Trauma complications Notes

NOTES NOTES TRAUMA COMPLICATIONS GENERALLY, WHAT ARE THEY? PATHOLOGY & CAUSES ▪ Disorders following traumas such as fractures, penetrating trauma, crush injuries, lacerations, hemorrhage, etc. ▪ Affected tissue damage → tissue homeostasis disruption ▫ Compartment syndrome: ↑ tissue pressure → blood-flow disruption → tissue ischemia, necrosis ▫ Rhabdomyolysis: damaged tissue contents release into bloodstream SIGNS & SYMPTOMS DIAGNOSIS LAB RESULTS ▪ Complete blood count (CBC), metabolic panel, muscle enzymes, urinalysis OTHER DIAGNOSTICS ▪ Asses injury mechanism TREATMENT OTHER INTERVENTIONS ▪ Treat underlying cause ▪ Pain, bleeding, tenderness; limb-, lifethreatening conditions COMPARTMENT SYNDROME osms.it/compartment-syndrome PATHOLOGY & CAUSES ▪ ↑ pressure in closed space compromises space’s blood supply ▪ Any body compartment can be affected (most commonly legs, arms) TYPES Acute compartment syndrome ▪ Most commonly caused by fractures ▫ Other causes hemorrhage, crush injuries, vascular puncture, penetrating trauma, severe circumferential burns, intravenous drug injection, revascularization procedures, poorfitting casts ▪ Most commonly affects leg, forearm; also foot, thigh, abdomen, gluteal region ▪ Fracture → hemorrhage, edema, necrotic debris accumulation → ↑ intracompartmental pressure exceeds perfusion pressure (10–30mmHg) → arteriolar collapse → compromised blood flow Chronic compartment syndrome ▪ Repetitive muscle use/exertion during vigorous exercise; most commonly affects leg OSMOSIS.ORG 711

▪ Exercise → ↑ muscle size → ↑ intracompartmental pressure → fluid exudation into interstitial space → compromised blood flow OTHER DIAGNOSTICS Acute compartment syndrome ▪ Untreated → irreversible nerve damage (sensory deficits, paralysis); infection; tissue ischemia → necrosis; limb amputation ▪ Volkmann’s contracture ▫ Permanent affected-limb flexion contracture ▪ Rhabdomyolysis, kidney failure Pressure measurement ▪ Acute compartment syndrome (usually not required ▫ Intracompartmental pressure > 25mmHg ▫ Delta pressure < 20–30mmHg (delta pressure = diastolic blood pressure ‒ measured compartment pressure) ▪ Chronic compartment syndrome ▫ Prior to exercise (≥ 15mmHg); after one minute of exercise (≥ 30mmHg); after five minutes of exercise (≥ 20mmHg) ▫ Diagnosis of exclusion SIGNS & SYMPTOMS TREATMENT COMPLICATIONS ▪ Symptom location depends upon affected compartment Acute compartment syndrome ▪ Rapid signs, symptoms progression ▪ Early signs ▫ Severe deep pain exacerbated by movement, not relieved by analgesics; swelling, tense muscle compartment, paresthesias ▪ Late signs ▫ ↓ pulse/pulselessness, anesthesia, function loss, paralysis Chronic compartment syndrome ▪ Symptoms occur during physical activity, subside when activity stops ▫ Insidious pain, tense muscle compartment, numbness, tingling, cramping, muscle bulging, foot-drop DIAGNOSIS LAB RESULTS ▪ Lab findings evident in later stages ▪ Acute compartment syndrome ▫ ↑ creatine kinase (CK) ▫ Myoglobinuria 712 OSMOSIS.ORG SURGERY ▪ Acute compartment syndrome ▫ Medical emergency: immediate management required ▫ Fasciotomy: all affected compartments → surgical decompression ▫ Escharotomy: burns ▫ Limb amputation: severe tissue necrosis ▪ Chronic compartment syndrome ▫ Fasciotomy/fasciectomy: moderate– severe cases OTHER INTERVENTIONS ▪ Chronic compartment syndrome ▫ ↓ exercise volume, physical therapy

Chapter 120 Trauma Complications Figure 120.1 Surgeons performing a fasciotomy on the lower leg of in an individual with compartment syndrome. RHABDOMYOLYSIS osms.it/rhabdomyolysis PATHOLOGY & CAUSES ▪ Extensive muscle necrosis, muscle cell content release into bloodstream ▪ Muscle damage → ATP depletion → membrane cell pump dysfunction → ↑ intracellular Ca2+ due to ↓ efflux → Ca2+-dependent protease activation, hydroxylases, nucleases → cell death, muscle cell content release (myoglobin, CK, Ca2+) CAUSES ▪ Trauma/compression ▫ Crush injury, prolonged immobilization (comatose individuals), acute compartment syndrome, hyperthermia, severe third-degree burns, ▪ ▪ ▪ ▪ ▪ postoperative surgical trauma Metabolic/genetic factors ▫ Metabolic myopathies, glycogen storage diseases, mitochondrial disease Infections ▫ Influenza types A, B; HIV; coxsackievirus Medication ▫ Statins, colchicine, propofol Substance abuse ▫ Amphetamines, cocaine, alcohol Others ▫ Electrolyte disorders, exertional activity, snake venom, hyperkinetic states OSMOSIS.ORG 713

COMPLICATIONS ▪ Acute renal injury ▫ Massive myoglobin release exerts toxicity to renal tubules → acute tubular necrosis ▪ Acute compartment syndrome ▪ Hyperkalemia, hypocalcemia, metabolic acidosis ▪ Disseminated intravascular coagulation (DIC) ▪ Electrolyte imbalances → cardiac arrhythmias TREATMENT OTHER INTERVENTIONS ▪ IV fluids, electrolyte-imbalance correction ▪ Kidney function monitoring ▪ Severe cases ▫ Dialysis/hemofiltration SIGNS & SYMPTOMS ▪ Severity-dependent ▪ Non-specific symptoms ▫ Fever, nausea, dyspepsia, vomiting ▪ Muscle pain, weakness, affected muscle swelling ▪ Oliguria/anuria (acute renal injury) ▪ Dark urine discoloration DIAGNOSIS LAB RESULTS ▪ ↑ CK ▫ Most sensitive, nonspecific indicator ▪ Myoglobinuria ▪ Hyperuricemia ▫ Blood urea nitrogen (BUN), creatinine ▪ ↑ Lactate dehydrogenase (LDH) ▪ Electrolyte imbalances ▫ Hyperkalemia, hypocalcemia (early signs) 714 OSMOSIS.ORG Figure 120.2 Urine of an individual with rhabdomyolysis.