67 Principles of Trauma Flashcards
Describe the primary assessment of the trauma patient (ABCs).
Describe the primary assessment of the trauma patient (ABCs).
- Airway: Assess the patient’s airway by observation and listening. If the patient is talking, airway and breathing are essentially sufficient. Assess for bleeding, loose teeth, inhalation injury (in case of burn), and level of consciousness. Decreased level of consciousness (GCS 8 or less) is an indication of potential inability to protect the airway and need for elective intubation. Orotracheal intubation with in-line cervical stabilization is the method of choice; however, orofacial trauma or a difficult airway may require a surgical airway (see Chapter 77). In the setting of blunt or penetrating tracheal injury, intubation should ideally be performed in the OR. This is done with adequate equipment for a surgical airway open and readily available and with the neck prepped and draped prior to intubation attempts. Manipulation of the traumatically injured airway during intubation attempts may lead to critical decompensation, which requires immediate, emergent surgical airway.
- Breathing: Assess by looking, listening, and feeling. Look for equal chest rise bilaterally. Auscultation can be difficult in the trauma bay but should be performed to evaluate for absence of breath sounds suggesting pneumothorax or hemothorax. Palpate for crepitus of the chest wall suggesting rib fracture with potential underlying pneumothorax. Evaluate for “flail chest”—three or more ribs with fractures in two or more locations. Paradoxical respiration of this segment and impaired pulmonary mechanics can lead to both life-threatening hypoxia and hypercapnia. Additionally, this substantial injury mechanism is often associated with refractory, life-threatening hypoxia even with mechanical ventilator support.
- Circulation: Assess circulation with frequent vital sign assessments, pulse exam (all extremities), skin color/capillary refill, and mentation. Circulatory assessment may be challenging in the extremes of age, with concomitant heart disease, in athletes and pregnant women, and with medications, hypothermia, and pacemakers.
- Disability: A brief neurologic exam and assessment based on the Glasgow Coma Scale is essential, particularly if the patient requires therapeutic paralysis for intubation (recognize if patient is moving extremities and document facial nerve function prior to administering paralytic agents).
- Exposure/Environmental Control: Perform a full physical examination for injury, especially in the nonalert patient, while minimizing hypothermia.
What is an AMPLE history?
What is an AMPLE history?
An AMPLE history involves the key elements that can rapidly be obtained by the patient or patient’s friends or family when the patient has a limited ability to provide medical history. It consists of:
- Allergies
- Medications
- Past Medical History
- Last PO Intake
- Events leading to the trauma.
What are the methods of verifying a secure airway after intubation or surgical airway procedure?
What are the methods of verifying a secure airway after intubation or surgical airway procedure?
A secured airway must always be verified, including patients who are intubated in the field. The intubation itself should involve direct visualization of the vocal cords. Observation of equal chest rise/fall should occur. Auscultate for bilateral breath sounds, with consideration of the possibility of right main stem intubation. Capnography should be rapidly used to assess proper position; a small plastic insert is placed onto the endotracheal tube and is assessed over the duration of several breaths. Return of carbon dioxide confirms endotracheal positioning, and is indicated by a color change from purple to yellow on the capnography insert. Persistent purple coloration indicates no CO2 return (Yellow = mellow, Purple = problem) (Figure 67-1). A chest radiograph can demonstrate the position of the endotracheal tube above the carina, but does not necessarily rule out the possibility of esophageal intubation. Bronchoscopic confirmation of endotracheal tube placement is generally not feasible in the trauma bay setting.
Figure: A, Capnograph has turned yellow, indicating return of CO2. This device attaches to an endotracheal tube and changes color from purple to yellow with CO2 return. B. Capnograph remains purple, indicating no return of CO2.
What are the indications for chest tube placement?
What are the indications for chest tube placement?
