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Mass casualty and Trauma > Trauma > Flashcards

Trauma Flashcards

1
Q

ARS Indications in a trauma patient

A

GCS < 10

SBP < 70

Small Paeds may be inappropriate for ARS device

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2
Q

What are the 3 major factors that influence ICP

A

Hypoxia

Hypercapnia

Hypotension

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3
Q

Signs of Tension pneumothorax

A
  • ⇑ Respiratory distress in the awake patient
  • ⇓ SpO2 to <92% despite O2
  • ⇓ Conscious state
  • Poor perfusion or ⇑ HR +/- ⇓BP
  • ⇑Peak inspiratory pressure (ventilator) / stiff bag
  • ⇓ EtCO2
  • ⇑JVP
  • Tracheal shift
  • Low SPO2 on O2 (late sign)
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4
Q

CPP formula is?

A

CPP = MAP - ICP

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5
Q

What are the 3 principles of distribution in trauma?

A

The trimodal distribution of death

Immediate

Progressive

Delayed

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6
Q

What are the 5 applications of force

A

Acceleration

Deceleration

Rotational

Horizontal

Vertical

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7
Q

What are the 3 points of (Immediate) trauma in the trimodal distribution

A
  • Death occurs in seconds to minutes
  • Due to severe CNS or brain stem injury, injury to heart, aorta, great vessels.
  • Patients are rarely salvageable
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8
Q

What are 2 points of (Progressive) trauma in the trimodal distribution

A
  • Death due to Sub-dural or extra-dural haematoma, haemo/pneumothorax, splenic, or hepatic injury, unstable pelvic #’s
  • These are the “GOLDEN HOUR” patients.
    Considered preventable if injuries promptly identified and treated
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9
Q

What are the points of (Delayed) trauma in the trimodal distribution

A

Death due to : Irreversible brain injury

  • Sepsis
  • Multi-organ failure
  • Acute respiratory distress Syndrome (ARDS)
  • Systemic Inflammatory Response Syndrome (SIRS)
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10
Q

What is the Triade of death

A
  • Hypothermia
  • Coagulopathy
  • Acidosis
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11
Q

Hypothermia Causes/Cautions

A
  • Environmental – assume your patients temp is dropping before your eyes
  • expose only areas that you are examining
  • remove all wet clothing
  • Hypovolemia – think hidden haemorrhage
  • Intoxication and head injuries will impair the bodies ability to regulate temperature.
  • Shivering wastes valuable cellular energy and oxygen in your patient, and produces more lactic acid.
  • Ambient temp of normal saline – may be only 15 degrees in winter
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12
Q

Coagulopathy Causes/Cautions

A
  • Regardless of the cause, results in the potential continual haemorrhage.
  • Trauma and acidosis can reduce the bodies ability to clot.
    as the body gets colder, it loses its ability to clot .
  • Impaired platelet function, inhibition of clotting factors, they need blood not normal saline.
  • Normal saline and packed RBC can dilute the remaining clotting factors and contribute to the acidosis.
  • Or:
    The Clotting cascade can become abnormally activated – causing excessive clot formation and subsequent breakdown (fibrinolysis) out of proportion to the injury.

Now consuming the last of the bodies remaining clotting factors = difficult to maintain haemorrhage control

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13
Q

Acidosis Causes/Cautions

A
  • In trauma, major contributor is poor perfusion. (blood loss, peripheral vasoconstriction, and decreased cardiac output) severely impair oxygen delivery
  • Therefore increased tissue oxygen demand outweighs oxygen delivery
    Anaerobic metabolism utilised – by product of this is Lactic acid, leading to a severe metabolic acidosis
  • Respiratory acidosis – hypoventilation, respiratory depression, or obstruction, resulting in hypercapnia.
  • Think narcotic or alcohol OD, TBI, flail chests, COPD.
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14
Q

As per CPG what are the fluid considerations with Hypovolemia

Haemorrage

A
  • Aim for SBP > 70 can be tolerated above 70 for 2/24
  • IF SBP <70
    • Manage Haemorrage first if possible
    • immediate transport
    • Give 250 ml bolus’s titarate to BP
    • Max 2 lts
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15
Q

The treating priorities (organs) of Trauma

A
  • Head
  • Chest
  • Abdo
  • Pelvis
  • Limb
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16
Q

Chest Trauma Causes/concerns

A

Is it Blunt or Penetrating.

