Chapter 1: Trauma Flashcards
How can you tell that a patients airway is present?
- Patient is conscious
2. Speaking in a normal tone of voice
When should an airway be secured?
- If the patient is unconscious with a GCS of 8 or under.
- If breathing is noisy or gurgling
- Severe inhalation injury
- If necessary to connect patient to a respirator
How is an airway most commonly inserted?
Orotracheal intubation.
Under direct vision with use of a laryngoscope, while monitoring pulse oximetry
Can orotracheal intubation be done in the presence of cervical spine injury?
Yes, if the head is secured and not moved. Another option in this setting would be nasotracheal intubation over a fiber optic bronchoscope.
When is the use of a fiber optic bronchoscope mandatory?
If there is subcutaneous emphysema in the neck
The presence of subcutaneous emphysema in the neck is a sign of what?
A sign of major disruption of the tracheobronchial tree.
When do you resort to cricothryoidotomy?
- Laryngospasm
- Severe maxillofacial injuries
- Impacted foreign body that cannot be dislodged
How do you establish that breathing is okay?
- Hearing breathing sounds on both sides of the chest
2. Having a satisfactory pulse oximetry
What are the clinical signs of shock?
- Low blood pressure (90 mm Hg systolic)
- Tachycardia
- Low urinary output
What is considered a low urinary output?
Under 0.5 mL/kg/h
In a trauma setting, what causes shock?
- Hypovolemic-hemorrhagic shock (most common)
- Pericardial tamponade
- Tension pneumothorax
What event normally causes a pericardial tamponade or a tension pneumothorax?
There must be a trauma to the chest- blunt or penetrating
In shock caused by bleeding what is the CVP?
CVP is low due to empty veins clinically
What is the CVP a in cardiac tamponade?
The CVP is high
What is the CVP in a tension pneumothorax?
The CVP a is high presents as distended head and neck veins
How does a tension pneumothorax present?
- Severe respiratory distress
- One side of chest has no breath sounds
- Hyper resonant to percussion
- Tracheal deviation away from effected side
- All of the shock symptoms
What is the first step of treatment of hemorrhagic shock?
Volume replacement 2 L of lactated ringers
2 peripheral IV lines, 16 gauge
What is another way to access children for an IV line access?
In children under the age of 6, intraosseous cannulation of the proximal tibia is the alternative route
How is cardiac tamponade diagnosed?
Clinical diagnosis
Do not order X-rays, if unclear diagnosis chose sonogram
What is the management of cardiac tamponade?
- Pericardial window
- Pericardiocentesis
- Fluids!
How is a tension pneumothorax diagnosed?
Clinical diagnosis!
What is the management of a tension pneumothorax?
- Start with a big needle into the affect pleural space
2. Chest tube connected to underwater seal
Where do you place the chest tube in a patient with tension pneumothorax?
Inserted high in the anterior chest
What are some causes of hypovolemic shock?
- Bleeding
- Burns
- Peritonitis
- Pancreatitis
- Massive diarrhea
How do you treat hypovolemic shock?
Treat by stopping the bleeding and blood volume replacement.
What are some causes of intrinsic cardiogenic shock?
- Massive myocardial infarction
2. Fulminating myocarditis
What does the CVP of intrinsic cardiogenic shock look like?
High CVP, big distended veins
What should you never ever give someone who is in intrinsic cardiogenic shock?
FLUIDS and blood!! Could be lethal
How do you treat intrinsic cardiogenic shock?
Circulatory support- ionotrops
When does vasomotor shock present?
- Anaphylactic shock
- High spinal cord transsection
- High spinal anesthetic
How does vasomotor shock present?
- Patient is pink and warm
2. CVP is low (circulatory collapse)
How do you treat vasomotor shock?
Pharmacological treatment to restore peripheral resistance (vassopressors)
Additional fluids will help
Do you need surgery in a penetrating head trauma?
Yes!
Do you operate on linear skull fractures? If so, when?
They are left alone if they are close (no overlying wound)
Open fractures require wound closure
What types of patients with head traumas get a CT scan?
All patients who has become unconscious to look for intracranial hematomas
When can a head trauma patient be released home?
If CT scan is negative and the patient is neurologically intact
What do chemical burns require on presentation?
Massive irrigation to remove the offending agent.
What are some examples of alkaline and acidic burns?
Alkaline burns: liquid plumr, drano
Acid burns: battery acid
Which type of burn is worse: Alkaline or acidic burns?
Alkaline burns
Do you try to neutralize the agent in a chemical burn?
No! Irrigation must begin as soon as possible at the site.
High-voltage electrical burns appear in what manner?
Always are deeper and worse than they appear to be.
What are some concerns associated with high-voltage electrical burns?
- Myoglobinemia- myoglobinuria- renal failure
- Orthopedic injuries secondary to massive muscle contractions
- Late development of cataracts and demyelinization syndromes.
