Muscle Skeletal Trauma - Revised

8/14/2019 Muscle Skeletal Trauma - Revised

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ScenarioScenario

You respond to a football field for anYou respond to a football field for an

accidental injury. Your patient is a 23-yearaccidental injury. Your patient is a 23-year

old male who is complaining of severe rightold male who is complaining of severe right

ankle pain. You note gross angulation andankle pain. You note gross angulation anddeformity of the ankle and carefully removedeformity of the ankle and carefully remove

his shoe to assess his distal circulation. Yourhis shoe to assess his distal circulation. Your

examination reveals that there is almost noexamination reveals that there is almost no

perfusion to his foot.perfusion to his foot.


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YOUR SCENEYOUR SCENE


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DiscussionDiscussionDiscussionDiscussion

What exam findings would lead you to believe thatWhat exam findings would lead you to believe thatperfusion to the extremity is poor?perfusion to the extremity is poor?

Describe actions that should be taken immediately toDescribe actions that should be taken immediately toimprove blood flow to the foot.improve blood flow to the foot.

How will you determine if your actions are successful?How will you determine if your actions are successful?

What anatomical structures are likely involved in thisWhat anatomical structures are likely involved in thisinjury?injury?

What exam findings would lead you to believe thatWhat exam findings would lead you to believe thatperfusion to the extremity is poor?perfusion to the extremity is poor?

Describe actions that should be taken immediately toDescribe actions that should be taken immediately to

improve blood flow to the foot.improve blood flow to the foot.

How will you determine if your actions are successful?How will you determine if your actions are successful?

What anatomical structures are likely involved in thisWhat anatomical structures are likely involved in thisinjury?injury?


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Introduction to Musculoskeletal InjuriesIntroduction to Musculoskeletal Injuries

Millions of Americans experience annually.Millions of Americans experience annually.

Multiple MOIMultiple MOI

Falls, Crashes, Violence, etcFalls, Crashes, Violence, etc Multi-system traumaMulti-system trauma


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Anatomy & Physiology of theAnatomy & Physiology of the

Musculoskeletal SystemMusculoskeletal System

Skeletal Tissue & StructureSkeletal Tissue & Structure

Protections organsProtections organs

Allows for efficient movementAllows for efficient movement Stores salts and other materials needed forStores salts and other materials needed for

metabolismmetabolism

Produces RBCsProduces RBCs


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Pathophysiology of thePathophysiology of the


Muscular InjuryMuscular Injury

ContusionContusion

Compartment SyndromeCompartment Syndrome Penetrating InjuryPenetrating Injury

FatigueFatigue

Muscle CrampMuscle Cramp Muscle SpasmMuscle Spasm

StrainStrain


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Appendicular skeleton (126 bones)Appendicular skeleton (126 bones)

Pectoral girdle (4)Pectoral girdle (4)

ClavicleClavicle

ScapulaScapula

Upper limbs (60)Upper limbs (60)

Pelvic girdle (2)Pelvic girdle (2)

Lower limbs (60)Lower limbs (60)


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Anatomy Skeletal SystemAnatomy Skeletal System

Bone ClassificationsBone Classifications

Long bonesLong bones

Short bonesShort bones

Flat bonesFlat bones

Irregular bonesIrregular bones


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Bone AgingBone Aging

Birth to Adult (18-20)Birth to Adult (18-20)

Transition from flexible to firm boneTransition from flexible to firm bone

Adult to elderly (40+)Adult to elderly (40+)

Reduction in collagen matrix and calcium saltsReduction in collagen matrix and calcium salts

Diminution of bone strengthDiminution of bone strength

Spinal curvatureSpinal curvature


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Muscular Tissue &Muscular Tissue &

StructureStructure

600 muscle groups600 muscle groups

Types of musclesTypes of muscles

SmoothSmooth

StriatedStriated

CardiacCardiac


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Skeletal MusclesSkeletal Muscles

