Basics of Trauma Flashcards
What is the Initial Assessment
A
B
C
D
E
steps?
Initial Assessment
- for any trauma call or any call really for that matter that enters the ER this is the way in which you approach the situation
- you MUST complete, intervene if nessecary and stabilze one layer before moving to the next
- always call out your postive and negative findings to the room as you go
A: Airway
- probable need to intubate
B: Breathing
- breathsounds?
C: Circulation
- bleeding? fluids?
D: Disability
- GCS sclae
E: Exposure
- trauam naked to assess the body
Airway
Breathing
AIRWAY
- assess patency of the airway (within the C-collar precautions)
- is the patient talking? = probably in tact airway
- any obstruction (FB, fracture, etc.) ?
- GCS < 8 = intubate
in C spine collar = dont tilt head back to intubate
secure?
- secure placement with ET tube, confirm by auscultating, looking at ETCO2 measures on the device (end tidal Co2) to see if the ventilation is working
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BREATHING
- a secure airway does not mean they are accurately ventilating
- think about the lungs here: the biggest concern is a PTX or hemothorax
Assess
- expose neck and chest
- examine for tracheal deviation
- listen for breath sounds BILATERALLY
Address
- tension pneumothorax: absent breath sounds unilaterally, dyspnea & hypotension with trachial deviation = emergent needle decompression &/or chest tube (needle decomp. in the 4th-5th midaxiallry line)
- massive hemothorax: absent breath sounds, hypotension = chest tube placement with auto transfusion (give the blood back to them)
Circulation
CIRCULATION
- think about the blood volume, hemorrhage and cardiac output, where is the bleed and how to correct it
- once the tension pneumo is excluded or corrected & the hypotension remains = think about a bleed
Address
- Level of Consciousness = amont of cerebral perfusion
assess distal pulses in all extremities
- lack a pulse? problem probably in that limb (a SBP of 90-100 will have pulses, anything lower you probabl wont feel)
see the bleed?
- try to stop it via tournequet or quick suture close (especially the scalp)
give blood products:
- 1- 1.5 L of LR bolus THEN swap to blood products
if pt. remains hypotensive despite control of external bleeding = think about internal bleeds
Internal Bleeding
- FAST Exam: to see interal bleeding from US
- pelvic xray: to see for internal bleeds
unstable and postive FAST? = to the OR
open book pelvic fracture = pelvic binder
D: Disability (Neurologic Evaulation)
Disability: do the GCS assessment
GCS: never 0!
minor = 13-15
moderate = 9-12
severe = 3-8
less than 8 = intubate
GCS
- Eye Opening Response
- Verbal Response
- Motor Response
if the GCS Score is low… consider why
- head trauma?
- hypovolemia/shock
- hypoglycemic
- durs/alcohol?
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Pupils
- equal? reactive? Size? pinpoint or dialted?
Motor/Sensation
- evaluate for SCI
- sensation? can they move all exteremities
- purposeful = crosses midline
- docorticate ( towards core-chest)
- decerebrate (away from chest)
E: Exposure
EXPOSURE
- trauam naked: remove clothing
Need to assess entire body = role pt. on their side to examine back (while keeping them in spinal precautions on the board)
- evaule back via roll
- lift arms to evaluate axilla
- spread legs to see perineum
- palpate spine
cover with blankets!!
also take this time toe valute environemtn expousre (frosbite and burns
Trauma Codes
Traumatic Cardiac Arrest
Thoracotomy (Open Chest)
Traumatic Cardaic Arrest
- B/L chest tubes
- central line
- CPR
- H/Ts for most common cuases of teh cardiac arrest
Thoracotomy
- clam-shell opening to identify vascualture and cariadac injury
- allow for cardiac massage
cardaic arrest?
CPR
B/L chest tubes
thoracotomy
Secondary Survey
Secondary Survery
- done after the ABCDE’s to get a better idea and more through impression of the pt.