What do you give to treat the myoglobinemia-myoglobinuria-renal failure in a patient who has had a high voltage electrical burn?
- Give plenty of fluids
- Osmotic diuretics like mannitol
- Alkalinize the urine
Where are some of the orthopedic injuries secondary to massive muscle contractions occur after a high voltage electrical burn?
- Posterior dislocation of the shoulder
2. Compression fractures of vertebral bodies
How do respiratory burns occur?
Occur with flame burns in an enclosed space and are considered chemical injuries caused by smoke inhalation.
How is diagnosis of inhalation injury confirmed?
With fiberoptic bronchoscopy
What is the key issue that needs to be determined when encountering an inhalation injury?
Whether respiratory support (a respirator) is needed or not.
How is it determined if a patient needs a respirator I’d they’ve had inhalation injuries?
Obtaining blood gases
How do you treat someone if they have elevated carboxyhemoglobin levels?
100% oxygen will shorten the half life of carboxyhemoglobin.
What can circumferential burns of the extremities lead to?
Cutoff of the blood supply as edema accumulates underneath the unyielding eschar.
What accumulates under a deep burn?
Fluid- which is essentially plasma that has been temporarily lost from the circulating space and trapped at the burn site.
What happens with circumferential burns of the chest?
Difficulty breathing.
What procedure is done to relieve the fluid from under circumferential burns?
Escharotomies. Done at bedside, no need for anesthesia.
What should you think of when a child comes in presenting with scalding burns?
Child abuse.
How can you tell if a child has had burns due to abuse?
Burns on both buttocks.
If the pattern of the burn doesn’t match the story of the event.
What is the most critical, life-saving component of the management of extensive thermal burns?
Fluid replacement.
If, in extensive burns, the patient has an internal shift of fluids what should you be worried about happening?
Hypovolemic shock or death.
What is the rule of 9s?
Assigning 9% of body surface to the head and each upper extremity, double that to each lower extremity, and 4 times that much for the trunk.
What is the target hourly urine rate for a severely burned patient?
1 or 2 mL/kg/hr.
In a severely burned patient what is the CVP a that you want to avoid?
A CVP a over 15 mm Hg.
How is fluid infusion actually done in a patient with severe burns?
Fluid infusion is begun at an arbitrary, predetermined rate and then adjusted as needed.
What is an appropriate predetermined rate of fluid infusion in the adult?
Start at 1,000 mL/hr of lactated ringer without sugar on anyone whose burns exceed 20% of body surface and then adjust as needed to produce the desired urinary output.
Why is sugar avoided in the lactated ringer?
So as not to introduce an osmotic dieresis from glycosuria, which would invalidate the meaning of the hourly urinary output.
How does the estimation of fluid needs in burned babies differ from adults?
Babies have bigger heads and smaller legs; thus the rule of 9s assigns two 9s to the head and both legs total share 3 9s instead of 4.
How do third degree burns appear in babies?
The areas look deep bright red, rather than the leathery, dry gray appearance in the adults.
What is an appropriate rate of initial fluid administration in burned babies?
20mL/kg/hr if the burn exceeds 20% of body surface, to be fine tuned in response to urinary output.
What are some other important aspects of burn care?
- Tetanus prophylaxis
- Cleaning of the burn areas
- Use of topical agents
What is the standard topical agent in burn care?
Silver sulfadiazine
If deep penetration is desired for topical agents of burn care what should you use?
Mafenide acetate is the choice. Make sure not to use it everywhere else because it can produce acidosis.
What is used as a topical agent for burns around the eyes?
Triple antibiotic ointment
What happens after 2-3 weeks of wound care and general support to the burns that have not regenerated?
Grafted.
When does rehabilitation start for a burn patient?
Day 1
What is the concept behind early excision and grafting of a burn patient?
- To save costs and Minimize pain, suffering and complications
- Removal in the OR on day one of the burned areas, with immediate skin grafting.
What type of patient is a candidate for early excision and grafting of burns?
Can be done only for fairly limited burns (under 20%) that are obviously 3rd degree
What type of care is required for all bite victims?
- Tetanus prophylaxis
2. Wound care
Is rabies prophylaxis required in provoked dog bites?
No rabies prophylaxis, other than observation of the dog to see for developing signs of rabies.
What if the dog bite is to the face, do you provide rabies prophylaxis?
Yes, because it’s close to the brain and then discontinued if observation of the dog is reassuring.
What is the difference between provoked and unprovoked dog bites?
Provoked is petting the dog while it’s eating,or otherwise
Teasing the dog.
How do you treat an unprovoked dog bite?
Rabies prophylaxis is mandatory (immunoglobulin plus vaccine)
What are the signs that a patient has been envenomated after a snakebite?
- Severe local pain
- Swelling
- Discoloration developing within 30 minutes of the bite.
