1- Eval of the Trauma Patient Flashcards
Immediate trauma mortality is defined as death at the scene due to what?
Disruption of the great vessels, heart, lungs, or moajor body cavity
Early trauma mortality is defined as death how long following injury?
1-4 hours
Early trauma mortality (1-4 hours post injury) is usually a result of what?
CV or pulmonary collapse
Late trauma mortality is defined as death how long following injury?
Days to weeks (less common)
Late trauma mortality (days to weeks post injury) is primarily due to what?
Sepsis and multiple organ failure
What is the most common cause of preventable mortality?
Hermorrhage
What are the top two causes of trauma mortality?
CNS injury, exsangunation/hemorrhage
What is the standard of care for trauma patients and the standardized protocol for pt eval?
Advanced Trauma Life Support (ATLS)
What does SALT stand for? (SALT mass casualty triage algorithm)
Sort, Assess, Lifesaving Interventions, Treatment/Transport
In Step 1 of SALT, you sort pt based on severity of sx. In what order would you assess pts?
1st = still/ obvious life threat, 2nd= purposeful movement, 3rd= walk
What life saving interventions might be used as part of SALT?
Control major hemorrhage, open and position airway (if child given 2 rescue breaths), chest decompression
What level trauma center provides highest level of care, leaders in research, clinical care and education?
Level 1
What level trauma center provides definitive care in a wide range of complex traumatic patients?
Level 2
What level trauma center provides initial stabilization and tx. and may care for uncomplicated trauma pts?
Level 3
What level trauma center provides initial stabilization and transfers all trauma patients for definitive care?
Level 4/5
Trauma triage utilizes what? (3)
SALT, tags, trauma center levels
Stabilizing a trauma pt, identifying life threatening injuries/ initiating adequate supportive therapy, rapidly organizing definitive therapy/ transfers to facility for definitive txs all fall under what evaluation of a trauma pt?
Initial evaluation/ primary survey
What does ABCDE stand for? (part of primary eval)
Airway, Breathing, Circulation, Disability, Exposure
What is a FAST exam? (part of primary eval)
Focused Assessment with Sonography for Trauma
What is included in A-airway? (primary eval)
Assess for signs of respiratory distress and protection of airway
What is included in B-breathing? (primary eval)
Maintain adequate oxygenation and ventilation
What is included in C-circulation? (primary eval)
Control hemorrhage, maintain adequate end-organ perfusion
What is included in D-disability? (primary eval)
Neuro eval AVPU (alert, verbal, pain, unresponsive), eyes, motor, GCS. Search for all possible injuries while preventing hypothermia
What is included in E-exposure? (primary eval)
Undress and redress patient, search for possible injuries/ prevent hypothermia
Airway inspect of an unconscious patient should include what?
Protect airway immediately, C-spine protection
Suction of secretions, chin lift/ jaw thrust, nasopharyngeal airway, and definitive airway are all examples of what?
Maintenance of airway patency as part of an airway intervention
Oxygen, NRBM, bag valve mask, and establishing a definitive airway are all examples of what?
Airway support as part of an airway intervention
What are the 2 types of definitive airway interventions?
Endotracheal intubation (protects airway) and surgical crichothyroidotomy
Oropharyngeal, laryngeal mask, and nasopharyngeal airways are all adjuncts, but not definitive txs. Why?
Pt can still vomit, choke, and aspirate
What should be done for all blunt trauma patients?
Cervical spine immobilization (via cervical collar or manual in-line stabilization)
What should be attempted before a cricothyroidetomy?
ET intubation
A successful croithyroidotomy should later be converted to what?
Orotracheal tube, tracheostomy
What 3 things are considered immediate threats to life when evaluating B-breathing?
Tension pneumothorax, massive hemothorax, cardiac tamponade
In pts w/ unstable breathing what imaging is recommended?
CXR
The following are signs of what and should be presumptively treated? Hypotension, dyspnea, ipsilateral decreased breath sounds
Pneumothorax
What is the tx for a PTX (pneumothorax)?
