Major Trauma

Question 1

Typical Signs and symptoms of a hypovolemic / trauma patient?

Answer 1

• Pain/bleeding
• Decreased RR
• Decreased O2 sats
• labored or shallow breathing
• use of accessory muscles
• decreased urine output
• cool pale skin, poor skin turgor
• Hypotension
• tachycardia/rapid/thread pulse
• anxious/confused/decreased GCS
• Cardiac arrythmias
• Hypertension (Pain response)

Question 2

Describe the purpose of fluid administration?

Answer 2

Plasma volume expander's, work to restore intravascular volume by increasing the oncotic pressure in the intravascular space (within the blood component). 
Water moves into the intravascular space, increasing the circulatory volume, which subsequently increases 
•	central venous pressure
•	cardiac output
•	stroke volume
•	blood pressure
•	urine output  
•	capillary perfusion

Question 3

What are the two most common crystalloid fluids?

Answer 3

Normal saline and Hartman’s solution (CSL)

Question 4

Describe crystalloid fluids?

Answer 4

Crystalloid fluids are a balanced salt solution that freely cross capillary walls. Its short lived - half life between 30-60 minutes.

Crystalloid fluids will demonstrate an early marked plasma expansion, which is short lived but can be maintained by using a colloid as well.

Question 5

What are the two most commonly used colloid fluids?

Answer 5

Gelatins (Gelofusion) and Albumin (Albumex)

whole blood, Packed RBC’s and FFP are also used if shock is due to hemorrhage.

Question 6

Describe Colloid fluids?

Answer 6

Colloids are better than crystalloids at expanding the circulatory volume, because their larger molecules are retained more easily in the intravascular space and increase osmotic pressure.

Gelatins can cause anaphylactic reactions and there is concern regarding the possible transmission of bovine spongiform encephalopathy (Mad cow disease)

Question 7

Typical diagnostic tests used in major trauma patients?

Answer 7

X-rays, CT, ultrasound, MRI, cross match Bloods/blood type, Blood alcohol level, drug screen, and pregnancy test.

Question 8

Whats involved in the primary survey of a major trauma patient?

Answer 8

ABCDE -
Airway and Protection of Spinal Cord
Breathing and Ventilation
Circulation
Disability
Exposure and Control of the Environment

Question 9

What airway assessments should be conducted on a trauma patient?

Answer 9

Vital Signs = RR, O2 sat
Mental Status = Agitation, drowsiness, Coma
Airway Patency = Secretions, Stridor, Obstruction
Traumatic Injury above the clavicles
Ventilation Status = Accessory muscle use, Retractions, Wheezing

Question 10

What would a hoarse or weak voice indicate?

Answer 10

subtle tracheal or laryngeal injury

Question 11

What would frequent noisy respiration’s indicate?

Answer 11

an obstructed respiratory pattern

Question 12

What are some typical airway interventions?

Answer 12

-Maintenance of Airway Patency:
Suction of Secretions
Chin Lift/Jaw thrust

-Airway Support:
give Oxygen
NRBM (100%)
Bag Valve Mask

-Definitive Airway:
Endotracheal Intubation

-Surgical Crichothyroidotomy

Question 13

General principles of spinal cord protection?

Answer 13

Protect the entire spinal cord until injury has been excluded by radiography or clinical physical exam in patients with potential spinal cord injury.

Question 14

Whats involved in the breathing and ventilation assessment?

Answer 14

Exposure of chest

• Tracheal Deviation
• Accessory Muscle Use
• Absence of spontaneous breathing
• Paradoxical chest wall movement

Auscultation to assess for gas exchange
-Equal Bilateral air entry

Palpation

• Broken ribs
• Injuries to chest wall

Question 15

Explain Tension Pneumothorax

Answer 15

Air trapping in the pleural space between the lung and chest wall. Sufficient pressure builds up and pressure to compress the lungs and shift the mediastinum

Question 16

Treatment of a Tension Pneumothorax

Answer 16

-Needle Decompression
2nd Intercostal space, Midclavicular line

-Tube Thoracostomy
5th Intercostal space, Anterior axillary line

Question 17

Signs and symptoms of a Tension Pneumothorax

Answer 17

Absent breath sounds
Air hunger
Distended neck veins
Tracheal shift

Question 18

Explain Hemothorax

Answer 18

Blood collecting in the pleural space and is common after penetrating and blunt chest trauma.

