TRAUMA Flashcards
1
Q
What is the process of prioritizing patient treatment during mass casualty events based on their need for or likely benefit from immediate medical attention
A
Triage
2
Q
What is the French word to sort
A
Triage
3
Q
What can change the categories of triage
A
Number of injured
Available resources
Nature and extend of injuries
Change in patients condition
Hostile threat in the area
4
Q
What is it called when the number of patients and the severities of their injuries DO NOT exceed the resources and capabilities.
A
Multiple casualties
5
Q
What is it called when the number of patients and the severities of their injuries DO exceed the resources and capabilities
A
Mass casualty
6
Q
What are the five principles of triage
A
Degree of life threat posed by the injuries sustained
Injury severity
Salvageability
Resources
Time, distance and environment
7
Q
What principle of triage is determined by considering the order of priorities identified during the primary survey of an individual patient and applying these same principles to a group of patients
A
Degree of life posed by the injuries sustained
8
Q
What principle of triage entails looking at each patient in a total global fashion and assessing the patient as a whole and not focusing on one severe injury
A
Injury severity
- ideally patients should be triaged solely on the severity of their injuries and not nationality
9
Q
What are the categories of military triage
A
IDME or DIME
10
Q
In military triage, what category is when the patient needs lifesaving interventions within minutes to up to 2 hours on arrival to avoid death or major disability
A
Immediate
11
Q
If a patient has controlled massive hemorrhage, retrobulbar hematoma, tension pneumothorax, a torso/neck/pelvis injury WITH shock or multiple extremity amputations. What military triage category would they be
A
Immediate
12
Q
If a patient has soft tissue injuries without significant bleeding, fractures, compartment syndrome, moderate to severe burns with less than 20% total, blunt or penetrating torso injuries WITHOUT signs of shock, or facial fractures without airway compromise, what military triage category would they be in
A
Delayed - require medical attention but CAN wait
13
Q
If a patient has minor burns, lacerations, contusions, sprains/strains, simple closed fractures without neuro compromise, or has a combat stress reaction what category of military triage would they be in
A
Minimal - can be treated with self aid, buddy aid or corpsman aid
14
Q
If a patient has massive head injuries with signs of impending death or coma, Cardiopulmonary failure, second and third degree burns in excess of 85% of the body, open pelvic fractures with uncontrolled bleeding and class IV shock or high spinal cord injury what military triage category would they be in
A
Expectant - requires complicated treatments that may not improve life expectancy
15
Q
When would you consider giving CPR on the battle field
A
Hypothermia
Near drowning
Electrocution
16
Q
When do casualties usually die in a field setting and why
A
Casualties typically die within the first hour due to the inability to breath, they bleed to death, or they have injuries which are so severe that the regulation by the brain of breathing and profusion is lost
17
Q
What are the two categories of combat stress
A
Light stress
Heavy stress
18
Q
If a patient is placed into the light stress category of combat stress what does that entail
A
Immediate return to duty or return to unit or units non combat support element with duty limitations or rest
19
Q
If a patient is placed in the heavy stress category of combat stress what does that entail
A
Send to combat stress control restoration center for up to 3 days reconstitution
20
Q
What is the mnemonic used when situation allows to manage combat stress
A
BICEP
Brief - keep interventions to 3 days or less
Immediate - treat as soon as symptoms are recognized
Central - keep in one area for mutual support
Expectant - reaffirm that we expect them to return to duty
Proximal - keep them as close as possible to the unit
Simple- do not engage in psychotherapy
Or refer
21
Q
In care under fire triaging of patients what is the priority
A
Get the patients who are not clearly dead to cover (not concealment) if possible
Continue the mission/fight. Gain fire superiority
22
Q
In tactical field care you should perform an initial rapid assessment of the casualty for triage purposes but this should take no longer than what time
A
No more than 1 minute per patient
23
Q
What should you base your causality collection point location on
A
Proximity to patients
Proximity to vehicle access
Proximity to HLZ
Geography, safety “geographic triage”
24
Q
What is level I (role/echelon)
A
First medical care they receive, includes immediate life saving measures, disease and non-battle injury prevention, combat and operational stress control and treatment is provided by:
Self aid/buddy aid
Combat life saver
Medical personnel - BAS or DDG/cruiser/destroyer
25
What are examples of medical personnel in level I care
Battalion aid station
Cruiser
Destroyer
26
What is level II (role/echelon)
Initial resuscitative care is the primary objective of care at this level. Saving life, limb and when necessary stabilizing for evacuation to level 3
27
What are examples of level II (role/echelon) at sea
(Sea) Casualty receiving and treatment ships (CRTS) deploy as part of an expeditionary strike group.
