C:\Users\Kubenstein\Downloads\Acidobaza, homeostaza,JIP\s135397403392331572_p130_i22_w640.jpeg — — — — — — — — — — — Jakub Lukáč -KÚCH —Specifics of patient´s anamnesis collection and examination in trauma patients are speed, briefness, thoroughness, decisiveness and ability of improvisation. —Differences are in examination of lightly injured, severely injured or in patient who is unconscious. — —Evaluation of patients state —Exclusion or confirmation of life-endangering state —Be vigilant —Think about the worst case scenario — — — — What is anamnesis from greek ἀνά, aná, ″open″, a μνήσις, mnesis, „memory“ –freely translated as „recollection“ Anamnesis is collection of several informations about patients health condition. Division: direct /indirect —Structured anamnesis - decreases risk of forgetting important information considering your —Structured examination-friend also J — -same mechanism — —****In general, the procedure of examination method remains the same, what changes are circumstances and form/extent- different approach is required in doctors office, different in ambulance, or in E.R. —Starts with patients entrance in doctors office —Opportunity of gaining patients trust —Forget your previous patient —Go through patients documentation —Introduce yourself —Give your patient enough space for self- explanation — — — — —General sequence: 1.Current illness 2.Personal anamnesis (operations, trauma) 3.Pharmaceutic anamnesis 4.Alergies 5.Vaccination 6.Abuses — —Current illness: —What happened? —When? —Does he remember exactly what happened?Head trauma? —What are the dynamics of problem? —What was the mechanism of injury ? —What else bothers the patient? —Consumption of any substances such as drugs/alcohol? —Similar trauma in past? —..... —..... —Osobní anamnéza: —S čím se pacient léčí? Na co je sledován? —Trpí nějakým infekčním onemocněním? —Jaké úrazy prodělal v minulosti? —Zažil současné trauma již v minulosti? —Po čem má pacient (na břiše, končetinách, hlavě) jizvy? —Podrobil se pacient v minulosti operaci? Čeho? — — —Pharmaceutic anamnesis: —What does the patient take?Regular medication? —Dosage, grammage? —Anticoagulatory drugs? —Who else knows patients medication? —Does the patient have meds with him?Who can bring them? —Last documentation with current meds? —What allergies does the patient have? —What reactions occur after he takes the medicine? —Any allergies to desinfectants, plasters, food? —Ask precisely in elderly!!! -apply Tetanic anatoxin in patients vaccinated more than 5 years ago –Tetavax (i.m.) -if last vaccination happened more than 10 years ago – re-vaccinate with tetanic imunoglobulin (passive imunization – Tetabulin, Tega )(i.m. -ask for specific reactions to vaccinations in the past -ask for immunodeficient illness -let patient stay in vicinity at least for 15-30 minutes -send patient to his/her general practitioner - —Zásady fyzikálního vyšetření (vyšetření smysly): —Aspekce —Palpace —Perkuse —Auskultace —Per rectum —Olfakce —Characteristics of injuries change according to age, sex, season, etc... —Common injuries: -cuts, bites, stab wounds -fractures -dislocations -distorsions, distensions, ruptures -POLYTRAUMA -.... -..... - - — — — — — — — — — — — — — — — — — at least one organ system injury endangers patients life — — —Triage positivity – indication for transport to special facility –Trauma Centre C:\Users\Kubenstein\Desktop\polytrauma-2-638.jpg —Pozitivita: stačí pozitivní 1 položka v alespoň 1 skupině „F“ nebo „A“ nebo „M“, skupina „P“ obsahuje pomocné faktory. —F. Fyziologické ukazatele: 1. GCS < 13 2. TK syst < 90 mmHg 3. DF < 10 nebo > 29/´ —A.Anatomická poranění: 1. Pronikající kraniocerebrální 2. Nestabilní hrudní stěna 3. Pronikající hrudní poranění 4. Pronikající