Question 19

Signs and Symptoms of Hemothorax

Answer 19

Absent or diminished breath sounds
Dullness to percussion over chest
Hemodynamic instability

Question 20

Treatment of a Hemothorax

Answer 20

-Chest Tube

-Thoracostomy
10-20% of cases will require Thoracostomy for control of bleeding

Question 21

Explain Flail chest?

Answer 21

• Direct injury to the chest resulting in an unstable segment of the chest wall that moves separately from remainder of thoracic cage
  -Typically results from two or more fractures on 2 or more ribs
  Generally Accompanied by a pulmonary contusion

Question 22

Treatment of a flail chest?

Answer 22

Improve Abnormalities in gas exchange
Early Intubation for patients with respiratory distress
Avoidance of overaggressive fluid resuscitation

Question 23

What are the three different types of shock in trauma patients?

Answer 23

-Hemorrhagic
Assume hemorrhagic shock in all trauma patients until proven otherwise
Results from Internal or External Bleeding

-Obstructive
Cardiac Tamponade
Tension Pneumothorax

-Neurogenic
Spinal Cord injury

Question 24

Intubation is recommended for a trauma patient when a GCS score goes below which number?

Answer 24

8

Question 25

Potential source of bleeding in a major trauma?

Answer 25

Chest
Abdomen
Pelvis
Bilateral Femur Fractures

Question 26

Explain Circulation assessment for a major trauma patient?

Answer 26

BP, HR, peripheral circulation, capillary refill (central chest), IV access, fluid resuscitation

Question 27

Define Pericardial Tamponade

Answer 27

Pericardium or sac around heart fills with blood due to penetrating or blunt injury to chest

Question 28

Treatment of Pericardial Tamponade

Answer 28

-Open Thoracotomy

Question 29

What does AVPU stand or?

Answer 29

• Alert,
• Responds to verbal stimuli
• Responds to Pain
• Unresponsiveness

Question 30

Which assessments would you do to assess disability?

Answer 30

GCS, AVPU, BSL, urine output, abdomen distention, rectal exam

Question 31

What assessments would you do to assess Exposure?

Answer 31

-Remove all clothing
Examine for other signs of injury
Injuries cannot be diagnosed until seen by provider

-Logroll the patient to examine patient’s back
Maintain cervical spinal immobilization
Palpate along thoracic and lumbar spine
Minimum of 3 people, often more providers required

-Avoid hypothermia
Apply warm blankets after removing clothes
Hypothermia = Coagulopathy
Increases risk of hemorrhage

Question 32

Define DIC?

Answer 32

Disseminated intravascular coagulation (DIC) is characterized by systemic activation of blood coagulation, which results in generation and deposition of fibrin, leading to microvascular thrombi in various organs and contributing to multiple organ dysfunction syndrome (MODS).Consumption and subsequent exhaustion of coagulation proteins and platelets (from ongoing activation of coagulation) may induce severe bleeding, though microclot formation may occur in the absence of severe clotting factor depletion and bleeding.

Question 33

Define Rhabdomyolysis

Answer 33

Rhabdomyolysis is a syndrome caused by injury to skeletal muscle and involves leakage of large quantities of potentially toxic intracellular contents into plasma. Its final common pathway may be a disturbance in myocyte calcium homeostasis

Question 34

Signs and symptomsof rhabdomyolysis?

Answer 34

-Myalgias
-Generalized weakness
-Darkened urine
In practice, however, presentation varies considerably. Additional nonspecific symptoms include fever, nausea, and vomiting.