pmaci Flashcards
pass exam on 10th
when to reassess primary in secondary survey?
If the pt deteriorates at any stage, the primary survey must be immediately reassessed.
when should the gcs scale be repeated during secondary survey in a trauma pt?
in the head to toe examination when examining head. look at pupils and PEARL during this part.
what helps predict the injury in trauma?
moi - based on direction and amount of energy.
AMPLE?
A-allergies
M-medications currently used
P-past illnesses/Pregnancy
L-last meal
E-events/Environment related to the injury
in trauma once short hx ample has been obtained what can you move onto?
a thourough head to toe examination.
main things to look for in head to toe when assessing neurological system in trauma?
ears should be examined looking at the mastoids for battle signs and nose for septal hematoma and to observe oral cavity for dental alignment and broken teeth.
what should you look for when examining c spine in trauma when doing a head to toe?
the spine should be examined for midline tenderness and the need for c spine imaging assessed accordingly.
what should you look for when inspecting the thorax in trauma head to toe?
shoulder girdle should be inspected for external injuries and palpated for tenderness and instability. The chest wall should be re-examined thoroughly and any injuries detected during the primary survey re-inspected. The ribs should be palpated one by one, looking for bony tenderness and/or instability.
the chest should be re-auscultated and should do a cardiovascular examination.
what should you do when looking at adbo and pelvis in a trauma head to toe?
should be reinspected, looking for evidence of bruising or external injuries. the abdo should then be palpated for tenderness gaurding and rebound tenderness. pelvis should then be gentle palpated for any bony tenderness or instability. excess manipulation of the pelvis should be avoided as this can cause or worsen haemmorrhage associated with a pelvic fracture.
what should you assess in msk in a head to toe examination in trauma?
all extremities should be examined, looking for bruising,lacerations and ovbious deformities. all bones should be palpated for evidence of tenderness and the range of movement of the joints assessed. small bones in hands and feeet included.
what makes up the lethal triad?
hypothermia, acidosis and coagolupothy
passive re-warming techniques of a trauma pt who is hypothermic?
remove from cold environments, adequate pt coverage with blankets and recover once reassessed, increasing ambient room temp.
External active warming techniques for trauma pts with hypothermia?
heated blankets, convective air blankets, reflective blankets, radient heat sources, airway gas warming.
internal active warming techniques in hypothermic trauma pts?
admin of warmed iv fliuds, peritoneal lavage, extracorporeal circulatory warming (cardiovascular bypass, continuous arteriovascular rewarming ((CAVR)) , venovenous techniques)
what is severe facial trauma an indicator of?
potential intracranial trauma.
how to diagnose mandibular fractures? trauma*
ability to occlude teeth, conscious pt should be able to close their teeth in correct position, a disrupted occlusion may be because of missing teeth, fractures or dislocations and tmj hemarthrosis.
what are maxilliary fractures usually the result of?
high energy trauma
what do pts with a maxillary fracture present with?
bilateral periorbistal bruising and gross facial swelling. usually occlusion of teeth is disrupted and an anterior open bite with only contact of the molar teeth.
what is an immediate concern with a base of skull fracture?
haemmorrhage and airway problems.
what signs might there be to show a base of skull fracture?
bruising of mastoid process and CSF rhinorrhoea.
when are maxillofacial injuries considered in the primary survey?
when they cause cat haem.
cervical injury leads to what kind of paralysis?
quadraplegia
thoracic injury leads to what kind of paralysis?
paraplegia
lumbar injury leads to what kind of paralysis?
paralegia
how many cervical vertebrae are there?
7
how many thoracic vertebrae are there?
12
how many lumbar vertebrae are there?
5
how many fused vertebrae are there?
5
what are in between the cervical, thoracic and lumbar vertebrae?
intervertebral discs and facet joints?
spinal cord injury is most likely to occur when which vertebrae is damaged?
c3
when does the spinal cord finish? approx*
L1
what are dermatomes?
sensory nerves stemming from spinal cord in specific areas of the skin
what are myotomes?
motor nerves in specific muscles.
where is zone 1 penetrating trauma to the neck?
clavical to the cricoid cartilage
where is zone 2 penetratig trauma to the neck?
from cricoid cartilage to angle of mandible
where is zone 3 in penetrating neck trauma?
from angle of mandible to bas of skull.
what is a primary SCI?
occurs at time of injury. the injuries will reduce the blood supply to the cord or will affect the structure
what will complete transection of the spinal cord result in?
death.
partial transection to spinal cord result depending on what?
may be temporary or perminant depending on the amount of swelling and cord tissue ischaemia that develops.
what is a secondary spinal cord injury?
occurs minutes or hours after the primary injury and it is the role of the health care professional to minimise the risk.
what happens when a secondary spinal cord happens?
secondary inj continues to swell or surrounding structures such as bone or haematoma continue to compress cord.
what can worsen a secondary spinal cord injury?
mechanical instability - careful handling and positioning required, mainatain in-ine immobilisation.
hypoxia - injuries at c3/4 can damage phrenic nerve causing paralysis of diaphragm. these pt require mechanical ventilation.
hypoperfusion - if a disruption to the blood flow to the spinal cord occurs spinal function is reducedand eventually cell death of spinal cord tissue occurs leading to perminant damage.
what is spinal shock?
complete loss of all neurological function, including reflaxes and rectal tone below level of SCI. a transient condition caused by swelling of cord following injury. can last hours to several weeks, only after swelling has reduced will the SCI be assessed to see if it is perminant or temporary.
