approach to trauma Flashcards
What are the principles of immediate care in a pre-hospital setting?
CALL 911
- assess potential safety issues
- quickly assess patient based on
- mechanism of injury
- level of consciousness
- vital signs
What are the indications of potential significant injury?
- penetrating trauma
- major fracture
- major burn
- evidence of high velocity impact
What are low velocity penetrating injuries?
- caused by knives, spikes of glass
- focused over small area
what are high velocity penetrating injuries?
- firearm injuries
- dissipated over wide area
- the higher the velocity of the missile the more damage
What are the pre-hospital resuscitation principles?
A irway maintenance B reathing adequacy C ontrol external bleeding & treat shock D isability (immobilize patient) - communicate with receiving hospital & immediate transport to closest appropriate facility - history taking
why is triage done?
- to deal with a large number of casualties
- based on need for treatment & available resources
- done pre-hospital by EMS team based on trauma
scoring system
BEST medical care to LARGEST number of patients resulting in BEST POSSIBLE outcome
The revised trauma score (RTS) is based on?
- Glasgow coma scale (GCS)
- systolic blood pressure (SBP)
- respiratory rate (RR)
the injury severity score (ISS) is based on?
3 most severely injured body regions have their score squared & added together to produce score
the trauma & injury severity (TRISS) scale is based on?
- combines anatomical (ISS) & physiological (RTS) measures of injury severity
- patient age
- probability of survival
What are the triage categories within the hospital?
1 = code red LIFE THREATENING needs immediate management (tension pneumothorax) 2 = code yellow URGENT (fractured femur) 3 = code green MINOR delayed (contused wound) 4 = code white DEAD
TREAT LIFE THREATENING FIRST IF IT DOES NOT EXCEED THE ABILITY OF FACILITY
what should the initial management of seriously injured patients consist of?
1- primary survey & concurrent resuscitation
2- secondary survey
3- diagnostic evaluation
4- definitive care
What does the primary survey consist of?
A irway maintenance with cervical spine protection B reathing & ventilation C irculation with hemorrhage control D isability (neurologic status) E xposure & environmental control
How should the C-spine control occur?
place a hard collar with sand bags by the sides of the head until the cervical spine has been cleared
Which patient do not require early attention to the airway?
- conscious
- don’t show tachypnea
- have a normal voice
EXCEPT
- penetrating injury to the neck
- expanding neck hematoma
- evidence of chemical or thermal injury to the upper
airway
- extensive subcutaneous air in the neck
- complex maxillofacial trauma
What are the causes of airway obstruction in trauma?
- tongue
- blood
- vomitus
- foreign body
- soft tissue swelling
- in upper airway burn
- in maxillofacial/laryngeal/trachebronchial trauma
What are the signs of airway obstruction?
- noisy breathing
- choking
- stridor
- dyspnea
- aphonia
- dysphonia
What technique should be used for airway obstruction?
- positioning
- head-tilt/chin-lift (jaw thrust if suspected C-spine injury)
- finger sweep with caution
- suctioning
- oral airway/nasal airway (tongue)
- endotracheal intubation
When should endotracheal intubation be inserted?
- in patients with apneaa
- inability to protect airway due to
- altered mental status
- impending airway compromise due to inhalation injury
- hematoma
- facial bleeding
- soft tissue swelling or aspiration
- inability to maintain oxygenation
Who should we preform a cricothyroidotomy on?
- patients in whom intubation has failed
- contraindication of intubation due to extensive facial injuries
Who should an emergent tracheostomy be preformed on?
- patient with laryngotracheal separation
- laryngeal fractures
What is the normal breathing rate?
16 - 20
how is breathing guaranteed in injured patients?
- all patients should receive supplemental oxygen
- be monitored by pulse oximetry
What should be done to assess breathing?
LOOK
- symmetry of chest expansion
- signs of increased effort
- skin color
LISTEN
- mouth & nose
- lung fields
FEEL
- mouth & nose
- symmetry of expansion
what are he signs of inadequate ventilation?
- tachypnea
- bradypnea
- signs of distress
- nose flaring
- retractions
- accessory muscle use
- tripod positioning
- cyanosis
What are the causes of inadequate ventilation?
