Trauma Flashcards
Unintentional Injury
Leading cause of death for people ages 1-44
Leading causes of unintentional fatalities:
Motor vehicle traffic (MVA, pedestrian, bicyclists)
Poisoning
Falls
Triad of death: a lethal cascade
predictor of poor outcome with severe blood loss in the middle
Coagulopathy: excessive fluid dilution, metabolic events, hyperthermia, DIC
Acidosis: build-up of lactic acidosis, build up of Co2 from poor lung functioning, slow breathing
Hypothermia: wet clothing, IV fluids=shivering, decreased tissue perfusion, decreases removal of lactic acid.
Emergency room nurse
Prompt recognition of patients requiring immediate intervention => ___
_______: roles and responsibilities for trauma patient on admission to ER
PPE
Stressful environment
triage -
Triage-takes a lot of experience to triage appropriately
Team assembling-
“Code Trauma”: have specific responsibilities/role
Triage “to sort”
Process of sorting or quickly determining victim acuity
Categorizes patients so that ___________ based on illness severity and resource utilization
Emergency Severity Index (ESI): Five levels of triage (1-5)
most critical are treated first
ESI-1 & ESI-2 most critical
ESI-3, ESI-4, ESI-5 patients are stable
How sick, how soon need to be seen?
With the ESI, patients are assigned to triage levels based on both their acuity and their anticipated resource needs.
ESI-1 any threats to life (_____)
ESI-2 high risk situation
ESI-3,4,5(nL vs) depends on # of resources(ECG, labs, radiology studies, IV fluids)
cardiac arrest
Primary Survey
A: airway
B: breathing
C: circulation
D: disability
E: exposure and environmental control
When a trauma patient first comes in. Trauma resuscitation requires immediate treatment, these five things to prevent death. Trauma viewed as multisystem disease. Identify and treat life-threatening conditions first. Primary (ABCDE) & secondary (FGHI) survey for all trauma patients
Secondary Survey
F: full set of vital signs & family
G: give comfort measures
H: head to toe assessment & history
I: Inspection of posterior surfaces
A
Airway with simultaneous cervical spine stabilization and/or immobilization
Open airway
Always assume injury to cervical spine
Stabilize/immobilize cervical spine
Remove or sx foreign bodies
Insert airway or prepare for intubation
Nearly all trauma deaths that occur immediately, due to _____ .
S/Sx of compromised airway:
Suspect cervical spine trauma in any patient with ______________________; open airway with modified _________
airway obstruction
face, head, or neck trauma and/or significant upper chest injuries
jaw thrust maneuver
Breathing
Assess adequacy of _____
Look, listen, and feel parameters
All trauma patients should receive ______ during initial evaluation/may need BVM
If we must intubate, it is preferred rapid sequence intubation:
If unable to intubate due to injury or edema or a failed intubation: emergency _______ or _______, which is a lifesaving measure.
ventilation
high-flow oxygen (NRB)
induce unresponsiveness followed by neuromuscular blockade to cause muscular relaxation(sedate and paralyze).
cricothyrotomy or a tracheostomy
End tidal CO2 monitoring
Increased use of end tidal CO2 monitoring (______) in trauma patients-why?
capnography
More accurate than pulse ox.
Circulation
Check central pulse (quality)
Blood pressure, HR, skin color, oxygen saturation, cap refill
If absent pulse, start CPR
STOP THE BLEED!
Determine source of blood loss
Hemorrhage is cause of early post-injury deaths; can occur in several areas:, pelvis, femur, liver, spleen, kidney, head, chest (organs that are vascular or areas that can hold a lot of blood)
Check carotid and brachial
2 large bore IVs (14, 16g)
Type and cross match
Administer fluid/blood products
Aggressive fluid resuscitation: LR or NS
Can give ______ while waiting on type and cross
Type and cross typically takes 45 min.