Have striationsHave striations

Greater strengthGreater strength

Referred to as striatedReferred to as striatedmusclemuscle

Are under voluntary controlAre under voluntary control

Also called voluntaryAlso called voluntarymusclesmuscles


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Skeletal MusclesSkeletal Muscles

Conscious controlConscious control

40% of total body mass40% of total body mass

Two attachmentsTwo attachments Origin: More fixed and proximal attachmentOrigin: More fixed and proximal attachment

Insertion: More movable and distal attachmentInsertion: More movable and distal attachment

Contractions are rapid and forcefulContractions are rapid and forceful


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Smooth MusclesSmooth Muscles

Walls of hollow organsWalls of hollow organs

(e.g., urinary bladder(e.g., urinary bladder

and uterus)and uterus)

Walls of tubes (e.g.,Walls of tubes (e.g.,respiratory, digestive,respiratory, digestive,

reproductive, urinary,reproductive, urinary,

and circulatoryand circulatory

systems)systems)

Innervated byInnervated by

autonomic nervousautonomic nervous

systemsystem

Regulates size of lumenRegulates size of lumenof tubular structuresof tubular structures

Contractions strongContractions strong

and slowand slow


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Cardiac MusclesCardiac Muscles

Have strength ofHave strength ofskeletal muscle andskeletal muscle andendurance of smoothendurance of smoothmusclemuscle

Provide for movementProvide for movementof blood through theof blood through thebody on a continuousbody on a continuousbasisbasis

Respond to stimulation fromRespond to stimulation from

the nervous systemthe nervous system

Highly sensitive to lack ofHighly sensitive to lack ofoxygenoxygen

Respond to lack of oxygenRespond to lack of oxygen

with pain in that areawith pain in that area

(angina)(angina)


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Cardiac MusclesCardiac Muscles

MyocardiumMyocardium

Forms middle layer of heartForms middle layer of heart

Innervated by autonomicInnervated by autonomic

nervous system but contractsnervous system but contracts

spontaneously without anyspontaneously without any

nerve supplynerve supply

Contractions are strong andContractions are strong andrhythmicrhythmic


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TendonsTendons

Bands of connectiveBands of connectivetissuetissue

Bind muscles toBind muscles to

bonesbones Allow for power ofAllow for power of

movement across jointsmovement across joints

Supplied by sensorySupplied by sensory

fibers that extend fromfibers that extend frommuscle nervesmuscle nerves


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BursaeBursae

Flattened, closed sacs ofFlattened, closed sacs ofsynovial fluidsynovial fluid

Where tendon rubs againstWhere tendon rubs againstbone, ligament, or other tendonbone, ligament, or other tendon

Reduce frictionReduce friction

Act as shock absorberAct as shock absorber

Fill with fluid when infected orFill with fluid when infected orinjuredinjured


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CartilageCartilage

Connective tissueConnective tissue

covering epiphysiscovering epiphysis

Surface for articulationSurface for articulation

Allows for smoothAllows for smooth

movement at jointsmovement at joints
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LigamentsLigaments

Connective tissue thatConnective tissue that

crosses jointscrosses joints

Attaches bone toAttaches bone to

bonebone

Stretch more easilyStretch more easily

than tendonsthan tendons

Allow for stable rangeAllow for stable rangeof motionof motion


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FasciaFascia

Dense fibrous connective tissueDense fibrous connective tissue

Forms bands or sheetsForms bands or sheets

Covers muscles, blood vessels, and nervesCovers muscles, blood vessels, and nerves Supports and anchors organs to nearbySupports and anchors organs to nearby

structuresstructures


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Pathophysiology of thePathophysiology of the


Joint InjuryJoint Injury

SprainSprain

SubluxationSubluxation

DislocationDislocation

Bone InjuryBone Injury

Open FractureOpen Fracture

Closed FractureClosed Fracture

Hairline FractureHairline Fracture

Impacted FractureImpacted Fracture


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TERMSTERMS

SubluxationSubluxation An incomplete dislocation An incomplete dislocation

LuxationLuxation A complete dislocation A complete dislocation

CrepitusCrepitus A grating sound associated with A grating sound associated with

rubbing of bone fragments.rubbing of bone fragments. Angulated fractureAngulated fracture A broken bone where there A broken bone where there

is a departure from a straight boneis a departure from a straight bone

Fracture dislocationFracture dislocation An injury in which the joint An injury in which the joint

is dislocated and a part of the bone near the jointis dislocated and a part of the bone near the jointfracturesfractures