- go in a head to toe fashion to indetify other injuries that need attention
- also helps idenitfy possible mechanism of injuries
Skull
- basialr skull fx? depression? fractures? lacerations?
Face
- palpate face for facical fx. and stabbility
Eyes
- globe rupture?
- increase IOP?
Ears
- hemotympanum? sigsn of internal head injury
- lacerations
Nose
- blood?
- septal deviation?
- singed nasal hairs? smoke
Mouth
- teeth? missing?
- intraoral lacterations
Neck
- open wounds
- seatbelt sing: bursing of upper neck
Secondary Survery (from the neck) pt. 2
Chest
- rib tenderness or deformity
- penitrating wounds
Abdomen
- soft and nontender?
- penitration?
Pevlis
- stable?
- rectal tone? can be done if youre nevous about SCI
- blood in orifices?
Flank (back)
- assess for ecchymosis (can be done on initial role)
Back (during long roll)
- midline tenderness or stepoffs
Arms and Legs
- pulses? recheck
- deformities
- open fractures
- tissue injuries
- sensation/strength
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Intervention
- reduce any fractures if NV compromised
- ABI cna be done to determine vascular injuries
- immobilze unstable fractures
- pressure dress teh wounds
e-FAST Exam
indications
locations
Indications
- blunt trauma
- unstable penitrating trauma
- good for kids/pregnant
US basics
- fluid = dark
- fat = bright
- bone = brightest
negative fast doesnt rule out intra-abdominal injury
Stable? can do all locations than intervene
unstable if find a postive finding at a location; intervene
Locations
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Cardiac
- get 4 chamber window
- subxyphoid or parasternal views
- look for pericardial effusion
RUQ
- fluid between liver and kidney
LUQ
- fluid between spleen and kidney
Pelvis
- fluid in plevis
- identify bladder
Lung
- midclavicualr line 2/3 intercostal
- look for lung sliding = the waves on a beach
- if barecode (no slidng) = PTX
TBI: in trauma assessment
things to remember
Monroe-Kellie Doctrine
Severity
severity: classified by the GCS scale
remeber: severity does not always correlate with size of hemorrhage
- older people: more atrophy: more room for the brain to get thrown around and swell before we know its happening
Monroe-Kellie Doctrine
- total volume of intracrainal contents has to saty constnat – so somehting has to give/decrease in order to keep same amount there
Subdural Hematoma
Subdural - below the dura
- collection between dura and arachnoid
- bleeding from bridging vessels = CRESCENT shape
- underlying brain damange more severe than EDH because injury to parynchma high
CT
Epidural Hematoma
Epidural = above the dura
- between dura and skull
- MMA is most common artery to bleed but can be venous, venous sinus too
- football shape on imaging
- pt. will have classic LOC, leucid interval then steep decline
- often temporal lobe
CT
Subarachnoid Hemorrhage
- between arachnoid and pia mater
- bleeding can be traumatic (see on the edges) or atramatic (anyuresym rupture, middle MC)
CT
Intraparenchymal hemorrhage
think about this as a bruise
- a contusion of the brain tissue: frontal or temportal MC
- blossom over time: like can continue to bruise = follow up imaging!!!
CT head continuously to monitor
Diffuse Axonal Injury
- high velocity impact, acceleration/decelleration injury
- see multiple punctate hemorrages on the boarder of the grey and white matter
- DAI = stretched axons; not torn
Symptoms
- severe = unconsciousness
- less severe = on imaging you can see mild areas which are less severe punctates
Dx. MRI
Treatment of TBI: Minor
Minor TBI : GCS 13-15
when do you get a CT?
- if the GCS < 15 2 hours after injury
- 2+ vomiting
- age > 65
- anyone on blood thinners
- LOC > 5 minutes
- amnesia before the event
- dangerous mechanism of injury
the PECARN score can be used to determine if kids need CT of head
Observe/Admit those with…
- abonormal CT
- deterioriating LOC
- mderate/severe HA
- durg/alcohol intox.
