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Emergency Med - Exam 2 > 18 - Polytrauma Patient > Flashcards

18 - Polytrauma Patient Flashcards

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1
Q

What you should get from this lecture

A
  • Vitals are everything
  • Trauma needs surgery
  • Shock
  • Trauma guidelines, primary surveys, C-spine clearing
  • Importance of re-eval
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2
Q

Trauma in the US

A
  • Leading cause of death ages 1-44
  • 160,000 deaths annually
  • 400 Billion $ annually
  • Not much research (military does)
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3
Q

Trauma by type

A
  • MVA 59%
  • Falls 13%
  • Assaults 12%
  • Burns 3%
  • Other 12%
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4
Q

Falls in elderly

A

Falls are a big issue
o 2005 in those >65y/o, 8000 Traumatic Brain Injury and 56,000 hospitalizations
o Hip/wrist/spine fractures (osteoporosis)

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5
Q

Why elderly fall

A
  • Vision, balance, neuropathy (cant feel bottom of feet), meds, autonomic dysfunction, arrhythmias
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6
Q

Burns

A

Significant burns typically get transferred to burn center
o Partial thickness >5% TBSA
o 3rd degree burns
o Burns of hands, face, peri-area, over joints
o Airway issues
o Electrical

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7
Q

What you can expect to see in trauma

A
  • Blood, amputations, eviscerations, deformity or nothing
  • Calm or emotional
  • Organized and running well vs. chaos
  • Hot, cold, crowded, messy
  • Lots of staff or understaffed
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8
Q

Trauma alerts

A
  • Most hospitals have guidelines as to when to call a trauma
  • Often 2 levels – determines who responds
  • Based on mechanism and/or injury
  • Level 1 (shock, penetrating head/neck/chest)
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9
Q

** The evaluation starts when you first see a patient **

A
  • Neuro status (awake, moving, yelling)
  • Obvious injuries (blood, skin color)
  • Stabilization/IV access
  • EMS or family or nurse story
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10
Q

Do not become overly distracted by obvious injury

A
  • Still go through your ABCDEs
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11
Q

Primary survey

A
  • Airway (includes C-spine)
  • Breathing
  • Circulation
  • Disability
  • Exposure
  • Treat anything you find in the survey that is life threatening
  • This is the list of priorities, in this order (for now) … but in reality all occurs at once
  • Trauma notes often written ABCDE
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12
Q

Airway

A
  • If the patient has a drive to breath, can they? Is there anything mechanically stopping the flow of air? If they are talking to you, it is a good sign
  • If there is a problem, act immediately (suction, sweep foreign bodies, pull the jaw)
  • How do you know? patients voice, gurgling sounds, stridor
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13
Q

Breathing

A
  • Is the patient breathing well enough to support their vitals? Are they neurologically intact enough to protect their airway?
  • They will likely have O2 on by now…but if not add
  • Rate, pulse ox, sounds, equality, chest wall and trachea
  • Intubate if not breathing
  • Chest tube for pneumothorax or hemopneumothorax, bag, address open chest wounds
  • LMA = easy to put in, airway
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14
Q

Circulation

A
  • Mental Status
  • Skin
  • Peripheral pulses
  • Heart sounds
  • Urine output (you won’t see this right away, but it is important to keep track of)
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15
Q

Circulation

A
  • BP (radial pulse =70 systolic…sometimes) , pulse, color, extremity temperature, neuro-status
  • Anxious followed by confused
  • Stop obvious bleeding (don’t pull anything out of pt. like knives)
  • IV access (IV fluid and or blood)
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16
Q

What if you can’t get an IV in?

A
  • Get a smaller IV
  • Go for bigger veins (head in kids, breast in adult)
  • IO (very fast and effective)
  • Central line
  • Cut down (saphenous vein)
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17
Q

Easy Intra-Osseous IV

A
  • Drill an IV right into the bone

- Does not hurt going in, but hurts coming out

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18
Q

What do you put in the IV?

A
  • Crystalloid fluid (NS or LR)
  • Blood
  • (Later possible antibiotics, pain and nausea meds)
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19
Q

Circulation evaluation is trying to rule out or rule in…

A
  • **SHOCK **
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20
Q

Blood loss

A
  • Tibial fracture or humeral fracture can bleed 750 mL into tissue (compartment syndrome…)
  • Femur 2X that (AND if broke femur may have ruptured femoral or iliac artery)
  • Pelvic fracture can be fatal (motorcycle passengers, horse riding)
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21
Q

Hemorrhagic shock

A
  • Diminished tissue perfusion secondary to blood loss
  • Need to re-establish enough volume to get preload high enough to get pressure high enough
  • Initially can do through IV Fluids, but if enough blood loss need blood
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22
Q

How to treat shock

A

Initially IV fluids
o 2 L NS or LR wide open (bolus goes in very fast to correct vitals)
o Kids bolus 20 ml/kg in bolus – may repeat
o If not responding to fluids, need blood

Give blood
o O negative blood
o Typed
o Typed and cross-matched only if time

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23
Q

What are you looking for in response?

A
  • Better skin, vitals, mental status
  • Urine output (remember, kidneys will sense if volume is low and stop making urine – also kidneys easily damaged from hypoxia)
24
Q

Definitive treatment for hemorrhagic shock…

A

SURGERY

25
Q

Can you use pressers if in a pickle?