LHD - largest medical capability
LHA
CVN
28
What are examples of level II (role/echelon) on ground
(Ground) medical battalion- provides surgical care for the MEF
Shock trauma platoon(STP) - smll fwd unit supporting the MEF
Forward Resuscitative surgical suite(FRSS) - fwd deployed surgical suite due to MedBN being too big
Role 2 light maneuver (R2LM) - mobile medical unit designed to support large maneuver formation - sends to role 3 or R2E
Role 2 enhanced (R2E) - provides basic secondary health care built around primary surgery, ICU and ward beds - they can send straight to role 4 without stop at 3
29
What is level III (role/echelon) of care
The highest level of care available within a combat zone. Advanced resuscitative care is the primary objective of care
30
What are examples of level III (role/echelon) of care
Fleet hospitals
Hospital ships (USNS Comfort/Mercy)
31
What is the highest level of care in a combat zone
Level III (role/echelon) of care
32
What is level IV (role/echelon) of care
Definitive medical care is the primary objective at this level
33
What are examples of level IV (role/echelon) of care
OCONUS hospitals
- NH Yokosuka
- Landstuhl regional medical center
34
What is level V (role/echelon) of care
Restorative and rehabilitation care is the primary objective of care at this level
35
What are examples of level V (role/echelon) of care?
NMCSD
Walter reed medical center
36
What is timely, efficient movement and en route care provided by medical personnel to the wounded by being evacuated from the battlefield to a MTF using a medically equipped vehicle or aircraft
Medical evacuation (MEDEVAC)
37
What is the movement of casualties from the point of injury to medical treatment by non-medical personnel. Causalities transported under these circumstances may not receive en route medical care
Casualty evacuation (CASEVAC)
38
What utilizes the USAF FIXED WING aircraft to move sick or injured personnel within the theater or operations
Aeromedical evacuation
39
What is the maintenance of treatment initiated prior to evacuation and sustainment of the patients medical condition during evacuation
En route care
40
What are some litters that can be used to transport patients
Standard
Stokes
SKED
improvised
41
How should the patient be moved on a litter
Patients must be carried on the litter FEET first except when going uphill or up stairs, then their head should be forward unless the patient has a fracture of the lower extremities then they should be carried uphill or up stairs feet first and down hill or down stairs head first to prevent the weight of the body from pressing on the injury
42
What command should be used by litter bearers in order to prevent undue haste
Steady
43
What are some methods of ground evacuation
M997 ambulance
M1035 ambulance
MK23 and 7 ton: non medical vehicle
44
What are some methods of air evacuation
UH 60 Blackhawk
SH-60B seahawk
CH-46 Sea Knight
CH-53 D/E Sea Stallion
CH-1 Huey
MV-22 Osprey
C-2 Grey hound
P-3 Orion
C-130 Hercules
45
When would cabin altitude restriction (CAR) be considered
Penetrating eye injuries
Free air in body cavity
Severe pulmonary disease
Decompression sickness or arterial gas embolism
46
What medevac/casevac priority is must the casualty be evacuated within 2 hours in order to save life, limb or eye sight
Urgent
47
If a patient has uncontrolled hemorrhage, shock not responding to IV therapy, head injuries with signs of ICP, or extremities with neuro compromise what medevac/casevac category is the patient
Urgent
48
What medevac/casevac category is when the casualty must be evacuated within 4 hours or condition could worsen
Priority
49
If a patient has flail chest segments without respiratory compromise, open fractures, spinal injury, or major burns what medevac/casevac category would they be
Priority
50
What medevac/casevac category is when casualty must be evacuated within 24 hours for further care
Routine
51
If a patient has mild/moderate burns, simple closed fractures, minor open wound, or is a terminal casualty what medevac/casevac category would the patient be
Routine
52
What is line one of a 9 line
Location of pickup (grid coordinates)
53
What is line 2 of a 9 line
Frequency/ call sign of pick up site
54
What is line 3 of a 9-line
Number of patients by precedence
A- urgent
C- priority
D- routine
55
What is line 4 of a 9-line
Special equipment needed
A- none
B- hoist
C- extraction equipment
D- ventilator
56
What is line 5 of a 9 line
Number of patients by type
L - # of litter
A- ambulatory
57
What is line 6 of a 9 line
Security at the pick up site
N- no enemy
P- possible enemy
E- Enemy in area