- skull fx.
- no support
- GCS < 15
- focal neuro deficts
anyone who doesnt have the above = discharge with good instructions
Treatment of TBI: Moderate
Moderate TBI : GCS 9-12
anyone in this class needs a CT scan & will be admitted
Admission
- if you cant admit; send to a neruo facility who can
- frequent neurochecks
- CT follow up 6-24 hours after
Improve? = discharge
Deteriorate? = repeat imaging & if they GCS to an 8, manage as severe
Treatment of TBI: Severe
Severe TBI: GCS 8 or less
Management
- ABCDE’s: this means intubate to secure an airway
- get a good neuro exam
Therapeudics (to lower the ICP)
- mannitol
- hypertonic saline
- hyperventilation (less used)
- maintain SBP < 140-160 (goldie locks spot to allow good perfusion but not too high that it increase ICP)
Surgery Interventions
- interventircular drain
- ICP Monitor
- Craniectomy/otomy
Facial Trauma
- assessment of what
- LeFort Fractures
Assessment
- first; airway? they might need emergent trach.
- they porbbaly will have bad hemorrhage: stop the bleed if able
- evaluate for globe trauma
- consider CTA for the possibility of carotid artery shearing in a bilateral mandibular fx. or severe facial trauma
LeForts Fracture
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LeFort 1
- horizontal maxillary fracture of the upper teeth bone/lip area
- fracture passes horizontally
LeFort 2
- Pyramidal fracture: teeth at the base, superior nasal suture at the apex
LeFort 3
- craniofacial disjunction
- this includes the maxillo-frontal sutures, zygomatic arch, orbital wall
Penitrating Neck Trauma
Zones
Treatment
Zone 1
- betweel clavicle and the superior cricoid cartilage
Zone 2
- inferior cricoid cartilage to the mandible
- caroitds here
- vertebral arteris,
- internal jugular
- trachea
- esophagus
Zone 3
- from the angle of the mandible to the base of the skull
- distal caroitids
- vertebral artereirs
- pharynx
Treatment
- wound exploration
- direct visualization of the esophagus = endoscopy
- direct visualization of the trachea = bronchoscopy
- radiologic evaculation of teh esophagus = esophogram for a leak with barium = the next day
Blunt Cerebral Vascular Injury
- symptoms
- risk factors
- diagnosis
- treatment
Cerebral Vascualr Injury = think about the vertebral and carotid arteries
Symptoms
- bleeding from neck, nose or mouth
- neck hematoma = thats EXPANDING
- focal neruo deficts (TIA, horners)
- neuro deficts that arent found on CT
Risk Factors
- LeForts II/II + mandibualr fx.
- basilar, occiptal condyle fracture
- cervicalcublux, C1-C2 fx.
- hanging or clothesline injuires
Diagnosis
- CT or MR angiogram
Treatment
Grade 1 = anticoag/platelet them
Grade 2 = OR repair, or anticaog/platlet
Grade 3 = endovasucalr treatment
Pneumothorax (3 types)
treatments
Tension PTX
- should be found during primary assessment
- needle decomp and chest tube
Simple PTX
- observe or chest tube placement
Open PTX (sucking chest wound)
- occlusive dressing secured on three sides
- DO NOT place a chest tube through the opening , but put one
Hemothorax
treatment
Hemothorax
- present with hypotension and shock
- large blood volume accumulation
- any pleural effusion seen in a trauma is considered a hemothorax until proven
Treatment
- if they are bleed > 1.5 L or > 200mL for 2-4 hours= send to the OR (they’re bleeding from a big vessel)
- anyone else: chest tube placement to drain blood
Chest Tube
- large bore for blood: 4th-5th ICS
- monitor output and suction
- remove chest tube only once its been < 50 per day
Cardiac Tamponade
etiology
- pericardial effusion thats impacting electrical conductivity of the heart
- can be from penitrating woudn or blunt trauma
Becks Triad: muffled heart sounds, hypotension & JVD
left sided tension PTX can mimic this
Diagnosis
- FAST exam and confirm with a pericardial window (effusion will drain if +)
Blunt Cardiac Injury
what can occur
signs
monitor
What can occur
- myocardial mucle contusion (brusie)
- cardiac chamber or valve rupture
- coronary artery dissection
can be due to like a sternal fracture
Signs
- EKG changes : STEMI, PVCs, ST, Afib, BBB
Treatment
- monitor tele 24 hours
- monitor troponins
- arrythmia highest risk in first 24 hours
Traumatic Aortic Injury
mechanisms
CXR findings
Treatment
Mechanism
- a high velocity/decelleration injury
- can be found with concourrent spinal and bowel injuries
common casue of death in pts.
