EM Trauma 1 (general trauma) Flashcards
remarks on trauma
trauma
- leading cause of death among children and adults under 46 y/o
US’ highest fatality rate due to trauma:
-firearms
-suffocation
-drowning / submersion
in accordance with the principles of ATLS, inured patients are assessed and treated based on 3 concepts:
- Treat the greatest threat to life first
- A detailed history is not essential to begin the evaluation of a patient with acute injuries
- The lack of definitive diagnosis should never impede the application of an indicated treatment
Specifi injuries that should be immeditewly identified and addressed during the primary survey include
airway obstruction
tension pneumothorax
open pneumothorax
flail chest
massive internal or external hemorrhage
cardiac tamponade
trauma: if the patient is obtunded….
assume a cervical spine injury until proven otherwise
obtunded = a person sleeps more than usual, responds slowly to verbal or painful stimuli and with incomprehensible verbal responses
levels of consciousness
- normal
- confused (V4)
- lethargic (E4)
- somonolent (E3)
- obtunded (E3, V2)
- stuporous (E2 or M5 and below)
- comatose
NEXUS crtieria
National Emergency X-Radiography Utilization Study
1. No posterior midline cervical spine tenderness
2. No evidence of intoxication
3. Alert mental status
4. No FNDs
5. No painful distracting injuries
-failure to meet any one criterion indicates need for cervical spine imaging
CCS rule
Canadian Cervical Spine rule
Any high-risk factor that mandates radiography?
-age >64y
-dangerou mechanism
-paresthesias in extremities
Any low-risk factor that allows safe assessmet of range of motion
-simple rear-end collision or
-sitting position in the ED or
-ambulatory at any time or
-delayed onset of neck pain or
-absence of midline cervical spine tenderness
Able to rotate neck actively?
45 degress left and right
No radiography indicated if all criteria are met
Essential characteristics of level 1 trauma centers
meet the admission volume requirements
≥1200 trauma patients yearly or
≥240 admissions with an Injury Severity Score of >15
maintain a surgically directed critical care service
participate in the training of residents and be a leader in education and outreach activities
conduct trauma research
trauma’s B’s
Inspect thorax and neck for
1. deviated trachea
2. open chest wounds
3. paradoxical chest wall motion
4. crepitus at neck or chest
remarks on pulses
(+) carotid pulse means ≥60 mm HG
(+) femoral pulse means ≥70 mmHg
(+) radial pulse means ≥80 mmHg
indication for thoracotomy or VATS
Massive hemothorax
initial chest tube output of >1500 mL, or
>200 mL/hour
remarks on hemorrhage
hemorrhage of up to 30% of total blood volume may be associated with only mild tachycardia and a decrease in pulse pressure
fluid resus in hemorrhage
establish 2 large-bore IV lines - 18 gauge or larger
infuse 2L of LACTATED RINGER’S - fluid of choice
Class I hemorrhage
up to 15% blood volume loss
(up to 750 mL)
<100 bpm
normal or increased PP
normal BP
Class II hemorrhage
15-30% blood volume loss
(750-1500 mL)
100-120 PR
decreased PP (< 40 mmHg)
Normal BP
Class III hemorrhage
30-40% blood volume loss
(1500-2000mL)
120-140 PR
decreased PP
low BP
Class IV hemorrhage
> 40% blood volume loss
2 L
> 140 pr
dec PP
low BP
MOA of tranexamic acid
antifibrinolytic agent
-prevents cleavage of plasmin and degradation of fibril
remarks on tranexamic acid
decreases relative risk of death by
32% if within 1 hour of injury
21% if within 1-3 hours
remarks on head trauma
Assume that a patient with a history of head trauma with GCS ≤14 to have significant intracranial injury until proven otherwise
remarks on hyperventilation as therapy
mild hyperventilation may reduce intracranial pressure, although at the expense of cerebral vasoconstriction and hypoperfusion
avoid hyperventilation during the first 24 hours after injury when cerebral blood flow is often critically reduced
remarks on “exposure”
No primary survey is complete without completely disrobing the patient and examining carefully for occult bruising, laceration, impaled foreign bodies, and open fracutres
logroll: palpate the spinous processes for tenderness or deformity
remarks on hypothermia
adverse effects:
-coagulopathy and increased bleeding
-reduced myocardial function
remarks on traumatic cardiac arrest
the best outcomes were in patients with stab wounds to the chest
remarks on ED thoracotomy
The strongest recommendation for performing ED thoracotomy can be made for patients with penetrating chest trauma with witnessed signs of life during transport to or in the ED and at least cardiac electrical activity upon arrival
there were no survivors among patients with blunt trauma and no respiration or pulse in the field. ED thoracotomy for this group is not indicated (including in the presence of myocardial electrical activity)
remarks on urethral meatus
if meatal blood is present or the prostate is displaced, which suggets a urethral injury, perform RETROGRADE URETHROGRAPHY before inserting a Foley catheter
Most frequently missed conditions in the secondary survey
orthopedic
