Postoperative Care and Rehab - Palomar Health
Transcript of Postoperative Care and Rehab - Palomar Health
Compartment syndrome case
A 16 year old male was retrieving a tire from his truck bed on the side of the highway in the pouring rain when a car careens off of the road and sandwiches the patients legs between the bumpers at freeway speed.
Compartment syndrome DEFINED
Definition: Elevated tissue pressure within a closed fascial space
• Pathogenesis
– Too much in-flow: results in edema or hemorrhage
– Decreased outflow: results in venous obstruction caused by tight dressing and/or cast.
• Reduces tissue perfusion
• Results in cell death
Compartment syndrometissue survival
• Muscle– 3-4 hours: reversible changes
– 6 hours: variable damage
– 8 hours: irreversible changes
• Nerve– 2 hours: looses nerve conduction
– 4 hours: neuropraxia
– 8 hours: irreversible changes
Physical exam• Inspection
– Swelling, skin is tight and shiny
• Motion– Active motion will be refused or unable. Must see dorsiflexion
• Palpation– Severe pain with palpation
• Alarming pain with passive stretch
Physical exam• Evaluations from nurses, therapists, and orthotech’s are CRITICAL
• If you call a doctor and say that you think the patient has compartment syndrome, the doctor will come to the hospital right away
• Error on the side of caution but please learn exam
Treatment• Remove all compressive
dressings
• Elevate the leg to level of the heart
– Helps promote in-flow to out-flow
• Fasciotomy emergently
Fat emboli syndrome• 22 year old male dirt bike rider
with bilateral femur fractures
• Pod #1 S/P ORIF
• Mental status changes, agitation
• RR 24
• O2 saturation 89
Fat emboli• Typical patient
– Men > Women
– Common age ranges: 10-40
– Long bone and pelvic fractures
• Pathogenesis (unknown)
• Mechanical theory
– Venules in bone held open by bony attachments: marrow content material passes through heart into lungs
• Biochemical Theory
– Embolized fat degrades into toxic intermediaries
Fat emboli syndrome• Symptoms
– Classic Triad
• Hypoxemia– (desaturation,
tachypnea)(96%)
• Neurologic abnormalities– (agitation)(59%)
• Petechial Rash (20-50%)
• Red-brown rash in non dependent regions:– Head, neck, anterior thorax,
axillae, subconjuctiva
Fat emboli
• Diagnosis
– Clinical tests to rule out other causes
• Treatment
– Treat the cause: fix fractures
– Supportive care: fluids and oxygen
Deep vein thrombosis15% of all hospital deaths
• Genetic risk factors:– Factor V Leiden
– Prothrombin gene mutation
• Acquired risk factors:– Advanced age
– Obesity
– History of Previous DVT
– Cancer
• Triggering Factors:– Surgery
– Injury
– Estrogen Therapy/Pregnancy
Virchows Triad: Endothelial cell activation, stasis, hypercoagulability.
Pulmonary Embolism/DVTSigns and Symptoms
• Dyspnea sudden onset
• Tachypnea >20 resp/min
• Tachycardia >100
• Pleuritic chest pain
• Cough/hemoptysis (pulmonary infarction)
• Exam:– Leg swelling
– Dilated superficial veins
– Warmth
– Tendernous along course of veins
DVT• Prevention:
– Start propholaxis as soon as possible
– When hemorrhage is controlled
• When you have a DVT:Activity:– Aissaoui N et al. A meta analysis
of bed rest verus early ambulation in the management of pulmonary embolism, deep vein thrombosis, or both. Int. J Cardiol. 2009; 137:37-41
• Sequential stockings– Theoretically can lead to PE if
DVT present– OR protocol screening– >72 hours
DVT/PE• Emboli clog pulmonary arteries
• Cause ventilation/ perfusion mismatch hypoxia
• If large enough, reduces cardiac output
• Syncope
• Sudden death
• Electromechanical dissociation
DVT screeningtrauma patients
• Despite propholaxis incidence of DVT exists in high risk patients
• Screening controversial
• Current weekly screening protocol is in place at Palomar on high risk patients
Secondary survey• Missed injuries happen
• Can be fatal
– Missed femur fractures
– Missed tibia fractures
• DO A HAND OVER HAND EXAM ON EVERY TRAUMA PATIENT.
SHOCK• Understand signs and symptoms
of SHOCK
• Body tries to maintain homeostasis
• Remove blood
• HR increases
• PVR resistance increases to maintain BP
• Renal perfusion decreases less UOP
Nurse Jackie syndrome• Painful condition
• Can be fatal
• Avoid by
– Returning all pens
– Answering calls promptly or else
– She will memorize your cell number
– Call at 2am for Colace
POST TRAUMA/POST OPPROBLEM PREVENTION
• External fixators
• Infection
• Pressure Ulcers
• Contractures
• Swelling
• Fracture Blisters
External fixation• External fixators
– Mostly all temporary spanning external fixators
• Damage Control Orthopaedics
• Preoperative Soft tissue healing ankle. Knee, and some open fractures– Rapid stabilization
– Maintains length and alignment
– Permits patient mobilization
– Allows examination and treatment of skin
• Suspended traction– Strict elevation
– Toes above nose
– Pressure relief
Pressure ulcers• External fixators
– Heavy
– Fix joints in one position leading concentrated prolonged pressure
• Overhead trapeze
– Helps with patient repositioning
• Air beds PRN
External fixationswelling
• Elevation until you an see skin wrinkles
• Ice
• Evidence of efficacy is limited
• Cochrane database
• Compression can help but not advisable in acute trauma
External fixatorpin care
• Insufficient evidence exists to recommend one regimen over another
• Weekly pin site dressing changes are enough
contractures• Lower ext
• Knee flexion contracture – Increase patellofemoral pressure
– Gait disturbance
– 3 months to get extension in distal femur fractures
• Ankle equinus– Forefoot pressure transfer
– Difficulty walking uphill
– Gait disturbance
• Upper extremity
• Fingers• Elbow and shoulder usually stay
immobilized for short term
contractures• Knee
– Position of comfort
– Knee flexed
• Ankle
– Sleep and resting position
– Plantar flexed
infections• Pre-operative antibiotics
• Open Fractures
– Post-op antibiotics 48-72 hours
• Tetanus
• Early recognition
• Intuition
• Healing wounds
– Dry
• Infected wounds or wounds with hematoma– Drainage
– Redness
– Skin edges won’t adhere
Pain management orthopaedic trauma
• Poor peri-operative pain management negatively effects outcomes– Contributes to PTSD– Lead to chronic pain– Refusal to engage in PT– Delayed return to work
• Narcotics– Bad – Many side effects
• Nerve blocks– Not a good idea in acute trauma
• Multimodal Pain Management Regimens– Ketorlac – 48 hours– Pregabalin/Gabapentin– Tylenol– Ice
Psychologyorthopaedic trauma
• Underappreciated
• PTSD
• Anxiety
• Depression
• Worse Functional Outcomes
PsychologyOrthoPaedic Trauma
• Recognize symptoms early
• Early Interventions
– Meditation
– Support Groups
– Pastoral Care