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Module 14 > The Trauma Patient: Triage, Evaluation, Stabilization > Flashcards

The Trauma Patient: Triage, Evaluation, Stabilization Flashcards

1
Q

what does death from trauma tend to be associated with

A

intra-thoracic

intra-abdominal

CNS trauma

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2
Q

what is the primary survey and triage for

A

rank and manage injuries based on their threat to life

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3
Q

how do you survey the respiratory system

A
  1. resp pattern
  2. resp rate
  3. mucous membrane colour
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4
Q

how do you survey the cardiovascular system (4)

A
  1. heart rate
  2. pulse quality
  3. mucous membrane colour
  4. capillary refill time
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5
Q

how do you survey the neurological system (5)

A
  1. mentation:

alert (responsive to voice, pain or unconscious)

obtunded (mentally dull)

stuporous (semi-conscious)

comatose (unconscious)

  1. pupil size & PLRs
  2. eye position & movement
  3. motor responses
  4. blood pressure
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6
Q

what is done intially in trauma patients

A

stabilization

assessing pulse quality, IV access & fluid therapy, supplemental oxygen, ECG to assess cardiac rhythm

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7
Q

what are pulmonary contusions

A

compression-decompression injury following blunt trauma

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8
Q

what do pulmonary contusions cause and what does this result in

A

pulmonary interstitial & alveolar hemorrhage/edema which results in ventilation-perfusion mismatch & hypoxemia

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9
Q

why must you observe a patient with pulmonary contusions

A

may observe progessive deterioration over several hours

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10
Q

what is pneumothorax

A

accumulation of air within the pleural space –> creates atelectasis of lungs which then don’t participate in gaseous exchange (aren’t inflating)

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11
Q

what is the difference between open and closed pneumothorax

A

open: secondary to rib fracture
closed: secondary to ruptured alveolus/bronchus/trachea/esophagus

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12
Q

what is the diagnosis

A

pneumothorax

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13
Q

what is the diagnosis

A

tension pneumothorax

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14
Q

what is tension pneumothorax and why is it life threatening

A

site of air leakage acts as one-way valve

pleural pressure increases during each inspiration until it is greater than atmospheric pressure

hypoxemia develops due to atelectasis –> poor venous return results in CV collapse & shock

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15
Q

what is a diaphragmatic hernia/rupture

A

sudden increase in abdominal pressure with an open glottis is thought to result in a tear to the diaphragm –>

presence of herniated organs within the pleural space contributes to hypoxemia

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16
Q

what does a diaphragmatic hernia/rupture

A

reduced venous return may contribute to CV signs

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17
Q

what are fractured ribs often associated with

A

pulmonary contusions & pleural space disease

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18
Q

what can result in pain-associated hypoventilation

A

fractured ribs +/- pulmonary contusions

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19
Q

what is flail chest

A

fracture (dorsally & ventrally) of 2 or more adjacent rib segments results in paradoxical chest wall motion

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20
Q

how do you assess thoracic trauma (5)

A
  1. physical exam: breathing pattern, auscultation & percussion
  2. trans-thoracic ultrasonography (pleural/pericardial effusion)
  3. diagnostic (& therapeutic) thoracocentesis
  4. thoracic imaging: radiography or CT
  5. ECG
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21
Q

how do you diagnose pneumothorax with physical exam

A

dull dorsal lung sounds and hyper-resonance of the chest on percussion

“barrel-chest” as an indicator of tension pneumothorax in severely dyspneic/cyanotic patients

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22
Q

how do you diagnose diaphragmatic hernia with physical exam

A

lung sounds may be dull ventrally or you may hear borborygmi on auscultation of the thorax

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23
Q

how do you diagnose traumatic hemothorax/chylothorax with physical exam

A

dull lung sounds ventrally

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24
Q

what are the goals of therapy of pneumothorax (2)