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Pathophysiology Mechanism ofPathophysiology Mechanism of

InjuryInjuryFive forces cause bone and joint injuryFive forces cause bone and joint injury

Direct forceDirect force

Indirect forceIndirect force

Twisting forceTwisting force

PathologicalPathological

FatigueFatigue


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Classifications of MusculoskeletalClassifications of Musculoskeletal

InjuriesInjuries

Injuries include:Injuries include:

FracturesFractures

SprainsSprains

StrainsStrains

Joint dislocationsJoint dislocations


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Musculoskeletal InjuriesMusculoskeletal Injuries

Direct traumaDirect trauma

Blunt force applied to an extremityBlunt force applied to an extremity

Indirect traumaIndirect trauma Vertical fall that produces spinal fracture distant from siteVertical fall that produces spinal fracture distant from site

of impactof impact

Pathological conditionsPathological conditions Some forms of arthritisSome forms of arthritis

MalignancyMalignancy


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Pathophysiology FracturesPathophysiology Fractures

Unstable ProximalUnstable Proximaland distal ends moveand distal ends movefreely in relationshipfreely in relationship

to each otherto each other

Open Skin is open,Open Skin is open,allowing introductionallowing introductionof bacteria, dirt, andof bacteria, dirt, and

other foreign bodiesother foreign bodies

Closed Skin is intactClosed Skin is intact

Fracture with dislocationFracture with dislocation Fracture at joint with Fracture at joint withinjury to supportinginjury to supportingstructuresstructures

Impacted JammedImpacted Jammedtogether so there is notogether so there is nomovement betweenmovement betweenproximal and distalproximal and distal

bonesbones


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FracturesFractures

Break in continuity of bone or cartilageBreak in continuity of bone or cartilage

Complete or incompleteComplete or incomplete Line of fracture through boneLine of fracture through bone

Open or closedOpen or closed Integrity of skin near fracture siteIntegrity of skin near fracture site


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Classification of FracturesClassification of Fractures

OpenOpen

ClosedClosed

ComminutedComminuted

GreenstickGreenstick

SpiralSpiral


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ImpactedImpacted


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Compartment SyndromeCompartment Syndrome

Muscle enclosed in tough non-stretchableMuscle enclosed in tough non-stretchable

membranemembrane

Pressure builds from bleedingPressure builds from bleeding

Applied to blood vessels and nervesApplied to blood vessels and nerves

Circulation impossibleCirculation impossible

Develop over a period of hours (6Ps)Develop over a period of hours (6Ps)

Gangrene (Long Term)Gangrene (Long Term)


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Joint DislocationsJoint Dislocations

Normal articulating ends of two or more bones are displacedNormal articulating ends of two or more bones are displaced

Luxation: Complete dislocationLuxation: Complete dislocation

Subluxation: Incomplete dislocationSubluxation: Incomplete dislocation Frequently dislocated jointsFrequently dislocated joints

Suspect joint dislocation when joint is deformed or does notSuspect joint dislocation when joint is deformed or does nothave normal range of motionhave normal range of motion

Dislocations can result in great damage and instabilityDislocations can result in great damage and instability


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Dislocation - AngulatedDislocation - Angulated


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SprainsSprains

Partial tearing of ligamentPartial tearing of ligament Caused by sudden twistingCaused by sudden twisting

or stretching of jointor stretching of jointbeyond normal range ofbeyond normal range ofmotionmotion

Common in ankle andCommon in ankle andkneeknee

Graded by severityGraded by severity First-degree sprainFirst-degree sprain

Second-degree sprainSecond-degree sprain Third-degree sprainThird-degree sprain
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StrainsStrains