Complications: #ribs,

  • flail segments,
  • pulmonary contusion,
  • myocardial injury (tamponade or contusion),
  • open wounds (haemo/pneumothorax)
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17
Q

Chest Injury #ribs =

A
  • Pain on inspiration and potential pleural lung injury – Hypoventilation due to pain
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18
Q

Chest Injury Flail =

A
  • 2 or more #ribs that allow the chest wall to move independently
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19
Q

Chest Injuries - Myocardial and pulmonary

A

Myocardial contusions/tamponade – think stabbings.
Pulmonary contusions – think blunt injuries / CPR

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20
Q

Chest Trauma - Diaphragm

A

Diaphragm injuries – can impact expansion and inflation of one or both lungs. (bowel sounds in
chest are not normal)

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21
Q

Tension Pneumothorax Pathophysiology

A
  • Escape of air into the pleural space through a one way flap or valve. Enters pleural space during inhalation but cannot escape during exhalation.
  • Increasing pressure in the pleural space leads to collapse of the lung on the affected side, with associated hypoxia as the lung’s gaseous exchange is compromised.
  • ⇢Tension on the internal structures, eventually compressing them and impeding their ability to function
  • Tends to push the mediastinum in the opposite direction (evidenced by tracheal deviation AWAY from the affected side).
  • Intrathoracic pressure also increases as a result which overcomes the pressure of venous return. This leads to reduced cardiac output and poor perfusion
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22
Q

What are the outer layers of the brain

A
  • Dura – protective covering of the brain
  • Dura Mater – epidural space that contains the meningeal arteries
  • Arachnoid Mater – subarachnoid space contains CSF : approximately 150mls surrounds the adult brain (500mls/day produced)
  • Pia Mater
  • Cerebral Cortex (brain)
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23
Q

Rising ICP +/- herniation may result in:

A

Increased pressure on the medulla oblongata which contains:

  • reticular formation = agitation, N&V
  • vasomotor centre = increased BP
  • cardiac inhibitory centre = decreased HR
  • respiratory centre = increased/decreased/irregular respirations
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24
Q

Traumatic head injury aims of treatment

A

Management aim:

Air way is priority
Decreasing secondary HI to save neurological tissue. Correct the following

Hypovolemia from other injuries may cause hypotension – this can lead to a further decrease in cerebral perfusion. Isolated TBI does not usually cause hypotension – look for other causes. SBP aim 120mmhg and O2Sa over 84 and monitors ETCO2

Aim is to prevent a secondary HI by recognizing and treating hypoxia, hypercapnia, or hypo perfusion (hypovolemia, Hypotension)

Hypovolemia from other injuries may cause hypotension – this can lead to a further decrease in cerebral perfusion.

Avoid – initiating gag reflex
Hypo/hyperventilation

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25
Q

Brain trauma Aims

A

AIM : airway and ventilation. SaO2 >95%, ETCO2 30-35 mmHg
Maintain CPP (BP >120 mmHg) (maintain above 80mmhg)
60 mmhg – cerebral vessels max. dilated.
<60 mmhg – cerebral ischemia.
>150 mmhg – increased ICP.

prevent secondary HI

Position head at 30* midline (if no c –spine considerations)

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26
Q

Blunt head trauma

A

Blunt Head trauma with a GCS 13 -15 either with or without loss of consciousness/amnesia with ANY

  • *5** – any loss of consciousness exceeding 5 minutes
  • *H** – skull # (depressed, open or BOS)
  • *E** – vomiting more than once
  • *D** – neurological deficit
  • *S** - seizure
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27
Q

5 Heads more detail

A
  • 5 minutes or greater of LOC err on the side of caution
  • H – head injury – large haematomas, lacerations, #, facial injuries, skull structure is important. Fluid leaking from the nose or ear, raccoon eyes, patient irritation. More common in elderly.
  • E – Emesis – vomit x1 normal post HI. More than once would suggest a rising ICP = BAD.
  • D – dysfunction. ANY change to motor or sensation or function means that the spinal cord is injured.
  • S – seizure – ANY in the setting of a traumatic or non traumatic head injury is BAD. ( eclamptic pts)

Typical patients are your sports people, MCA’s, Elderly from standing height, intoxicated pts. (they need to be collared – I known God looks after these people, because GOD sends US!!)

Falls from standing height does not seem obvious, - remember your Trauma stats - falls account for 38% deaths.

