Open Fracture Approach

– Primary Survey –

PPE: goggles, mask, gown, gloves

AIRWAY + C-SPINE:

• Talk to the patient (patent airway, conscious, in pain?)
• Ask pt to open their mouth (inspect for foreign bodies)
• Look, listen, and feel (hoarseness, cough, stridor)
• Oxygen mask
• Apply C-collar

BREATHING:

• Inspect neck + palpate trachea (edema, distended neck veins, subcutaneous emphysema)
• Expose chest: inspect, palpate, percuss, auscultate (circumferential burns, symmetrical breathing)
• Pulse oximetry
• CXR + pelvic X-ray

CIRCULATION:

• BP, pulses, capillary refill
• Insert 2 large-bore Iv cannula in ante-cubital fossa
• Draw blood for CBC, cross match, coagulation, electrolytes, chemistry, pregnancy, tox, ABGs
• Run warmed 2L crystalloids
• Examine pelvis, abdomen, limbs (for circumferential burns, swelling, fractures)
• External bleeding
• FAST

DISABILITY:

• Pupils
• GCS

EXPOSURE:

• Check temperature
• Remove clothes and fully expose the patient
• Cover the pt w\ blankets to prevent hypothermia

LOG ROLL + PR EXAM

ADJUNCTS:

• ECG
• Decompression: NGT + foley cath

 

– Secondary Survey –

1. AMPLE history:
   • Allergies
   • Medications
   • Past medical hx
   • Last meal
   • Event \ Environment:
     • Time
     • Location (closed vs open space)
     • Cause (thermal, chemical, electrical, …)
     • Associated injuries
     • What first aid did the pt get?
2. Complete head-to-toe physical examination
3. Re-evaluation of the pt
4. Specific tests (CO level > 10%)
5. Definitive treatment

 

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– Open Fracture Management –

(If at the beginning of the station the examiner says, “you’ve already done your primary and secondary surveys” -> jump straight to here!)

1. Assessment: “describe what you see”
   • Location, size, depth
   • Soft tissue, muscle, bone
   • Gustillo staging
   • Active bleeding? Stop it
   • Compartment syndrome? Fasciotomy
2. Neurovascular examination (including; pulses, pulse oximetry, doppler US)
3. Remove any obvious foreign bodies (irrigate w\ saline only if grossly contaminated)
4. Cover it w\ sterile dressing
5. Reduce + splint
6. Reassess neurovascular status
   • Know how to examine pulses and nerves in upper and lower limbs
   •  If persistently diminished pulses even after attempted realignment -> call vascular for arteriographic evaluation
7. Analgesia
8. Tetanus
9. Abx:
   • Grade I: cefazolin
   • Grade II: cefazolin + gentamicin
   • Grade III: cefazolin + gentamicin + penicillin
10. X-ray
11. Take to OR w\in 6 hrs: I&D + Ex Fix + leave wound open (cover w\ sterile dressing)
12. Take back to OR w\in 2-7 days: permanent fixation + soft tissue coverage
    • Soft tissue coverage:
      • Grades I –> secondary intention
      • Grades II + IIIA –> delayed primary (w\out tension) or split thickness skin graft
      • Grades IIIB + IIIC -> call plastic for flap coverage

 

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