X - armed escort required
58
What is line 7 of a 9 line
Method of marking
A- panels
B- PYROTECNICS
C- Smoke
D - None
E - other
59
What is line 8 of a 9 line
Patient nationality and status
A- US military
B- US civilian
C- Non US military
D - Non US Civilian
E - EPW
60
What is line 9 of a 9 line
NBC contamination
N - Nuclear
B - biological
C- chemical
61
What are the four categories of a MIST report
Mechanism of injury
Injuries sustained
Signs/symptoms
Treatment
62
What is the branch of mechanics that studies the motion of a body or a system of bodies without consideration given to its mass or the forces acting on it, its essence revolves around motion
Kinematic
63
What is Newton’s first law
States every object will remain at rest or in uniform motion unless compelled to change its state by the action of an external force. We know it more commonly as inertia
64
What is Newton’s second law
Defines force (F) is equal to the product of the mass (m) and acceleration (a)
F=ma
65
What are the forms energy can take in relation to kinematics
Mechanical
Thermal
Electrical
Chemical
66
What are the four ways a bullet dissipates
Heat
Energy used to move tissue radically outward
Energy used to form a primary path by direct crush of the tissue
67
What is it called when a solid object strikes the human body or when the body is in motion and strikes a stations object the tissue particles are knocked out of their normal position creating a hole or cavity
Cavitation
68
What is the deviation of the projectile in its longitudinal axis from the straight line of flight
Yaw
69
What is the forward motion around the center of mass
Tumbling
70
What is the mushrooming of the projectile that increases the diameter of the projectile, usually a factor of 2, increases the surface area and hence the tissue contact area by four time
Deformation
71
What is it when multiple projectiles can weaken the tissue in multiple places and enhance the damage rendered by cavitation
Fragmentation
72
What are the four ways a bullet can be enhanced
Yaw
Tumbling
Deformation
Fragmentation
73
What is an example of low energy level projectiles
Knives
Needle
Ice pick
- hand driven weapons
74
What is examples of medium energy level projectile
Firearms with muzzle velocity of less than 1500 feet
9mm
45 auto
75
What are examples of high energy level projectiles
Firearms with muzzle velocity more than 1500 feet per second
.44 magnum
76
What are two signs that are absolute indications for laparotomy following penetrating or blunt abdominal trauma
Peritonitis
Hemodynamic instability
a third relates to the inability to examine the patient reliably after a penetrating injury
77
Penetrating injuries to what area of the body carry a 90% mortality rate
Head
Victims with GCS of 3-5 have only a small chance of an acceptable outcome
78
What are the four categories of a blast injury
Primary
Secondary
Tertiary
Quaternary
79
What is a primary blast injury
Effects of over pressure and under pressure of a blast wave - uncommon except in form of a PERFORATED TYMPANIC MEMBRANE
80
What is secondary blast injuries
Flying debris/fragments, mussels in conjunction with the “blast wind” (mass of air displaced by the explosion)- penetrating ballistic fragmentation or eye penetrating
81
What is tertiary blast injury
Body displacement - fracture or traumatic amputation, closed/open head injury
82
What is quaternary blast injury
Burns - burns, crust, asthma, COPD, breathing problems
83
What is the leading cause of preventable death on the battle field
Hemorrhage
84
What is the most common cause of massive external blood loss in combat
External extremity injury
85
For internal massive hemorrhage what is should be implemented
Controlled (hypotensive) resuscitation should be implemented
86
What are the TCCC approved TQ’s
Combat application tourniquet (C.A.T)
Special operations forces tourniquet tactical (SOFT-T)
Emergency and military tourniquet (EMT)
87
What are the TCCC approved hemostatic agents
Combat gauze - recommended first choice
Celox gauze or Chito Gauze
XStat - First expanding wound dressing FDA approved
88
Junctional wounds refer to what body structures
Groin
Buttocks
Perineum
Axillae
Base of neck
Extremities at sires to proximal limb tourniquets
89
What are the TCCC approved junctional tourniquets
Combat ready clamp (CROC)
Junctional emergency treatment tool (JETT)
SAM junctional tourniquet
90
Where should a tourniquet be applied
2-3 inches above the site
Or
If unable to identify - high and tight
91
What is the time frame that hemostatic dressings should be applied
Should be applied with at least 3 minutes of direct pressure (optional for XStat).
