Archive for May, 2007

MUSCULOSKELETAL TRAUMA: Head, Skull, and Face:

May 23, 2007

Skull Fractures:          

May be obvious = dented, depressed, open.
The skull is thick in front, top, back, and thin on the sides.
The most dangerous are temporal area fractures, because the middle meningeal artery may be severed causing bleeding into the skull.
There can be dramatic superficial swelling = hematoma, usually harmless.
May have “Battle’s sign” (ecchymosis behind & below the ears), which indicates basal skull fracture, very dangerous. 

The severity of the injury is deteremined by the level of consciousness.

AVPU Scale                or         Glascow Coma Scale (GCS)
A-awake                                  Eye Opening (1-4)
V-verbal                                  Motor Response (1-6)
P-pain                                      Verbal Response (1-5)
U-unresonsive             (GCS < 8 = severe head injury) 

The danger is bleeding/swelling inside the cranium that can cause increasing ICP. 

Signs of increasing ICP:
Change in Level of Consciousness:
They become irritable, angry as their LOC decreases down the AVPU scale.
Respiration rate and depth will increase, hyperventilation.
Heart Rate will slow, bradycardia, as the systolic blood pressure increases.
Blood Pressure: The systolic blood pressure will increase faster than the diastolic causing a widening of the pulse pressure (systolic – diastolic pressures).
Vomiting can occur as the ICP increases.
In severe head injuries cerebrospinal fluid (CSF) may leak out of the nose, ears, or wounds. 

Evacuate at first signs of increasing ICP.
Cover wounds with dressings, being careful not to depress fragments.
Examine spine carefully for possible injury associated with the head trauma.  

Facial Fractures:
Orbit injuries – check for “Blowout fx”, one eye cannot look up.
Le Fort fxs” of the face will have a loose hard palate or maxilla.
Fractured nose, may bleed, easy to control, cosmetic injury.
Monitor for runny nose that will not stop, can indicate leaking CSF.
Fractured jaw, teeth will not fit properly, cannot easily open/close, check TMJs.                 
Avulsed teeth, replace into socket or transport in patient’s own spit.
Greatest concern with facial injuries is the airway.

This blog is powered by the Wilderness Medicine Newsletter, now celebrating 20 years of publication. The WMN is published and distributed online six times each year by TMC Books, and subscriptions cost as little as $10 per year. To find out more, or to subscribe online, click here.

Musculoskeletal Trauma: Spinal Cord Injury Mangement:

May 2, 2007

Pre-hospital personnel are trained to treat all possible spinal cord injuries based on the Mechanism Of Injury (MOI) as well as symptoms and complaints.

It is important in the wild environment for rescuers to recognize a possible back injury based on MOI, but, it is equally important that they be able to rule out a spine injury or “clear the spine” by a proper history and physical exam in order to avoid an unnecessary litter evacuations.

SPINE EXAMINATION & EVALUATION:

1.  Mechanism of injury (MOI):
The neck, cervical vertebra, is broken by flexion and axial loading (C4/5)
The upper back, thoracic vertebra, by direct force.
The lower back, lumbar vertebra, by compression or rotation (T12/L1)

2.  Level of Consciousness (LOC):
AVPU scale: Awake, Verbal, Pain, Unconscious
Are the conscious, coherent, sober, or in any way obtunded.
Monitor every 15 minutes until stable, every 1 hour x 24 hours.
If unconscious or obtunded, treat as if injured until AWAKE & ALERT.

3.  Pain & Guarding:
Is there a “distracting” pain.
Are they complaining of pain anywhere in the vertebral column.
Is there radiating pain, numbness, paresthesias into the hands/arms.
Are they guarding or is there paravertebral muscle spasm.

4.  Tenderness (tenderness = pain on palpation):
Is there pain on palpation over the vertebra or in the vertebral muscles.

5.   Circulation, Sensation, & Motion (CSM):
Can they feel and move all four extremeties.
Can they move their neck and back,
With movement, is the back pain free,
With movement, is there any locking sensation or impairment.

TO CLEAR THE SPINE & BACK, they must be:
Awake, alert, oriented x 3, completely sober, have no distracting pain.
Be pain free and no palpable tenderness on physical exam.
No palpable step-offs or malalignments.
Have full C/S/M in all 4 extremeties (not caused by another injury).
Active range of motion without pain or locking.

Spinal Cord Injury Management:
Move patient into proper anatomical position = supine.
Maintain alignment = move as a unit when lifting or rolling.
Keep supine, unless an airway problem that requires the “Recovery position”
The most dangerous cervical motion is flexion.
The most dangerous thoracic & lumbar motion is rotation out of alignment.
Provide cervical immobilization with bulky, conforming, comfortable materials.
Keep supine on ensolite pad in bivouac.
If unconscious, monitor airway, if unable to monitor place in recovery position.
Transport on well-padded but rigid/stiff back supporting materials.

Cervical Collars:
Long-term cervical collars can become very uncomfortable.
You can improvise a very comfortable and immobilizing collar with a soft blanket or
clothing such has a pile jacket.  They provide support, comfort, and warmth.

Backboards:
Backboards or litters are only necessary for the carry-out. 
They will become very painful over time so they require extra padding especially behind the knees and in the small of the back.
Backboards are not required in litters.
 
While waiting for help to arrive simply keep the patient still and comfortable.
Remember not to flex the neck and keep the spine straight by log rolling the patient.

This blog is powered by the Wilderness Medicine Newsletter, now celebrating 20 years of publication. The WMN is published and distributed online six times each year by TMC Books, and subscriptions cost as little as $10 per year. To find out more, or to subscribe online, click here.