Injury to muscle or itsInjury to muscle or itstendontendon

Overexertion orOverexertion oroverextensionoverextension

Common in back and armsCommon in back and arms May have significant lossMay have significant loss

of functionof function

Severe strains may causeSevere strains may cause

avulsion of bone fromavulsion of bone fromattachment siteattachment site


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Pathophysiology of the MusculoskeletalPathophysiology of the Musculoskeletal

SystemSystem

Inflammatory & Degenerative ConditionsInflammatory & Degenerative Conditions BursitisBursitis

TendinitisTendinitis

ArthritisArthritis OsteoarthritisOsteoarthritis

DegenerativeDegenerative

Rheumatoid ArthritisRheumatoid Arthritis

Chronic, systemic, progressive, debilitatingChronic, systemic, progressive, debilitating GoutGout

Inflammation of joints produced by accumulation of uric acidInflammation of joints produced by accumulation of uric acidcrystalscrystals


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BursitisBursitis

Inflammation of bursaInflammation of bursa

Small, fluid-filled sacSmall, fluid-filled sac

acts as cushion at aacts as cushion at a

pressure point nearpressure point nearjointsjoints

Most important bursaeMost important bursae

are around knee, elbow,are around knee, elbow,

and shoulderand shoulder


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BursitisBursitis

Bursitis is usually from:Bursitis is usually from:

PressurePressure

FrictionFriction

Injury to membranes surrounding the jointInjury to membranes surrounding the joint

TreatmentTreatment

Rest, ice, and analgesicsRest, ice, and analgesics


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TendonitisTendonitis

Inflammation of tendonInflammation of tendon Often caused by injuryOften caused by injury

Symptoms include:Symptoms include: PainPain

TendernessTenderness

Restricted movement of muscleRestricted movement of muscleattached to affected tendonattached to affected tendon

TreatmentTreatment

Nonsteroidal antiinflammatoryNonsteroidal antiinflammatorydrugs (NSAIDs)drugs (NSAIDs)

Corticosteroid medicationsCorticosteroid medications


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ArthritisArthritis

Joint inflammationJoint inflammation Pain, swelling, stiffness, and rednessPain, swelling, stiffness, and redness

Joint diseaseJoint disease Involving one or many jointsInvolving one or many joints Many causesMany causes

Varies in severityVaries in severity Mild ache and stiffnessMild ache and stiffness Severe pain and later joint deformitySevere pain and later joint deformity


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ArthritisArthritis OsteoarthritisOsteoarthritis

(degenerative arthritis)(degenerative arthritis)

most commonmost common

Pain usually managedPain usually managed

with antiinflammatorywith antiinflammatory

agentsagents


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Extremity TraumaExtremity Trauma

Signs and symptomsSigns and symptoms

Pain on palpation orPain on palpation or

movementmovement

Swelling, deformitySwelling, deformity CrepitusCrepitus

Decreased range ofDecreased range of

motionmotion

False movementFalse movement

(unnatural movement(unnatural movement

of extremity)of extremity)

Decreased or absentDecreased or absent

sensory perception orsensory perception or

circulation distal tocirculation distal to

injuryinjury


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Six "P"s of CompartmentSix "P"s of Compartment

SyndromeSyndrome

1. Pain1. Pain On palpation (tenderness)On palpation (tenderness)

On movementOn movement

2. Pallor2. Pallorpalepale skin or poor capillary refillskin or poor capillary refill3. Paresthesia3. Paresthesiapinspins and needlesand needles

sensationsensation

4. Pulses4. Pulsesdiminisheddiminished or absentor absent

5. Paralysis5. Paralysisinability to moveinability to move6. Pressure6. Pressure


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Associated ComplicationsAssociated Complications

