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Toronto Notes 2019 Traumatology
Investigations
• urethra:retrogradeurethrography
• bladder:U/A,CTscan,urethrogram±retrogradecystoscopy±cystogram(distendedbladder+post-void) • ureter:retrogradeureterogram
• renal:CTscan(best,ifhemodynamicallystable),intravenouspyelogram
Management
• urologyconsult • renal
■ minor injuries: conservative management
◆ bedrest, hydration, analgesia, antibiotics
■ major injuries: admit
◆ conservative management with frequent reassessments, serial U/A ± re-imaging
◆ surgical repair (exploration, nephrectomy): hemodynamically unstable or continuing to bleed
>48 h, major urine extravasation, renal pedicle injury, all penetrating wounds and major • ureter lacerations,infections,renalarterythrombosis
■ ureterouretostomy • bladder
■ extraperitoneal
◆ minor rupture: Foley drainage x 10-14 d ◆ major rupture: surgical repair
■ intraperitoneal
◆ drain abdomen and surgical repair
• urethra
■ anterior: conservative, if cannot void, Foley or suprapubic cystostomy and antibiotics ■ posterior: suprapubic cystostomy (avoid catheterization) ± surgical repair
Orthopedic Injuries
• seeOrthopedics(seeShoulderOR11,KneeOR32,WristOR21,AnkleOR38)
Goals of ED Treatment
• diagnosepotentiallylife/limbthreateninginjuries
• reduceandimmobilizefractures(cast/splint)asappropriate • provideadequatepainrelief
• arrangeproperfollow-upifnecessary
History
• useSAMPLE,mechanismofinjurymaybeveryimportant
Physical Exam
• look(inspection):“SEADS”swelling,erythema,atrophy,deformity,andskinchanges(e.g.bruises)
• feel(palpation):alljoints/bonesforlocaltenderness,swelling,warmth,crepitus,jointeffusions,and
subtle deformity
• move: joints affected plus those above and below injury – active ROM preferred to passive
• neurovascularstatus:distaltoinjury(beforeandafterreduction)
LIFE- AND LIMB-THREATENING INJURIES
Table 10. Life- and Limb-Threatening Orthopedic Injuries
Emergency Medicine ER15
In the case of gross hematuria, the GU system is investigated from distal to proximal (i.e. urethrogram,cystogram,etc.)
Description of Fractures
SOLARTAT
Site
Open vs. closed
Length
Articular
Rotation
Translation Alignment/Angulation Type e.g. Salter-Harris, etc.
Life-Threatening Injuries (usually blood loss)
Major pelvic fractures
Traumatic amputations
Massive long bone injuries and associated fat emboli syndrome Vascular injury proximal to knee/elbow
Open Fractures
Limb-Threatening Injuries (usually interruption of blood supply)
Fracture/dislocation of ankle (talar AVN) Crush injuries
Compartment syndrome
Open fractures
Dislocations of knee/hip Fractures above knee/elbow
• communicationbetweenfracturesiteandexternalsurfaceofskin–increasedriskofosteomyelitis
• removegrossdebris,irrigate,coverwithsteriledressing–formalirrigationanddebridementoftendone
in the OR
• controlbleedingwithpressure(noclamping)
• splint
• antibiotics(1stgenerationcephalosporinandaminoglycoside)andtetanusprophylaxis
• standardofcareistosecuredefinitivesurgicalmanagementwithin6h,timetosurgerymayvaryfrom
case-to-case
When Dealing with an Open Fracture, Remember “STAND”
Splint
Tetanus prophylaxis
Antibiotics
Neurovascular status (before and after) Dressings (to cover wound)