32. Multi Trauma Flashcards
OA common injury sites - 3
extremity
craniofacial
closed head
What determines the amount of tissue damaged in a gunshot wound?
kinetic E of bullet - determined by bullet w, v
In what 4 ways do gunshot wounds cause trauma to surrounding tissue?
direct laceration
crush injury
shock waves
cavitation (displacement of tissue forward and radially)
MVC: associated injuries in - head on collision
facial
LE
aortic
MVC: associated injuries in - rear end coll
hyperext injury of cspine
c spine #
central cord syndr
MVC: associated injuries in - lateral/t-bone collision
thoracic injury
abdo injury - spleen, liver
pelvic
clavicle, humerus, rib #
MVC: associated injuries in - rollover
cursh injury
compression # of spine
MVC: associated injuries in - ejection
spinal
MVC: associated injuries in - windshield damage
closed head injury
FACIAL #
Skull #
cervical spine #
MVC: associated injuries in - steering wheel damage
thoracic injuries
sternal and rib #
- flail chest
cardiac contusion
aortic injuries
htx, ptx
MVC: associated injuries in - dashboard involvement/damage
pelvic/acetabular injury
dislocated hip
Restraint/seat belt use: associated injuries in - lap belt only in a three point restraint
chance #
abdo injury
head and facial injury and fracture
Restraint/seat belt use: associated injuries in -proper 3pt restraint
sternal and rib #
pulmonary contusion
Restraint/seat belt use: associated injuries in -shoulder belt only
c spine injuries and #
concern for possible “submarine” out
Air bag deployment: associated injuries in ?-
UE soft tissue injury and #
LE injury and #
Ped vs automobile injuries at low braking automobile
tibia and fibular #
knee injuries
Ped vs automobile injuries at high speed
waddel’s triad: tibia adn fibula or femur #
truncal injuries
craniofacial injuries
Bicycle injuries, automobile related mc injuries:
closed head
handblebar: spleen/liver lac, additional intraabdo
consider penetrating
Bicycle injuries, non-automobile related mc injuries:
extremity injuries
handlebar injuries
Falls - LD50?
36-60ft
(fatal to 50%)
Vertical impact injuries
calcaneal and LE #
pelvic #
closed head injury
c-spine #
renal and renal vascular injuries
Horzontal fall impact injuries
craniofacial #
hand and wrist #
abdo and thoracic visceral injuries
aortic injury
When to use a torniquet for circulation?
++ bleeding
Goal of the secondary survey
(1) obtain pertinent historical data about the patient and injury; and (2) identify and manage all significant injuries by performing a systematic, complete examination. An AMPLE (allergies, medications, past medical history, last meal, envi- ronments and events) history should be obtained
Blunt trauma goal of management, focusing on localizing injury to what possibl 4 things?
(1) obvious external hemorrhage; (2) long bone fractures; (3) pelvic fractures; or (4) internal hemorrhage.
What does Rosen’s state is a sufficient airway protection?
gcs >/=9
suficient resp effort
no active emesis
no significant oropharyngeal bleeding
What consideration is helpful before intubation?
gcs
If no respiratory distress, breathing wise, what to consider for empiric tx
bg
narcan
tx and ID non traumatic hypocia/hypoventil
No bilateral breath sounds, what to consider?
tension ptx
open ptx
massive htx
Bilateral breath sounds present, what breathing issues to consider?
flail chest
cardiac injury
pulmonary contusion
Main two distinctions of shock in rosen’s
hemorrhagic
or other
Physical exam for hemorrhage finding?
external
thoracic
abdo
pelvis
long bone
Rosen’s basics for hemorrhagic resuscitation
- Adequate IV access
- Minimum—two bore IVs
- Balanced resuscitation
- 1-2 L warmed isotonic fluids
- Packed red blood cells, platelets, plasma–> 2:1:1 vs 1:1:1 ratio
- Prevent hypothermia
- Consider tranexamic acid 1 g IV bolus over
10 minutes, followed by 1 g IV infused over 8 hours
Treatment of long bone fracture hemorrhage site vs pelvic #
long bone - reduce, splint
pelvic #: reduce pelvic vol, wrap pelvis, angio embolize
PE pieces for A, B, C
A - Protecting airway? * Insufficient resp effort
* GCS ≤ 8
* Vomiting or bleeding
B -
* Equal breath sounds
* Use of accessory muscles * Tachypnea
* Oxygen saturations
* Cyanosis
C
* Tachycardia
* Hypotension
* Decreased capillary refill * Cool/mottled extremities
Intubation considerations for blunt trauma
- Maintain in-line immobilization
- Assess for laryngeal/ tracheal injury
- Anticipate blood/ emesis in airway
Intubation considerations for penetrating trauma
Watch for expanding hematoma
* Anticipate significant bleeding
* Impaired video/ fiberoptic techniques
Special airway considerations in blunt trauma
Severe
maxillofacial
injuries
* Cervical spine
immobilization
* Consider
awake intubation for cervical spine injuries
Special airway considerations in penetrating trauma
- Vascular injury
- Significant bleeding
- Airway displacement or obstruction
Special considerations of blunt trauma - breathing
- Chest contusions
- Flail segment
- Bowel sounds
in chest
Penetrating trauma - special considerations for B
- Chest injury * Significant
bleeding - Sucking chest
wound
Circulation - special considerations of blunt vs penetrating trauma
- Positive FAST * Unstable
pelvis - Long bone
fracture * Signs of
retroperitoneal bleeding
Obvious vascular injury
* External hemorrhage
Secondary survey - aspects of general assessment and critical dx
Level of consciousness
Glasgow Coma Scale (GCS) score