břišní poranění 5. Nestabilní pánevní kruh 6. Zlomeniny ³ 2 dlouhých kostí (humerus, femur, tibie) —M. Mechanizmus poranění: 1. Pád z výše > 6 m 2. Přejetí vozidlem 3. Sražení vozidlem rychlostí > 35 km/h 4. Katapultáž z vozidla 5. Zaklínění ve vozidle 6. Smrt spolujezdce —P. Pomocná kritéria: 1. Věk < 6 let 2. Věk > 60 let 3. Komorbidita kardiopulmonální C:\Users\Kubenstein\Desktop\injury-severity-score.jpg -scoring system – correlation with mortality and morbidity — —Primary survey- A,B,C,D,E principle —Secondary survey – head to toe examination —Tertiary survery- definitive examination after patients stabilisation C:\Users\Kubenstein\Desktop\abe lemons funny quotes basketball.jpg — —Knee examination: position, palpation, range of motion, inspection, manipulation, aspiration — —We ask for: time and mechanism, feeling of click, patin, dislocation, sound phenomenon, previous knee injury of same or opposite side, operations, and many more... — —We evaluate patients : age, body weight, activity, hobbies... —Meniscus injury: horizontal rotation with vertical load, partially flexed knee —Injury to collateral ligaments: force from side —Injury to cruciate ligaments: —LCA – in weight-loaded knee, rotation of femur in opposite way to tibia (deceleration with change in way) —LCP – fall on flexed knee, hyper-rotation of knee joint —At least briefly examine opposite (healthy) knee —Aspection: defiguration, antalgic position, colour, hematoma, volume,axial/non-axial position, position of patella (dislocation?) walk, range of motion —Palpation: palpation of pain, temperature, scrooping, „click-phenomenon, movement, effusion —Manipulation: functional tests of knee joint —Aspiration: in joint effusion, diagnostic/therapeutic aspiration —Palpation- palpable defect, drásoty, scrooping–jack- plane sign,ballotement of patella, milking —In case of patellar fracture suspicion– do not flex the knee !!! —Aspection– we watch patellar position in knee joint — — C:\Users\Kubenstein\Desktop\images.jpg — C:\Users\Kubenstein\Desktop\images (2).jpg —Lachmann-most realiable test – knee flex in 20-30° -(opened knee joint), we manually elicit laxity in femur to tibia movement —Pivo-shift test- knee in extension, press against the heel, internal tibial rotation, valgus pressure on knee joint– subluxation of tibia —Anterior drawer test- knee flexed in 90°,doctor sits on patients leg, finger on hamstrings, thumbs around lig. patellae, pull towards yourself - laxity — C:\Users\Kubenstein\Desktop\Anterior-Cruciate-Ligament-Injury-3.gif — C:\Users\Kubenstein\Desktop\download.jpg — C:\Users\Kubenstein\Desktop\jisakos-2018-March-3-2-89-F2.large.jpg —Diagnostic/therapeutic method– we check for colour, amount, presence of fat drops, taste... J C:\Users\Kubenstein\Desktop\A432766_1_En_10_Fig2_HTML.gif —Posterior drawer test – -quite rare —Sac test — C:\Users\Kubenstein\Desktop\32381tn.jpg C:\Users\Kubenstein\Desktop\Valgus-Stress-Test.jpg —Varus – valgus test – knee in full extension + force from the side – if laxity is present, there might be injury to both collateral and cruciated ligaments —-during light-semiflexion – probably an isolated injury to collateral ligaments —Purpose of these test is to trap both menisci in between the femur and tibia —McMurray test – fingers on knee fissure,knee in hyperflexion, we add intra/extra- rotation, while slowly extending the knee – we watch for pain, „click“ in knee —Steinmann I – knee flexion + intra/extra-rotation —Steinmann II – with increasing flection, pain moves to back —Extension test (sign)- we palpate front part of joint fissure on knee joint, then extend the knee – if pain occurs, the test ist positive —Childress test – tenderness of joint fissure when kneeling —Appley test – patient in prone position – we apply vertical force on foot, and rotate- positivity in case of pain — — C:\Users\Kubenstein\Desktop\m_1407857142.jpg — C:\Users\Kubenstein\Desktop\mos5701.ryu.fig03.jpg — C:\Users\Kubenstein\Desktop\download (1).jpg — C:\Users\Kubenstein\Desktop\mos5701.ryu.fig05.jpg —Increase in volume in matter of hours/days-sign of synovial effusion or blood collection (hemarthros) -if more than one day ( probably synovial effusion) —Hemarthros is an indication for acute ASC!!! —If patient is extremelly painful, and there is no blood in the knee, or mechanical block – examination in second session —X ray of both knee joint – for the sake of comparism —CT of the knee joint – in unclear finding or in suspicion for intraarticular fracture —MRI – in case of unclear finding —Always examine the popliteal fossa – aneurysm, ganglions, Baker´s cyst — —ULTRASOUND OF THE KNEE JOINT? YES OR NO? — — — — — — — —..............................................answer? — C:\Users\Kubenstein\Desktop\no-god-no-god-please-no-no-no-via-com-14745602.png — C:\Users\Kubenstein\Desktop\52279468.jpg —One of the most common injuries —– it affects all groups of people (children, old people, sportsmen, women, men, smokers, atheists, believers) —Character of injury: soft-tissue injury, bone injury, sprains,... — C:\Users\Kubenstein\Desktop\03_Talus_Disp_Neck_4a_540.jpg — C:\Users\Kubenstein\Desktop\no-inversion-2-with-text-new.jpg —It doesnt cause instability, unlike in dislocations —Damage to sof-tissues, ligaments — — — — C:\Users\Kubenstein\Desktop\380px-Inversion-Eversion.png C:\Users\Kubenstein\Desktop\9a382d4a218ede9d01154dd2eed733d7.jpg — C:\Users\Kubenstein\Desktop\grades of ankle sprain (1).png — C:\Users\Kubenstein\Desktop\grades-of-sprain.png —Most often an injury to lateral ligaments of the knee joint C:\Users\Kubenstein\Desktop\entorse-foulure-cheville-foulée.png —-mechanism of injury, repeatedly same injury? —-inspection —-palpation —-movement -X-ray (supinatio, pronation, AP movement of talar bone) -!!! Always compare with opposited side!!! -outer/inner ankle C:\Users\Kubenstein\Desktop\inversion-injury33-with-text-new.jpg —Ligaments of outer ankle: lig. fib-tal. Ant. (FTA, PTFA,CFA —Inner ankle: lig.Deltoideum — — C:\Users\Kubenstein\Desktop\a00150f07_resize.jpg —Squeeze test (Hopkins test): squeezing fibula agains tibia in the middle third – pain in distal part of tibio-fibular joint represents possible injury to syndesmosis —Anterior drawer test: testing integrity of the knee joint in AP way (LFTA,PTFA) —Talar tilt test: test integrity of calcaneo-fibular ligament — C:\Users\Kubenstein\Desktop\images (5).jpg C:\Users\Kubenstein\Desktop\5-Figure5-1.png —Dislocations, fractures, rotatory cuff injuries C:\Users\Kubenstein\Desktop\Shoulder-Dislocation.jpg —Anatomy: most mobile joint – small articul. surface of glenoid, huge humeral head —Static and dynamic stabilizers: —-static: labrum, capsule, lig. Transversum, lig. coracohumerale —-dynamic: m.deltoideus, rotatory cuff, tendon of m.bicip.brach. — —Diagnosis: anamnesis, aspection, palpation, Xray, neurologic examination? C:\Users\Kubenstein\Desktop\hippocrates.jpg —Hippocrates – pull in longitudinal axis– we put our heel in patients armpit/pull with towel, extremity in slight extrarotation — — — — — — — — —Artl – shoulder over back-rest of chair, extremity pulled in longitudinal axis, slight extrarotation converted to intrarotation, adduction —- firstly send patient to X-ray -control perifery, movement, circulation -- control X-ray after reposition -verbal analgetisation -always find out how old the dislocation is - careful and technically right reduction to minimize the risk of iatrogenic injury (Bankart, Hill-Sachs lesion, fractures) —Common insertion for four shoulder