docGinger Mars CCRN, MSN, NP-C
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Ginger Mars CCRN, MSN, NP-C
A truly Collaborative Approach to Care Ginger Mars CCRN, MSN, NP-C Nurse Practitioner Department of Reconstructive Plastic Surgery NYU Langone Medical Center New York Trauma 1. A serious injury or shock to the body, as from violence or an accident. 2. An emotional wound or shock that creates substantial, lasting damage to the psychological development of a person, often leading to neurosis. 3. An event or situation that causes great distress and disruption. Management of Mangled Extremity Combined expertise of: à Trauma Surgeon à Vascular Surgeon à Orthopedic Surgeon à Plastic/Reconstructive Surgeon à Nursing staff Priorities Priority of multi‐system injury: “Life over limb”. à ATLS guidelines ABC’s à If other life‐threatening injuries treatment of extremity limited to Stabilization of injured extremity Control of bleeding Is the limb salvageable? Visual & Manual Examination à Examination of wound: Vascular Pulses, color, temperature, turgor Angiography Bone Inspection, xrays, CT scans Soft‐tissue Skin, subcutaneous tissue, muscle and periosteum Nerve Motor & Sensory Questions the Surgeon Asks Does the extremity require revascularization? à Is it technically possible? Is the soft tissue defect treatable with local or free tissue transfer? Is there bone loss? à Is bone loss reconstructible? Is there nerve injury? à Is it reparable? Decisions Gustilo Fracture Score Predictive Salvage Index (PSI) Mangled extremity severity score (MESS) Nerve Injury,Ischemia, soft‐tissue injury, skeletal injury, shock & age of patient score (NISSSA) Limb Salvage Index (LSI) Hemodynamic instability Gustilo Fracture Score Developed 1976 Grades open fractures based on degree of soft tissue injury. Gustilo found that infection rates increased as amount of soft tissue coverage decreased. Amputation rates were highest for type IIIC injuries. Gustilo Fracture Score i – open fx w wound <1cm ii – open fx w wound >1cm/no soft tissue damage iii – open fx w extensive soft tissue damage iiiA – iii w adequate soft tissue coverage iiiB – iii w soft tissue loss/periosteal stripping/bone exposure iiiC – iii w arterial injury requiring repair Mangled Extremity Severity Score Developed in 1990 Provides objective criteria for choosing limb salvage or amputation Validated by multiple studies Score of 7 or > was 100% predictive of eventual amputation. MESS Skeletal soft tissue injury à Low à Medium à High à V. High energy 1 2 3 4 Limb ischemia à Near normal 1 à No pulse/dec cap refill 2 à Cool, insensate, paralyzed 3 Double if >6 hours Shock à SBP always >90 0 à Transient hypoT 1 à Persistent HypoT 2 Age (year) à <30 0 à 30‐50 1 à >50 2 Primary Operative Exploration Fracture fixation Repair vessels Tendons, nerves Debridement Wound assessment Serial debridements Non-definitive wound closure Temporary closure Definitive wound closure Second Look Soft tissue reconstruction within 48-72 hours Wound closure Major issues with LE reconstruction Full force of body weight is transposed thru the legs à Tibia provides 85% of WB of LE Hydrostatic pressure on legs increases incidence of edema, deep vein thrombosis and venous stasis problems. LE much more prone to atherosclerosis than upper extremity. Principles of Lower Extremity Reconstruction Mechanism of Injury Tissue damage is proportional to the energy transferred à MVA Transfers 50x the energy of bullet à GSW Transfers 20x the energy of a fall à Falls Proportional to height of fall & body weight Wounds appearing similar on presentation progress differently depending on mechanism of injury. Areas of soft tissue injury may initially appear viable Wounds appearing similar on presentation progress differently depending on mechanism of injury. Areas of soft tissue injury may initially appear viable Fracture Management Stable framework must be constructed prior to soft tissue repair Fracture fixation comes