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OCHT Term III > Differential Diagnosis - Trauma & Non-Traumatic Pain > Flashcards

Differential Diagnosis - Trauma & Non-Traumatic Pain Flashcards

1
Q

Mechanisms of Head Trauma

A
  • Blunt - cerebral hematomas, IICP
  • Acceleration/Deceleration - Coup Contrecoup
  • Penetrating
  • Explosion
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2
Q

Primary Injuries vs Secondary Injuries of Head/Brain Trauma

A

Primary Injuries: injuries to the brain itself at time of impact

  • Fractures: open vault, BSF, depressed, linear fractures
  • Blood vessel injuries: epidural or subdural (slower venous bleed)
  • Brain Tissue injuries: concussion, intracerebral hemorrhage

Secondary Injuries: injuries as a result of primary injuries

  • Cerebral herniation, ICP, Seizures
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3
Q

What class/type of medication would be important to know for head injury patients?

A

anti-coagulants - because you want to know if they may suffer from ++hemorrhaging

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4
Q

Signs/Symptoms of brain trauma

A

headache

dizziness

N/V

Decreased LOA

LOC

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5
Q

Cushing’s Triad

A

↑BP, ↓HR, irregular RR

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6
Q

As per Head Injury protocol in BLS, what are the signs of cerebral herniation?

A
  • Deteriorating GCS < 9 with any of the following:
    • (1) Dilated and unreactive pupils,
    • (2) Asymmetric pupillary response, or
    • (3) A motor response that shows either unilateral or bilateral decorticate or decerebrate posturing
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7
Q

Basilar Skull Fracture (BSF) signs and symptoms

A
  • otorrhea
  • rhinorrhea
  • mastoid bruising
  • periorbital ecchymosis
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8
Q

Signs and symptoms of epidural bleed

A
  • confusion
  • dizziness
  • drowsiness
  • unequal pupils
  • head trauma with LOC
  • N/V
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9
Q

Signs and symptoms of subdural bleed

A
  • slower onset
  • headache that keeps getting worse
  • personality changes
  • drowsiness
  • confusion
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10
Q

As per Head Injury Standard in the BLS, what are potential life/limb/function threats to consider and what clinical presentations should the paramedic observe for?

A

1) Consider potential life/limb/function threats:

  • intracranial and/or intracerebral hemorrhage
  • neck/spinal injuries
  • facial/skull fractures
  • concussion

2) Observe for:

  • fluid from ears/nose (e.g. CSF)
  • mastoid bruising
  • abnormal posturing
  • periorbial ecchymosis
  • agitation or fluctuating behaviour
  • urinary/fetal incontinence
  • emesis
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11
Q

TRUE or FALSE. As per Head Injury guidelines in the BLS, patients with suspected concussions require transport for further assessment.

A

True

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12
Q

Treatment for head injury patients as per the BLS

A

1) Ventilate pt if they are apneic or respirations are inadequate

  • (a) if ETCO2 monitoring is available,
    • maintain at 35-45 mmHg BUT
    • if signs of cerebral herniation are present after measures to address hypoxemia and hypotension, hyperventilate to maintain ETCO2 at 30-35 mmHg
  • (b) if ETCO2 monitoring not available and measures to address hypoxemia and hypotension have been taken, and patient shows signs of cerebral herniation, hyperventilate:
    • Adult: ~20 breaths/min (1 every 3 sec)
    • Child: ~25 breaths/min (1 every 2-3 sec)
    • Infant <1 y.o.: ~30 breaths/min (1 every 2 sec)

2) If protruding brain tissue present, cover with non-adherent material (eg. moist, sterile dressing; plastic wrap)

3) if CSF suspected, apply losse sterile dressing over source opening

4) if pt is consciou and no SMR, position them sitting/semi-sitting

5) if pt is on a spinal board/scoop, elevate head 30°

6) prepare for potential problems: respiratory distres/arrest, seizures, decreasing LOC, and agitation/combativeness

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13
Q

Why do you elevate head and hyperventilate the cerebral herniation patient?

