emt wk 3

outer layer of bone

cortical/compact bone

core of long flat bones and found under the cortical bone at the end of long bones (and purpose)

spongy bone - impact absorption & houses red bone marrow (where red blood cells are made)

center of long bone shaft + its purpose

medullary cavity = holds/stores bone yellow marrow

near end of bone and purpose

epiphyseal line = location of growth plates (children)

different types of bones (human body)

• long bones (long shaft and rounded heads) —> ex) femur, humerus, etc

• short bones (cube-ish shaped with thin layer of compact bone surrounding spongy interior) —> ex) wrist/ankles

• flat bones (thin and generally curved) —> ex) sternum and skull

• sesamoid (bones embedded into tendons) —> ex) patella

• irregular (irregular shape/complicated) —> ex) spine/pelvis

what are joints and what are the types?

joints: where bones come together

• fibrous (held together w dense and connective tissue) - no mvmt

• cartilaginous (connected by cartilage w some movement)

• synovial (capsule of synovial fluid and allowing for movement — have articular cartilage @ end of bone making up the joint) = most common joint type (knees, elbows, shoulders, etc)

types of synovial joints

types based on movement they allow:

• gliding joints

• hinge joints

• pivot joints

• saddle joints

• ball and socket joints

cartilage

firm, flexible connective tissue that lines the end of bones + provides shape/support in other areas of body

ligament (can it regenerate?)

fibrous connective tissue connecting bone to bone & provide support for joints

(do not regenerate if damaged)

tendons (can it regenerate?)

fibrous connective tissue connecting muscle to bone

(can heal slowly from damage)

fascia

bands/sheets of connective tissues surrounding muscles & other internal organs — compartments are sections in body containing muscles and nerves which r surrounded by fascia

what is a fracture?

broken bone

what is disclocation?

joint disruption so bone ends no longer are in contact

subluxation

incomplete disruption of a joint

sprain

injury (stretching/tearing) to ligaments, articular capsule, synovial membrane, or tendons (only those crossing joints)

strain

stretching/tearing of muscle (and tendons) causing pain and swelling

sprain vs strain

sprain = stretching/tearing ligaments (bone to bone)

strain = stretching/tearing muscle or tendons (muscle to bone)

amputation

severing extremity from body

open vs closed fractures

open fractures = overlying skin is broken (bleeding, route for infection)

closed = overlying skin is together

displaced vs non-displaced fractures

displaced = moved from normal position and produce deformity by shortening, rotation, or angulation

non-displaced = no deformity

types of fractures (can be displaced or not)

• transverse

• oblique

• spiral

• comminuted

• avulsion

• impacted

• fissure

• greenstick

transverse fracture

straight across bone

oblique fracture

angular

spiral fracture

broken from twisting

comminuted fracture

break into several pieces

avulsion fractures

fragment of bone is separated from main mass

impacted fractures

bone fragments are driven into each other

incomplete fractures

bone is still partially joined

pathological fractures

caused by weakness/diseased bone (from underlying condition)

dislocation

may or may not pop back in (depending on patient’s movement) & may have deformity

findings:

• swelling

• tenderness when palpated

• locked joint

• potential impaired circulation or numbness

• can also damage supporting tissues and joint capsules too

sprains symptoms

(similar to non-displaced fractures)

• point tenderness over injured ligaments

• swelling and ecchymosis (discoloration from bruising)

• pain preventing normal joint movement

• joint instability (too much motion)

strain

“pulled muscle”

violent muscle contraction or excessive stretching

no deformity, minor swelling

possible increased pain w passive movement (when third party moves body part)

Compartment Syndrome

SYMPTOMS: pain out of proportion to findings during physical exam, muscle weakness, “pins and needles”, pallor, numbness, & pain is aggravated by passive stretch of muscles in compartment

develop within 3-48 hrs

from increased pressure in compartment containing muscles/nerves —> fractures, crush injuries, burns can cause

fascia does NOT stretch well —> minor bleeding can still raise pressure in compartments and begin process —> restricted blood flow to tissues —> permanent damage

what to do if patient has orthopedic emergency

• splint patient

• take to trauma center for surgical intervention

• assess CSM on extremities (before AND after apply splint)

