Module 5 Flashcards
Acceleration
injuries involve a change in speed of an object. As speed or velocity increases so does the tissue damage.
Deceleration
injuries, in contrast, result from the decrease in speed and causes objects or organ strikes with a stationary object.
Compression
injuries result from the application of a squeezing or inward force. This may occur as a result of a fall or crushing force. Subsequently,
solid organs rupture,
vascular organs bleed, and
hollow organs spill their contents into the peritoneal cavity
The paper bag effect
In a traumatic accident, a person will often instinctively take a deep breath or “gasp” and hold his or her breath. This deep breath fills the lungs with air (paper bag) and closes the glottis (neck of the bag).
On impact, the chest is hit (by the steering wheel, ground, or handle bars), which causes the internal pressures of the lungs to increase.
Hole is created in the lung and pleural covering, creating a pneumothorax.
Major organs in chest
Heart
Lungs
Aorta
Rib fracture complications
Pain
Inability to take deep breaths -atelectasis
Pneumothorax
Flail chest
Flail chest
segment of ribs that moves opposite to the rest
doesn’t allow lung expansion
Pneumothorax signs and symptoms
decreased unilateral breath sounds
SOB
Tracheal deviation- trachea will shift towards the opposing side
pneumothorax interventions
chest tube
Pulmonary contusion
bruised lung
Supportive management
O2
Cardiac contusion
Bruise on heart
Heart can’t beat effectively causes decreased cardiac output
Traumatic aortic injury- transection
aorta is attached to the spine in some places but not all so with acceleration or deceleration it can tear
Wide mediastenium on chest X-ray
TO THE OR
penetrating injuries
stab wounds, impalements, and gunshot wounds
are concentrated in a smaller area, involve less energy, and may have fewer secondary injuries associated with them. (exception is gunshot wounds)
Documenting Gun Shot Wounds
distance from the weapon to the victim during the shooting
wounds and their appearances
suspected number of shots
description of gun powder soot and burns, scorching of wound edges, tearing of the skin and location of palpable bullets
blood loss at the scene and amount of fluid the patient has already received
patient condition at the scene
Gunshot wounds
As the bullet enters tissue, it creates a sonic wave as well as a cavity. The tissue then recoils leaving a permanent wound track or cavity. As the bullet passes through tissue, it creates both temporary and crush injuries, stretching the tissues in its path.
the closer the range of the gun shot, the more potential damage the person may suffer.
Gunshot and Stab Wound Disclosure Act in BC
it is mandatory to report any confirmed cases or suspicious cases involving gunshots or stabbings to the police
What information must be reported to police?
- The injured person’s name, if known;
- The fact that the person is being treated, or has been treated; and
- The name and location of the health care facility or where an emergency medical assistant treated the individual.
Penetrating chest trauma
Pneumothorax Hemothorax cardiac tamponade pericardial/cardiac wound Tracheal/esophagus trauma
how do we prep for trauma
allocates roles to the team
damage control resuscitation
Management begins with damage control resuscitation to minimize blood loss and maximize tissue perfusion and oxygenation to optimize outcome.
The three pillars of management:
permissive hypotension,
hemostatic resuscitation
damage control surgery
ATMIST
Pt handover form EHS
Age Time of injury Mechanism of injury Injuries sustained Signs and symptoms Treatment given so far
Prep for trauma
Assemble team
assign roles
brief team
Get equipment and drugs ready
Horizontal assessment
Components of the ABCD paradigm and initial investigations (such as chest and pelvic X-Ray, and blood tests) are carried out by several people at the same time, coordinated by the trauma team leader. This allows the team to have the required clinical information quickly
Labs needed in a trauma panel
CBC VBG Group and screen/crossmatch Urea & Electrolytes INR/PTT
TIC TRAUMA INDUCED COAGULOPATHY
TIC is characterized by endothelial dysfunction, dysfibrinogenemia, platelet dysfunction and an imbalance of pro- and anticoagulant factors with systemic anticoagulation. This process is exacerbated by hypothermia, acidemia, and resuscitation with hypocoagulable fluids,
DAMAGE CONTROL RESUSCITATION (DCR)
Avoidance or strict limitation of crystalloid use.
Target resuscitation to low normal blood pressure to limit hemorrhage and prevent rebleeding from recently clotted sites.