Needle decompression [4th or 5th (adults) or 2nd intercostal space in mid-axillary line], immediately followed by tube thoracostomy
What should be anticipated in an unstable trauma patient and what should be performed)
Hemothorax and pneumothorax, should perform tube thoracostomy
What is determined and placed at time of circulation assessment?
Blood type and cross match. IV catheters placed (16 guage or larger)
The following are used to control what type of hemorrhage? Manual pressure, proximal compression, elevation, hemostatic agents
Arterial
Direct pressure is used to control what type of hemorrhage?
Venous
When do you perform an emergency throactomoy?
Pt w/o central pusles
What is the base deficit for a class I hemorrhage and is there a need for blood?
0 to -2, monitor need for blood
What is the base deficit for a class II hemorrhage and is there a need for blood?
-2 to -6, possible need for blood
What is the base deficit for a class III hemorrhage and is there a need for blood?
-6 to -10, yes need for blood
What is the base deficit for a class IV hemorrhage and is there a need for blood?
-10 or less, massive transfusion needed
What is the TX for shock?
Step down if pt continues to be in shock:
1L crystalloids NS or LR →
1-2 units O Neg PRBCs →
MTP (massive transfusion protocol)
What is the ratio for PRBC: FFP: platelets with MTP (massive transfusion protocol)?
1:1:1 ratio
A rapid infuser works at what rate?
Over 1000 mL/min
What is evaluated as part of the disability/ neuro eval?
LOC (GCS score), pupils, motor/sensory
When is imaging performed as part of the disability/ neuro eval?
Motor deficit, spinal cord sensory level
For GCS ≤ 8 what do you need to do?
Intubate
What is the scale for GCS?
3-15 points (Eyes 4, Verbal response 5, Motor response 6)
What are commonly missed regions as part of the exposure full body eval?
Scalp, axillary folds, perineum, abd folds
The following are given to a pt under what circumstances? Warm blankets, warm IV fluids and blood, external warming devices, warm room
Hypothermia, < 35C
How is a pt to be evaluated as part of the exposure eval (primary survey)?
Completely undressed
What is considered the lethal triad of trauma/ shock?
Hypothermia, coagulopathy, acidosis
What is the treatment for hypothermia?
Remove wet clothing and warm pt
What is the treatment for coagulopathy?
Permissive hypotension and give blood products > crystalloids
What is the treatment for acidosis?
Stop bleeding and treat shock
A head to toe exam, detailed hx, thorough PE, adjunct studies (avoiding tests you can’t do anything about) is part of what?
Secondary survey
What is AMPLLE history as part of the secondary trauma survey?
Allergies, Meds (blood thinners?), PMH, Last meal, LMP (pregnant?), Events that led to trauma
What are the two broad catergories of trauma as part of hx for mechanism related info?
Blunt trauma vs penetrating trauma
In reference to the NEXUS cervical spine rule, radiography is unnecessary if a patient satisfies ALL of what low risk criteria? (5)
No midline spinal tenderness, no focal neuro deficits, normal alertness, no intoxication, no painful distracting injury
When is a CT head recommended for a pt younger than 2 yo?
AMS or GCS < 15 or palpable skull fx
When is CT head recommended for pt > 2 yo?
AMS, GCS < 15, Signs of basilar skull fx
What are the reversal agents for antiplatelets?
Platelets, +/- desmopressin (DDAVP)
What are the reversal agents for Coumadin?
FFP, Vit K, PCC (Prothrombin complex concentrate), factor VIIa
What are the reversal agents for Heparin?
Protamine sulfate
What are the reversal agents for Pradaxa?
Praxbind, PCC (Prothrombin complex concentrate)
What are the reversal agents for Xarelto/ Eliquis?
PCC (Prothrombin complex concentrate)
What dx modalities are might be used for secondary survey of the chest?