• apply cold packs to reduce swelling

what to do when about to splint

expose entire area for assessment

splint in position of deformity IF…

distal pulses are present and there are no life threats

what to do if lose distal pulse when splint

apply some manual traction to realign (put injury in correct anatomical position) —> splint!

what/where to immobilize when fracture on shaft of long bone

immobilize JOINTS above and below bone

what/where to immobilize when injury is on/around joint

immobilize BONES above and below joint

hazards of improper splinting

• nerve, tissue, blood vessel compression

• reduced distal circulation

• injury aggravation

• nerve, tissue, blood vessel, muscle injury bc of excessive mvmt of bone/joint

• delayed transport of patient w life threatening injuries

why do you usually not drive code 3 for musculoskeletal injuries

dangerous + aggravate pain from injury

what is one of only times u drive code 3 w musculoskeletal injuries?

pulseless limb (even after manual traction)

treatment for clavicle/scapula injuries

splint w sling and swathe (make sure hand is NOT dangling and it is in position of function (curved))

acromioclavicular (AC) joint injury

AC joint connects outer end of clavicle and acromion process (of scapula) —> ligament tear

• AC separation (“AC separation”) = common in football/hockey when fall/land on point of shoulder

—> can lead to end of clavicle sticking out + tenderness over joint

clavicle/shoulder injury —> sling and swathe!

shoulder dislocations

(glenohumeral joint = where head of humerus meets glenoid fossa of scapula)

when head of humerus is no longer in correct anatomical position in regards to the glenoid fossa at the glenohumoral joint

symptoms:

• significant pain and guarding

• humeral head can protrude anteriorly (usually shoulder dislocations are anterior)

• potential numbness on outer part of shoulder and maybe hand (from axillary nerve compression)

treat w SLING AND SWATHE

what to do if arm cannot be brought to chest when trying to splint them (shoulder dislocation)?

pad space between arm and chest w pillow or roll of blankets

humerus fracture

can happen anywhere along humerus

• elders = increased likelihood of proximal fractures from a fall

• youth = increased likelihood of midshaft fracture from violent injury

treat w SLING AND SWATHE

elbow injuries

distal fractures (more common in children) —> can cause deformity and severe swelling

• locked joint w pain (esp if try moving)

—> immobilize above and below injury + apply sling and swathe + pad for comfort

forearm fracture

common in very young and old — esp if fall onto outstretched arms

—> splint (immobilize wrist) & sling (patient comfort)

wrist/hand injuries

splint w forearm and hand immobilized in a sling for comfort

pelvic fractures

very painful + life-threatening, can lead to severe blood loss, maybe deformity

—> use pelvic binder (or sturdy pants)

hip dislocation

hip is usually very stable, so takes a lot to dislocate (MVC, fall into a standing position)

• hip dislocation is usually posterior —> can compress sciatic nerve —> impaired leg/foot sensation

signs:

• severe hip pain

• strong resistance to joint mvmt

• tenderness in lateral/posterior aspect (when palpate)

• femoral head can be felt/palpated in muscles of buttock

(unlike hip fracture) dislocation could lead to internal rotation

what to do when hip dislocation

—> do NOT try to reduce dislocated hip

• splint dislocation

• place patient supine on backboard

• support affected limb w pillows

• secure limb to backboard w long straps

more common “hip” fracture

proximal femur fracture (more common in elderly)

• shortened/externally rotated lower limb

—> assess pelvis to rule out pelvic injuries

femoral shaft fracture

can be anywhere on shaft —> pain, deformity, angulation, muscle spasms and external rotation @ fracture site

up to 1 L of blood loss —> can present w shock symptoms (just from upper leg alone)

risk of vascular/nerve damage if bone fragments injure vessels/nerves

what to do when mid shaft femur fractures

can use traction splint (traction down femur by constantly pulling on ankle and pushing against pelvis) to reduce pain and decrease bleeding

when are you unable to use traction splints

if have or suspect knee, hip, pelvis, lower leg, foot, ankle injuries

—> also (depending on area), contraindication when have open mid shaft fracture bc concern for infection