Specific complaints
gcs </=8
focal mo deficit
Secondary survey - aspects of head assessment and critical dx vs emergent
pupils - sh/size/reactivity
contusions
lacs
evidence of skull #
hernation syndrome vs emergent: globe rupture, open skull #, csf leak
Secondary survey - aspects of face assessment and critical dx vs emergent
contusion, lac, midface instability, malocclusion
airway obs due to bleed
facail #, mandible #
Secondary survey - aspects of neck assessment and critical dx vs emergent
penetr injury, lacs
trach deviatiion
JVD
subcut emphysema
hematoma
midl cervical tenderness
carotid injury, pericardial tamponade, trach/largyneal #, vascular injury, cervical #, dislocation
Secondary survey - aspects of chest assessment and critical dx vs emergent
resp effort, excursion
contusins
lacs
focal tenderness, crepitus
subcut emphysema
heart tones muffled
breath sounds (symmetric)
impending resp failure, flail chest, cardiac tamponade, tension ptx
vs
cardiopulmonary, intrathoracic injury, rib #, ptx, htx
Secondary survey - aspects of abdo/flank assessment and critical dx vs emergent
contusions, penetr injury, lacs
stability, symphseal tenderness
blood (urethral meatus, vag bleed, hematuria)
rectal exam
pelvic hemorrhage, unstable pelvic #, colorectal injury/bleed
urogenital injury vs urethral injury
Secondary survey - aspects of neurogenic assessment and critical dx vs emergent
midline bony spinal tenderness
mental status
paresthesias
sensory level
mo function, including sphincter tone
spinal #, disloc, epidural hematoma, subdural hematoma, spinal #/dislocation
cerebral contusion, shear injury, sci, contusion, n root injury
Secondary survey - aspects of extremities assessment and critical dx vs emergent
contusin, lac, deformity, focal tenderness, pulses, cap refill, eval of compartments
compartment syndr, vascular injury, nv injury, arterial injury, arterial injury, hemorrhagic shock, arterial injury, compartment syndrome
rhabdo, #
List trauma labs
Electrolyte levels, liver function studies, interna- tional normalized ratio (INR), urinalysis, blood typing and screening (or cross-matching, depending on severity of injury), lactate levels, and base deficit
bhg if women
Criteria for obtaining thoracic imaging:
7
(1) age above 60 years, (2) rapid deceleration mechanism, (3) chest pain, (4) drug or alcohol intoxication, (5) abnormal alertness and mental status, 6) distracting painful injury
7) tenderness to chest wall palpation
American College of Surgeons RQ for presence of a surgeon at major resuscitation
A surgeon should be present in the emergency department on trauma patient arrival or within 15 min if any of the following major criteria are found:
- Confirmed hypotension (systolic blood pressure <90 mm Hg)
- Gunshot wounds to the neck, chest, abdomen, or proximal extremities
- Intubated patients transferred from the scene
- Respiratory compromise requiring an emergent airway
- Penetrating gunshot wound to the neck, chest, abdomen, or pelvis
- Glasgow Coma Scale score <8 attributed to trauma
- At the discretion of the emergency clinician
Rosen’s vitals reasons to transfer to trauma 1 center
gcs </=13
spbp <90
RR <10 or >29
Rosen’s injuries recommended transfer to trauma 1 center - list 7
- All penetrating injuries to head, neck, torso and extremities proximal to elbow or knee
- Chest wall instability or deformity (eg, flail chest)
- Two or more proximal long bone fractures
- Crushed, degloved, mangled, or pulseless extremity
- Amputation proximal to wrist or ankle
- Pelvic fractures
- Open or depressed skull fracture
- Paralysis
Falls , high risk auto crash, auto vs ped vs motorcycle crash reasons to transfer to trauma 1 centre
- Falls
– Adults: >20 feet (one story is equal to 10 feet)
– Children: >10 feet or two or three times the height of the child - High-risk auto crash
– Intrusion,**including roof: >12 inches occupant site; >18 inches any site – Ejection (partial or complete) from automobile
– Death in same passenger compartment
– Vehicle telemetry data consistent with a high risk of injury - Auto vs. pedestrian/bicyclist thrown, run over, or with significant (>20 mph) impact * Motorcycle crash > 20 mph
Special population reasons to transfer to level 1 trauma centre
- Older adults
– Risk of injury/death increases after age 55 years
– SBP < 110 might represent shock after age 65 years
– Low-impact mechanisms (eg, ground level falls) might result in severe injury - Children
– Should be triaged preferentially to pediatric-capable trauma centers - Anticoagulants and bleeding disorders
– Patients with head injury are at high risk for rapid deterioration - Burns
– Without other trauma mechanism: triage to burn facility – With trauma mechanism: triage to trauma center - Pregnancy > 20 weeks * EMS provider judgment
East guidelines for a thoracotomy
pulseless with signs of life after penetr thoracic injury - includes pupillary response, spont vent, presence carotid pulse, measurable or palpable BP, extremity movement, cardiac electrical activity
pulseless w /o SOL after penetrating thoracic injury
pulseless w /o or WITH SOL after penetrating extra-thoracic injury
pulseless WITH SOL after blunt injury
NOT for pulseless without SOL after blunt injury
West guidelines for a thoracotomy
blunt - <10 min prehospital CPR
penetr trauma:
- <15 min prehosp CPR
- <5 min prehosp CPR in pt with penetr trauma to neck/extremity
other: + profound refr shock
