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ACP Practical Exam Preparation > Trauma > Flashcards

Trauma Flashcards

1
Q

What are prehospital management priorities for TBI?

A
  • Avoid hypoxia
    • target SpO2 ≥ 94%
  • Avoid hypotension
    • target MAP ≥80mmHg or SBP ≥110mmHg
  • Avoid hypothermia
    • prevent heat loss
  • Optimize ICP
    • Elevate head to 30 degrees
    • Loosen collar, tube ties, etc.
    • target MAP ≥80mmHg or SBP ≥110mmHg
    • Target EtCO2 between 30–35 mmHg; do not hyperventilate
  • Prepare for seizures/vomiting
    • Prepare for midazolam or intubation
  • Rapid transport
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2
Q

What tool is required to differentiate between concussion and intracerebral hemorrhage? What is a concussion AKA?

A

CT scan! Go to hospital!

mTBI

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3
Q

Give specific hemodynamic targets and fluid administration strategies for the following traumatic presentations:

  • General trauma (i.e. anything not listed below)
  • Head Trauma
  • Spinal cord and neck Trauma
  • Burns
  • Electrical Injuries
  • Crush Injuries
A
  • General trauma (i.e. anything not listed below)
    • Target SBP ≥90mmHg (MAP ≥65mmHg)
    • Permissive hypotension is mentioned, but not defined
    • 500mL N/S aliquots to a MAX of 2000mL
  • Head Trauma
    • SBP ≥110mmHg or MAP ≥80mmHg
  • Spinal cord and neck Trauma
    • SBP >120mmHg or MAP ≥80-85mmHg
  • Burns
    • SBP >120mmHg
  • Electrical Injuries
    • For low voltage: normal guidelines
    • For high voltage injuries (> 1000 Volts): initial bolus of 5 ml/kg followed by 100 ml/hour
  • Crush Injuries
    • Consider administering normal saline 2 L immediately prior to release of crush force (CPG: H02)
    • No hemodynamic targets given
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4
Q

Why should TXA NEVER be given through a primary line, and only as a “piggyback” or very slow push

A
  • Giving any infusion via a primary line leaves 20-30mL of fluid in the administration set. When giving small volumes of drug, this constitutes severe underdosing
  • Setting up for “piggyback” infusion reduces the amount of wasted medication
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5
Q

The two essential co-mordities which must be avoided in TBI are:

A
  • Hypoxia and hypotension
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6
Q

What are 3 common locations of subcutaneous emphysema in the presence of pneumothorax?

A
  • Chest wall
  • Neck
  • Axillae
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7
Q

Describe fluid replacement in major burns

A
  • Fluid bolus 500 mL up to maximum of 2 L
  • Target SBP of >120mmHg
  • In cases of prolonged conveyance, use the modified parkland burn formula
    • (Patient weight in kg) x (total burned surface area in %) x 1.5 ml = (volume to be administered over 8 hours)
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8
Q

What is important information to gather when a patient has electrical injuries (i.e. information about the electricity)

A
  • Type of current
    • voltage
    • amperage
    • AC or DC
  • Duration of contact
  • Path of current flow
    • Hand to Foot?
    • Hand to Hand?
    • Foot to Foot?
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9
Q

Lightning injuries typically result in greater or lesser physical injury than high-voltage injuries? Why?

A

lesser!

  • very short duration of contact with the patient (super high voltage and current, but for a short time)
  • current tends to flow around the outside of the body, and as a result, internal electrical injuries are rare.
  • Burns tend to be superficial, not requiring agressive fluid management

But they do cause cardiorespiratory arrest…..

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10
Q

The T-POD may be applied over clothing, true or false

A

FALSE!

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11
Q

Per BCEHS CPGs, what are findings that indicate presence of thoracolumbar spinal injuries (5), and how does this influence treatment?

A
  • Fall from height > 3m
  • Axial loading to head or base of spine
  • High speed MVC > 100 km/h
  • Rollover MVC
  • New back deformity, bruising, or bony midline tenderness

In the absence of nexus criteria for cervical SMR, these patients should be left supine (do not sit them up or raise the head of the stretcher)

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12
Q

Describe the use of therapeutic hypo- or hyperventilation in head injuries

A

They are not done.

