18 - Polytrauma Patient Flashcards
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
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)
3
Q
Trauma by type
A
- MVA 59%
- Falls 13%
- Assaults 12%
- Burns 3%
- Other 12%
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)
5
Q
Why elderly fall
A
- Vision, balance, neuropathy (cant feel bottom of feet), meds, autonomic dysfunction, arrhythmias
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
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
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)
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
10
Q
Do not become overly distracted by obvious injury
A
- Still go through your ABCDEs
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
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
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
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)
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)
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)
17
Q
Easy Intra-Osseous IV
A
- Drill an IV right into the bone
- Does not hurt going in, but hurts coming out
18
Q
What do you put in the IV?
A
- Crystalloid fluid (NS or LR)
- Blood
- (Later possible antibiotics, pain and nausea meds)
19
Q
Circulation evaluation is trying to rule out or rule in…
A
- **SHOCK **
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)
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
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
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
Can you use pressers if in a pickle?
- Not for low volume status, dopamine or doputamine will do more DAMAGE if volume is already low
- Double traumatic amputee - NO!
26
ABC… Disability
```
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
***Intoxication***
- ***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
ABCD Exposure
- Expose patient, check for injury but keep warm
29
So, let’s review
- First Look
- Packaging
- ABCDE
30
Secondary survey
- 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
Head
- Scalp lacs
- Facial instability
- Ears
- Eyes
- Mouth
32
Head trauma
- 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
C-spine and back
- ***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
Signs of head trauma
- Change in consciousness
- Ask the same question repeatedly
- Can’t answer questions correctly
- Doesn’t remember
- Agitated
35
***NEXUS***
```
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
Future of C collar?
- 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
Chest
- Heart
- Breath sounds
- Bruising…. Same as ABCs but time to be more thorough
38
Abdomen
- Tenderness
- Bruising
- BS
- Rigidity
- Injury to liver, spleen, pancreas
39
Pelvis
- Rock hips
- Check for hip rotation/shortening
- High riding prostate
- Blood at urethral meatis
40
Extremities
- Neuro/vascular status
| - Bruising/deformity/tenderness
41
NG tube and foley
- 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
Typical basic orders
- CBC
- CMP (chem 7 + liver enzymes)
- Amylase (pancreas injury)
- Urine, U-pregnancy
- Coags
- X-rays: C-spine, chest, pelvis (or “pan scan” CT)
43
If any head trauma…
- CT head
- CT neck
- +/- CT facial bones (CT sinus is what they call it)
44
If suspicious of neck…
- 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
If any belly pain…
- CT abdominal/pelvis (oral and IV chest x-ray)
| - Some places have rapid US to quickly look for liver, spleen lac
46
If chest trauma
- CXR vs CT if suspicious of vascular issue
| - EKG
47
Anything bony that hurts
- X-ray
48
***When people die from trauma***
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
***Trauma Lessons***
- 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
Traumas can leave a mark
- 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
Summary
- C-collar is an issue
- Florida article – trauma center (amazing situation)
- Debriefing is important
52
CASE STUDY
o 20 something year old male, dropped off at the door
o Moaning, bleeding, somewhat
o First step is safety – gown up
53
ABCs
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
Evaluation
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
Trauma center
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
First step
o Look at the whole body, address any smaller wounds or concerns