A

Hyperventilation - Decreases PCO2 levels which causes vasoconstriction (reducing cerebral blood flow and thus decreasing ICP)

Elevating head 30° - promotes cerebral venous draining to help with reducing ICP

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14
Q

Mechanisms of Chest Injuries

A

MVC

Stab/GSW

Blast

Falls

Sports

Inhalation

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15
Q

Types of chest injuries

A
  • flail chest
  • fractures
  • pulmonary edema - excess fluid in the lungs
  • open/tension pneumothorax/hemothorax
  • Cardiac tamponade - cardiac compression due to accumulation of fluid in the pericardial sac (pressure exerted by the pericardial fluid equals or even exceeds diastolic pressure within the heart chambers, which interferes with heart filling)
    • but Lisa said it’s “accumulation of pericardial fluid in this space)
  • Pericardial effusion - accumulation of any fluid in pericardial cavity
  • Esophageal rupture
  • Aortic Rupture
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16
Q

General signs and symptoms of chest injuries

A
  • SOB
  • diaphoretic
  • chest pain
  • restlessness
  • hypoxia
  • cyanotic
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17
Q

Definition and Signs and symptoms of flail chest

A
  • chest instability (paradoxical movement)
  • tenderness
  • crepitus
  • paradoxical movement
  • Definition: 2 or more ribs broken in 2 or more places
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18
Q

Signs and symptoms of pulmonary edema

A
  • SOB/dyspnea
  • sputum (pink, frothy)
  • crackling/gasping
  • tachycardia
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19
Q

Signs and symptoms of hemothorax

A
  • hypotension
  • decreased air entry on side of injury (or absent breath sounds); dull to percussion
  • flat neck veins
  • cyanosis
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20
Q

S/S of open pneumo

A
  • SOB
  • bubbling, frothing wound
  • Decreased A/E
  • Trachea deviates away from affected side (if prolonged)
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21
Q

S/S of tension pneumothorax

A
  • Dyspnea (SOB)
  • Anxiety
  • tachypnea
  • JVD (due to pressure building up on RA, not allowing it to contract or expand which causes backed up pressure and vein distension)
  • tracheal deviation - towards unaffected side
  • decreased air entry
  • hypotension (due to inability to pump blood out)
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22
Q

Signs and symptoms of cardiac tamponade/pericardial effusion

A
  • chest pain
  • SOB
  • tachycardia
  • Becks Triad - hypotension, muffled heart sounds, JVD (indication of cardiac tamponade)
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23
Q

Signs and symptoms of esophageal rupture

A

hemoptysis (coughing up blood)

vomiting up blood

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24
Q

Signs and symptoms of an aortic rupture

A

ripping/tearing straight through the back

hypotension

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25
Q

Treatment for flail chest

A
  • pressure/support (bulk dressing) - secured with 3 horizontal pieces and 1 vertical piece with tape (*NOT CIRCUMFERENTIAL DRESSING to prevent impediment of laboured breathing)
  • assist with ventilations/oxygen as required
  • if needed, roll to uninjured side (for spinal board/extrication, this is different than leaning/positioning the to injured side on stretcher)
    *
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26
Q

As per the BLS PCS, what is the protocol for patients who have a suspected pneumothorax and require ventilations?

What is the protocol for positioning of patients?

A
  • ventilate with a lower tidal volume and rate of delivery to prevent exacerbations of increase intrathoracic pressure;
  • if patient is conscious and SMR is not indicated as per SMR standard, position patient sitting or semi-sitting;
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27
Q

Chest Injury Standard (as per BLS) (7 steps)

A
  1. consider life/limb/function threats such as tension pneumo, hemothorax, cardiac tamponade, myocardial contusion, pulmonary contusion, SCI, and flail chest;
  2. auscultate lungs for air entry and adventitious sounds;
  3. if patient has penetrating chest injury, assess for:
    1. entry/exit wounds
    2. trach deviation
    3. JVD
    4. airway and/or vascular penetration (frothy, foamy hemoptysis sucking wounds)
  4. if patient has open or sucking chest wound, treat it appropriately (covered in another flashcard)
  5. if pneumo + requiring ventilations, ventilate lower tidral volume and rate of delivery to not exacerbate intrathoracic pressure
  6. place in sitting or semi-sitting if no SMR
  7. if patient has a chest injury, prepare for potential problems, including: tension pneumo, cardiac tamponade, cardiac dysrhythmias, hemoptypsis
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28
Q

Treatment for hemothorax

A
  • positioning (position of comfort, lean to injured side)
  • vitals/O2
  • early recognition (recognizing potential for condition progression and monitoring vitals) - be prepared for shock
  • *note that hemothoraces may have late onset
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29
Q

Hemothorax is most commonly secondary to what MOI?

A

penetrating trauma

30
Q

Treatment for esophageal or aortic rupture?

A

Assist with positioning due to vomiting, prepare for shock

load and go

31
Q

Mechanisms for abdominal injuries

A
  • blunt
  • penetrating
  • falls
  • MVA
  • stabbing
  • GSW
32
Q

Types of abdominal injuries

A

Solid organs

Hollow organs

33
Q

General signs and symptoms of abdominal injuries

A
  • abdo pain
  • shock
  • bruising
  • swelling
34
Q

What solid organs are in the abdomen and what signs and symptoms will they present with if injured?