injuries of knee ligaments

—> stable femur and tibia w splint & use padding (comfort) during transport

—> (if LOCKED knee) use blankets/pillows under knee when in stretcher

knee dislocation

check CSM bc increased risk of damaging popliteal artery by compression or laceration —> apply traction

dislocated patella

usually lateral displacement (bulge) & lack of patella in correct position

—> splint injury (under a lot of tension so might relocate during splinting)

tibia/fibula fractures

tibia has higher likehood of creating open fracture (breaking through skin) bc so close to surface

can have knee, mid shaft, or ankle pain

what to do differently when splint ankle/foot injury

leave toes exposed to assess for circulation (CSM)

what is orbit and what is its purpose?

round bony structure/socket that eye lies in —> help protect eye from injury

6 bones form major structure of face

• nasal bone

• 2 maxillae (upper jawbones)

• 2 zygomas (cheek bones)

• mandible (jawbone)

the exposed part of the ear is comprised of __ covered by skin

cartilage

what is ur pinna?

external, visible part of the ear

what r ur earlobes?

fleshy portion under ur ears

what is ur tragus?

small, rounded, fleshy bulge (cartilage flap) immediately anterior to ear canal (think of what u push when trying to not hear smth)

what is ur mastoid process?

prominent bony mass ~1cm behind external ear opening

motion of the mandible occurs @ _____

temporomandibular joint (hinge joint)

angle of the mandible

below ear and anterior to mastoid process

major blood vessels in the neck

carotid arteries + jugular veins

globe of eye keeps its shape bc of ___

the pressure of fluid within its two chambers:

• vitreous humor = clear, jellylike fluid near BACK of eye

• aqueous humor = clear, watery fluid in front of eye lens

penetrating trauma to eye can cause __ humor to leak out

aqueous —> but can make more w time

NOTE: aqueous humor is fluid in the anterior chamber (in front of lens) vs vitreous humor is fluid in the posterior chamber (behind the lens)

retina is connected to the ___

optic nerve

conjunctiva

delicate membrane that covers surface of eye

sclera

white part of eye (tough, fibrous tissue extending over globe to keep eye structure and protect layers/stuctures underneath

lacrimal glands

(tear glands) —> keep conjunctiva and inner surface of eyelids MOIST

how does blinking work?

• sweeps fluid from lacrimal glands to clean eye surface

• tears drain onto inner side of eye through 2 lacrimal ducts into nasal cavity

cornea

clear transparent membrane in front of eye —> allows light to enter

pupil

eye opening which allows light into back of the eye

iris

circular muscle and surrounding tissues behind cornea (adjusts size of pupil to control how much light gets in)

iris is pigmented (diff eye colors!)

lens

behind iris and focuses image onto retina

the brain interprets ___ as vision

optic nerve impulses

possible injuries to face and neck

primarily around airway obstruction:

• bleeding in mouth —> can clot

• aspirating vomit = obstruction

• dislodged teeth or dentures

• swelling from soft tissue

maybe also brain/spine injuries

soft tissue injuries (face/neck)

face/neck = very vascular, so…

• more swelling than in other parts of body

• penetrating trauma —> severe bleeding

• blunt injuries —> vessel wall break —> hematoma (bruising)

general head/neck injuries management

priority: maintain open airway

recovery position to empty airway

→ if on backboard, can tilt to one side to allow blood/vomit to drain out of airway

control external bleeding w direct pressure (BUT not too much pressure if possible skull fracture)

CALL ALS

what to do w avulsed tissue

(avulsed = detached tissue)

if still attached to body —> put avulsed tissue in “normal” position if possible and cover with DRY, STERILE DRESSING

if separated from body —> wrap avulsed tissue in sterile dressing, put in plastic bag, keep it COOL (do NOT put directly on ice) —> (can maybe still graft tissue onto body later)

facial fractures (and when to suspect)

suspect if sustained direct blow to nose or mouth

signs/symptoms:

• bleeding in mouth

• cannot swallow or talk

• loose/absent teeth

• loose/movable bone fragments

• patient says closing jaw “just doesn’t feel right” — irregular bite

—> take spinal precautions (assess for c-spine / brain injuries) bc need a lot of force to fracture these bones