A
  • Not for low volume status, dopamine or doputamine will do more DAMAGE if volume is already low
  • Double traumatic amputee - NO!
26
Q

ABC… Disability

A 
Neuro Status evaluation via Glascow Coma Scale – (3-15)
o	Eyes (4)
o	Verbal (5)
o	Motion (6)

NEED TO KNOW
o 3 = Dead
o 8 = Intubate
o 15 = Normal

27
Q

Intoxication

A
  • ***Makes everything more difficult
  • ***Are they combative/tearful/slurring speech because drunk or head injury or in shock???
  • ***Uncooperative (may have to restrain)
  • ***Law enforcement
  • Don’t get UDS or ETOH unless may change what I do or liability
28
Q

ABCD Exposure

A
  • Expose patient, check for injury but keep warm
29
Q

So, let’s review

A
  • First Look
  • Packaging
  • ABCDE
30
Q

Secondary survey

A
  • Head to toe
  • Re-assess vitals
  • Get patient’s PMH, PSH, meds, allergies
  • When did they last eat?
  • Address wounds
  • **Re-assess over and over **
31
Q

Head

A
  • Scalp lacs
  • Facial instability
  • Ears
  • Eyes
  • Mouth
32
Q

Head trauma

A
  • 500,000 people die annually
  • 100,000 disabled
  • 10% die PTA (prior to arrival = before they get to the hospital)
  • Head CT if LOC or neuro deficits…what if intoxicated???
33
Q

C-spine and back

A
  • ***C-collar on until cleared with exam or imaging
  • ***Backboard – according to ATLS standards, backboard is for transferring patient (get off backboard quickly)
  • ***5% of head trauma also has c-spine injury
34
Q

Signs of head trauma

A
  • Change in consciousness
  • Ask the same question repeatedly
  • Can’t answer questions correctly
  • Doesn’t remember
  • Agitated
35
Q

NEXUS

A 
This is what is required for you to take the c-collar off and be cleared for a c-spine injury
o	No bony tenderness
o	No distracting injury
o	No neuro deficits
o	No cognitive dysfunction
o	No intoxication
36
Q

Future of C collar?

A
  • C collars were initiated when there was very little evidence that it helped
  • Some ER doctors leave the c collar on for 24 hours even if they are cleared by CT
  • It makes intubation tough, it hyperextends the neck
  • In 10 years it may be different, but right now we use C collars
37
Q

Chest

A
  • Heart
  • Breath sounds
  • Bruising…. Same as ABCs but time to be more thorough
38
Q

Abdomen

A
  • Tenderness
  • Bruising
  • BS
  • Rigidity
  • Injury to liver, spleen, pancreas
39
Q

Pelvis

A
  • Rock hips
  • Check for hip rotation/shortening
  • High riding prostate
  • Blood at urethral meatis
40
Q

Extremities

A
  • Neuro/vascular status

- Bruising/deformity/tenderness

41
Q

NG tube and foley

A
  • NG tubes are going out of style – it is a tube from nose into belly to empty out stomach
  • Foley really helps you measure urine output when is helpful
42
Q

Typical basic orders

A
  • CBC
  • CMP (chem 7 + liver enzymes)
  • Amylase (pancreas injury)
  • Urine, U-pregnancy
  • Coags
  • X-rays: C-spine, chest, pelvis (or “pan scan” CT)
43
Q

If any head trauma…

A
  • CT head
  • CT neck
  • +/- CT facial bones (CT sinus is what they call it)
44
Q

If suspicious of neck…

A
  • Get CT of neck
  • If can’t see to c7 on x-ray – get CT
  • CT much more sensitive + 2 sets eyes on images
45
Q

If any belly pain…

A
  • CT abdominal/pelvis (oral and IV chest x-ray)

- Some places have rapid US to quickly look for liver, spleen lac

46
Q

If chest trauma

A
  • CXR vs CT if suspicious of vascular issue

- EKG

47
Q

Anything bony that hurts

A
  • X-ray
48
Q

When people die from trauma

A

Trimodal peaks = 3 times when people die
o 1 = At scene, typically, from large vessel or head/neck
o 2 = Shortly after arrival to ER, so this is when transport times matter (chest, abdomen, head, pelvis)
o 3 = In ICU (from head, overwhelming infection, clots)

49
Q

Trauma Lessons

A
  • Definitive treatment for trauma is surgery (get surgeon involved)
  • Fluid/vital management is band-aid
  • Be mindful of shock
  • Keep checking vitals and repeating secondary surveys
  • Non-life-threatening injuries can wait
  • ETOH/drugs makes evaluation very challenging
50
Q

Traumas can leave a mark

A
  • Traumas are especially difficult for physicians and staff because they cause injury, disability and death in young people that is unexpected
  • Physicians are “expected” to not be affected…we are
51
Q

Summary

A
  • C-collar is an issue
  • Florida article – trauma center (amazing situation)
  • Debriefing is important
52
Q

CASE STUDY

A

o 20 something year old male, dropped off at the door
o Moaning, bleeding, somewhat
o First step is safety – gown up

53
Q

ABCs

A

o Airway – look in the mouth
o Breathing – very diminished breathing on the left, rate 30 times/minute. Sub Q emphysema left laterally, Pox 92%, needs chest tube
o Circulation – sweaty, pale, BP 80/49, pulse 129, keep an eye on urine output
o NOTE: when you go through the ABCs, you fix whatever you find before you move on to the next

54
Q

Evaluation

A

o Disability – Glascow determined to be a 9 previously, already intubated (not the best)
o Intubate at 8, 3 is dead
o Exposure shows GWS to the chest
o If you don’t get a response from giving IV fluid, you will need to start giving blood

55
Q

Trauma center

A

o If you are at a trauma center, trauma should be there or on way
o If not, initiate the trauma team and get person moving
o Do NOT delay transfer

56
Q

First step

A

o Look at the whole body, address any smaller wounds or concerns

Emergency Med - Exam 2 (11 decks)

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