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28
Q

Spine Anatomy

A

33 Vertebrae – (C7, T12, L5, S5,C4)

31 Pairs of nerves – (C8, T12,L5,S5,C1)

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29
Q

3 types of spinal injury

A
  1. direct mechanical injury
  2. tissue degeneration (within hours of the injury)
  3. complete spinal cord transection.
30
Q

Neurogenic Shock

A
  • Caused by sudden loss of the autonomic nervous system signals to the smooth muscle in in vessel walls.
  • This can result from severe Central Nervous System (brain and spinal cord) damage.
  • With the sudden loss of background sympathetic stimulation, the vessels suddenly become relaxed, resulting in sudden decrease in peripheral vascular resistance (vasodilation) and decreased blood pressure.
  • The vagus nerve remains intact (exits the BOS) and so becomes the Dominant nerve.
31
Q

Spinal damage S & S

A
  • HYPOTENSION- due to venous pooling and decreased venous return
  • BRADYCARDIA – due to unopposed parasympathetic response.
  • PARALYSIS – damage to motor nerves
  • PRIAPRISM – neurological and vascular causes
  • PARADOXICAL RESPIRATIONS – loss of innervation to the thoracic musculature
  • PARATHESIA – damage to sensory nerves
32
Q

Fracture and dislocation management Aims

A
  • Control External haemorrhage
  • Apply good splinting practice
  • Resolve neurological or vascular compromise (where possible) use judicious analgesia
    • Reducing a # : consider analgesia and likelihood of success
      *procedural analgesia
      *Irrigate
      *Traction and counter traction
      *Splint
      *Ongoing analgesia
33
Q

Causes of Altered Conscious state

A

AEIOUTIPS A - Alcohol / drug intox E - Epilepsy, Endocrine , electrolytes encephalopathy I - Insulin hypo / hyper O - Opiates overdose and oxygen U - Uremia, underdose (withdrawal) T - Trauma I - Intracranial or infection P - Poisoning pain psychosis S - Seizures

34
Q

CPP definition

A

Pressure gradient which the circulatory system must work against to perfuse brain

35
Q

MAP definition

A

Driving blood into the brain

36
Q

ICP definition

A

It provides resistance against MAP determining CPP

37
Q

Autoregulation of the brain

A

The brain has to have a steady constant flow of cerebral blood flow, if impacted by increased O2 the vessels will vasoconstrict and visa versa and if co2 is increased we get vasodilation and visa versa

38
Q

Treatment of TBI

A

Aim for SBP >120

If SBP <120 give max 40ml/kg titrating response

If post 40ml/kg SBP<100 consult for additional 20ml/kg

39
Q

Spinal Injury assessment

A
  • Look for changes in sensation
    • equal sensation in feet and hands and sides
  • Assess both sides
  • May present as
    • Numbness
    • Tingling
    • Pain
40
Q

Nexus Criteria

A

IF ANY red flags in the below S&S then must get collar

  • Over 65
  • History of bone or muscle weakness
  • Hard to assess ie
    • altered GCS
    • intoxicated
  • Significant distracting injury
  • Actual injury evidence so vertebrae pain or tenderness
  • unable to rotate neck 45 degrees without pain
41
Q

Types of Fractures and estimated blood loss

A
  • Ribs = 100 -150mls
  • Radius / ulna = 150-250mls
  • Humerus = 250mls
  • Tib/fib = 500mls
  • Femur = 1000mls
  • Pelvis = 1.5 - 3lt
42
Q

Define decompression illness

A

refers to injuries caused be a rapid decrease in the pressure that surrounds you either air or water

  • Scuba divers at risk of barro trauma if ascend to quickly this can cause a gas emboli
  • Unpressurised aircraft also at risk
43
Q

Boyles Law

A

As pressure increases gas volume decreases

ADD PIC

44
Q

Henry’s Law

A

The greater the pressure the higher the concentration of gas absorption

ADD PIC

45
Q

The effect of pressure and gas in diving

A
  • The deeper the dive the higher the pressure
  • At depth nitrogen diffuses into tissues
  • Ascend slow allows for nitrogen movement back out of tissues
  • If rapid ascending gas expands and is then trapped in tissues
  • Volume expansion is Boyles law
  • Trapped gas is Henry’s law
46
Q

What to document for suspected Barro trauma (bends)

A
  • how many dives
  • surface interval between dives
  • max depth
  • type of ascent (controlled or uncontrolled)
  • any safety stops
  • gas mix
  • level of exertion on during and post dive
  • Take all gauges to hospital
47
Q

Decompression illness signs and symptoms

A
  • Sinus or ear pain
  • Vertigo
  • Headache
  • Abdo pain
  • Joint pain
  • Seizure
  • Epistaxis
  • Dyspnoea
  • Itching skin
  • ACS Chest pain
48
Q