Neurogenic shock is caused by?
damage to the sympathetic pathways in spinal cord.
why does neurogenic shock not usually occur in injuries below t6?
because the SNS pathways exit the thoracic spine at t6
damage to the SNS will cause?
loss of vasomotor tone as sns helps to control the muscle tone in vessels and so if disrupted vessels willl be inable to constrict. instead vasodilation will occur. causing pooling in blood vessels and consequently hypotension.
loss of sympathetic innervation to the heart as sns helps to innervate the heart causing tachycardia as a response to insult. there will be no tachycardia.
what is good practice to have prepared when suctioning or intubating a patient with a sci and why?
the have prepared atripine. because with a cervica or high thoracic injury where there is damage it will cause bradycardia that cannot be automatically reversed.
what should you do when you have a pt with a sci but they are agitated?
do not immobilise. find and correct as best you can the cause of agitation. apply immobilisation when pt is calmer.
why should you apply 15l high flow o2 with a sci?
it reduces risk of secondary sci. could have diaphragmatic paralysis. pts with high thoracic spinal injury are at high risk of intercostal nerve paralysis.
SCI and SNS damage can mask symptoms of what?
hypovolaemic shock.
what is management for hypotension in neurogenic shock?
admin of appropriate fliuds in boluses - to avoid hypoperfusion and minimise risk of secondary SCI
poikilothermia
when pt loses control of own temp, associated with SCI, they will assume temp of environment.
what is a primary brain injury?
result from the structural effect of the injury to the brain.
how to prevent secondary injury to the brain
maintain adequate oxygenation and perfusion.
what three things does the monro-kellie doctrine state that exist in the skull and what does it say about them?
blood, csf and brain. an increase in one must necessarily result in a decrease in one or both of the other components of the skull otherwise intercranial pressure will increase.
what happens if intercranial pressure increases too much?
the brain will herniate. the most important site of herniation is at the base of skull where the foramen magnum exists which is a hole.
what happens if the brain herniates throught hte foramen magnum?
it will affect the brain stem. the brainstem is responsible for the heart rate and breathing ect. if severe enough those autonomic functions stop working and brain death occurs.
is the cranium completely closed?
yes apart from the foramen magnum wherethe brainstem extends through.
what happens can happen if you injure your cranium or cerebral tissue?
possible intrease to intercerebral pressure which can lead to haemorrhage or oedema. if this occurs it may result in life long cerebral disease and disability or death.
what is an impact loading tbi?
caused by direct blow to head - tbi is caused through a mechanical resulting in deformation of brain tissue as a result of compression, stretching or shearing.
what is impulsive loading (acceleration/deceleration) brain injury?
occurs when head is in motion and is stopped abruptly.
what is static loadin gbrain injury?
injury resulting from a slowly moving object trapping the head agaist a fixed object - essentially squeezing the head.
what is a secondary brain injury?
neurological damage that occurs hours or days after a primary brain injury, these may be preventable o reversible at a later stage.
what are secondary brain injuries laargely due to?
brain tissue hypoxia, oedematous brain tissue, systemic hypotension causing the brain to be under perfused.
fractures of the skull are described according to what?
the shape, site, displacement, whether they are depressed or not.
lineear skull fracture
usually caused by blunt trauma, consist of a line or crack in bone. may not necessarily require any treatment however there is risk of underlying brain injury.
depressed/compound skull fracture?
injury to skull where bone is displaced inwards known as a depressed skull fracture. the bone can be broken intoa number of pieces (comminuted) and if there is and associated scalp wound present the the fracture is classified as open or compound. depressed fragments of bone can damage the underlying brain tissue. compound fractures pose a risk of infection.
base of skull fractures?
a large amount of force required for a base of skull fracture so more common in high mechanism trauma such as an rtc. base of skull is in close proximity to the cranial nerves and large blood vessels so a fracture here is a serious life threatening injury. battle signs and racoon eyes and csf nfrom ears or nose.
epidural/extradural haemorrhage?
common following a head inj. a collection of blood forms between inner surface of skull and outer layer of dura. usually associated with a skull fracture. the bleeding sources from a torn meningeal artery usually or can result from venous blood from a torn sinus. commonly pt have a period of lucidity followed by a decreasing level of consciousness, although this is not reliable enough for a solid diagnosis.
subdural haematoma?
collection of blood in potential space between the dura and subarachnoid matter of meninges. results from stretching and tearing of bridging cortical veins as they cross the subdural space.