0- or LR
Circulation (fluids)
What would failure to respond to fluids possibly indicate? rapid surgical intervention is required (hypovolemic shock)
Warm Lactated Ringer’s solution
Isotonic
The components of LR are the closest to our blood crystalloids
Not usually used as a maintenance fluid because of added electrolytes such as Na+ and K+
Disability:
_____ is common in the early stages of shock, fight or flight response. As shock progresses their _______.
_____ about an event suggests an altered loc
______- indicative of brain injury- ominous sign
Brief neuro exam
Determine patient’s level of consciousness:
A –Alert
V – Responsive to voice
P – Responsive to pain
U – Unresponsive
or
Glasgow coma scale
PERRL
posturing
Agitation
LOC decreases
Amnesia
Posturing
Glasgow comma scale scoring can be impaired by drugs and alcohol
Exposure
Patient completely disrobed in preparation for secondary survey
Exposure to:
-
-
cold ambient temperatures, large volumes of room temperature IV fluids, cold blood products, and wet clothing hypothermia
-Heated blankets, overhead warmers, warmed fluids, warmed room, and Bair hugger
-Maintain privacy
-Preservation of evidence
Hypothermia: core temp _____ or less. Hypothermia is the easiest to treat of the trauma triad.
35 C or 95 F
Secondary survey
F
G
Finished primary
Labs you would anticipate:?
Blood at meatus-what would you suspect?
Facial fractures - NGT with US guidance
NGT tube- contraindicated with _________
Full set VS, focused adjuncts, facilitate family presence: continuous ECG,O2 sat, end-tidal CO2 monitoring; urinary catheter/NGT if indicated; tetanus; labs, X-rays; designate team member to support family
Give comfort measures: assess and reassess pain/anxiety
orbital or brain injuries
H and I
History andHead-to-toe AssessmentInspection
Obtain details of:
Head to toe assessment
AMPLE:
Log roll and inspect back for:
What did happen? ________ is important when obtaining history can help predict the types and combinations of injuries ie. If a fall, how high? if MVA, driver? Seatbelt? Airbag deployed?
May need to remove anterior portion of c-collar to see if any ____ or ____
incident/illness, mechanism and pattern of injury, length of time since incident, injuries suspected, treatment provided and pt’s response, LOC
allergies, meds, past health hx, last meal, events/environment preceding injury or illness
deformity, bleeding, lacerations, and bruises
Mechanism of injury
tracheal deviation or JVD
Diphtheria, Tetanus & PertussisVaccinations
DTaP (given to children under age __)
Tdap (_________)
Td (once every ____ after one Tdap)
TIG
When would you give TIG (tetanus immunoglobulin)?
_____, ____ - signs of tetanus
DTaP vs. Tdap – different _____ of vaccine
DTaP- given before (D comes before T)
7
one dose age 11-64 years
ten years
Given to someone showing signs of tetanus. They will still need vaccine sat some point
Lockjaw, spastic muscles
concentrations
Tetanus, diphtheria, and acellular pertussis(Tdap)
Only for individuals older than ___ years of age
Now routinely given around _____ years of age
Healthcare professionals should all have this vaccine
Pregnant women should get one dose of Tdap during every pregnancy (CDC, 2022)* “whooping cough”
Td is a derivative of Tdap…but without the ____
Td boosters should be given every ____
*CDC recommends all women receive a Tdap vaccine during the 27th through 36th week ofeachpregnancy, preferably during the earlier part of this time period. Why?
Given with ___, ___, & ____
7
11 or 12
pertussis.
10 years
burns, trauma, pregnancy
Trauma Signs
Battle’s: post-auricular ecchymosis, behind the ear, over the mastoid bone- basilar skull fx
Raccoon eyes- orbital fractures
Gray turners- internal bleeding retroperitoneal
Cullen’s- umbilicus
Liver laceration
Chest trauma types:
1. Penetrating
2. Blunt
-
-
-
Sternal fx usually by steering wheel, can cause pulmonary contusion. Increases mortality 50%, present like ____________
Sternal and rib fractures
Pulmonary contusion (mortality rate >50%)
Flail chest
ARDS presentation. Hypoxemia refractory to oxygen.