- tension pneumothorax
- open pneumothorax
- flail chest with underlying pulmonary contusion
where can systolic blood pressure be palpated?
- CAROTID at C6 = 60mmHg
- FEMORAL = 70 mmHg
- RADIAL = 80 mmHg
- DORSALIS PEDIS = 90 mmHg
should be measured manually every 5 mins in patients with significant blood loss until normal vital signs restored
any episode of hypotension SBP<90mmHg is assumed to be caused by what?
hemorrhage until proven otherwise
IV access should be achieved using what?
2 peripheral catheters, 16-gauge or larger
if difficult:
- saphenous vein cut downs at the ankle in adults (side of medial mallellous)
- intraosseous needle in proximal tibia under 6 years
(osteomyelitis)
how should major external hemorrhage be controlled?
gloved finger is place through wound directly into bleeding vessel & enough pressure should be applied to control active bleeding
how should minor severe bleeding be controlled?
manual compression of open wounds with active bleeding with a single 4x4 gauze & a gloved hand
What should be avoided in severe bleeding control?
- excessive dressings
- blind clamping
- tourniquets
How should a patient with an open fracture be managed?
fracture reduction with stabilization
What should be done for scalp lacerations?
skin staples
what does the neurological assessment of disability include?
- level of consciousness
- pupils (RRR)
- lateralizing signs
What are the GCS scores?
ranging from <9 severe injury, 9 - 12 moderate injury, 13- 15 is mild head injury
BEST EYE RESPONSE (4) 1- no eye opening 2- eye opening to pain 3- eye opening to verbal command 4- eye opens spontaneously
BEST VERBAL RESPONSE (5) 1- no verbal response 2- incomprehensible words 3- inappropriate words 4- confused 5- oriented
BEST MOTOR RESPONSE (6) 1- no motor response 2- extension to pain 3- flexion to pain 4- withdrawal from pain 5- localizing pain 6- obeys command
When should the secondary survey begin?
after the primary survey has been completed
in severely injured patient it may not begin until the patient has returned from OR
head to toe examination
patients history should be reviewed
What should be done in the secondary survey physical examination?
1- HEAD & FACE
- exclude midfacial injury & potential airway compromise
2- NECK
- inspect & palpate C-spine anteriorly & posteriorly for hematomas, crepitus, tenderness
- spine should remain immobilized until formally cleared clinically & radiologically
3- CHEST
- palpate entire chest wall & review primary survey
4- NEUROLOGICAL
- examine GCS regularly
5- ABDOMEN & PELVIS
- inspect for distention, bruising or penetrating wounds
- palpate iliac crest for pain which may indicate pelvic instability resulting from ring fractures
6- EXTREMITIES
- unless there is severe haemorrhage its not threatening
- deformed limbs should be manipulated into as near anatomical alignment
What should be done for stable stab patients?
never send them home before 24 hours
What is the deadly triad?
protracted surgery in a physiologically unstable patient can be fatal, especially in:
hypothermia
acidosis
coagulopathy
if resuscitation & early therapy is preformed in OR to control bleeding & prevent contamination its considered?
damage control surgery
secondary surgery could be done later to have final control
What should be done in a damage control surgery?
minimum surgery to stabilize condition
deliver active colloids, clotting products, & whole blood to avoid deadly triad
1- STOP ANY ACTIVE BLEEDING
2- CONTROL ANY CONTAMINATION
How is the abdomen closed after a damage control surgery?
temporarily using a sheet of plastic over the bowel (OPSITE)
What are the stages of damage control surgery?
1- patient selection 2- control of hemorrhage & contamination 3- resuscitation continued in ICU 4- definitive surgery 5- abdominal closure
What are the indications for damage control surgery?
- anatomical inability to achieve hemostasis
- complex abdominal injury
- combined vascular, solid, & hollow organ injury
- inaccessible major venous injury
- demand for non-operative control of other injuries
- anticipated need for a time-consuming procedure
IF A PATIENT IS NOT IMPROVING
how do we know a patient is not improving?
- decline of physiological reserve
- temperature <34
- PH <7.2
- serum lactate >5mmol/L (normal is <2.5)
- prothrombin time is >16s
- PTT >60s
- > 10 units blood transfused (delusional coagulopathy)
- systolic blood pressure <90mmHg for >60mins