muscles– —anterior portion- m.subscapularis —cranial portion– m.supraspinatus —posterior portion- m.infraspinatus, m. teres minor — —40% of adult population over 60 yrs old has extensive lesions of RC — — C:\Users\Kubenstein\Desktop\04132018vldmusculoskeletalrotatorcuff.jpg —signs: pain,oedema, weakness, decreases motion,asymetry, defiguration, haematoma, atrophy, pain in SA region —Acute trauma: usually pain is located vento-lateral- lack of actie movement (impossible abduction) — —If neurological/vascular deficit or bone trauma is not present, and patient is painful – delayed examination might help —compare to opposite side C:\Users\Kubenstein\Desktop\images (7).jpg C:\Users\Kubenstein\Desktop\download (5).jpg —M.supraspinatus - empty can test – —-tenderness when elevating against the physician —-drop arm test – elevate above 90°- remove support-inability to control the fall of the arm — — — —M.subscapularis - lift-off test – place extremity behind patients back, back of the hand pressed against the lumbal part of the back, then ask the patient to move hand back to front- deficit in intra-rotation as a sign of subscap. Musle injury C:\Users\Kubenstein\Desktop\codmans1366484078165.png —M. infraspinatus/m.teres minor- rameno při tělě, loket flektován v 90°, lékař tlačí proti extrarotaci – emituje bolest při defektu C:\Users\Kubenstein\Desktop\NearBleakAegeancat-small.gif — C:\Users\Kubenstein\Desktop\chest drain- de indentified.jpg C:\Users\Kubenstein\Desktop\img-0201.jpg — C:\Users\Kubenstein\Desktop\hqdefault.jpg -according to size,- total, partial (apical,restrosternal, sheath) -present in 50% of all blunt thoracic injuries -opened, closed, tension C:\Users\Kubenstein\Desktop\pneumothorax-13-638.jpg —-anamnesis, clinical finding, absence of unilateral breaht sounds, respiratory thoracic excursions decreases, hypersonor tap on thorax — —Tension PNO: tracheal deviation, increase of jugular veins volume, cyanosis, respiratory failure/insufficiency, hypotension — —X-ray might be a luxury you dont have !!!! —Fractures of 3 or more ribs —Hemothorax —Ventilation insufficiency —Pathological breath sounds —Control X-ray – stating the dynamics —Examine the amount of TROPONIN, ECG!!! —Caudal ribs, especially on left side!!! —Block fractures – admit to hospital —Breath exercises —Regime C:\Users\Kubenstein\Desktop\IMG_20180528_073016.jpg — -common fractures -substantial social, medical, and economical problem -80% of patients older 70 yrs -young adults – due to high energy trauma incidents -risk factors, prophylaxis -- complications– pneumonia hypostatica, thrombolembolia, infectus urogenitalis, decubitus, necrosis aseptica C:\Users\Kubenstein\Desktop\cca26d28b8ad5ddd7f317865b9a9d2_jumbo.jpg —Proximal femur fractures: -fr. of femoral head --fr. of femoral neck – intra/extra- capsular — C:\Users\Kubenstein\Desktop\xr_subcaphip.jpg C:\Users\Kubenstein\Desktop\Displaced-Right-Femoral-Neck-Fracture.jpg C:\Users\Kubenstein\Desktop\images (8).jpg C:\Users\Kubenstein\Desktop\images (9).jpg —Anamnéza, aspekce, palpace -fr. hlavice femuru – antalgické postavení, extrarotace, zkrácení pouze při luxaci -- fr. krčku femuru- zkrácená, extrarotace končetiny - —Doplnění: Odběry, RTG, při pochybnostech či komplexitě poranění doplnění CT, RTG S+P při příjmu — —CAVE: Neopomenout příčinu pádu pacienta/pacientky!!! —Examination, diagnostics C:\Users\Kubenstein\Desktop\25eaa10f218dbefeb2f2760fe0937f_gallery.jpg —Definition: Shortly lasting unconsciousness, with spontaneous improval, retrograde/antegrade amnesia, without local neurological deficit -signs -diagnostics -examination procedure - —In fact, it is considered as light axonal injury —Casuistics+patients — examination C:\Users\Kubenstein\Desktop\76775_128364067323150_1915157747_n.jpg