Prevent pneumonia with IS or flutter valve
Flail Chest
Fracture of several consecutive ribs in _____ separate places causing ____
causes,
signs and symptoms,
treatment
two or more
unstable segment
Causes: severe blunt injury – crushing roll-over injury due to a flipped ATV, MVA or a fall might cause it.
S&S:
Paradoxical breathing-the opposite of what it should be. (lung deflates when it should inflate)
Rapid, shallow respirations and tachycardia
Treatment:
Supportive therapy is key while the ribs heal
Rarely need surgery (external device), supportive therapy-taping, splinting.
If major injury, may be intubated
Thoracic Injuries
______: air enters the pleural space causing a total or partial collapse of the lung
-Loss of _______
-Signs and symptoms depend on ___
Types:
–
-
-
Hemothorax: may require ______
Treatment?
Pneumothorax:
negative pressure
size
Types:
-Simple or spontaneous
-Traumatic
-Tension
autotransfusion
Insert CT into pleural space: to drain fluid, blood or air; re-establish the negative pressure, and re-expand the lungs
Sometimes lung issues such as asthma can precipitate the pneumothorax
Spontaneous pneumothorax:
Primary:
Secondary:
Risk factors:
Treatment:
Rupture of small blebs
Primary: healthy young individuals
Secondary: as a result of lung disease
VATS procedure: video-assisted thoracic surgery – if it won’t stay inflated with chest tube
Tall and thin adolescent males are typically at greatest risk
Rupture of small blebs, leads to loss of negative pressure, lung collapses.
Traumatic pneumothorax
Closed- can occur during invasive thoracic procedures (“drop a lung”) like CVC insertion
Open pneumothorax- “sucking chest wound” (mediastinal shift)
Causes?
Open (flap may act as one-way valve) occurs with a penetrating wound.
Tension pneumothorax
Progressive build-up of air within the ______ and cannot escape
-
-
-
We want to prevent a tension pneumothorax because:
pleural space
Increased intrathoracic pressure
compression of lung on affected side
mediastinum shifts to unaffected side
decreased venous return
decreased cardiac output
(trapped air causes pressure on the heart and lungs)
Tension pneumo s/sx
Sudden pleuritic pain
Air hunger, decreased pulse ox
Marked tachycardia, delayed cap refill
Tracheal deviation
Decreased or absent breath sounds on affected side
Neck vein distention
Cyanosis
Profuse diaphoresis
Tension pneumo
Remember tension pneumothorax is one of your “t’s “ in causes of ____
Medical emergency!
Possible:
Not getting blood returning to the heart…what are we gonna do
PEA
circulatory collapse w/ hypotension and traumatic arrest
Tension pneumo treatment
Act fast!
Prepare patient for needle decompression followed by chest tube insertion to water seal drainage
First action, second action: needle decompression (angiocath inserted to release air, everything goes back into normal place); follow with CT insertion and connect to pleurovac drainage system
Cardiac Tamponade
Causes
Tx
Also another one of your “t’s “
in causes of ____!
blunt or penetrating trauma (hemorrhage)
diagnostic cardiac procedures
pericardial effusions from metastasis
Pericardiocentesis using echocardiography – immediate relief
PEA
Cardiac Tamponade-Beck’s Triad
JVD
Muffled of distant heart sounds
low blood pressure
Abdominal trauma
Etiology
- Blunt
compression & shearing injuries
may not be obvious - no open wound
Blunt: MVA usually; assoc with: low rib fx, femur fx, pelvic fx, thoracic injuries
Abdominal trauma can cause massive life-threatening blood loss into abdominal cavity.
- Penetrating
0pen wound
Abdominal trauma Clinical Manifestations:
MUST lift your patient’s gown to accurately assess abdomen!