A
  1. re-expansion of the collapsed lung
  2. improvement in venous return & cardiac output
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25
Q

how is a pneumothorax treated

A

thoracocentesis or thoracostomy tube placement

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26
Q

how is a thoracocentesis or thoracostomy tube placed

A

intermittent or continuous pleural drainage may be required

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27
Q

what should you consider in a rapidly deteriorating pneumothorax patient

A

induction

intubation

and IPPV

potential need for exploratory thoracotomy if the pneumothorax is ongoing/unresolved with intermittent drainage

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28
Q

how is an open pneumothorax treated

A

apply occlusive dressing

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29
Q

how are pulmonary contusions managed

A

supportive

oxygen supplementation: intubation & ventilation may be indicated in severe cases

avoid over-zealous fluids: damaged lung can be edematous

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30
Q

when do pulmonary contusions usually resolve

A

3-10 day period

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31
Q

how are diaphragmatic hernia/ruptures treated

A

surgical correction

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32
Q

how are fractured ribs treated

A

management of pain-associated hypoventilation

local blocks (lidocaine or bupivicaine)

systemic analgesics

33
Q

how are pleural/pericardial effusions treated

A

drainage where effusion is having clinical impact

34
Q

what are common neurological injuries following trauma

A

traumatic brain injury (TBI)

spinal cord injury (SCI)

may also have concurrent skeletal and soft tissue trauma affecting the head (fractured mandible, orbital fractures, soft palate trauma)

35
Q

what are primary traumatic brain injuries (3)

A
  1. concussion (no histological lesion)
  2. contusion (parenchymal hemorrhage and edema)
  3. laceration resulting in hematoma formation & brain compression either axial (within brain parenchyma) or extra-axial (epidural, subdural, subarachnoid)
36
Q

what are secondary traumatic brain injuries

A

combination of intracranial and systemic insults leading to neuronal cell death

37
Q

what are systemic insults to the brain (4)

A
  1. hypotension & hypoxia
  2. systemic inflammation (secondary to trauma)
  3. hypercapnia (increased CO2) and hypocapnia (decreased CO2)
  4. hyperglycemia, electrolyte imbalances, acid-base disturbances
38
Q

what are intracranial insults (4)

A
  1. increased intracranial pressure (ICP)
  2. compromise of blood brain barrier
  3. cerebral edema
  4. seizures
39
Q

what is raised intracranial pressure (ICP)

A

develops when the volume of the intracranial contents exceeds compensatory mechanisms

40
Q

what does increased ICP cause

A

brain herniation if not identified and treated

41
Q

what is transtentorial herniation

A

transtentorial: cerebrum herniating caudally

42
Q

what is transforaminal herniation

A

cerebellum herniates caudally through the forament magnum

43
Q

when should you consider ICH (3)

A

if you observe deterioration in neurological function

  1. deterioration in mentation, brain-stem function, postural changes (decerebrate rigidity)
  2. development of abnormal respiratory patterns
  3. systemic hypertension and bradycardia “cushing relfex”
44
Q

how do you assess the severity of TBI

A

glasgow coma scale

45
Q

what does the glasgow coma scale assess (5)

A
  1. level of consciousness
  2. brain-stem relfexes (pupil size, PLRs and eye movements)
  3. limb movements and postural reactions
  4. respiratory pattern
  5. blood pressure and heart rate
46
Q

what are the goals of therapy for TBI (3)

A
  1. ensure adequate oxygenation
  2. avoid and/or correct factors that predispose to secondary brain injury
  3. address raised ICP
47
Q

what should you do in patients at risk developing ICH (4)

A
  1. prevent hypercapnia by controlling PaCO2 between 30-35 mmHg (may require mechanical ventilation)
  2. maintain PaO2 > 80mmHg
  3. elevate the head 30 degrees and prevent jugular compression
  4. remove causes of increased intra-thoracic pressure
48
Q

what should you do where there is clinical evidence of marked ICH (deteriorating neurological status)

A
  1. reduce cerebral edema with hyperosmolar therapy
  2. reduce cerebral metabolic rate
49
Q

how do you reduce cerebral edema

A

hyperosmolar therapy

mannitol (0.5-1 g/kg IV over 20 mins)

hypertonic saline (4ml/kg of a 7.5% solution over 10 min)

