually managed by _________ extremely unstable almost always require internal fixation Chance fractures are _______. The classic mechanism of injury is: __________ transverse fractures through the vertebral body Chance fractures can be associated with what other injuries? retroperitoneal and abdominal visceral injuries Chance fractures are (stable / unstable) extremely unstable and are managed with: extremely unstable almost always require internal fixation Fracture-dislocations of the thoracolumbar spine are (stable / unstable) and are managed with: extremely unstable almost always require internal fixation The spinal cord terminates as the ________ at approximately the level of ____, and injury to this part of the cord commonly results in ________. They are particular vulnerable to ______ movements and so caution should be taken when __________. Long spine boards are recommended only for: extrication rapid patient movement transfers If active hemorrhage is not detected or suspected in spine trauma, persistent hypotension should raise the suspicion of ______. neurogenic shock Initial management of neurogenic shock should include: Fluid challenge Vasopressors (Phenylephrine, Dopamine, Norepinephrine) Urinary catheter placement Consultation with critical care and spine services Steroids are not indicated routinely due to lack of evidence for prevention of secondary injury. How best to measure core temperature in trauma patients? Invasive sites like the bladder and the esophageal accurately reflect core temperature. Non-invasive sites such as the rectum, oral cavity, axilla, temporal artery, and external auditory canal are more readily accessible but measurements between these sites can vary greatly. Interventions to warm hypothermic patients: External warming devices (e.g. Bair Hugger, warm blankets). Heat lamps. Thermal caps. Heated respiratory gases. Warmed intravenous fluids and blood products. Core rewarming with irrigation of the peritoneal or thoracic cavity with warmed crystalloid solutions. Extracorporeal bypass for severe hypothermia. Special considerations: Paced or pacemaker-ICD patients Heart rate may inappropriately remain at the device's set rate regardless of volume status. Many devices can be adjusted externally to increase heart rate. Long bone fractures above and below the diaphragm are associated with ________ injuries. internal torso Unstable pelvic fractures and open femur fractures are often associated with ________________. significant hemorrhage Brainpower Read More Bilateral femoral fractures have higher risks for ________ and management should include ________ 1. significant blood loss, severe associated injuries, pulmonary complications, multiple organ failure, and mortality. 2. early transfer to a trauma centre. Severe crush injuries can result in delayed ______, which has this major complication. rhabdomyolysis / leading to renal failure. Crush syndrome is also known as: traumatic rhabdomyolysis Rhabdomyolysis has many complications, including: acute renal failure hemodynamic shock disability pulmonary failure hyperkalemia hypocalcemia DIC metabolic acidosis Diagnostic features of crush syndrome include: Dark amber urine that tests positive for hemoglobin A positive myoglobin assay Serum creatinine kinase of ≥10,000 U/L Metabolic derangement (e.g. metabolic acidosis, hyperkalemia, hypocalcemia) Coagulopathy (e.g. DIC) Management of crush syndrome: Early and aggressive IV fluid resuscitation Alkalinization of the urine with intravenous administration of bicarbonate Osmotic diuresis Dialysis in select cases Define compartment syndrome and its consequence. Swelling into an intact muscular fascial space can cause an acute compartment syndrome that may lead to lasting impairment and loss of extremity without immediate diagnosis and treatment. Fat embolism syndrome definition and sequelae: An uncommon but highly lethal complication of long bone fractures, can lead to pulmonary failure and impaired cerebral function. Management of severe hemorrhage in MSK injuries: 1. Direct pressure is the most effective way to achieve hemorrhage control for deep soft tissue lacerations. 2. Appropriate splinting of long bone fractures can significantly reduce bleeding. 3. If a fracture is open, application of a sterile pressure dressing typically controls hemorrhage. 4. Concurrent fluid resuscitation is an important adjunct to mechanical measures. Management of traumatic amputation: 1. Application of a tourniquet if accompanied by severe hemorrhage. 2. When applying a tourniquet, tighten the tourniquet only until bleeding stops. 3. Always demarcate the time when a tourniquet was applied. 4. A single attempt to deflate the tourniquet may be considered in an otherwise stable patient if the time to operative intervention is longer than 1 hour. 5. Life must be preserved over limb if a tourniquet must remain in place for a prolonged period. A properly applied tourniquet must: 1. Occlude arterial inflow 2. Prevent occlusion of only the venous system, which can lead to increased hemorrhage and result in the swollen and cyanotic extremity. Pneumatic tourniquets may acquire pressure as high as ___ mmHg for the upper extremity, and ___ mmHg in the lower extremity. 250, 400 A candidate for replantation ideally should have: 1. Only an isolated extremity injury 2. Be hemodynamically stable 3. Have no other injuries that would require emergency resuscitation or surgical intervention. To prepare an amputated limb for replantation: 1. Thoroughly wash the amputated limb in an isotonic solution such as Ringer's lactate 2. Wrap the washed limb in a moist sterile gauze. 