If one fails to control the bleeding, it may be removed and a fresh dressing of the same type or different type can be applied
92
After a JETT has been applied, how often should it be assessed
Every 5 minutes to ensure the bleeding is still controlled
93
What should the application of junctional tourniquets be documented on
The CRoC label and the TCCC Card
94
JETT device application should not exceed what time limit
4 hours
95
The airway system is an open path that leads to atmospheric air through what structures
The nose, mouth, pharynx, trachea, and bronchi to the alveoli
96
Where is the respiratory control center
Neural control - primary control comes from the MEDULLA and PONS
97
What is the primary involuntary respiratory center
Medulla
98
What is the primary control of respiratory center stimulation
Cerebrospinal fluid pH
99
What is it called when there is no oxygen available at all
Anoxia
100
What is the fraction or percentage of oxygen in the space being measured
Fraction of inspired oxygen (FiO2)
101
Room air FiO2 is equal to what
21%
102
What literally means “deficient in oxygen” that is an abnormally low oxygen availability to the body or an individual tissue organ
Hypoxia
103
What is insufficient oxygenation, that is decreased partial pressure of oxygen in blood called
Hypoxemia
104
What are indications of O2 therapy
Cardiac and respiratory arrest
Hypoxemia (Sat <90%)
Hypotension (Systolic <100)
Low cardiac output and metabolic acidosis
Respiratory distress (RR >24/min)
- all trauma patients will get O2
105
How much oxygen is supplied by a nasal cannula
1-6 liters/ min
(TG says 1-4 liters/min)
106
What are indications for using hyperbaric oxygen
Decompression illness (the bends)
Carbon monoxide poison
Radiation necrosis
Reconstructive surgery
Some infection, wounds
107
What is 100% oxygen given at an increased pressure of 3 atm. Since normal air is 20% oxygen, pure oxygen is 5 times more oxygen and at 3 times normal air pressure, a patient gets 15 times more oxygen than normal
Hyperbaric oxygen
108
What is the first step in airway management
A quick visual inspection of the oropharyngeal cavity
109
What is the most common cause of airway obstruction
The tongue
110
What air way maneuver is given in casualties with suspected head, neck or facial trauma
Jaw thrust
111
What is one of the key components in airway maintenance
Prevention of gastric aspiration
112
Sellicks maneuver is used for what
Prevention of gastric aspiration
113
What is the BURP maneuver
Backward, upward, rightward pressure on the larynx
The maneuver improves visualization of the larynx structures and eases intubation
114
What is the most frequently used artificial airway device
Oropharyngeal airway
115
When would you use an OPA
Unable to maintain airway
Tongue continues to fall back
Assist in improving ventilation
Prevent intubated patient from biting an ET tube
116
What is the contraindications of using an OPA
Causality that is conscious or semiconscious
Complications due to gag reflex stimulation and use of OPA may lead to gagging, vomit. And laryngospasm in patients who are conscious
117
When can an NPA not be used
If a basilar skull fracture is suspected
118
What are complications of an NPA
Bleeding
Inserting into the brain with a basilar skull fracture
Nasal turbinate injury
119
What nare is preferred when using an NPA
Right because it is typically larger
120
What is the preferred supraglottic airway
I-gel
121
What is the indication for an i gel placement
An unconscious patient without significant direct trauma to airway/facial structures
122
What size of i gel is used in a typical adult
Size 4
Size 5 is used for adults over 200 IBS
123
When would you place an endotracheal tube
Unable to protect airway
Significant oxygenation problems, requiring need for high concentration oxygen
Casualty requiring assisted ventilation
Cardiac arrest
Severe hemorrhagic shock
124
What are contraindications of placing an endotracheal tube
PATIENT WITH EPIGLOTITIS
LACK OF TRAINING
Lack of proper indications
Obstruction of upper airway
CERVICAL FRACTURES
125
What are some complications of placing an endotracheal tube
Hypoxemia from prolonged intubation attempts
Trauma to the airway
Right mainstem intubation
Esophageal intubation
Vomiting leading to aspiration
Loose or broken teeth
Injury to vocal cords
