98. Trauma (16%) Flashcards
(Primary Survey with Simultaneous Resuscitation)
Describe Airway
- Airway with C-spine protection - anticipate airway compromise (eg. airway burn)
- Inspect (foreign bodies, facial/mandibular/tracheal/laryngeal injuries, burn)
- Clear airway (suction)
- Oxygen (mask, nasal prongs)
- Open Airway : Jaw-thrust, chin-lift, Oropharyngeal airway (if unconscious)
- Secure airway. Definitive airway if airway not maintainable (eg. GCS ≤8) (Intubation, supraglottic, cricothyroidotomy). Consider quick neuro exam prior to sedation
(Primary Survey with Simultaneous Resuscitation)
Describe Breathing
- Breathing and ventilation - RR, WOB, tracheal deviation, signs of injury to chest wall, auscultate
- Oxygen + pulse oximeter (O2 sat)
- Needle decompression, tube thoracostomy
- r/o pneumothorax, hemothorax, flail chest
(Primary Survey with Simultaneous Resuscitation)
Describe Circulation
- Circulation with hemorrhage control - bleed, pulse, BP, skin colour
- If possible, control hemorrhage before volume resuscitation
- Avoid “exploring” wounds unless directed by Trauma consultant
- Direct manual pressure to bleeding sites. Consider tourniquet (or alternative, eg. BP cuff) if pressure not effective and risk to patient life
- Identify internal hemorrhage (chest, abdomen, retroperitoneum, pelvis, long bones)
- Monitors
- IV x2. (Consider IO, central venous access ; 1L warmed fluids then blood products ; Consider Tranexamic acid)
Describe manamgenet : Internal hemorrhage
- Pericardial decompression
- Pelvic binder, extremity splints, surgery
(Primary Survey with Simultaneous Resuscitation)
Describe Disability
- (neuro) - GCS (LOC), pupils, lateralizing signs, glucose
- Change in mental status -> rule out ABC cause for decreased brain perfusion
- Consider CNS injury, hypoglycemia, CO, drugs (alcohol, narcotics)
If suspect traumatic brain injury, how to prevent hypotension and hypoxia ?
- Raise head of bed
- Consider mannitol (care as lowers BP) vs. hypertonic saline (preferred in hypotensive patient)
- Use ASIA tool to determine spinal cord injury level
(Primary Survey with Simultaneous Resuscitation)
Describe Exposure
- Exposure and environmental control - Undress but prevent hypothermia (warm blankets)
- Microwave can be used to warm crystalloids, but not blood products
- IV fluid warmer (Level One, Ranger) for blood products
Describe : Secondary Survey (5)
- AMPLE history from patient, family, EMS. (Allergies, Meds, PMH, Last meal, Events)
- Recheck ABCDE
- Head to toe (including log roll, rectal exam, vaginal exam)
- Bedside ultrasound (eFAST), Chest/Pelvis X-rays, DPL
- Medications : Analgesia, Antibiotics, Tetanus
Describe interventions to be done from head to toe in secondary Survey (5)
- NG or OG tube if no sign of basal skull fracture
- Urinary foley catheter if no blood at meatus or perineal ecchymosis. Urine output goal of 0.5mL/kg/h in adults (1mL/kg/h in pediatric, 2mL/kg/h in <1yo)
- Pelvic binder
- Immobilize deformed joints/bones
- Resolve reversible arterial compromise (dislocations)
Describe : Tension pneumothorax
- Thoracostomie à l’aiguille au niveau de la ligne médio-claviculaire du 2ème espace intercostal ou de la ligne axillaire antérieure/moyenne du 5ème espace intercostal, n’attendez pas la radiographie (peut faire une échographie au chevet)
- Drain thoracique au cinquième espace intercostal sur la ligne axillaire antérieure
Describe : Cardiac tamponade
- Penetrating chest wound
Beck triad (hypotension, distended neck veins, muffled heart sounds), pulsus paradoxus, Kussmaul sign (rise in JVP on inspiration) - Confirm with echochardiogram
- Péricardiocentèse
Name Life-threatening complications in trauma (6)
- Tension pneumothorax
- Cardiac tamponade
- Hemothorax
- Flail chest
- Upper airway obstruction
- Aorta lesion
Suspect shock or occult shock when ? (5)
- Isolated or persistent sBP<110mmHg (ask about lowest recorded BP)
- Shock Index ≥1 (ie. HR>sBP)
- Change in Shock Index from field to arrival ≥0.1
- Hemorrhage with flat IVC
- Loss of central pulses or signs of poorly perfused extremities
Name Types of Shock (7)
- Hypovolemic
- Obstructive
- Cardiogenic
- Distributive
- Endocrine
- Metabolic (acidosis, hypothermia)
- Drugs (CCB, BB, Digoxin)
Name types of hypovolemic shock (2)
- Hemorrhagic (Ectopic) until proven otherwise
- Non-hemorrhagic (GI, skin-burns, renal, third space, pancreatitis)
Name types of obstructive shock (2)
- Pulmonary vascular (PE)
- Mechanical (Tension pneumothroax, pericardial tamponade)
Name types of Cardiogenic shock (3)
- Cardiomyopathic (MI)
- Arrhythmogenic (tachy/bradyarrhythmia)
- Mechanical (valvular)
Name types of distributive shock (3)
- Sepsis
- Neurogenic (traumatic brain injury, spinal cord injury)
- Anaphylactic
- Inflammatory
Name types of endocrine shock (3)
- insuffisance surrénalienne
- thyréotoxicose
- coma myxœdème
Name types of metabolic shock (2)
- acidosis
- hypothermia
Describe things to take into consideration in transfers (5)
- Do not waste time doing investigations if you cannot treat (eg. don’t do CT abdo if you don’t have surgery)
- Refer to trauma center
- Consider most appropriate mode of transfer (ground vs. airplane vs. helicopter)
- Be wary of air travel for pneumothorax or low O2 saturations
- Consider intubation/chest tubes/procedures prior to transfer
Find opportunities to offer advice to prevent or minimize trauma. Name examples. (3)
- do not drive drunk
- use seatbelts
- helmets
In children with traumatic injury, rule out what ?
Abuse.
Carefully assess the reported mechanism of injury to ensure it corresponds with the actual injury.
