1 - Trauma In Adults Flashcards
Major causes of death following trauma are:
Head injury
Chest injury
Major vascular injury
What did the Trauma Care Systems Planning and Development Act of 1990 do?
Provided for the development of a model trauma care system plan to serve as a reference document for each state in creating its own system
What does a trauma patient receive in a well-run trauma center?
Multidisciplinary evaluation
Smooth transitions between the ED, diagnostic radiology suite, OR, and post-op intensive care setting
What are the essential characteristics of a Level I Trauma Center?
- 24-hr availability of surgeons in all subspecialties
- 24-hr availability of neuroradiology and hemodialysis
- Program that establishes and monitors effect of injury prevention and education efforts
- Organized trauma research program
EMS transports patients to the appropriate level of trauma center based on:
Vitals
Mental status
Mechanism of injury (perhaps the biggest factor in disposition)
Criteria for txp to a trauma center:
A lot
Slide 11
Information provided by EMS to receiving facility en route: (at minimum)
MOI Suspected injuries V/S Clinical sxs Exam findings Interventions performed
Prior to the patient arrival at the trauma center, ED staff will:
Assign tasks to team members
Prepare resuscitation and procedural equipment
Ensure the presence of surgical consultants and other care team members
ED care of the trauma patient begins with:
An initial assessment for POTENTIALLY SERIOUS INJURIES (i.e. r/o the life-threatening shit first)
Only after you’ve assessed airway, breathing, and circulation can you move on to:
Head-to-toe exam
If you find a life-threatening injury at any point in your exam:
STOP and treat it
Insertion of an oral airway can be difficult in patients with:
Intact gag reflex
In which patient should you avoid the use of NPA’s?
Suspected cribiform plate / basilar skull fx
When managing the airway of a trauma patient, whenever possible, you should utilize:
The two-person spinal stabilization technique
GCS < 8
Intubate
Caution - trauma patients with head injury, hypoxia, or drug- or alcohol-induced delirium are at increased risk for:
Self-harm
Why can trauma pt’s be tough to intubate?
The need to keep c-spine immobilized
Presence of blood or vomitus
Upper airway injury
What device can aid in the difficult trauma intubation?
Glidescope
Lets everyone else see what you’re doing, and aid in vocal cord visualization when direct observation is impractical
In order to secure an airway in a patient with severe anatomical facial injuries, you may need to perform:
Emergency cricothyroidotomy
Do all trauma patients require c-spine films?
No - careful clinical assessment can lead to c-spine clearance
What is NEXUS?
National Emergency X-Radiography Utilization Criteria
Tells you when you can omit c-spine films
Failure to meet any of the five items means you must get c-spine imaging
- No posterior midline cervical spine tenderness
- No evidence of intoxication
- Alert mental status
- No focal neuro deficits
- No painful distracting injuries
Nexus N - neuro E - ETOH X - distracting injury U - unstable (alterd mental) S - spine (midline tenderness)
Is it possible for patient to have c-spine injuries even if the films are good?
Yup, they could have unstable ligamentous injuries rather than bony pathology
CT of the cervical spine if the preferred initial imaging modality (for this reason, among others)
Injuries to look for on the “B” step of your initial assessment?
Deviated trachea
Crepitus
Paradoxical movement of chest wall segment
Sucking chest wound
Fractured sternum
Absence of breath sounds on either side of the chest
Intervention for tension pneumo?
Needle decomp
Intervention for hemo-pneumo?
Large bore chest tube
Intervention for sucking chest wound?
Occlusive dressing
Intervention for asymmetric breath sounds in the intubated patient?
Pull the tube back a little (likely right mainstem)
What if no breath sounds are heard, and massive hemothorax or vascular injury is suspected?
Thoracotomy or video-assisted thoracic surgery to find and stop the source of bleeding
“C” on primary assessment includes:
Level of consciousness Skin color Peripheral pulses (strength, quality) HR Pulse pressure
ID and control external hemorrhage
Slide 24
Blood loss classification chart
You can lose up to 30% of your blood and still only present with:
Mild tachycardia and a decrease in pulse pressure
Caution - this can quickly progress to profound hypoperfusion and decompensated shock, especially in kids (as they can compensate better, seem fine, and then suddenly go downhill crazy fast)
How can a patient on beta blockers complicate the presentation of the trauma patient?
Blunted response to hemodynamic instability
BB’s prevent HR increase, which is one of the earliest indicators of impending shock
If the trauma pt is hypotensive?
Two large bore IV’s (18G or larger)
NS or LR
What if you can’t get the IV?
