Introduction to trauma Flashcards
Trauma?
a physical injury
Injury a disease?
yes, it has a host and a vector of transmission
Leading cause of death?
injuries, motor vehicle, worldwide
Trimodal death distribution?
shows death due to injury occurs in one of 3 peaks
First peak?
occurs within seconds to minutes deaths- -apnea from injury to brain/ spinal cord -exsanguination from injury to great vessel cant treat, only prevent
Second peak?
minutes to hours after injury
deaths- subdermal and epidural hematomas, hemoneumothroax, ruptured spleen, laceration of the liver, pelvic fractures, and/or multiple impt injuries
try and decrease death here, golden hour of trauma
third peak?
occurs days to wks after
deaths- sepsis and multiple organ failure
what do all trauma patients require?
a systemic approach to management in order to maximize outcomes and reduce the risk of undiscovered injuries
History of the accident?
very important, crucial can come from several sources information concerning circumstances of the injury preexisting med conditions, meds may have to work with no info at all
Primary survey?
quick way to assess the patient in 10 seconds
goals in identifying and treating life-threatening injuries
ABCDE
ABCDE, Primary survey?
A-airway assessment and protection B-breathing and ventilation C- circulation assessment D- disability assessment E- exposure, with environmental control
Cervical spine protection?
missed injury can be devestating (chronic pain, paralysis)
different ways to clear cervical spine
generally awake, alert patients without neuro deficit
What to look at when assessing breathing?
abnormalities detected
-deviated trachea, crepitus, paradoxical movement of a chest wall segment, sucking chest wound, absence of breath sounds on either side of the chest
Hemmorrhagic shock?
common cause of death of postinjury death
rapid asses of hemodynamic status
external hemorrhage is identified and controlled
estimate blood loss bas on patients initial presentation
Best sign of significant blood loss?
pulse pressure
Glasgow coma scale?
quick, simple method for determing the level of consciousness that is predictive of patient outcome
3 categories
max score 15, min score 3
8 or less has become accepted definition of coma or severe brain injury
3 categories of Glasgow coma scale?
eye opening
motor response
verbal response
Secondary survey?
head to toe eval of trauma patient
does not begin until the primary survey is completed
resuscitative efforts are underway, normalization of vital functions has been demonstrated
AMPLE
examine each region of the body
AMPLE, secondary survey?
Allergies Medications currently used Past illness/Pregnancy Last meal Events/Environment related to injury
Classify/name traumatic injuries?
Severity (major, minor)
Type of force applied to body (blunt, penetrating)
Location (ocular trauma, wrist injuries, pelvic injury)
often combine these (blunt abdominal trauma)
Determine between minor and major?
field triage
assessment of 4 areas
Physiologic criteria for major trauma?
Glasgow Coma scale 29 breaths per minute, or need ventilatory support
Anatomic criteria for a major trauma?
all penetrating injury to head, neck, torso, and extremities proximal to elbow chest wall instability/deformity two or more proximal long bone fractures crushed, degloved, mangled, or pulseless extremity amputation proximal to wrist/ ankle pelvic fracture open or depressed skull fracture paralysis
Mechanism of injury for a major trauma?
falls (adult over 20 ft, child over 10 ft)
high risk auto crash (intrusion, inculding roof, ejection, death in same passenger compartment)
automobile vs pedestrian/bike
motorcycle crash
Special patient considerations?
Age Anticoagulation and bleeding disorder Burns Time sensitive injury End stage renal disease requiring dialysis pregnancy over 20 wks your judgement
Mechanisms of injury can be classified as?
blunt penetrating thermal blast all cases, there is a transfer of energy to tissue
Injury depends on?
the amount of speed on energy transfer
surface area over which the energy is applied
elastic properties of the tissues to which the energy transfered is applied
Injuried from blunt force most common?
falled being struck with firm object transportation accidents pedestrian injuries cycling accident
Injury from blunt force trauma results in?
contusions, abrasions, lacerations, sprain/strain, fractures
Penetrating trauma?
object may remain in the tissues, come back out the way it entered or pass through tissue and exit elsewhere
sharp objects, blunt objects, projectiles
weapons are classified by energy produced
weapon energy classification?