HemorrhageHemorrhage

InstabilityInstability

Loss of tissueLoss of tissue

Simple lacerationSimple laceration

and contaminationand contamination

Interruption of bloodInterruption of blood

supplysupply

Nerve damageNerve damage

Long-term disabilityLong-term disability

Blood LossBlood Loss


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Blood LossBlood Loss

ConcernsConcerns PelvisPelvis

Per BTLS: 2 units (1Per BTLS: 2 units (1

litter) to loss oflitter) to loss ofcomplete blood volumecomplete blood volume

(5 liters) or 500 ml per(5 liters) or 500 ml per

fracturefracture

FemurFemur Per BTLS: 2 units (1Per BTLS: 2 units (1liter) per fractureliter) per fracture

RibRib

Pneumothorax (canPneumothorax (can

bleed up to 3 liters perbleed up to 3 liters perpleural cavity)pleural cavity)

Be prepared to treatBe prepared to treat

hemorrhagic shockhemorrhagic shock


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Musculoskeletal AssessmentMusculoskeletal Assessment

Four classes ofFour classes of

patientspatients

Life-/limb-threateningLife-/limb-threatening

injuries or conditionsinjuries or conditions Includes life-/limb-Includes life-/limb-

threateningthreatening

musculoskeletal traumamusculoskeletal trauma

Other life-/limb-threateningOther life-/limb-threatening

injuries and simpleinjuries and simple

musculoskeletal traumamusculoskeletal trauma

Life-/limb-threateningLife-/limb-threatening

musculoskeletal traumamusculoskeletal trauma No other life-/limb-No other life-/limb-

threatening injuriesthreatening injuries

Isolated, non-life-/limb-Isolated, non-life-/limb-

threatening injuriesthreatening injuries


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Musculoskeletal Injury AssessmentMusculoskeletal Injury Assessment

Scene Size-upScene Size-up

Initial AssessmentInitial Assessment

Categories of urgencyCategories of urgency

Life & Limb threateningLife & Limb threateninginjuryinjury

Life threatening injury andLife threatening injury andminor musculoskeletalminor musculoskeletalinjuryinjury

Non-life threateningNon-life threateninginjuries but seriousinjuries but serious

musculoskeletal injuriesmusculoskeletal injuries

Non-life threateningNon-life threateninginjuries and only isolatedinjuries and only isolatedminor musculoskeletalminor musculoskeletalinjuriesinjuries

Rapid TraumaRapid TraumaAssessmentAssessment

Focused H&PFocused H&P 6 Ps: Pain, Pallor,6 Ps: Pain, Pallor,

Paralysis, Paresthesia,Paralysis, Paresthesia,Pressure, PulsesPressure, Pulses

Detailed Physical ExamDetailed Physical Exam

Ongoing AssessmentOngoing Assessment

Sports InjurySports InjuryConsiderationConsideration

A A i t d ChA A i t d Ch


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Age-Associated ChangesAge-Associated Changes

in Bonesin Bones Water content of intervertebral disksWater content of intervertebral disks

decreasesdecreases

Increased risk of disk herniationIncreased risk of disk herniation

Loss of stature is common - 3/4Loss of stature is common - 3/4

inchinch

Bone tissue disorders shorten trunkBone tissue disorders shorten trunk

A A i t d ChA A i t d Ch


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Age-Associated ChangesAge-Associated Changes

in Bonesin Bones Vertebral column assumes arch shapeVertebral column assumes arch shape

Costal cartilages ossify, making thorax more rigidCostal cartilages ossify, making thorax more rigid

Shallow breathing due to rigid thoracic cageShallow breathing due to rigid thoracic cage

Facial contours changeFacial contours change

FracturesFractures


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Limb -Threatening InjuriesLimb -Threatening Injuries

Knee dislocationKnee dislocation

Fracture or dislocation of ankleFracture or dislocation of ankle

Subcondylar fractures of elbowSubcondylar fractures of elbowRequire rapid transportRequire rapid transport


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Musculoskeletal Injury ManagementMusculoskeletal Injury Management

Other Injury ConsiderationOther Injury Consideration

Pediatric Musculoskeletal InjuryPediatric Musculoskeletal Injury

Athletic Musculoskeletal InjuryAthletic Musculoskeletal Injury

Patient Refusals & ReferralPatient Refusals & Referral

Psychological SupportPsychological Support


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General PrinciplesGeneral Principles