Ventilate at an age-appropriate rate

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13
Q

Should patients with new onset neurological impairment be transported on a clamshell stretcher? Why or why not?

A

Unknown! Conflicting guidance in CPGs!

  • Per NEXUS Criteria, new neurological deficits = simple SMR
  • Per CPG H05: “those with new onset neurological impairment require conveyance on a clamshell stretcher

Reasonable threshold? Full SMR for pts. with suspected spinal injury and new deficits since the deficits complicate evaluation for multi-trauma

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14
Q

Describe signs of cerebral herniation in TBI

A
  • Decreasing LOC
    • This should happen BEFORE the other symptoms!
    • If other symptoms are present with intact LOC, consider otehr causes
  • Cushing’s Triad
    • Systolic hypertension
    • Bradycardia
    • Irregular or absent respirations
  • Anisochoria (blown pupil)
  • Strabisus (“down and out” deviation of affected eye)
  • Contralateral hemiparalysis
    • May be ipsilateral if “kernohan’s notch” sybndrome develops
  • Abnormal posturing
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15
Q

In the absence of other complications, should helmets be left in place following injury to neck/spine?

A
  • probably! The evidence supports this
  • Evidence referenced in CPG H05
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16
Q

Describe pre-hospital management of the conscious drowning patient

A
  • Consider associated injuries (SMR?)
  • Position sitting up
  • Avoid hypothermia
  • Support ventilations
    • FiO2
    • CPAP
    • PPV + PEEP
    • SGA
  • Consider induction, ETI, and OG tube placement
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17
Q

Two common complications of head injuries in the field which must be anticipated are:

A

Seizures and Vomiting

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18
Q

Define SIPE and describe management

A
  • Swimming Induced Pulmonary Edema (SIPE)
    • a phenomenon seen in individuals undertaking strenuous surface swimming in cold water (e.g., triathletes or rescue personnel)
    • Symptoms include dyspnea, hypoxemia and possible hemoptysis with a presentation similar to cardiogenic pulmonary edema.
  • Treatment consists of oxygen administration, CPAP, and advanced airway management/mechanical ventilation as needed to correct hypoxemia.
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19
Q

What is the ONLY indication for TXA per BCEHS CPGs

A

Signs of shock or hypoperfusion, in association with an injury suggestive of occult or ongoing hemorrhage

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20
Q

The first three considerations in trauma destination determination are:

A
  • Failed airway?
    • Nearest ED
  • Blunt traumatic arrest?
    • Call for discontinuation
  • Penetrating cardiac arrest?
    • Bypass to trauma centre if <15minutes, otherwise;
    • Transport to nearest ED
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21
Q

What are hemodynamic targets for patients with suspected SCI?

A

SBP >120mmHg

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22
Q

Describe adult and pediatric dosing of TXA

A
  • <1 year; contraindicated
  • 1-12 years; 15 mg/kg IV over 10 minutes (via infusion)
  • >12 years; 1 g IV over 10 minutes (via infusion)
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23
Q

What are BCEHS indications for needle thoracentesis?

A
  • Decompression of tension pneumothorax with deteriorating vital signs indicating markedly decreased cardiac output, profound shock, or cardiac arrest.
  • Bilateral decompression is also indicated in cases of blunt traumatic cardiac arrest.

NOT INDICATED FOR REGULAR OLD PNEUMOTHORAX! MUST BE SIGNS OF TENSION PHYSIOLOGY!

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24
Q

Describe fluid resuscitation protocols for electrical burns/injuries

A
  • Low voltage (<1000V)
    • Follow standard guidelines for shock
  • High voltage (>1000V)
    • 5ml/kg followed by 100ml/hour (if normotensive)
    • Extended care and inter-facility goals should titrate fluid to achieve a urine output of 0.5-1ml/kg/hour.
25
Q

Give GCS ranges which delineate mild, moderate, or severe traumatic brain injury

A
  • ≥ 13 is indicative of mild injury
  • 9 - 12 is suggestive of a moderate injury
  • ≤ 8 is defined as a severe traumatic brain injury
26
Q

In needle thoracentesis, the ARS needle should be guided along:

a. ) the midline of the intercostal space
b. ) directly above the inferior rib
c. ) directly below the suprior rib
d. ) lateral to the medial rib

A

b.) directly above the inferior rib

blood vessels and nerves underlie the inferior border of each rib

27
Q

What is the minimum CPP required to avoid ischemic brain injury?