A patient with hypotension and decreased breath sounds in the trauma bay should be presumed to have a tension pneumothorax. Decompression should be immediately performed. Needle decompression can rapidly be performed with a 14-gauge needle catheter in the midclavicular second intercostal space just above the rib. Rapid decompression can also be performed with an incision in the anterior axillary fifth intercostal space (generally the level of the nipple). Entry into the pleural space will decompress the tension pneumothorax; the chest tube can then be placed through this incision (immediate intervention involves the incision; do not wait for a chest tube to be ready if tension pneumothorax is suspected). A chest tube is also placed when hemothorax is suspected by exam or imaging. The initial chest tube output will dictate further management; greater than 1500 cc of blood is an indication for exploratory thoracotomy. Follow-up chest radiograph should occur after chest tube placement. Open chest wounds (“sucking chest wounds”) occur where the pleural space/pulmonary circuit directly communicates with the external environment. Large tidal volumes are lost through this open pulmonary wound. Initial management can include “three-sided” occlusive dressing. However, optimal initial management would include chest tube placement on that side of the thorax with a three-sided occlusive dressing to allow decompression and prevent tension pneumothorax.
What are the five locations of blood loss in a trauma patient?
- What are the five locations of blood loss in a trauma patient?*
- Scalp/Street: The scalp and face are highly vascularized areas and scalp bleeding should promptly be addressed with pressure, sutures, clips, or staples in the significantly injured patient. The prehospital care should include a rapid report that describes any significant blood loss at the scene of the trauma or en route.
- Chest: Rib fractures (up to 100 ml each), lung laceration, or injury to the great vessels or heart can result in significant thoracic hemorrhage and should be assessed for by examination (observation, palpation, auscultation) and imaging (radiograph, ultrasound, computed tomography).
- Abdomen: Solid organ or mesenteric injury may result in hemoperitoneum and should be assessed for by examination (observation, palpation) and imaging (ultrasound, CT).
- Pelvis/retroperitoneum: Bleeding here may occur from pelvic fractures, vascular injury, or solid organ injury (kidney, pancreas) and can be assessed for by examination, pelvis radiograph, and CT.
- Bones: Blood loss from a pelvic fracture can be as much as 2000 ml, femur fracture 1000 ml, tibia 250 to 500 ml, and rib fracture 100 ml each. Evaluate by physical examination and imaging (radiographs) when injury is suspected.
Define shock.
Define shock.
Shock simply means inadequate tissue perfusion. In trauma, the most common cause is hemorrhagic shock, which requires immediate hemorrhage control and resuscitation with blood products and/or intravenous fluids. Shock may also result from spinal cord injury (spinal shock or neurogenic shock). Cardiogenic shock may occur from tension physiology such as tension pneumothorax or cardiac tamponade. Cardiogenic shock from direct myocardial injury is less common in the trauma setting but should be considered for patients with a history of heart disease (i.e., syncopal episode leading to motor vehicle collision) or significant anterior chest wall trauma or sternal fractures. Septic shock should be considered for patients with a significantly delayed presentation such as extremely prolonged extrication or time-consuming transfer from remote locations.
What are the classes of hemorrhagic shock?
What are the classes of hemorrhagic shock?
See Table 67-1. Patients may display normal vital signs despite significant blood loss, as depicted in Table 67-1, warranting thorough evaluation for all trauma patients.
What are the key elements of the neurologic evaluation of a trauma patient?
What are the key elements of the neurologic evaluation of a trauma patient?
Traumatic brain injury is very common in the blunt trauma patient. The Glascow Coma Scale is used to rapidly evaluate eye (4 points), verbal (5 points), and motor responses (6 points). A score ranges from 3 (worst) to 15 (normal) and is used to help classify brain injury (13–15 = minor, 9–12 = moderate, 3–8 = severe). At a minimum, the patient should also be assessed for movement in all four extremities. Stable patients should have motor and sensory evaluation of extremities during the secondary survey. Based on identified injuries, further neurologic assessment may be warranted (spine injury, extremity fracture). Imaging (CT brain) in stable patients or immediate intervention with intracranial pressure monitoring by neurosurgery (patients unstable for imaging evaluation) should be considered for all altered trauma patients.