Protecting Open WoundsProtecting Open Wounds

Positioning the limbPositioning the limb

Immobilizing the injuryImmobilizing the injury

Checking Neurovascular FunctionChecking Neurovascular Function

M l k l t l I j M tM l k l t l I j M t


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Musculoskeletal Injury ManagementMusculoskeletal Injury Management Splinting DevicesSplinting Devices

Rigid splintsRigid splints Formable SplintsFormable Splints

Soft SplintsSoft Splints

Traction SplintsTraction Splints

Other Splinting AidsOther Splinting Aids Vacuum SplintsVacuum Splints

Air SprintsAir Sprints

Cravats or Velcro SplintsCravats or Velcro Splints

Fracture CareFracture Care Joint CareJoint Care

Muscular & Connective Tissue CareMuscular & Connective Tissue Care


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Musculoskeletal Injury ManagementMusculoskeletal Injury Management Care for Specific FracturesCare for Specific Fractures

PelvisPelvis

Scoop StretcherScoop Stretcher

PASGPASG

Fluid ResuscitationFluid Resuscitation

FemurFemur

Traction SplintsTraction Splints

PASGPASG

Fracture versus hip doslocationFracture versus hip doslocation


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Musculoskeletal Injury ManagementMusculoskeletal Injury Management Care Specific FracturesCare Specific Fractures

Tibia/FibulaTibia/Fibula

ClavicleClavicle

Most frequently fractured bond in the bodyMost frequently fractured bond in the body

Transmitted to 1Transmitted to 1stst and 2and 2ndnd ribrib

Alert for lung injuryAlert for lung injury

HumerusHumerus

Radius/UlnaRadius/Ulna


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Musculoskeletal Injury ManagementMusculoskeletal Injury Management Care for Specific Joint InjuriesCare for Specific Joint Injuries

HipHip

KneeKnee

AnkleAnkle

FootFoot

ShoulderShoulder

ElbowElbow

Wrist/HandWrist/Hand FingerFinger

Joint

InjuriesAlert for

PMSCompromise

K Di l ti /F t ith NKnee Dislocation/Fract re ith No


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Knee Dislocation/Fracture with NoKnee Dislocation/Fracture with No

Distal PulseDistal Pulse

Gentle, steady tractionGentle, steady tractionwhile moving extremitywhile moving extremityinto normal alignmentinto normal alignment

Successful realignmentSuccessful realignment= Pop, loss of= Pop, loss ofdeformity, relief of pain,deformity, relief of pain,increased mobilityincreased mobility

Provide fullProvide full

immobilizationimmobilization

Should be attemptedShould be attemptedif transport will beif transport will begreater than 2 hoursgreater than 2 hours(even with a pulse)(even with a pulse)

Patellar dislocation Patellar dislocation Not limb threateningNot limb threatening


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Dislocation/Fracture RealignmentDislocation/Fracture Realignment

NeverNeverNever manipulate the elbow!Never manipulate the elbow!


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Soft & Connective Tissue InjuriesSoft & Connective Tissue Injuries

TendonTendon

LigamentLigament

MuscleMuscle


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ColdCold vs.vs. HotHot TherapyTherapy

ColdCold TherapyTherapy

Applied for 20 minutes periodsApplied for 20 minutes periods

First 24 hour Reduces pain and swellingFirst 24 hour Reduces pain and swelling

HotHot TherapyTherapy

After 24 hour Increases circulationAfter 24 hour Increases circulation

M l k l t l I j M tM l k l t l I j M t


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MedicationsMedications

Nitrous OxideNitrous Oxide 50% O2:50% N50% O2:50% N

Non-explosiveNon-explosive

Effects dissipate in 2-5Effects dissipate in 2-5minutesminutes

Easily diffused into airEasily diffused into airfilled spaces in body.filled spaces in body.