low energy- hand energized
med energy- handguns and shotguns
high energy- military or hunting rifles
Velocity of a missile?
most significant determinant of its wounding potential
speed of bullet creates a temporary cavity by tissue being compressed at the point of impact, caused by the shock wave initiated by the impact of the bullet
Entrance wound is determined by 3 factors?
shape of the missile
position of the missile relative to the impact site
fragmentation
Importance of exit wound?
to see if there is one
exit wound suggests the path of the missile
Clinical indications of inhalation injury?
face or neck burns
signeing of the eyebrows or nasal vibrissae
carbon depositis and acute inflammatory changes in the oropharynx
hoarseness
explosions with burns to the head and torso
Remove clothing for burn victims?
do not peel of adherent clothing
over 20% burn needs fluid resscitation (rule of 9s)
3 types of cold injury are seen in trauma?
Frostnip
Frostbite
Nonfreezing injury (trench foot)
Level IV trauma center?
initial care capability
mechanism for prompt transfer
transfer agreements and protocols
Level III trauma center?
trauma and emergency medicine services
24 radiology
published on call
Level II trauma center?
cardio, opthalmology, plastics, GYN surgery
operating room 24 hrs/ day
neurosurgery dept available
trauma multidisciplinary quality assurance committee
Level I trauma center?
24 hr available all surgical subspecialties
neuroradiology, hemodialysis
organized trauma research
program that established and monitors effect of injury prevention/ education
Direct blow to an extremity?
extravasation of blood and/or swelling of muscle tissue
increased muscular intracompartmental pressure
pressure exceeds profusion pressure it causes circulatory compromise
Acute compartment syndrome
Other causes of acute compartment syndrome?
lying on a limb can cause compartment syndrome
extrinsic compression
intraosseous infusion
Compartment most prone in the arm to acute compartment syndrome?
forearm(anterior and posterior)
Compartment most prone in the leg to acute compartment syndrome?
Leg (anterior)
Patients present with compartment syndrome?
5 P’s
Pain-deep, burning and poorly localized
Parethesia- cutaneous distribution of the nerves coursing through affected area
Pallor
late
Paralysis
Pulseless (may not, if large enough vessel, only muscle perfusion is main problem)
Pressure level for surgical intervention?
30 mmHg
Time frame before damage?
6-10 hours
muscle infarction, tissue necrosis, and nerve injury occur
Delayed diagnosis/treatment irreversible tissue ischemia?
permanent muscle damage
chronic pain
fibular nerve palsy in the leg
Volkmann contracture in upper extremity
Definitive surgical treatment for acute compartment syndrome?
fasciotomy
surgical incision is made along the length of the compartment to relieve the pressure
goal is to restore muscle perfusion within 6 hours
wound is left open for several days
after resolution of the edema the patient wound is closed
Rhabdomyolsis?
syndrome caused by injury to skeletal muscle and involves leakage of large quantities of potentially toxic intracellular contents into plasma
in WWII, died of renal failure
Rhabdomyolsis results from numerous causes?
Direct muscle injury Drug abuse Excessive muscular activity Genetic disorders Immunologic diseases Infections Ischemic injuries Meds Prolonged immobilization Heat stroke
Classic triad of Rhabdomyolsis?
muscle weakness, myalgias, and dark urine
brown is most common color urine
muscle groups may be localized or diffuse
history refelects inciting cause
Most severe complication with Rhabdomyolsis?
pigment associated renal injury
acute renal failure
metabolic deragements
disseminated intravascular coagulation
development of acute renal failure in Rhabdomyolsis?
decreased extracellular volume
myoglobin precipitation in renal tubules causes formation of obstructive casts
ferrihemate is formed from breakdown of myoglobin at a pH level of 5.6 or less
renal vasoconstriction and ischemia depleete tubular ATP formation and enhance tubular cell damage
Most reliable and sensitive test for muscle damage?
serum creatinine kinase (CK)
rise within 12 hours of muscle injury, peak 24-36
levels decline 3-5 days after resolution of muscle injury
Elevation of CK in Rhabdomyolsis?