Assess for referred pain which may indicate :
What is hematemesis/hematuria?
abdominal pain
guarding/splinting of abdominal wall
hard, distended abdomen (“Rigidity”: hard, distended, “board-like”)
decreased or absent bowel sounds
contusions, abrasions, or bruising over abdomen
scapular pain
hematemesis/hematuria
signs of hypovolemic shock
spleen, liver, or intraperitoneal injury. Blood/fluid irritating in the abdominal cavity and phrenic nerve involved
Abdominal trauma Complications
When solid organs injured (liver, spleen) bleeding can be profuse hypovolemic shock (requires aggressive fluid resuscitation)
When hollow organs (bladder, stomach) spill into peritoneal cavity risk for peritonitis and abdominal compartment syndrome
Compartments = can put pressure on diaphragm and lungs causing respiratory compromise
Abdominal trauma diagnostic studies
labs
urinalysis
CT
diagnostic peritoneal lavage (DPT)
focused assessment with sonography in trauma (FAST) on next slide
Labs: T &CM, BMP, CBC, liver fx tests, UA, CT, US
DPT-accurate, quick bedside assessment: checking for blood and bowel contents
10-15 min.
DPT and FAST can be done at bedside
Focused Assessment with Sonography for Trauma
Bedside ultrasound - used to rapidly examine all four abdominal quadrants and the pericardium to identify the presence of ______
Used in high risk injury of mechanism
Unstable and +FAST =
Stable and +FAST =
free fluid, usually blood.
goes straight to OR
goes to CT for better localization of the problem
Management of the patient with intra-abdominal injuries :
Impaled objects should never be removed except by skilled provider.
Pelvic binder used in suspected:
Who would use an oral gastric tube instead of NGT?
Primary survey
Document all wounds
If viscera are protruding, cover with sterile, moist saline dressing
Pelvic binder
Hold oral fluids
NG to aspirate stomach contents
Tetanus and antibiotic prophylaxis
Continuous monitoring and reassessment
Rapid transport to surgery if indicated
pelvic trauma to prevent from further injury. To help stabilize
Ab for open wound or a peritonitis
Head injury
Any injury or trauma to the:
___ & ___ most common cause
Factors that predict a poor outcome:
Suspect cervical spine injury with:
TBI more likely in males
scalp, skull, or brain
MVA & falls
Factors predicting poor outcome- abnormal neuro check, blood thinners, older age
face, head, neck trauma
Glasgow Comma Scale
GCS scores on arrival to hospital strong predictor
the ---- the GCS score, the less chance of survival
Minor:
Moderate:
Severe:
Comatose=
Totally unresponsive=
lower
Minor 13-15 GCS
Moderate 9-12 GCS
Severe 3-8 GCS
comatose = 8 or less
totally unresponsive = 3
Scalp lacerations
Profuse bleeding
Tx:
staple or suture closed
Skull fractures
Can cause _______
Manifestations:
Complications:
Skull fx frequently occur with head trauma. Type and fx depends on:
___ fracture are assoc. with a tear in the dura, leaking of CSF.
May have CSF leak-may have:
CSF leaks (basilar fracture)
Battles sign
Periorbital ecchymosis (raccoon eyes)
Halo sign (csf leak)
Intracranial infections, hematoma,
Meningeal and brain tissue damage
velocity, momentum, site of impact.
Basilar
May have CSF leak-may have rhinorrhea (clear fluid from nose or pt c/o of postnasal drip) or can have fluid draining from ear.
rhinorrhea (clear fluid from nose or pt c/o of postnasal drip) or can have fluid draining from ear.
Traumatic brain injury(TBI) includes:
Concussion
Diffuse axonal injury
Contusion (coup contre coup)
Hematoma
Concussion: local injury; sports-soccer, boxing, football.
Repeated concussions are cumulative effect-autopsies show __________
Concussion syndrome:
We do better with post concussion return to game protocol now.
chronic encephalopathy.
irritable, difficulty concentrating, reading, math skills.
Diffuse axonal injury
DAI-poor prognosis. All over brain injury. 90 % in a ______
persistent vegetative state
Contusion: minor to severe.
Coup contre coup: two injuries, assoc. with closed head injury,
____ common.
Increased mortality with ______.
seizures
anticoagulant
Epidural bleed is a medical emergency, usually ____ bleed.