CXR findings
- widened mediastinum
- large left hemothorax
- rightward tracheal deviation
Treatment
- open v endovascualr repair
Grades: Stanford/debakey
Grade 1: rip
Grade 2: tear
Grade 3: ballon
Grade 4: rupture
Diagnostics used for Abdonmial Trauma
FAST
Peritoneal Lavage
CT Scane
FAST
- early check for internal damange and bleed
- doesnt’ evaluate for bowel or pancreatic or diaphrghm injuries
Lavage
- can detect bowel injury
- put fluid in, pull out and assess if bloody
- doesnt get diaphgram or retroperitoneal
CT Scan
- most specific for abd. injuries
- misses bowel and diaphragm too
Penitrating Abdomnial Injuires
- Mechanisms
- stab wound: evaluation
- thoraco-abd. & lower chest eval?
Mechanisms
- GSW: the path is unpredictable
- Stab wounds: a diagnostic laparscopy evaulation can assess penitration and can convert to open in there is an injury found
Thoraco-abdominal/lower chest evaluation
- left hemi > right
- early surgical exploration preferred: diagnsis with laparomty or laparscopy
Solid Organ Injury
what organs
hemo unstable = how to treat
hemo stable = how to treat
Solid Organ Injury
- liver
- spleen
- kidney
blunt or penitrating trauma can causes this
all these injuires can be ranked on a grade 1- 5 for severity
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Hemodynamically unstable = go to IR for embolization & exploratoyr lap.
Hemodynamically stable = close monitoring with seiral exams
Hollow Organ Injury
early US and CT often miss this
penitrating trauma > blunt
if you see..
- seatbelt sign
- lumbar change fracture
think bowel injury
Penitrating = ex-lap with running the bowel for perforation
blunt but sus? = monitor, abd. exams, lactace labs
Indications for a Exploratory Laparotomy
Indications
- blunt aub. trauma + hypotentsion + a postive FAST
- blunt or penitrating abd. trauma with positive DPL (lavage)
- hypotension + penitrating abd. wound
- GSW
- bleed from stomach, rectum, GU tract with penitrating trauma
- peritonitis
- free air
- CT evidence of GI ruputure, bladder injury, severe visceral injury
- worsening exam or need for transfusion after IR
Pediatric Trauma
Bones
- rib fx. rare: but lungs get brusied
Shock
- kids can compensate longer, but then they get really bad
C-Spine Clearance
- differs for children
Head Trauma: kids have less space so small bleed = worse effects
always consider nonaccidental trauma
Geriatric Trauma
- less likely to be injured, but more likely to be fatal
- alwasy get their med list!!!!
- beta blockers mask hypotension sympotms
- high bleed risk with thinners
Pregnant Trauma
- abrupt decrease in material volume = significant O2 effect on baby
- mom is ually hypocapnia in late preg; if she ahs noraml, consider respiratoyr failure of abby
- always apply O2 to mom = to help baby asap on presentation
Assessment
- apply O2 to mom
- LLD postion (with spinal precautions)
- obtain fetal heart tones during FAST
- watch vaginal bleeding
- consutl OBGYN
- rhogram for RH- mom even if minor trauma
