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CRITICAL CARE
I . COMPARTEMEN SYNDROME
Definition : A complex symptom in which caused by elevated pressure in an enclosed
osseofacial space, can damage irreversibly the contents of the space.
Volkmanns Ischemia Volkmanns contracture
Definitive treatment: Fasciotomy, skin and fascia are left open; skin is grafted at a later
date.
Pathophysiologi:
Fat in the myellum into vascular system obliterated vascular in lungs and brain
ventilator distress & brain function disorder.
Theory:
1. Mechanical (marrow globular) : Bauss 1924.
It is caused : damage of the adipose tissue
damage of venous system
higher pressure in the bone marrow than in the venous system.
2. Biochemistry
Disorder of the stability chylomicron emulsion emboli of microglobules
3. Cathecolamine adrenal steroid pathway
stress mobilization of fat from the depot increase of FFA & triglyceride.
Base of treatment :
1. Proper and adequate of fracture management
2. Adequate shock management
3. Adequate pain control with analgetic
4. Respiratory support
5. Corticosteroid administration:
- Decrease of cerebral edema
- Anti aggregation of thrombosis
- Decrease of FFA in plasma
- Prevent decrease of pa O2
6. Restore of fluid and electrolyte balance
7. Others : - Antibiotic prophylaxis
- Digitalis
- Bronchodilator
Management:
Principal: - Prevent infection - Restore the limb functions
- Bone and soft tissue healing
Consist of:
1. Ensure the ABCs are stable
2. Complete examination include all of system organ
3. Close the wounds with the clean gauze
4. Immobilization the fracture
5. Recognition the fracture by the X-ray
6. Determined the vascular status
7. Preoperative debridement : - Fluid replacement - Anti tetanus
- Antibiotic prophylaxis
- Debridement & Irrigation
8. Reposition & fixation to secure the stability
9. Closure the wounds:
- Grade I & II Primary closure
- Grade III Delayed primary closure (3 5 days) or early free-flap
10. Early bone grafting if necessary (1 6 weeks)
11. Recognize and treat the complications adequately
Note :
If there is with vascular involvement :
< 4 hours : Stabilization fracture first than vascular repair
> 4 hours : repair vascular first than stabilize the fracture
To determine the vascular by: clinical / Doppler / arteriography
Muscle fibers edema 4 8 H
Muscle fibers die 6 12 H
IV. MULTIPLE TRAUMA
Definition: Patients with more than one organ system had been injured and they
influenced to life threatening.
Steps of ATLS (INITIAL ASSESMENT)
1. Preparation: pre hospital & in hospital phase
2. Triage: sorting the patients
3. Primary survey:
- Airway maintenance with cervical spine control. Alert
Verbal
- Breathing and ventilation Pain
Unresponsive
- Circulation with hemorrhage control.
- Disability and neurological status : - Level of conscious: AVPU
- Pupil size & reaction
3. Oxygenation
- Evaluation: Blood pressure, pulses, Respiratory rate
- Evaluation: breathing sound, heart beat sound.
if none * Tension pneumothorax: contraventile
* Hematothorax : chest tube
* Cardiac tamponade : pericardiocentesis4. IV line
administration:
- 2 (two) IV line with big and short needle, by taking blood sample (cross match,
pregnancy test for female, others)
- Bolus 1-2 liters of ringer lactate
- If need with venasection
5. Re-evaluation: I P P A, completely with:
- ECG observation
- Pulse oxymetry
- RT DC & MS
- Evaluate: AVPU and pupils
6. Open all of dress (undress), find the all source of external bleeding,
Stop the bleeding with clean / sterile gauze.
Remember, preventing iatrogenic hypothermia by coverage the patients.
7. Re-evaluation again : - All the vital sign
- Blood gas analysis
- Urine output
V. ACUTE HEMATOGENOUS OSTEOMYELITIS
Definition : acute infection of the bone (metaphysis) & marrow
Cause : - Staphylococcus aureus !!!
- Streptococcus pyogenes / pneumoniae (infant)
- Haemophylus influenza (child < 4 years)
- E.coli, Pseudomonas, Proteus (gram neg)
- Bactericides (an aerobe)
- Salmonella
Predisposing Factor:
- DM, malnutrition, drug addict, very elderly, debility
- Immunosuppressive therapy, immunodeficiency.
Site or infection: metaphysis area because:
- Area of growth cells
- Rich of vascular
- Thin cortex
- Slow blood flow
5. RESOLUTION
- Sclerosis and thickening of the bone
- Remodeling
Stage of clinical (Trueta, 1968)
* Stage I : process in the bone : tenderness
* Stage II : pus in medullar cavity & sub periosteal malaise, fever, pain, headache
* Stage III : pus in the soft tissue (abscess) with inflammation sign (calor, dolor, tumor,
rubor, functionless)
Sign & Symptom :
- Pain, malaise, fever, tenderness
- Local redness, warmth
- Swelling / edema
- Restrict of joint motions (refuse to move the limb)
- Lymphadenopathy
Treatment:
A. General supportive treatment: - IV line (dehydration?)
- Analgetic
B. Immobilization affected part: - splintage
- Skin traction
C. Eradication infection: Antibiotic, depend on culture & sensitivity test
Adult / child: - Flucloxacillin 3 4 days ( IV ) continued with 3 6 weeks (PO)
< 4 years: Cephalosporin 2nd generation Amoxicillin & clavulanic acid
D. Drainage
Must be done, if in 36 hours without better improvement with antibiotic. (Monitoring
LED, temperature, CRP). Drained by open operation under GA (drilling into the
medullar cavity)
Complications: - Suppurative arthritis
- Altered bone growth
- Chronic osteomyellitis
Bacterial growth
(Clostridia myositis)
Local edema
Tissue destruction
Thrombosis local vessels
Gas produced (H2S & CO2)
Distant spread
(More edema & more thrombosis)
32 48 hours
Late state