A

1) Splenic injury - L shoulder (Kerr’s sign - referred pain), pain and tenderness in LUQ

2) Liver injury - Guarding, RUQ, R shoulder pain (referred pain), jaundice

3) Kidney - flank pain, dysuria (painful urination), hematuria

35
Q

What hollow organs are found in the intestine and what S/S will they show if injured?

A

1) Bladder - lower abdominal pain, trauma at site, hematuria

36
Q

S/S of diaphragmatic rupture

A
  • bowel sounds in chest cavity
  • diminished breath sounds
  • abdomen appears scaphoid (sunken)
  • respiratory distress
37
Q

S/S of SCI

A
  • paralysis
  • parasthesia
  • muscle weakness
  • priapism
38
Q

Treatment for penetrating abdominal trauma (i.e. evisceration)

A
  • wet & occlusive dressing - abdo pad with saline and then foil blanket (a few cm larger than abdo pad) and tape
  • MAKE no attempt to replace intenstines back into abdomen
  • if penetrating object - log cabin
39
Q

Treatment for abdominal injuries secondary to blunt trauma

A

early recognition & prepare for shock (hypovolemia and drop in BP, potentially distended abdomen)

40
Q

According to the BLS, under the Abdominal/Pelvic Injury section of the Blunt/Penetrating Injury Standard, what potential life/limb/function threats is the paramedic considering?

A
  • rupture, perforation, laceration, or hemorrhage of organs and/or vessels in the abdomen and potentially in the thorax or pelvis, and
  • spinal cord injury,
41
Q

Potential differentials for head pain

A
  • Headache
  • Migraine
  • Intracranial/intracerebral events (subarachnoid hemorrhage, thrombosis i.e. stroke/TIA, tumour)
  • CNS or oher systemic infection (i.e. meningitis, encephalitis)
  • severe HTN (hypertensive crisis)
  • toxic event/exposure (i.e. CO poisoning)
42
Q

Head pain questions to ask

A
  • OPQRST
    • onset - gradual (subarachnoid bleeds) vs acute (epidural bleeds)
    • provoke/palliate - meningitis, migraines
    • quality - migraine
    • radiates
    • severity - for chronic migraine patients
    • T - come and go?
  • New type of headache or history of the same?
  • Change in mental status? -stroke, TIA, tumor, meningitis/encephalitis, subarachoid bleed
  • Sinus/dental pain? - infection, maybe tumor, encephalitis
  • Visual changes? stroke, tumors, migraine
  • Hearing loss? tumor, migraine
  • N/V? subarachnoid bleeds, meningitis, headaches, stroke, abscesses, tumors
  • Epistaxis? hypertension (esp with headache)
  • What and where were you when it began? to rule out environmental factors
  • Nuchal rigidity - meningitis
43
Q

Ax of head pain includes what?

A
  • LOA/LOC - such as LSN for strokes and subarachnoid
  • Swelling of face: dental/infection
  • Neuro sx - drift, grip strength, mobility/gait, facial droop - stroke/TIA
  • Fever (temp) - meningitis, encephalitis
  • Nuchal rigidity - chin to chest or side to side (meningitis)
  • BP - HTN (epistaxis and headaches)
  • Pupillary Response - troke, subarachnoid hemorrhage, tumor
  • Visual Disturbances
44
Q

Treatment for head pain

A
  • early recognition
  • pain management - ibuprofen
  • Following stroke guidelines
45
Q

Acute Stroke Bypass Protocol

A

1) Assess patient to determine if he/she has one or more of the symptoms consistent with onset of an acute stroke:

  • inappropriate words or mute
  • slurred speech
  • unilateral arm weakness or drift
  • unilateral facial droop
  • unilateral leg weakness or drift

2) LSN <6 hr

3) Contraindications:

  • CTAS 1 and/or an uncorrected ABC issue
  • Stroke symptoms resolved prior to paramedic arrival or assessment
  • Blood Glucose Level <3 mmol/L (unless corrected and stroke-like symptoms still persisting)
  • Seizure at the onset of symptoms or that is observed by the paramedic
  • GCS <10
  • Terminally ill or is in palliative care
  • Duration of transport to the Designated Stroke Centre will exceed two hours;

4) Secondary screen for LVO using LAMS

5) Inform CACC of LAMS score

6) If stroke center transport has already been initiated and patient’s symptoms improved significant or resolve during transport, contiue to stroke center

46
Q

Differentials for abdominal pain

A

HIPOI

1) Hemorrhage: AAA, ruptured ectopic pregnancy & miscarriage, esophageal varices (abnormally enlarged veins in the esophagus due to obstructed blood flow in portal vein)

2) Infection/Inflammation - cholecystitis, pyelonephritis (kidney infection), appendicitis, diverticulitis, peritonitis, pancreatitis, ulcers, GERD

3) Perforation - bowel, hernia

4) Obstruction -bowel

5) Ischemia - torsion (testicular), bowel

47
Q

Signs and symptoms of hemorrhaging in the abdominal area.

