neuro status - glasgow coma scale - spinal cord injury (neuro shock)

B6.072 The Basics of Trauma Flashcards by Lauren Sinik

mechanisms of blunt trauma injury

falls
MVC
assault
pedestrian struck
MCC
bicycle wreck

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mechanisms of penetrating injury

stab wounds
GSW
SGW
impalement

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special situations that cause traumatic injuries

explosions
burns
crush injuries
drowning
hypothermia/exposure

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rule #1 of trauma

don’t panic

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pre-requisites of initial trauma assessment

wide angled view (don’t get distracted by gory injury)
pattern recognition skills
ability to triage and set priorities
organized structure

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overview of primary survey

A- secure airway
B- ensure breathing
C- is it shock?
D- deficit/deformity
E- where are all the injuries

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overview of secondary survey

more detailed history
look them over head to toe
reassess
FAST
adjuncts
imaging studies

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A is for airway

clear and establish a good airway
-consider intubation for coma, shock, obvious airway compromise, some thoracic injuries
maintain C-spine stabilization

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B is for breathing

chest excursion and breath sounds
-flail chest (paradoxical movement)
pneumothorax
-open
-tension
massive hemothorax

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treatment of pneumothorax

needle decompression followed by chest tube

chest tube drains blood from the lungs

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C is for circulation

perfusion (mental status, skin, pulse)
control bleeding with pressure
pericardial tamponade
establish 2 large bore IVs
resuscitate with blood early, especially for hemorrhagic shock

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most common cause of shock in trauma patients

hemorrhagic

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Becks triad

JVD
muffled heart sounds
hypotension

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massive blood loss

loss of a blood volume within 24 h or acute 50% reduction of total blood volume within minutes of injury

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massive transfusion

> 10 units PRBC or equivalent patient’s blood volume in 6-24 h

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what class of hemorrhagic shock presents with hypotension

class 3
class 1 and 2 have normal BP, so need to be on the lookout early

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triad of hemorrhagic shock

hypothermia
acidosis
coagulopathy

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treatment of hemorrhagic shock

balanced resuscitation

1: 1:1
blood: FFP: platelets

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D is for disability

neuro status

glasgow coma scale
spinal cord injury (neuro shock)

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D is for deformity

obvious broken bones

-open vs closed (tetanus status, antibiotics, more urgent OR)

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Glasgow coma scale scores

minor brain injury: 13-15

moderate: 9-12
severe: 3-8

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neurogenic shock

due to high spinal cord injury which leads to interruption of sympathetic vasomotor input

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physical findings in neurogenic shock

hypotension
bradycardia
warm extremities

treatment of neuro shock

volume resuscitation followed by vasopressors if not resolved with volume

E is for exposure

``` remove clothes temperature (warm blankets and fluid) log roll -maintain spine precautions -palpate for spinal deformities -rectal exam to check tone, blood, prostate ```

what do you do if a patient decompensates at any point during the primary / secondary survey?

respond and restart survey at ABCDE again

important components of patient history

tetanus | AMPLE (allergy, meds, PMH, last meal, environment)

common imaging in secondary survey

CXR pelvis Xray FAST CT

blood sampling /monitoring in secondary survey

type and cross | ABG

what is the FAST exam

``` quick ultrasound to scan for blood in the abdomen 4 view: 1. hepatorenal pouch 2. perisplenic space 3. pelvis 4. pericardial black = fluid ```

pros of FAST exam

``` fast portable bedside non-invasive may be repeated ```

cons of FAST exam

not specific for injury no evaluation of retroperitoneum will miss bowel injuries

what is the next step in management if your FAST is positive and the pt is hypotensive

go to the OR

management of fractures in trauma scenarios

stabilize relocate dislocated joints reassess pulses

what is an effect of long bone/pelvic fractures

increased blood loss

what is a step you can take in the management of a bad pelvic fracture

bring patient to IR for embolization

what are some difficulties with abdominal trauma

high morbidity and mortality if unrecognized (massive hemorrhage, sepsis) internal injury difficult to assess in the field often confounding factors present

epidemiology of abdominal trauma

7-15% of all trauma deaths penetrating injuries account for <10% blunt injuries are the most difficult to diagnose and have a 10-30% mortality 75% of blunt abdominal trauma is due to MVCs

abdominal vs thoracic injuries

abdominal: found on secondary survey and higher % require surgery thoracic: found on primary survey and lower % require surgery

define the abdomen on the anterior

``` between nipples (diaphragm) and pubic symphysis between axillary lines ```

define the abdomen on the posterior

between scapular tips to crest of iliac wings

solid organs in the peritoneal cavity

liver spleen risk of hemorrhage > hypotension

hollow organs in the peritoneal cavity

stomach intestines colon risk of contamination > peritonitis

components of retroperitoneal cavity

solid organs (kidneys, pancreas) large blood vessels (aorta and vena cava) potential space for massive hemorrhage

results of deceleration forces

differential movement of fixed and non-fixed structures | tearing occurs leading to bleeding and contamination

organs most commonly injured in blunt trauma

solid organs (spleen, liver kidney

blunt diaphragm injury

can be due to increased abdominal pressure or lacerations from rib fractures

blunt small bowel injuries

"seat belt injury" | can be due to crushing, deceleration, or increased pressure

2 types of blunt bladder injury

1. intraperitoneal rupture with full bladder (need surgery) | 2. extraperitoneal rupture with pelvic fracture (heal with foley decompression)

assessment of abdominal trauma

look: distension, bruising, seat belt sign feel: tenderness, guarding, rebound, soft vs rigid

peritoneal signs

= acute abdomen - guarding - rebound tenderness - percussion guarding

what is the response to discovery of an acute abdomen

laparotomy

what are some factors that could make a physical exam unreliable within trauma

if it is normal associated (distracting) injuries head injury intoxication

pitfalls in physical exam in trauma patients

- blood is not initially irritating to the peritoneum - altered sensorium decreased physical exam - small bowel injury may not show signs of peritonitis for many hours

treatment of small bowel perf

debridement and primary repair

treatment of transverse colon perf

transverse colectomy