massive transfusion protocol
Early hemorrhage control
Ratio of blood product administration
1:1:1
PRBC
Platlets (4 units per bag)
FFP
RISKS AND COMPLICATIONS ASSOCIATED WITH LARGE VOLUME RESUSCITATION WITH BLOOD PRODUCTS
Hypothermia Impaired hemostasis- dilution of clotting factors Hypocalcemia and citrate toxicity Hyperkalemia Volume overload/over transfusion Alloimmunization Risk of transfusion reaction
Who do we try save first in trauma involving pregnancy
The mother
Cardiac changes in pregnancy
Increasing heart rate Increased cardiac output 40% increase in blood volume (causes us to miss it until its late) Pregnancy can exacerbate bleeding Lower MAP in 1st and 2nd \+++CAN MINIC SHOCK+++
Respiratory changes in pregnancy
40% increase in minute ventilation (higher RR)
Decreased vital capacity (less room in thorax for lungs)
Respiratory changes in pregnancy
40% increase in minute ventilation (higher RR)
-Normal hypercapnia less reserve for acidosis
Decreased vital capacity (less room in thorax for lungs)
Harder to intubate/Bag
High risk for aspiration
Increased O2 consumption
Decrease oxygen reserve
Gastroinestinal physiologic changes
Reduced sphincter response and Gi motility so they are at a high risk for aspiration
Increased acid production
Put NG in to decompress
List 8 unique considerations in the management of the pregnant trauma patient
- Pregnancy alterations in BP and HR can mimic shock
- The gravid uterus syndrome
- Blood volume increases can mask hypovolemic shock
- Pregnancy can exacerbate traumatic bleeding
- Reduced FRC – tube quickly
- Increased 02 consumption needs
- reduced sphincter response and GI motility (increased aspiration risk)
- increased acid production (consider early gastric decompression)
Fetal distress is detected with:
- Non-stress testing
- Abnormal baseline HR (> 120-160)
- Assess for Late decelerations - Fetal movement assessment (subjective)
placental abruption pathophysiology,
Blunt trauma leading to abruption results in 60% of fetal losses
Placental (inelastic) separation/shearing (abruption) form the uterus (elastic uterus)
Can occur with NO visible abdominal trauma
Can lead to uterine contractions which further inhibit blood flow
placental abruption clinical findings
- painful, vaginal bleeding
- abd cramps
- uterine tenderness
- Frequent uterine contractions
- Maternal shock
- change in fetal HR
- fetal distress (most sensitive indicator of abruption )
placental abruption management
Expectantly
If mother and fetus are stable:
Usually closely monitored in hospital
After 32 weeks – OB may elect to do deliver early
placental abruption Diagnosis:
Requires the kleihauer-betke test
looks for circulating fetal blood in maternal blood
fetal stress test
placental abruption Complications:
Premature labour
Stillbirth
There is an exponential rise in fetal mortality with increasing amounts of abruption
Abruption can lead to maternal coagulopathy (resulting in DIC)
Gravid uterus syndrome
Compression in IVC
15-30% tilt to the left to get them off the IVC
Manually displace fetus off IVC
Signs of fetal distress (3)
- Abnormal baseline HR normal 120-160
- Decreased variability (Normal beat-beat variability and long term variability)
- Late decelerations
Indicate fetal hypoxia
List 2 potential uterine injuries
Pre-mature labour / contractions
Uterine rupture
Pre-mature labour / contractions
Most common problem is uterine contractions after trauma
myometrial and decidual cells release prostaglandins –> contractions
Uterine rupture
Often due to severe MVCs with pelvic fractures
penetrating trauma is rarely a cause
Diagnosis is difficult and may be confused with liver/spleen injury
fetal parts palpable, massive hemoperitoneum and shock –> high mortality
alterations to the primary and secondary survey in the pregnant trauma patient.
From the start: mother is always the first priority
Maternal resuscitation
Primary survey
“ABCT + UFO”
Primary survey- Focus on mother
A+B-give 02 early, get a secure airway: do RSI, goal PaC02 is 30 mmHg
C-HR and BP are not consistent predictors of well being
uterine blood flow may be reduced with no external signs of bleeding or trauma avoid vasopressors
T-“not D” Tilt the mother!
U-uterus: if uterus above umbilicus: likely >24 weeks
FO- Fetal Tones: Modify primary survey to assess uterine size and presence of fetal tones
Maternal resuscitation
Fetal evaluation
(1) fetal heart rate
(2) fetal movement
Signs of fetal distress (3)
abnormal baseline HR normal 120-160
decreased variability-normal beat-beat variability and long term variability
Late decelerations-indicate fetal hypoxia
Maternal resuscitation
Secondary survey
Get maternal detailed info ? Weeks pregnant, number of babies, GTPAL Hx. ? uterine tenderness ? contractions ?vaginal bleeding Pelvic exam: ? signs of ferning on uterine fluid? (ruptured membranes) ?cervical dilatation Swabs for G+C ? GBS status Bimanual exam for pelvic bone protrusion
Peri mortem C-Section
start 4 mins after arrest if no ROSC
What should we use to contain clothes of a patient who was assaulted
Paper bag
5 meds to consider for pt who have been assaulted
Pregnancy
Exposure- Hep B and HIV
Pain
STI
What causes the breakdown of DNA
Plastic
Heat
Light
Moisture
When do we assess the fetus in a pregnant trauma
secondary assessment
Advantage of perimortem c-section for mother
increased venous return cardiac output can increase by 25-30%
A woman’s blood volume increases by ____ during pregnancy
30-50%
Minimum requirement for fetal monitoring post trauma
4 hours is the minimum requirement for fetal monitoring post trauma
Signs and symptoms of placenta abruption
vaginal bleeding
8 or more contractions per hour in the first four hours of monitoring
abdominal pain
Discharge of a pregnant woman after a trauma from the hospital
There should be no vaginal bleeding
Contractions should have resolved
Membranes should be intact