DoseDose

Inhaled & selfInhaled & selfadministeredadministered

OnsetOnset 1-2 minutes1-2 minutes

Not A Biotel OptionNot A Biotel Option

DiazepamDiazepam

BenzodiazepineBenzodiazepine

AntianxietyAntianxiety

AnalgesicAnalgesic

DoseDose 5-15 mg titrated5-15 mg titrated

OnsetOnset

10-15 minutes10-15 minutes

DurationDuration

15-60 minutes15-60 minutes

Counter AgentCounter Agent

FlumazenilFlumazenil

Dislocation of AcromioclavicularDislocation of Acromioclavicular


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Dislocation of AcromioclavicularDislocation of Acromioclavicular

JointJoint


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Humerus InjuryHumerus Injury

Older adults and childrenOlder adults and children

Difficult to stabilizeDifficult to stabilize

ComplicationsComplications Radial nerve damage ifRadial nerve damage if

fracture in middle or distalfracture in middle or distalportion of humeral shaftportion of humeral shaft

Humeral neck fracture mayHumeral neck fracture maycause axillary nervecause axillary nerve

damagedamage Internal hemorrhage intoInternal hemorrhage into

jointjoint

Posterior Dislocation of the ElboPosterior Dislocation of the Elbow


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Posterior Dislocation of the ElbowPosterior Dislocation of the Elbow

Joint with Marked DeformityJoint with Marked Deformity


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Severe Open Fracture of ForearmSevere Open Fracture of Forearm

Penetration of Forearm Ca sed b NailPenetration of Forearm Caused by Nail


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Penetration of Forearm Caused by NailPenetration of Forearm Caused by Nail

GunGun

Greenstick Fracture WithGreenstick Fracture With


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Greenstick Fracture WithGreenstick Fracture With

Marked DeformityMarked Deformity


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Fracture of the Distal RadiusFracture of the Distal Radius


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Hand Injury from a Motorcycle CrashHand Injury from a Motorcycle Crash


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Femur InjuryFemur Injury

Diameter of right thighDiameter of right thigh

represents increasedrepresents increased

blood volume of 2 to 3blood volume of 2 to 3

LL


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Open Fracture of the Lower LegOpen Fracture of the Lower Leg


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Foot that was Run Over by the WheelFoot that was Run Over by the Wheel


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Foot that was Run Over by the WheelFoot that was Run Over by the Wheel

of a Railway Coachof a Railway Coach



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MedicationsMedications

OxygenOxygenNitrous OxideNitrous Oxide

Morphine SulfateMorphine Sulfate

FluidsFluids

OxygenOxygen

Nitrous OxideNitrous Oxide

Morphine SulfateMorphine Sulfate

FluidsFluids


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Nitrous OxideNitrous OxideNitrous OxideNitrous Oxide

Indications:Indications:Adjunct analgesicAdjunct analgesicfor ischemic chest pain Severefor ischemic chest pain Severepain or discomfort in all patientspain or discomfort in all patientswithout contraindications.without contraindications.

Precautions:Precautions: Must be selfMust be selfadministered Check machineadministered Check machine

gauges daily for propergauges daily for properconcentrations Monitor bloodconcentrations Monitor bloodpressure and pulse oximetrypressure and pulse oximetryvalues during administrationvalues during administration

Side Effects:Side Effects:Hypotension Dizziness NauseaHypotension Dizziness Nausea

and vomitingand vomiting

ContraindicationsContraindications: Any altered: Any alteredlevel of consciousness or headlevel of consciousness or headinjury Chronic obstructiveinjury Chronic obstructivepulmonary disease Chestpulmonary disease Chesttrauma or actual/suspectedtrauma or actual/suspected

pneumothorax Abdominalpneumothorax Abdominaltrauma Major facialtrauma Major facialtrauma Acutely psychotictrauma Acutely psychoticpatients Pregnancy, other thanpatients Pregnancy, other thanactive labor Any patient (adultactive labor Any patient (adultor pediatric) unable to self-or pediatric) unable to self-

administer Decompressionadminister Decompressionsicknesssickness


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Q S O S?


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QUESTIONS?QUESTIONS?

Documents

Muscle Skeletal Trauma - Revised