CXR, US lung, CT w/ contrast, chest CTA (if vascular injury suspected)
What diagnostic modalities might be used for secondary survey of abdomen?
Contrast abdomen/ pelvis CT, US
How long does it take for Cullen’s sign to appear? (superficial edema and bruising in the subcutaneous fatty tissue around the umbilicus)
24-48 hrs
What is Grey Turner’s sign?
Bruising of the flanks (between last rib and top of hip)
What can result from a shoulder belt injury/trauma?
Blunt carotid injury, strangle injury
What is the most frequently injured organ in penetrating trauma and 2nd most frequently injured organ in blunt abd trauma?
Liver
What is the most frequently injured organ in blunt trauma in adults and most important to save in kids?
Spleen
What three things dose a rectal exam assess for?
spinal cord injury, pelvic fx, penetrating abd trauma
How does a rectal exam assess for spinal cord injury?
Assess for sacral sparing
How does a rectal exam assess for a pelvic fx?
Assess for open fx
How does a rectal exam assess for a penetrating abd trauma?
Assess for gross blood
During the pelvis exam, what should you do if you suspect fx?
Bind pelvis, check for blood at the meatus (urethral injury)
When putting in a foley tube, you should beware of what type of injury?
Urethral injury
When putting in an NG tube, you should beware of what type of injury?
Mid face fracture (OG tube better)
What are the soft signs of an extremity penetrating trauma?
Small non expanding hematoma, venous oozing, hx of pulsatile bleeding, unexplained neuro deficit (sensory or motor)
Active or pulsatile bleeding, expanding hematoma, pulseless limb, shock (due to vascular injury), compartment sundrome, and bruit thrills are all signs of what?
Hard signs of vascular injury
What is considered to be a normal/ abnormal ankle-brachial index (ABI)? (used to indicate lower extremity injury)
Normal > 0.9, abnormal < 0.9
What is considered to be a normal brachial-brachial index? (used to indicate upper extremity injury)
Normal > 0.9
If pt presents with hard signs od extremity penetrating trauma what is the course of action?
To OR
If patient presents with soft signs of penetrating trauma and has an ABI < 0.9, what is the next step?
CT angiography extremity
If pt presents w/ no signs of extremitiy penetrating trauama what is the course of the action?
XR
If pt presents with soft signs of vascular injury but ABI > 0.9, what does this indicate?
No arterial injury
What performed first if pt presents with open or closed fx?
Assess neuro/vascular status
What is used for bleeding with open or closed fractures?
Pressure or tourniquet
What should be done if a pt presents with an open or closed fracture to prevent further injury?
Immobilize
If pt presents with fx and area is cold or pulseless, what is the next step?
Reduce to get better aligment if
If pt presents with an open fracture, what should they be given?
Tetanus and abx
What are the 6 P’s of compartment syndrome?
Pain (worse w/ passive stretch), paresthesia, pallow, poikilothermia-polar, paralysis, pulselessness (late finding)
What specific imaging studies should be ordered with potential vascular injury?
CT angiogram neck/ extremity
In trauma “PAN SCAN” non-contrast CT is mostly used. What areas of the body utilized CT w/ contrast?
Chest/Abdomen/Pelvis
What are the tetanus prone wound characteristics?
> 6 hrs old, configuration- stellate, avulsion, abrasian, >1cm in depth, mechanism of injury- crush, burn, missile wound
Signs of what are often present on a tetanus prone wound?
Infection, devitalized tissue, contamination, ischemic/ denervated tissue
If pt w/ clean or minor wound but has unknown or received < 3 tetanus containing vaccines. Do you give the pt DTaP, Tdap, or Td? What about TIG?
Yes DTap, Tdap, Td. No TIG
If pt w/ clean or minor wound but has received ≥ 3 tetanus contain vaccines. Do you give the pt DTaP, Tdap, or Td? What about TIG?