50
Q

how do you reduce cerebral metabolic rate

A

anesthesia

barbituate therapy

hypothermia

51
Q

what are examples of abdominal therapy (7)

A
  1. hemoabdomen/hemoretroperitoneum
  2. uroabdomen/uroretroperitoneum
  3. bile peritonitis
  4. septic peritonitis
  5. pancreatitis
  6. diaphragmatic rupture
  7. body wall rupture
52
Q

how do you assess for abdominal trauma

A

admonial radiography/CT

abdominal FAST (aFAST)

53
Q

what is the aim of FAST

A

detection of free abdominal fluid

54
Q

what are the points of aFAST

A
  1. diaphragmatic-hepatic DH location
  2. spleno-renal SR
  3. cysto-colic CC
  4. hepato-renal HR
55
Q

where is the diaphragmatic-hepatic DH location and what does it evaluate

A

sub-xiphoid view the hepatodiaphragmatic interface, gallbladder region, pericardial sac, pleural spaces

56
Q

where is the spleno-renal (SR) location and what does it evaluate

A

left flank view to access the splenorenal interface and areas between the spleen and the body wall

57
Q

where is the cysto-colic CC location and what does it evaluate

A

a midline bladder view to assess the apex of the bladder

58
Q

where is the hepato-renal HR location and what does it evaluate

A

a right flank view to assess the hepatorenal interface and areas between intestinal loops, right kidney, and body wall

59
Q

what other diagnostics can be done to assess abdominal trauma

A

abdominocentesis and/or diagnostic peritoneal lavage

60
Q

what would indicate hemoabdomen

A

parenchymal organ laceration or major vessel disruption if the PCV of the abdominal fluid approximates to the peripheral PCV

trauma of > 1 organ (combo of laceration and uroabdomen may reduce PCV)

61
Q

what would indicate uroabdomen

A

if creatinine concentration in abdominal fluid is over 2 times peripheral blood or potassium is 1.4 (dog) or 2 (cat) times serum level

62
Q

what would indicate spetic peritonitis

A

identify intraceullular bacteria, degenerate neutrophils on cytology (high fluid lactate: low fluid glucose)

63
Q

what would indicate an intestinal perforation

A

particulate material (plant material)

64
Q

what would indicate bile peritonitis

A

bilirubin content of the fluid is signifcantly higher than plasma levels

as this is an inflammatory condition you’ll see neutrophils

65
Q

what is hemoabdomen caused by

A

bleeding from spleen, liver and kidney

66
Q

when would you suspect hemoabdomen

A

RTA patient presenting with signs of hypovolemic shock

67
Q

what is diagnosis of hemoabdomen based on

A

free peritoneal fluid (aFAST) which has a PCV similar to peripheral blood

68
Q

what are the goals of therapy in hemoabdomen

A

management of hypovolemic

control of bleeding: surgical or conservative (medical) management

69
Q

what are conservative management of hemoabdomen

A

external counter-pressure using an abdominal wrap

70
Q

what are surgical management of hemoabdomen

A

internal counter-pressure +/- autotransfusion

potential requirement for splenectomy, liver lobectomy, nephrectomy

71
Q

what is uroabdomen caused by

A

secondary to injury to the kidneys, ureters, bladder, urethra

72
Q

when could uroabdomen develop

A

as a late complication of blunt abdominal trauma

73
Q

which develops first hematuria or uroperitoneum

A

hematuria is often present before uroperitoneum develops

74
Q

could a patient urinate despite trauma to urinary tract

A

potentially

75
Q

how is uroabdomen diagnosed

A

imaging (including contrast radiography) to determine where urine is leaking from

76
Q

how is uroabdomen managed

A

surgical correction but medical stabilization may be required before surgical intervention is possible

metabolic consequences –> hyperkalemia are potentially life threatening

77
Q

what are skeletal injuries that can occur following trauma

A

mandibular symphyseal fractures are common

78
Q

when is poor outcome common

A

intra-thoracic, intra-abdominal and CNS trauma

Module 14 (29 decks)

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