first à Traction à Casting/splinting à Intramedullary pinning/nailing à Internal or EXTERNAL FIXATION Internal Fixator External Fixator External Fixator with frame Lower Extremity Reconstruction Goal: To salvage the threatened limb which will be more favorable/functional than a prosthesis à If extremity cannot be salvaged, goal is to maintain maximum functional length of stump. Lower Extremity Salvage Long, complicated process à Pts must be aware of expected course, anticipated functional outcome à Psychosocial factors must be addressed prior to attempted limb salvage Although normal function rarely achieved, most patients are grateful for salvaged limb. à No long‐term study comparing Why are distal leg wounds problematic? Poor skin elasticity Frequent severe edema Venous congestion High rate of osteomyelitis Foot/ankle requires good flap durability due to friction/shear by walking and footwear. Challenges of LE Reconstruction Lengthy recovery Cost $$$$$ Abnormal ambulation Patient/Family Expectation Chronic Pain Ideal Outcome of extremity salvage is full return to functioning society. Path to full recovery is slow and may result in delayed amputation. LEAP (Lower Extremity Assessment Project) à Multicenter comparison on complex LE injuries More likely be re‐hospitalized More likely to undergo multiple operations An event or situation that causes great distress and disruption How can we help our patients cope with the trauma? Issues Patients Must Deal With Medical Psycho‐Social à Pain à Loss of Income à Nutrition à Lack of Control à Multiple surgeries à Drug/ETOH abuse à Wound care à Legal Issues à Rehabilitation à Home/Family Issues à Insurance à Mobility à Body Image Members of the Team Surgeons à Trauma à Vascular Residents/NP’s/PA’s Nurses à Orthopedic PT/OT à Reconstructive Social Work Medical Doctors Home Care à Infectious Disease Nutrition à Psychiatry Family/Friends à Internal Medicine à Physiatry Case Study 25 y/o female, no PMH Passenger mini‐bike struck by car à Injury occurred 4 years prior to presentation @ NYU à No fracture, all soft tissue injury Previous skin graft x 2 Recent osteomyelitis on IV antibiotics Single, from Bermuda; no family in NY à Works as model & bartender à + smoker (both tobacco & marijuana) Prior to admission at outside hospital Purulent drainage Surgery at outside hospital - debridement - attempted closure Dangling begins Leeches Prior to discharge home Case Study 54 y/o male without reported PMH à Dignosed with DM following injury Employed, married Crush injury with 200lb metal weight at work à Open R 1st metatarsal fx à 2nd metatarsal base fx à 3rd metatarsal neck fx à Degloving injury to dorsum of foot 2 years post op Great toe amputation Due to Osteomyelitis Ambulatory, but not back to work Case Study 15 y/o male with no PMH à Jehovah’s witness Pedestrian struck by bus à Crush injury right foot à Multiple fractures/degloving injury à Nerve injury Multiple organism + wound cultures Developed post‐injury depression à Major weight loss, anxiety Wound upon transfer Multiple debridements à MRSA/VRE from outside hospital cultures à Enterobacter, MRSA, alpha‐hemolytic strep from NYU cultures After serial debridements Ready for microvascular free flap Case Study 57 y/o male without significant PMH Employed, married with 2 children (15 & 18) Pedestrian struck by car Fractures: RLE comminuted tibial fracture Degloving RLE injury à 2 failed free flaps prior to transfer to NYU Incidental finding: GIST tumor Two months after surgery at NYU Almost 7 months after the initial accident Case Study 24 yr old female, No PMH MVA – motorbike – taxi collision Single, family lives out of state Avulsion injury right foot Absent sensation heel DP, PT pulses intact Fx of the calcaneum, lat cuneiform & cuboid No other injuries External Fixator Placed Post‐debridement The defect Heel reconstruction Latissimus Flap&Skin Graft Ambulating in 2 months Several Years later: Returns with open wound to heel