Classic signs: __________, brain compensates at first, but it’s s fixed structure, can only tolerate so much bleeding before they decompensate.
Headache, n/v, unresponsive.
Need:
arterial
Disoriented, then have a lucid interval
surgery, craniotomy to evacuate hematoma
Subdural bleed is usually a slower bleed, ____ in nature.
Acute and chronic.
Difficult to distinguish from:
venous
a mentally declining older person or someone with Alzheimer’s.
Subdural bleed is usually a slower bleed, ____ in nature.
Acute and chronic.
Difficult to distinguish from:
venous
a mentally declining older person or someone with Alzheimer’s.
Epidural hematoma-medical emergency b/c it is arterial
Either case of hematoma- requires a _____
craniotomy
Nursing Management Head injury
ABC:
-Administer O2 via ______
-Intubate if GCS ___
-Control external bleeding w/ _____
-IV access x 2 large bore
-Stabilize cervical spine
Goals:
Maintain cerebral oxygenation & perfusion
Prevent secondary ____
CT and MRI scans
Cushings triad: worsening head injury; the body’s response to increased ICP:
non rebreather mask
<8
sterile pressure dressing
cerebral ischemia
cushings triad:
Widening pulse pressure (Inc SBP and dec. DBP), bradycardia, irregular resp= brain herniation leading to cardiac and resp arrest.
Musculoskeletal Trauma
Complications of Crush Injuries:
When a person is caught between opposing forces (for example, you’re standing behind a car that backs up on you, trapping your lower extremities)
Hypovolemic shock
Paralysis of body part
Erythema and blistering
Damage to body part
Renal dysfunction
Fractures
Disruption or break in continuity or structure of the bone
Some are “pathologic” in nature
2 Types
- Open (compound)
Skin is broken and bone is exposed - Closed (simple)
Skin has not been ruptured and bone is not exposed
Emergency Managementof Fractures
Treat life threatening injuries first
Ensure ABCs
Control external bleeding with:
–Direct pressure
–Sterile pressure dressing
–Elevation of extremity
Check neurovascular status distal to injury
–Elevate injury if possible
Apply ice packs to affected area
X-rays
Last tetanus?
Traction
Skin Traction
Short term (____) treatment
Nothing ___ the skin
Skeletal traction
Longer periods…long term pull
Pin (Steinmann pin) or wire is inserted into the bone to align and immobilize the part
Traction helps prevent or reduce ____, ____, and ____, helps to ___ the fracture (restore a fx bone to its normal anatomical position).____
With skeletal traction: risk for infection at pin site(s) and pulleys must be able to move freely
48-72 hrs
penetrates
pain and muscle spasms, and immobilization
reduce
ORIF
Complications of fractures
compartment syndrome
fat embolism
infection
venous thromboembolism
Complications of fractures
Compartment Syndrome
-2 basic causes
-remember 6 P’s
-
-
Compartment syndrome usually involves the leg, but can occur in ___, ___, ___, & ____;
Causes:
If you can’t feel a pulse?
Worried about _____
Tx: if it’s the cast, remove, if no improvement, may need ____, cut through fascia so we can restore circulation, otherwise will lose extremity
UO: with muscle damage in crush injuries, myoglobin released can clog tubules in kidney and get ______
Causes: 1.) decreased compartment size (cast too soon, then edema, or drsg, burn around the leg, like a tourniquet)
2.) increased compartment contents(d/t edema, bleeding or both)
remember 6 P’s: pain (disproportionate to injury to passive motion, despite pain med administration), increasing pressure in the compartment, paresthesia (numbness, tingling), pallor, paralysis, pulseless (late sign, check cap refill) or diminished pulses
-emergency fasciotomy
-neurovascular assessments
-urine output
arm, shoulder, abdomen, and buttock
If you can’t feel a pulse?