A

55-60mmHg

28
Q

Describe cooling of burns pre-hospitally

A
  • Provide 15-20 minutes of cooling with cool (not cold) running water
    • Include cooling time by bystanders, if applied
  • Remain on scene to complete optimal cooling if immediate transport is not indicated (i.e. does not fit criteria of “MAJOR BURNS”)
  • If transport is required, flushing with N/S may be effective
  • Avoid whole-body cooling if possible
  • Monitor for hypothermia
29
Q

Should a chest seal be placed over the ARS needle hub following needle thoracentesis?

A

NO!

30
Q

Why should ALL patients with suspected drowning (respiratory impairment following submersion/immersion in a liquid) be transpoorted to hospital?

A

due to the risk of developing secondary hypoxemia over subsequent hours

31
Q

How long should electrical burns be cooled?

A

No longer than 1-2 minutes

32
Q

How is cerebral perusion pressure (CPP) calculated? What are normal ranges for CPP, ICP, and MAP?

A

CPP = MAP - ICP

  • Normal ranges
    • CPP: 60-80mmHg
    • MAP: 70-100mmHg
    • ICP: 7-15mmHg
33
Q

Does the NEXUS tool apply to thoracic or lumbar spinal injuries?

A

No! C-spine only!

34
Q

The most common cause of death and severe disability in trauma is:

A

Head injuries

35
Q

Describe Battle’s sign and its significance

A
  • Mastoid ecchymoses (bruising behind ears)
  • Sign of basilar skull fracture
  • LATE finding; Poor sensitivity but reasonable specificity for BSF
    • DO NOT use to exclude Dx of BSF
36
Q

Per BCEHS guidelines, what differentiates High-voltage and low-voltage electrical injuries?

A
  • high voltage > 1,000 volts
  • low voltage < 1,000 volts
37
Q

According to trauma services BC, what constitutes a major burn?

A
  • > 20% total body surface area (TBSA) partial and/or full thickness, any age
  • > 10% TBSA partial and/or full thickness, age < 10 or > 50
  • > 5% TBSA full thickness, any age
  • Burns to face, hands, feet, genitalia, or joints
  • Electrical burns
  • Chemical burns
  • Inhalation injury
  • Any burns associated with major trauma
38
Q

What are the two interventions approved by BCEHS for open chest wounds?

A
  • Commercial vented chest seal (preferred)
  • Occlusive dressing taped on 3 sides.
39
Q

The most immediate threat in both high and low voltage injuries is:

A

Cardiac arrest

40
Q

Describe co-incidence of SCI and hypothermia with drowning

A
  • SCI is uncommon in drowning
  • hypothermia is common
41
Q

What is the minimum age for which surgical cricothyrotomy is indicated

A

8yrs old

for younger patients, use needle cricothyrotomy

42
Q

List indictions and contraindications for use of a T-POD

A
  • Indications
    • Major mechanism suggestive of pelvic fracture with any of the following:
      • Hemodynamic instability (heart rate > 100 or systolic blood pressure < 90 mmHg)
      • Pelvic pain on exam
      • Pelvic instability
      • Decreased level of consciousness
      • Major injury distracting from pelvic exam
  • Contraindications
    • Neck-of-femur (“hip”) fractures
    • Falls from standing height or other simple falls
43
Q

What electrolyte imbalance may result from severe burns or electrical injuries?

A

hyperkalemia

44
Q

What is the preferred and secondary site for needle thoracentesis?