—> TAKE OFF JEWELRY BC POSSIBLE SWELLING (esp in first few hours-day)

mandible, maxillary and dental injuries

(more common - usually from MVCs, assaults)

if suspected mandible fracture (since need a lot of force to fracture mandible) —> also check if other facial trauma and/or c-spine injuries

signs/symptoms:

• facial swelling

• instability when feel facial bones

• misaligned/fractured/avulsed teeth

dental injuries

prevent tooth from becoming airway obstruction —> remove loose dentures/dental bridges

maintain direct pressure to stop bleeding (tooth being violently displaced out of socket)

handle teeth by the CROWN, not the ROOT

put avulsed teeth into sterile saline (bring when transport)

notify facility abt avulsed tooth bc re-implantation is necessary within narrow time window (20 min -1 hr after trauma)

cheek injuries (think impaled object + bleeding treatment)

if impaled object in cheek causes airway compromise —> RARE instance where can remove object

if bleeding cheek —> provide direct pressure from inside AND outside (make sure not too much gauze so no airway obstruction)

what to do for eye injury

do a proper eye exam:

• check if entire circle of iris is visible

• check for PERRL (pupils are equal, round, react equally when exposed to light)

• check if both eyes move together (when follow moving finger)

• check if eye discoloration (eye, iris bleeding, redness)

• check if any obvious foreign matter

• asking/assessing patient abt clarity of vision or sensitivity to light

• check if any previous eye surgeries/injuries

foreign objects in eye

(even a grain of sand) can cause redness and inflammation of the conjunctiva —> conjunctivitis

—> patient might feel like object is still there after remove bc scratched eye (possibility)

patient difficulty keeping eyes open bc bright light irritates

if SMALL object —> use SALINE to flush it out (start from inner corner and flush outward - to prevent get in other eye)

if LARGE object —> can NOT take out so stabilize (bandage around BOTH EYES —> to prevent other eye from moving - eyes move together)

chemical eye burns

chemical —> flush eyes out with water or sterile saline (inside to outside)

—> send saline through nasal cannula (lie over nose bridge) bc can drip into both eyes and flush out

—> force patient’s eyelids open

if alkaline solution or strong acid, irrigate eyes >=20 minutes bc can penetrate eyes deeply

thermal eye burns

can burn eyelid off (bc ppl close eyes from reflex)

—> cover BOTH eyes with moist, sterile dressing

—> eye shield (prevent as much light getting into eyes as possible)

infrared rays, sunlight CAN damage retina (permanent damage)

intense lights CAN cause superficial burns (like sunburn but to eye)

1. stop burn

2. cover eyes

3. prevent light from entering

4. get to higher level of care

eye laceration

if laceration on eyelid —> direct pressure (but not too hard)

if laceration on globe —> do NOT put direct pressure on eye

• can hinder blood supply to back of eye —> permanently damage retina

• can squeeze out more fluid —> make worse

—> put them SUPINE (minimize fluid loss) + moist, sterile dressing (cover BOTH) + protective shield

blunt trauma to eye

can cause “black eye” or severely damaged globe (range)

• orbit fracture (ex - blowout fracture = lose tension around eye from broken bone and no longer support eye)

• fractured bones can trap eyes so no move right, double vision, vision issues

• retinal detachment (cloudy vision, flashing lights) —> cover both eyes, send to hospital

hyphema - bleeding into anterior chamber of eye —> can impair vision = LIFE-THREATENING

iif eye is displaced out of socket —» do NOT move back into place (LEAVE it there, cover BOTH eyes w moist/sterile dressing, transport as fast as possible, keep SUPINE)

eye injuries AFTER head injury (aka how to tell if head injury by looking at eyes (??))

findings that suggest possibility of head injury:

• anisocoria (unequal pupil sizes)

• eyes pointing in different directions

• eyes cannot follow moving finger

• bleeding under conjunctiva (obscure sclera)

• protrusion/bulging of eye

if unconscious patients —> keep eyes closed so no dry up

blast injury

foreign objects —> stabilize, cover BOTH eyes, transport

do NOT force eyelids open if swelling/hematoma bc can increase pressure

give CLEAR, VERBAL directions