Worried about rhabdomyolysis
fasciotomy,
acute tubular necrosis (ATN)
Complications of fx
2. Fat Embolism Syndrome
Symptoms, if present,
typically occur 24 to 72 hours after the trauma;
Treatment
Esp. with long bone fx or pelvic fx or multiple fx. Fat emboli released from the bone marrow at the fracture site into the venous system
Petechial=_____
Similar to ARDS presentation
shortness of breath, confusion, and a transient petechial rash
Treatment
Reduce long bone fractures
Intravascular fluid resuscitation with fluids/albumin, may require intubation
coagulopathy
Complications of fx cont.
- Infection
Open fractures-> - Venous Thromboembolism
aggressive surgical debridement + antibiotic therapy + tetanus & diphtheria prophylaxis
Environmental Emergencies
Management of the Patient With Poisoning
Treatment goals:
Remove or inactivate the poison before it is absorbed
Provide supportive care in maintaining vital organs systems
Administer specific antidotes
Hasten the elimination of the poison
Poison Control Center
Poisons
ABCs
Monitor VS, LOC, ECG, UO
Laboratory specimens
Determine:
Signs and symptoms of poisoning and tissue damage
Health history
Age and weight
what, when, and how much substance was ingested
Management of the Patient with Ingested Poisons
-
-
-
-
Use of emetics* (do not induce vomiting with corrosive agents)
Gastric lavage
Activated charcoal
Administration of specific antagonist as early as possible (i.e what for acetaminophen OD?) Acetylcysteine (NAC)
May include diuresis, dialysis
Poisons
*Emetics (induce vomiting)not used as much anymore.
Gastric lavage if done within the ____; activated charcoal to help absorb poison and eliminate it from your body.
Corrosive going down, just as corrosive coming up
Possible psychiatric consultation if suicidal or self-harm attempt; accidental poison ingestion=>education on prevention & poison proofing instructions, esp. with children
first hour
Snake Bite Treatment
S/sx of envenomation:
May progress without treatment
Tetanus, analgesia, possible fluid or vasopressors
Possible administration of antivenom (between ____)
DO NOT leave patient ____
edema, ecchymosis, hemorrhagic bullae–necrosis, lymph node tenderness, n/v, metallic taste in mouth
Lie down, remove constrictive items, clean and cover wound, immobilize the injured body part below the level of the heart; mark the area with pen to monitor progression
4-12 hrs
unattended- they can deteriorate very quickly
What don’t you do? Suck out venum, turnictae, ice
Manifestations & treatment for spider bites
Black Widow
Bites feel like pinpricks
Systemic effects within 30 min:
TX:
Brown Recluse
Bites are painless
Systemic effects; within 24 to 72 hours,:
TX:
Black widow:
abd. rigidity, N/V, HTN, tachy, paresthesia’s
Severe pain
ice, elevation, last tetanus, analgesic, benzos, antivenom if necessary
Continuous monitoring!
Brown Recluse:
fever, chills, N/V, malaise, joint pain, reddish to purple in color site, necrosis
clean with soap and water, possible hyperbaric O2 or surgical debridement
Tick Bites/Lyme disease
Occur in grassy or wooded areas
Pathogen (bacteriumBorrelia burgdorferi) transmitted by tick can cause: Rocky Mountain Spotted Fever, West Nile virus, Lyme disease
Steps to prevent Lyme disease:
using insect repellant, remove ticks promptly, avoid tick-infested areas, check for ticks on self and pets
Stages of Lyme disease
diagnosis
Stage I
S/Sx: flulike, bull’s-eye rash (not always)
TX: antibiotics (10-21 days)
Stage II
S/Sx: facial nerve palsy, joint pain, memory loss, poor motor coordination, adenopathy, cardiac issues
Stage III
S/Sx: arthritis, neuropathy, myalgia and myocarditis
Progresses to stage 2 and 3 if not treated; even with treatment, 10-20% of patients experience long-term
effects (post treatment lyme disease syndrome)
Eliza test
Despite treatment, may progress to further stages
If chest tube won’t stay inflated:
VATS procedure: video-assisted thoracic surgery
Compartments =
can put pressure on diaphragm and lungs causing respiratory compromise
irritable, difficulty concentrating, reading, math skills.
concussion syndrome
Disoriented, then have a lucid interval
Epidural bleed