A
  • Preferred: 5th intercostal space at mid-axillary line
  • Secondary: 2nd intercostal space at mid-clavicular line
45
Q

Describe pathophysiology of lung injury following drowning

A
  • Water in the lungs results in alveolar collapse (atelectasis) which leads to a ventilation perfusion mismatch and impaired gas exchange.
  • Lung injury may take up to six hours to develop following a submersion incident
46
Q

Describe landmarking of the T-POD belt

A

The center of the belt should be aligned with the greater trochanter of the femur

47
Q

What are indications and contraindications for FONA?

A
  • Indications
    • Inability to ventilate, oxygenate, or intubate a patient
  • Contraindications
    • ABSOLUTE: INABILITY TO IDENTIFY LANDMARKS OR AIRWAY STRUCTURES
    • Relative: trauma to the neck
    • Relative: history of perithyroid tumors or radiation to the neck
    • Relative: expanding hematomas or other pathologies distorting structures in the neck
48
Q

What size of ETT is used for surgical cricothyrotomoy?

A

6.0 cuffed

49
Q

What are contraindications for TXA administration?

A
  • Hypersensitivity to tranexamic acid
  • Gastrointestinal hemorrhage
  • Time since injury to administration > 3 hours
  • Age < 12 years (PCP) or < 1 year (ACP)
50
Q

What is the optimal positioning for a patient with suspected TBI, and why?

A
  • Head elevated 30 degrees
  • Improves venous outflow to lower ICP and improve CPP, reducing risk of ischemic brain injury and herniation

  • Elevating to 30 degrees is associated with a drop in ICP from 3-10mmHg (mean of 6.1 mm Hg)*
  • Normal CPP is 60-80, while 55-60 is threshold for injury, so a difference of 6 is significant!*
51
Q

How is triage different in lightning strikes then other cases of trauma?

A

Reverse triage victims of a lightning strike: patients in cardiac or respiratory arrest should be treated first.

52
Q

Describe Ketamine dosing for induction of anaesthesia in trauma

A
  • if shock index <1; 2mg/kg IV/IO
  • if shock index >1; 1mg/kg IV/IO

Consider fentanyl as an adjunct to induction

Consider topical lidocaine as an adjunct to induction

53
Q

Describe field management of abdominal evisceration

A

Cover extruded bowel or eviscerated abdominal contents with moist, sterile dressings followed by an occlusive layer

54
Q

A ‘scaphoid’ or sunken appearance to the abdomen is indicative of:

A

diaphragmatic rupture

55
Q

What is YOUR threshold for intubation in TBI????

A
  • Indications
    • DLOC with blunted airway reflexes; OR
    • Vomiting >1; AND
    • Unable to safely maintain airway with less invasive measures
      • poor mask seal
      • poor i-gel fit
      • complex extrication
  • Must be able to maintain hemodynamics and oxygenation
56
Q

Differntiate between “immersion” and “submersion”

A
  • a submersion involves the whole body, including the airway, being submerged in water.
  • Immersion does not necessarily imply submersion.
57
Q

Describe the components of Full SMR, Simple SMR, and thoracolumbar precautions. Describe when each is used.

A
  • Full SMR
    • C-Collar + Clamshell + Foam rolls
    • Used for all multi-trauma
  • Simple SMR
    • C-collar only
    • Head of bed elevated if head injury present
    • Use when NEXUS criteria present, but no multi-trauma
  • Thoracolumbar precautions
    • Supine positioning on matress, no collar or clamshell
    • Do not sit patient up or elevated head
    • Use when NEXUS is absent, but there is a high-risk mechanism or signs of TL trauma.
58
Q

What are the five NEXUS criteria?

A

Short form

  • Midline tenderness?
  • New Deficits?
  • ALOC?
  • Intoxicated?
  • Distracting injury?

Long form

  • Does the patient have midline tenderness of the cervical spine?
  • Is the patient’s level of consciousness altered? (Must be alert and oriented to time, person, place, and event.)
  • Are there new focal neurological deficits?
  • Is the patient intoxicated? (Judgement and pain sensation must be intact.)
  • Is there a major distracting injury significant enough to interfere with their ability to assess pain response when palpating spine?

ACP Practical Exam Preparation (10 decks)

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