levels 5 times range suggest
suspect at 2-3 times levels if risk factors for
Plasma myoglobin reliable?
not reliable measurement
half life of 1-3 hours and is cleared from plasma within 6 hours
urine myoglobin measurements are preferable
Urine dipstink test for blood that has pos finding in abscence of RBCs on microscopic exam?
suggests myoglobinuria
Treat Rhabdomyolsis?
fluid resuscitation and prevention of end organ complications -expansion of extracellular volume -correction of electrolyte imbalance -serial physical exams and lab studies -diuretics (loop) dialysis may be require if renal failure
Fat emboli syndrome?
occurs following trauma to long bone or pelvis
risk increases with the number of fractures (why more than one long bone fracture)
theory one on Fat emboli syndrome: Mechanical?
large fat depositis are released into the venous system, deposit in the pulmonary capillary beds, can travel through arteriovenous shunts to the brain
theory two on Fat emboli syndrome: Biochemical?
hormonal changes caused by trauma and/or sepsis induce systemic release of free fatty acids as chylomicrons
acute phase reactant, such as C-reactive proteins, cause chylomicrons to coalesce
helps explain nontraumatic forms of fat embolism syndrome
Diagnose Fat emboli syndrome?
one major and 4 minor criteria, plus fact microglobulinemia, must be present to formally diagnose
Major criteria for Fat emboli syndrome?
Respiratory symptoms
sings of radiologic disease
cerebral signs without other etiologies
petechial rash
minor criteria for Fat emboli syndrome?
pulse that is over 110 bbm
fever over 38.5
retinal changes of fat globules or petechiae
renal dysfunction
jaundice
acute drop in hemoglobin and/or platelets
elevated sedimentation rate
Petechiae Fat emboli syndrome?
reddish-brown nonpalable petechiae develop over the upper body, within first 24-36 hrs, particular over the axilla
therapy Fat emboli syndrome?
supportive
most recover
corticosteroids may be beneficial in preventing FES, the evidence is insufficient to recommend them routinely
mortality rate 10-20%
Thoracic trauma is a significant cause of mortality?
hypoxia, hypercarbia, acidosis
Pneumothorax?
presence of air or gas in the pleural cavity
occurs in potential space between visceral and parietal pleural of the lung
tension pneumothorax?
when a “one way” valve air leak occurs from the lung for through the chest wall
- penetrate/blunt trauma, can collapse affected lung
- mediastinum displaced
- tracheal deviation
Treat tension pneumothorax?
immediate decompression
-need decompression
definitive treatment requires a chest tube
Sucking chest wound?
may result in pneumothorax
opening in chest wall is 2/3 the diameter of the trachea, air will preferentially pass through the deficit with each respiratory effort
treat Sucking chest wound?
closing the deficit with an occlusive dressing
-tape on 3 sides to provide a flutter type valve effect
-remove chest would form soon as possible
definitive treatment is surgical closure
Flail chest?
occurs when a segment of the chest wall does not have bony continuity with the rest of the throracic cage
-usually results from trauma with multiple rib fractures, cause severe disruption of normal chest wall motivation
major problem with flail chest?
underlying pulmonary contusion must treat that adequate pain control medical manage of pulmonary injury surgical stabilization if severe
When perform surgery on hemothorax?
loss of more than 1000 mL of blood
continued bleed from chest (150-200 mL/h for 2-4 hrs)
repeated blood transfusion to maintain hemodynamic stability
Cardiac tamponade?
accumulation of fluid in the pericaridal space
results in reduced ventricular filling
most commonly results from penetrating injuries
FAST exam (focused assessment with sonography for trauma)
common symptoms of cardiac tamponade?
dyspnea, tachy, elevated JVD
Beck’s triad
Beck’s triad?
increased JVD, hypotension, diminished heart sounds
Removal of the pericardial fluid?
definitive therapy for hemothorax
emergency subxiphoid percutaneous drainage
echo guided pericardiocantesis
Pelvic injury?
requires significant energy
injury to organs contained within the bony pelvis
associated with severe hemorrhage due to the extensive blood supply to the region