3. Wrap this part in a similarly moistened sterile towel and place in a plastic bag 4. Transport the plastic blade in an insulated cooling chest with crushed ice. 5. Do not freeze the amputated limb. Features that indicate an interruption to arterial blood supply include: Cold, pale, pulseless extremity Rapidly expanding or pulsatile hematoma Abnormal ankle brachial index (ABI <0.9 indicates abnormal arterial flow secondary to injury, or 70% incidence of associated nonskeletal injury Mangled extremity injuries with prolonged ischemia, nerve injury, and muscle damage may require: Amputation, a life-saving intervention if hemodynamic abnormalities result from the injured extremity. With respect to wounds, and open fracture is assumed until proven otherwise if: the wound is affecting the limb with an associated fracture. The preferred antibiotic for open fractures is a _______. Delay in antibiotic administration ___ hours is related to an increased risk of infection. first-generation cephalosporins >3 hours Open joint injuries may be confirmed using: Findings will include: Direct surgical exploration. CT arthrography - the presence of intra-articular gas. Injection of saline or dye into the joint to determine whether the joint cavity communicates with the wound Examination findings that are closely associated with fractures and indicate need for an x-ray include: Tenderness with bony deformity Obvious bony deformity Joint diffusion Abnormal joint tenderness Distal neurovascular injury The only reasons to forgo x-ray before treating a dislocation or fracture is: The presence of secondary vascular compromise or impending skin breakdown from the fracture (e.g. severe skin tenting and distal pulselessness of an ankle fracture-dislocation) A _________ often reduces spontaneously before assessment, and may not have any gross external or radiographic anomalies until physical exam of the joint is performed and ligament instability is detected clinically. knee dislocation Match the clinical finding to the pathological implication: Loss of sensation to pain and touch Loss of sensation in a stocking or glove distribution Pulse discrepancies, coolness, pallor, paresthesia, and motor function abnormalities in normotensive patients ABI <0.9 Spinal or peripheral nerve injury Early sign of vascular impairment Arterial injury Impaired arterial flow or peripheral vascular disease Nerve / Motor / Sensation / Injury Ulnar Index and little finger abduction Little finger Elbow injury Nerve / Motor / Sensation / Injury Median, distal Thenar contraction with opposition Distal tip of index finger Wrist fracture or dislocation Nerve / Motor / Sensation / Injury Median, anterior interosseous Index tip flexion None Supracondylar fracture of humerus (in children) Nerve / Motor / Sensation / Injury Musculocutaneous Elbow flexion Radial forearm Anterior shoulder dislocation Nerve / Motor / Sensation / Injury Radial Thumb, finger metocarpophalangeal extension First dorsal web space Distal humeral shaft, anterior shoulder dislocation Nerve / Motor / Sensation / Injury Axillary Deltoid Lateral shoulder Anterior shoulder dislocation, proximal humerus fracture Nerve / Motor / Sensation / Injury Femoral Knee extension Anterior knee Pubic rami fractures Nerve / Motor / Sensation / Injury Obturator Hip adduction Medial thigh Obturator ring fractures Nerve / Motor / Sensation / Injury Posterior tibial Toe flexion Sole of foot Knee dislocation Nerve / Motor / Sensation / Injury Superficial peroneal Ankle eversion Lateral dorsum of foot Fibular neck fracture, knee dislocation Nerve / Motor / Sensation / Injury Deep peroneal Ankle/toe dorsiflexion Dorsal first to second web space Fibular neck fracture, compartment syndrome Nerve / Motor / Sensation / Injury Sciatic nerve Ankle dorsiflexion or plantar flexion Foot Posterior hip dislocation Nerve / Motor / Sensation / Injury Superior gluteal 1. Image joint above and below suspected fracture site, and obtain orthogonal films (e.g AP and lateral views). 2. Avoid excessive manipulation as may increase soft-tissue damage and cause needless pain. 3. Periodically reassess neurovascular status, especially if immobilized or patient is sedated. 4. Immobilization including the joints above and below the fracture. 5. Surgical consultation Risk factors for tetanus [ ] Wound ≥6 hours old [ ] Contused or abraded wound [ ] ≥1 cm in depth [ ] High velocity missile [ ] Associated with thermal injury [ ] Significantly contaminated [ ] Denervated or ischemic tissue Traction splint for femoral fracture is contraindicated if: ipsilateral tibial shaft fracture Femoral fracture - immobilization: Traction splint Alternative: binding injured leg to opposite leg (à la buddy taping) Hip fracture - immobilization: Traction splint or Foam boot traction or Skin traction, keeping knee in slight flexion Knee injuries - immobilization: Long-leg plaster splint, maintaining 10° flexion to reduce tension on neurovascular structures Commercially available knee immobilizer (e.g. Zimmer) If only internal or external knee ligament, or meniscal injury, no immobilization is necessary - off-weight bearing with crutches only. Tibial fractures - immobilization: Long-leg plaster splint, maintaining 10° flexion to reduce tension on neurovascular structures Ankle fractures - immobilization: Immobilize using a well-padded posterior ankle splint to decrease pain, and avoid pressure over bony prominences. Ulnar gutter splints (Boxer splint) - indications: For fractures and sprains of the ring and small fingers. Radial gutter splints - indications: For fractures and sprains to the bones of the middle and pointer fingers. Thumb spica splint - indications: For nearly all thumb fractures, dislocations, and sprains. It is also useful for fractures to the scaphoid. Volar forearm (cockup) splints - indications: For fractures to the bones of the wrist and the index, middle, and ring fingers. Sugar-tong splints - indications: For fractures of the forearm and wrist. Elbow injuries - immobilization: Elbow injuries can be immobilized in a flexed position, either using a padded sugar-tong splint or a sling- and-swathe device. Upper arm injuries - immobilization: Splint to the body, or using a sling and swathe. Shoulder injuries - immobilization: Sling-and-swathe device or a hook-and-loop type sling