Cerebral arterial gas embolism (cage)

A

GCS less than 15 Any seizure Any LOC

49
Q

Decompression illness management

A
  • Handle with care Position supine
  • Administer high flow oxygen
  • Consider tension pneumothorax if SOB
  • Avoid rapid rewarming due to increased gas trapping Manage
  • symptoms as per individual CPG
  • Notify transport to chamber If chest clear = administer 1000mls normal saline over 15-20 mins can repeat every 4 hours
50
Q

Airway/ventilation consideration in a Traumatic head injury

A
  • if airway is patent and tidal volume is adequate with trismus (DO NOT INSERT OPA/NPA)
  • If airway not patent and gag present insert NPA and ventilate
  • If intubation not possible/not authorised and gag absent insert LMA
  • Ventilation = 6-7ml/kg maintain sats >95% etco2 30-35 SBP >120
51
Q

Which would a spinal injury occur for loss of sympathetic tone

A

Above T2

52
Q

What is different about the vagus nerve

A

It is a parasympathetic carnival nerve that exists at the base of the skull therefor bypasses spinal column that is responsible for regulation of internal organs and vasomotor activity

53
Q

In a trauma patient what is subcutaneous emphysema and what dose it mean

A

It means air has escaped the plural space into the subcutaneous tissue and patient is no longer tensioned

54
Q

What dose an open book (pelvis) mean

A

It means the pelvic ring has broken/interrupted

55
Q

signs and symptoms of an open pelvis

A
  • mechanism (fall, MVA, horse, motorbike, blunt force)
  • deformity (bruising, legs raised, can’t straighten leg)
56
Q

How dose the Triad of death effect your trauma patient

A

Severe bleeding =

  • decreased oxygen delivery which leads to hypothermia
  • decreases coagulation cascade prevents blood from clotting
  • absence of blood bound oxygen and nutrients
  • increasing glucose metabolism which causes lactic acidosis
  • increasing blood acidity (metabolic acidosis)
  • overall reduction of efficiency in heart muscles
  • further reducing oxygen delivery thus triggering a deadly cycle
57
Q

Absence of visible blood loss what are some signs to look for in your patient (think suspected hypovolemia)

A
  • internal signs - pulmonary bleeding including haemoptysis, respiratory crackles
  • visible bruising on chest and abdomen
  • peritoneal signs - tenderness, guarding, rigidity, distension
  • long bone breaks/open book pelvis
  • abnormal VSS (isolated tachycardia +- hypotension)
58
Q

Define Coup/Contracoup injury

A

Coup = moving object impacts stationary head

Contrcoup = moving head strike stationary object

59
Q

How much blood loss is considered life threatening in the average adult

A

Above 2000ml/greater than 40% blood loss

60
Q

What GCS is at the patient when they are not eye opening, not talking and abnormal extension to pain

A

GCS 4

61
Q

What GCS is the patient who is eye open to voice, verbally inappropriate and localising to pain

A

GCS 11

62
Q

Cushings triad (Head)

A
  • irregular/ decreased respirations
  • bradycardia
  • systolic hypertension (widening pulse pressures)
  • this indicates increasing ICP (late sign indicating brain herniation is imminent)
63
Q

What GCS is the patient who is Eye opening, confused, and localising to pain

A

GCS 13

64
Q

How dose the brain maintain ICP

A

The brain has a constant flow of cerebral blood and can maintain this even when CPP changes this is called auto-regulation via vasoconstriction and vasodilation

65
Q

What are three major factors that influence ICP

A
  • Hypoxia
  • Hypercapnia
  • Hypotension
66
Q

Which AV medications do we carry that affect BP

A
  • GTN
  • Morphine
  • Ketamine
  • Stemitil
  • Midazolam
    Frusemide
67
Q

How do we manage a combative head injured patient

A
  • Analgesia
  • Moprhine or Rent as per CPG
  • If pain relief fails IM Morphine
68
Q

What GCS is the patient with the following, eye opening to pain, incomprehensible sounds, withdrawing from pain

A

GCS 8

69
Q

What is Paradoxical breathing

A

Its chest wall movement that is opposite to the abdominal

70
Q

What GCS is the following patient with spontaneous eyes, incomprehensible sounds, localising to pain

A

GCS 11

71
Q

Treating principles of trauma

A

* Identify and manage conditions that pose an immediate life threat.

* Minimise the time from injury to definitive care

* Minimise the triad of death (hypothermia, acidosis, coagulopathy)

* Analgesia in a timely and effective manner

Mass casualty and Trauma (4 decks)

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