What blood work is needed for those who have had envenomated snakebites?
- Type and cross
- Coagulation studies
- Liver and renal function
What is the current preferred agent for rattlesnake bites?
CROFAB, for which several vials are needed.
What does anti end, dosage depend on?
Dosage relates to size of the envenomation, not to the size of the patient. Children get the same dose as adults.
What is the only valid first aid for a patient who has suffered a snakebite?
Splint the extremity during transportation.
What are some things you should not do for a snakebite?
- Do not make cruciate cuts.
- Do not suck out venom
- Do not wrap with ice
- Do not apply a tourniquet
What do brightly colored coral snakes have that need to be promptly neutralized?
Neurotoxin! Neutralized with a specific antivenin.
Do you wait for signs of envenomation with coral snakes?
No! Neurotoxin!
What is the mnemonic for identifying a true coral snake?
“Red on yellow, kill a fellow”meaning red rings and yellow rings touch each inter
Why do people die from bee stings?
Anaphylactic reactions.
How does an anaphylactic reaction appear?
- Wheezing
- Rash
3.hypotension (vasomotor shock)
“Pink and warm” shock
What is the treatment of choice for an anaphylactic reaction?
Epinephrine 0.3 to 0.5 mL of 1:1,000 solution
Should the bee stinger be removed?
Yes, but without squeezing them
How do black widow spiders look?
Black with a red hourglass on their belly
How do patients present after being bitten by a black widow spider?
- Nausea
- Vomiting
- Severe generalized muscle cramps
What is the antidote to a black widow spider bite?
IV calcium gluconate and muscle relaxants
How do brown recluse spider bites present?
Not right away, the next day a skin ulcer develops, with necrotic center and a surrounding halo of erythema.
How do you treat brown recluse spider bites?
Dapsone helps; surgical excision may be needed but should be delayed until the full extent of the damage is evident (as much as 1 week) skin grafting may be needed.
How do you handle human bites?
- Extensive irrigation
- And debridement in the OR
Need specialized orthopedic care
How do human bites present?
Sharp cut over the knuckles on someone who was punched someone else in the mouth and was cut by the teeth of the other person.
What are the signs of a fracture affecting the base of the skull?
- Raccoon eyes
- Rhinorrhea
- Otorrhea
- Ecchymosis behind the ear
What is the significance of a base of the skull fracture?
It indicates that the patient sustained very severe head trauma, thus requiring that we assess the integrity of the cervical spine.
How do you assess the integrity of the cervical spine in a suspected base of the skull fracture?
An extension of the head CT to observe the cervical spine
What should be avoided in patients with base of the skull fractures?
Nasal endotracheal intubation should be avoided.
What are the 3 components that cause neurologic damage from trauma? And how can they be managed?
- The initial blow (no tx)
- The subsequent development of a hematoma that displaces the midline structures. (Surgery)
- The later development of increased intracranial pressure (ICP)- (medical measures)
What is the classic sequence of events for an acute epidural hematoma?
- Modest trauma to the side of the head
- Unconsciousness
- Lucid interval (completely asymptomatic and returns to activities)
- Gradual lapsing into coma again
- Fixed dilated pupil
- Contralateral hemiparesis with decerebrate posture
With a epidural hematoma what does it mean when one pupil is fixed and dilated?
90% of the time that is the side of the hematoma
What will the CT scan show in an acute epidural hematoma?
Biconvex, lens-shaped hematoma
What is a cure for acute epidural hematoma?
Emergency craniotomy
What is the difference in a patient with acute subdural hematoma vs acute epidural hematoma?
- Trauma is bigger
- Patient is usually much sicker (not fully awake and asymptomatic at any point)
- Neurologic damage is severe (because of the initial blow)
What will the CT scan show for an acute subdural hematoma?
CT scan will show semilunar, crescent shaped hematoma.
What will help a Midline deviation in an acute subdural hematoma? Prognosis?
Craniotomy, but prognosis is bad.
What is the therapy for no midline deviation in an acute subdural hematoma?
Therapy is centered on preventing further damage from subsequent increased ICP.
- ICP monitoring
- Elevate head
- Hyperventilate
- Avoid fluid overload
- Give mannitol or furosemide
When giving diuretics for an acute subdural hematoma what do we have to be mindful of?
Do not diurese to the point of lowering systemic arterial pressure.
When is hyperventilation suggested for someone with acute subdural hematoma? What is the goal PCO2?
When there are signs of herniation and the goal is PCO2= 35
Why do we give sedation and make patients with acute subdural hematomas hypothermic?
- Sedatives decrease brain activity and decrease oxygen demand
- Hypothermia reduces oxygen demand
When does diffuse atonal injury occur?
More severe traumas.
What does a CT scan show in a diffuse atonal injury?
Diffuse blurring of the gray-white matter interface and multiple small punctuate hemorrhages.