A
  • ruptured AAA - deep constant lower abdo pain and back pain. pulsating feeling near navel
  • ruptured ectopic - cramping, sharp, sudden onset, hypotension, possible syncope & shock
48
Q

S/S of infection/inflammation of abdominal organs.

A
  • localized tenderness
  • chills
  • fever
49
Q

S/S of bowel performation/hernia in the abdomen.

A
  • sudden generalized onset of severe pain with guarding and tenderness
  • peritoneal sx: fever, diarrhea, N/V, ++pain generalized
50
Q

S/S with bowel obstruction

A
  • some distention (constipation)
  • potential vomiting
  • pain
51
Q

S/S of ischemia in the abdominal region (ie. testicular torsion, bowel ischemia)

A
  • Testicular torsion: abnormal positioning of testicles with discolouration, sudden onset ++ pain (localized)
  • Both: no fever, no peritoneal pain
52
Q

Abdo pain questions to ask

A
  • OPRQST
  • N/V/D
  • Frank blood in stool (lower GI issue) or coffee stool or emesis
  • Pregnany?
  • Last menstrual period?
  • Last BM?
  • Urine output and odour
53
Q

Assessment for abdominal pain

A
  • CLAPPS TARD
  • Discolouration
  • Guarding
  • Location - Quadrant/Flank
  • Scars
  • Bower sounds
  • Fever (to rule in/out)
  • BP (esp for bleeding related abdo calls)
  • 12-lead - for abnormal symptoms of MI
54
Q

When auscultating the abdomen for bowel sounds, what is the ideal direction to start and finish?

A

RLQ ⇒ RUQ ⇒ LUQ ⇒ LLQ

follow the direction of the intestines

55
Q

Describe the difference between normal, hypoactive, and hyperactive bowel sounds.

A

Hypoactive bowel sounds: 1 sound every 3-5 minutes

Normal bowel sounds: 5-30 sounds/min

Hyperactive bowel sounds: >30 sounds/min

56
Q

Discomfort in the RLQ can be associated to

A

Appendicitis

Diverticulitis

57
Q

Discomfort in the RUQ can be associated to

A

Cholecystitis

female, fatty, 40, fertile (RUQ pain)

  • good indications that it’s gallstones
  • discolouration (greyish) bowel movements
58
Q

Flank pain on the back can be a symptom of

A

pyelonephritis

59
Q

Discomfort in the LLQ can be associated to

A

diverticulitis

60
Q

Discomfort in the LUQ can be associated with problems of which organ?

A

spleen

61
Q

Pancreatitis would have discomfort in what area of the abdomen?

A

usually epigastric

62
Q

How do you locate McBurney’s point and what signs/symptoms would you be looking for?

What condition is this likely indicative of?

A

McBurney’s point: between belly button and pelvis (R ASIS - Right anterior superior iliac spine), 2/3rd of the way down (tenderness is maximal at this point during acute appendicitis)

Rebound tenderness x fever = appendicitis

63
Q

Abdominal Pain treatment

A

Early recognition

pain directive

N/V directive - Gravol (dimenhydrinate)

64
Q

Differentials for back pain

A
  • AAA/thoracic aortic aneurysm
  • Aortic Dissection
  • Intra-abdominal disease (pancreatitis, peptic ulcer)
  • Pyelonephritis
  • Acute spinal nerve root(s) compression
  • Possible occult injury (such as pathological fractures)
65
Q

Questions to ask for back pain

A
  • OPQRST
  • Numbness/tingling
  • additional abdo questions that make sense
66
Q

Assessment of back pain

A
  • Neurological deficits
  • BP
  • Deformity
  • See abdo pain assessments if appropriate
67
Q

Treatment for back pain

A
  • Early reocgnition
  • minimize movement
  • Pain - as per directive
68
Q

As per the Back Pain (Non-Traumatic) Standard, you are required to do a secondary survey to assess:

A
  • back, for abnormal appearance/findings,
  • chest, as per Chest Pain (Non-Traumatic) Standard ⇒ subQ ephysema, accessory muscle use, urticaria, indrawing, shape, symmetry, tenderness
  • abdomen, as per Abdominal Pain (Non-Traumatic) Standard ⇒ pulsations, scars, discolouration, distention, masses, guarding, rigidity, tenderness
  • distal pulses, and
  • extremities for CSM
69
Q

If a thoracic aneurysm is suspected, what do you need to do?

A

perform bilateral BP

70
Q

What % of blunt chest trauma occurs during MVCs?

A

80%

OCHT Term III (25 decks)

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