Conversion of a cervical spine injury without neurological deficit to one with neurological deficit
126
What is the “universally accepted” size of endotracheal tube for unknown victim
7.5mm
127
What size ET tube is used in men
8.0mm
128
What size ET tube is used in women
7.0mm
129
What two types of blades are used for endotracheal tube intubation
Miller blade (straight)
Macintosh blade (curved)
130
What position is the patient in if the head is extended and the neck is flexed
Sniffing
131
The insertion of an endotracheal tube should be no longer than what from the time you stop ventilating the patient until the time you remove the stylet
No longer than 30 seconds
132
What can be used in environments where you cannot auscultate the lungs due to environmental noise
End tidal O2 monitor (purple to gold window)
133
If the endotracheal tube is placed into the stomach/esophagus what will you hear
Will produce a gurgle sound in the Epigastric area
If this happens remove the tube and attempt placement after 1 minute of oxygenation and ventilation
134
What airway is designed to facilitate the placement of an advanced airway in a patient in respiratory distress by providers with minimal training
Esophageal tracheal combitube airway
135
What are the two sizes of comitube airways
37 Fr (patients 6ft or 122 to 183 cm tall)
41 Fr (patients more than 5ft or 152cm tall)
136
What are the contraindications of using a combitube
Patients with intact gag reflex
Patient with known esophageal pathology (like GERD)
Used in patients under 5 feet with standard combitube under 4 feet with combitube SA
137
What are the complications of using a combitube
Sore throat, dysphagia, and upper airway hematoma
Esophageal rupture is rare
These complications may be partially preventable by avoiding overinflation of the distal and proximal cuffs
138
What are the complications of placing an laryngeal mask airway
Aspiration because LMA does not completely prevent regurgitation and protect the trachea
Laryngospasm
Sore throat
139
What is the optimal position the patient should be in when placing an LMA
Sniffing
140
What are three ways to verify placement of ET tube
Auscultate the Lungs
Auscultate the Epigastric
End tidal
141
What is the most important instrument for surgical cricothyrotomy
Scalpel
142
What is the primary purpose of a crcothyroidotomy
Provide an emergency breathing passage for a patient whose airway is closed by:
TRAUMATIC INJURY TO THE NECK
BURN INHALATION INJURY
CLOSING OF AN AIRWAY DUE TO ALLERGIC REACTION TO BEE OR WASP STINGS
Or unconscious
143
What are the two types of cricothyroidotomy
Needle
Surgical
144
What are indications for a cricothyroidotomy
Massive midface trauma precluding the use of BVM
Inability to control airway using less invasive maneuvers
Ongoing tracheobronchial hemorrhage
145
What are complications of a cricothyroidotomy
Prolonged procedure time
Hemorrhage
Aspiration
Misplaced or false passage of ET tube
Injury to neck structures or vessels
Perforation of the esophagus
The longer the period of use the greater the risk of complications
146
How big of a vertical incision over the cricothyroid membrane will you make
3 cm
147
How long can a surgical cricothyroidotomy be left in place for
24 hours
148
What is the disruption of heart rhythm that occurs as a result of a blow to the area directly over the heart at a critical time during the cycle of the heart beat causing cardiac arrest
Commotio cordis
149
What is a simple pneumothorax
Presence of air in the pleural space
150
What is an open pneumothorax
Also called a sucking chest wound
Involves a pneumothorax associated with a defect in the chest wall
151
What is a tension pneumothorax
Occurs when air continues to enter the pleural space but has not avenue to egress
152
What is the initial management of an open pneumothorax
Close the defect in the chest wall and administer supplemental oxygen
153
What is a possible complication of a simple pneumothorax
Could turn into a tension pneumothorax at any moment
154
When should a needle decompression be performed
When the following three criteria are met:
Evidence of worsening respiratory distress or difficulty with BVM device
Decreased or absent breath sounds
Decompensated shock (SBP <90)
155
Who does spontaneous simple pneumothorax occur in
Young white males