No worries - just pop an IO in (E-Z IO drills are super fast and effective)
If you’ve got a little more time or you’re feeling saucy, go for a PICC line
How can you maximize flow rates?
Pressure bag
If you give your trauma pt 2L of LR, reassess, and they’re not any better, now you need to:
Transfuse type O blood (O neg for women of child-bearing age)
Patients requiring massive transfusion generally require:
Urgent surgical intervention to control hemorrhage
Recommended ratio for PRBC’s and FFP?
1:1
Two big contributors to coagulopathy that should be identified and corrected ASAP?
Acidosis (fix with bicarb)
Hypothermia (fix with warmed IVF, heat packs to neck/groin/axilla, and bear-hugger blanket)
In a patient with an appropriate mechanism for head trauma and either AMS or a GCS < 15, we can assume the patient has:
A significant head injury until proven otherwise (i.e. check the sugar, consider drugs or booze)
Pros and cons of mild hyperventilation?
Pro - can reduce ICP
Con - can cause cerebral vasoconstriction and hypoperfusion
Is prophylactic hyperventilation recommended?
No - in the first 24 hrs after injury, when cerebral blood flow is often critically needed, we should AVOID hyperventilation
The exposure step of the primary survey includes:
Gettin em naked and rollin em over
Keep the spine stable during the roll, check the spine
How important is the routine rectal exam?
Its utility is debated
But it can help ID gross bleeding or loss if tone in suspected SCI
The use of hypothermia is gaining traction as a therapy for severe brain injury - what cons must be considered?
Risk of coagulopathy and increased bleeding
One way to ensure head injuries that would benefit from surgery are ID’d quickly?
Don’t do anything that isn’t completely necessary (i.e. secondary survey type stuff) until AFTER they’ve been through the donut of truth
How to intubate someone with a c-collar?
Take it off, maintain manual in-line stabilization, intubate, put it back on
If the penetrating abd pt has abdominal tenderness or distention on palpation AND HOTN:
They probably need emergent exploratory laparotomy
Get them to OR ASAP
What ensures better outcomes in penetrating trauma patients in shock?
Early operative intervention
If you’ve got a couple mins to kill before txp to the OR, you might as well:
Place a foley, some extra IV’s, NG-tubes - anything you can do to help surgery happen faster
If someone is shot in the abdomen, do I need to order a CT?
Fuck no, they’re gonna need emergent exploratory laparotomy anyway- just send em right to the OR
Indications for ED thoracotomy:
Slide 38
Penetrating:
If they’re pulseless, with CPR being performed, and have reactive pupils, spontaneous movement, or some kind of myocardial electrical activity, consider the thoracotomy
If they’re pulseless, with CPR being performed, but they have none of the above signs of life, no thoracotomy
Blunt: No thoracotomy (even if some electrical activity)
During the secondary survey, what is also happening simultaneously?
Continuous / serial assessment of BP, HR, and responses to interventions
If you find meatal blood or the prostate is displaced, what must you do prior to insertion of a foley cath?
Perform retrograde urethrography
Which injuries often remain undiagnosed on secondary survey, even with diligent exam?
Injuries to esophagus, diaphragm, and small bowel
Hence, serial imaging in the hospital may be required for delayed presentation
What are the most frequently missed conditions in trauma exam?
Orthopedic
Fuck orthopedics
Standard imaging for patients that aren’t going straight to OR or donut of truth?
Plain films of:
C-spine
Chest
Pelvis
What the e-FAST:
Ultrasound
Rapid and effective screening tool to ID major intraperitneal bleeding, pericardial tamponade, pneumothorax, and hemothorax as the source of HOTN or shock
When is e-FAST performed?
Immediately after the primary survey
What test for definitive imaging of the abdomen?
CT with IV contrast
If your patient is getting a head CT, most places will give you a:
C-spine CT at the same time
In general, the liberal use of CT scan in the setting of trauma is:
Strongly encouraged to detect problems not clinically apparent
However, you also don’t wanna irradiate someone unless you have to, so use clinical judgement on who needs it
Labs in trauma
Type and screen
H/H
Urine dipstick (blood)
EtOH level
Women? HCG
Trauma pt with AMS?
Check that sugar , diabetes or not
In trauma patients older than 55, consider:
ECG and troponin
Maybe they had a massive MI and THAT’S why they crashed their car….
Prior to patient transfer, you must:
Complete a rapid but thorough primary and secondary assessment
Communicate EVERYthing to receiving facility to ensure continuity of care
Send lab results, imaging studies, and complete patient record with them when they go
What did the grape do when he got stepped on?
He let out a little wine