No vaccine or TIG given
It pt presents with a wound contaminated w/ dirt, feces, saliva, a puncture wound, avulsion, or wound resulting from missiles, crush injury, burns or frost bite and has unknown tetnus vaccine recoord or received < 3 tetanus containing vaccines. Do you give them DTaP, Tdap, Td? What about TIG?
Yes DTap, Tdap, Td. Yes TIG
It pt presents with a wound contaminated w/ dirt, feces, saliva, a puncture wound, avulsion, or wound resulting from missiles, crush injury, burns or frost bite and has received ≥ 3 tetnus containing vaccines. Do you give them DTaP, Tdap, Td? What about TIG?
No vaccine or TIG given
It HIV+ or severely IMC pt presents with a minor or contaminated wound should you give TIG regardless of their tetanus immunization?
Yes
If pt w/ ≥ 3 tetanus immunization presents with clean/minor wound but last vaccine was received ≥ 10 yrs ago, do you give tetanus vaccine?
Yes
If pt w/ ≥ 3 tetanus immunization presents w/ contaminated/complicated wound but last vaccine was received ≥ 5 yrs ago, do you give tetanus vaccine?
Yes
What is the rule of palms helpful to assess?
Assess TBSA < 15%
What is the rule of palms for a peds pt?
Entire palmar surface- 1%, palm only- 0.5%
What is the rule of palms for an adult pt?
Entire palmar surface- 0.8%, palm only- 0.5%
When can the modified Brooke/ Parkland formula be used for burns?
> 15% TBSA in peds, >20% TBSA in adults
What is the modified Brooke/ Parkland formula/ volume of RInger’s Lactate?
2mL- 4mL x %BSA x weight (kg) → give half in first 8 hrs and half in next 16 hrs
What is considered a 1st degree burn?
Superficial thickness
What is considered a 2nd degree burn?
Superficial partial thickness to deep partial thickness
What is considered a 3rd degree burn?
Full thickness
What is the management for a deep partial thickness burn (2nd) or full thickness (3rd) burn?
Needs grafting
Pt presents with a burn that is erythematous. What stage is it?
1st- superficial thickness
Pt presents with a burn that is wet, pink, and with blisters. What stage is it?
2nd- superficial partial thickness
Pt presents with a burn that is less wet, red, +/- blisters. What stage is it?
2nd- deep partial thickness
Pt presents with a burn that is dry and white. What stage is it?
3rd- full thickness
What is the Broselow pediatric emergency tape used for?
A reference at each color bar on the tape informs you of equipment sizes to perform emergency resuscitation on the child
In what position are pregnant females > 20 wks placed s/p trauma?
LLD @ 30˚
A perimortem C-section should be initiated when?
Within 4 minutes post maternal arrest
What is the goal of a perimortem C-section?
To remove fetus and continue resuscitation of both mother and fetus (maternal CPR should be continued during procedure)
What is the #1 cause of death of Americans under age 50?
OD
When treating pain in outpatient trauma pt, what is important for naive opioid pts?
Keep them opioid naive
What is the max duration that opioids should be prescribed for pain in outpatient trauma pt?
3 days (throw away any remaining)
Caution with what tx should be taken for medication in pain for inpatient trauma pts?
NSAIDs
What is the goal of managing pain for inpatient trauma pts?
Augment opiates w/ non-opoiods
What is the range for BP in permissive hypotension?
SBP 80-100
What is the tx for an open PTX?
3 way seal (blocks are from entering but allows air to escape)
When is an occlusive dressing used?
When you want to create an air and water tight seal, designed to stick to patients regardless of blood, sweat, hair or anything else that might be on them
A combat application tourniquet (CAT) or quick clots are used to help control what?
Bleeding
GCS of ≤10 means what?
Maximun GCS for intubation
Pt in a coma will have a GCS score of what?
< 8
Battle’s sign, raccoon eyes, & hemotympanum are all signs of what?
Head trauma
When performing a secondary survey of the lower abdomen/pelvis. How many people are required to roll a pt?
Minimum of 3