How are spinal cord injuries assessed?
How are spinal cord injuries assessed?
All patients suspected of having spinal cord injury should be properly immobilized. A neurologic exam assesses extremity movement, strength, sensation, and reflexes. A rectal exam is performed to evaluate for tone. Palpation of the entire spinal column for step-offs or tenderness is performed. In the absence of abnormalities on exam, distracting injuries, or intoxication, a gentle assessment of range of motion is then performed. Imaging is warranted for continued suspicion and may include cervical spine radiographs (lateral, anterior-posterior, and odontoid views, including C7 and T1 vertebrae) or computed tomography of the cervical spine (T, L-spine dependent on injury mechanism and exam findings). Magnetic resonance imaging is useful for neurologic deficits not explained by CT imaging, and may also be useful for clearing the cervical spine in an obtunded patient who otherwise may suffer from skin breakdown resulting from prolonged preemptive collar placement. MRI is most useful to exclude cervical spine ligamentous injury in the first 24 hours following trauma prior to nonspecific edema development, which MRI can later identify as a false positive.
What are the vascular access options for a trauma patient?
What are the vascular access options for a trauma patient?
An ideal vascular access for the trauma patient is a large-bore peripheral intravenous catheter (14 or 16 gauge). This short length, large-diameter catheter can allow rapid infusion of blood or fluid, but may be difficult to place in an acute setting. Additional options in order of ease of placement and rate of fluid delivery possible include: intraosseus access in the tibia/sternum, saphenous vein cutdown with large-bore peripheral IV placement, or central venous access (femoral, subclavian, or jugular vein).
When is blood transfusion indicated in a trauma patient?
When is blood transfusion indicated in a trauma patient?
A trauma patient who displays hemodynamic instability (HR >100, SBP <90) despite a fluid challenge (2 L crystalloid) and is suspected to have ongoing hemorrhage should receive uncrossed, O-negative packed red blood cells while patient specific type and crossmatch are performed.
What is the “Bloody Vicious Cycle”?
What is the “Bloody Vicious Cycle”?
Coagulopathy, acidosis, and hypothermia all contribute to each other, resulting in ongoing bleeding that cannot be controlled surgically and is uniformly fatal if not reversed. Aggressive patient and fluid warming and correction of coagulopathy with blood product resuscitation is warranted and may necessitate quick, basic surgery (“damage control surgery” to halt surgical hemorrhage and prevent ongoing contamination) to allow for more optimal resuscitation including correction of temperature, acidosis, and coagulopathy to continue in the intensive care unit setting.
What is a massive transfusion protocol?
What is a massive transfusion protocol?
Massive transfusion protocols are designed to facilitate transfusion of an appropriate ratio of blood products including packed red cells, fresh frozen plasma, platelets, and cryoprecipitate. Such protocols facilitate rapid preparation from the blood bank and help ensure appropriate ratios of product are given.
What are the key aspects of the chest radiograph for the trauma patient?
What are the key aspects of the chest radiograph for the trauma patient?
The chest radiograph in a trauma patient allows for rapid assessment for airway deviation, subcutaneous emphysema, pneumothorax, hemothorax, rib fractures, or mediastinal widening that may be indicative of great vessel injury. It can also assess the positioning of an endotracheal tube, central venous catheter or nasogastric tube.
What is the FAST?
What is the FAST?
Focused Abdominal Sonography for Trauma (FAST) is a rapid bedside test that assesses for fluid (presumed to be blood in setting of trauma) in various spaces. When performed and repeated during evaluation, it is a sensitive indicator of abdominal bleeding. Prior surgery (adhesions), ascites, body habitus, and user error are pitfalls. It entails four views:
- Pericardial view assesses for cardiac activity and blood in pericardial space
- Spleno-renal view assesses for blood loss in left upper quadrant
- Morrison’s pouch is the most dependent portion of the abdomen, right upper quadrant
- Pelvis view assesses for blood in perivesicular space/pelvis/lower abdomen