Age 16-25 years old
Very lanky, thin, runners build
156
What are some complications associated with a needle thoracentesis
Hemothorax
Bacterial infection (cellulitis)
Air embolism
157
What size catheter is used in a needle thoracentesis
10-16g catheter with 3-10cc syringe attached
158
How much blood can the pleural space accommodate
2500-3000mL therefore a hemothorax can represent a source of significant blood loss
159
Where can the bleeding come from with a hemothorax
The bleeding may come from the chest wall musculature, the intercostal vessels, the lung parenchyma, pulmonary vessels, or the great vessels of the chest
160
What is the primary cause of hemothorax (<1500ml of blood)
Lung laceration
Or
Laceration of an intercostal vessel or internal Mammary artery due to either penetrating or blunt trauma
161
What are the indications for performing a chest tube
Drainage of large pneumothorax (>25%)
Drain hemothorax
After needle decompression of a tension pneumothorax
Pleural effusion
Emphyema
Simple/closed pneumo
Open pneumo
162
What is the chest tube size for adult or teen male
28-32 Fr
163
What is the chest tube size for adult to teen female
28Fr
164
What is the chest tube size for a child
18Fr
165
How do you measure the length of the chest tube
Midaxillary line at the 5th intercostal space to the inferior tip of the scapula
166
Where is the incision made for the chest tube
At the 5th intercostal space in the midaxillary line where the lower skin wheal was anesthetized, create a 2-4cm incision that follows the rib
167
How often should chest tube dressing be changed
Every 24 hours or if the dressing becomes saturated
168
What is the breaking of 2 or more ribs in 2 or more places called
Flail chest
169
What are signs of flail chest
Shortness of breath
Paradoxical chest movement
Bruising/swelling of affected chest area
Crepitus
170
What is a abnormality associated with pulmonary contusion
Prevention of gas exchange because no air enters these alveoli
171
What is the shelf life of collected fresh whole blood
24-48 hours but the sooner you can deliver it to the patient, the more plentiful the functional components remain
172
All males can receive what blood product
O pos or O neg at anytime
173
All females of childbearing years should receive what type of blood
O negative unless it is a matter of life or death
174
If a female receives O positive blood what is a complication that occur
The Rh negative mother that was exposed to Rh positive blood will start to attack the fetal blood cells inducing HYDROPS FETALIS leading to fetal death
175
If a patient has lost 1500-2000mL of blood, pulse > 120, decreased blood pressure, 30-40 RR, and urine output of 5-15mL what class of hemorrhagic shock is this
Class III - 30% blood loss
176
If a patient has lost more than 2000mL of blood, HR >140, decreased b/p, >35 RR, and urine output negligible what class of hemorrhagic shock is this
Class IV - >40% of blood loss
177
What does an radial pulse mean in terms of possible systolic b/p
Systolic is below 80mmhg
178
1 amp of calcium glucose is given every ____ units of blood
4 units to avoid toxicity and hypocalcemia
179
The normal human liver can process how many units of fresh whole blood without needing additional calcium
13 units
16 units is when a reaction happens if no calcium is given
180
What will you do if a blood transfusion reaction occurs
Immediately stop the transfusion
Maintain a patent IV/IO Line, start fluid bolus with balanced crystaloid
Assess the patient
181
What is the flow rate for a blood transfusion over the first 15 minutes
Set flow to deliver 10-30mL of blood (1gtt/4-6 sec=1ml/min)
182
How often will you measure vital signs for the first 15 minutes of a blood transfusion
Every 5 minutes
183
After the first 15 minutes of a blood transfusion if there is no evidence of a reaction what will the drip rate then be
200ml/min and monitor vital signs at least every 15 minutes
184
What will you do if there is a transfusion reaction
Flush the tubing and filter with approximately 50ml of NS to deliver residual blood
185
What is the blood transfusion documented on
SF 518 and SF 600 and forward to role III hospital in country
186
When would you administer TXA
Hemorrhagic shock
One or more amputations
Penetration torso trauma
Evidence of severe bleeding
187
What does TXA do
Prevents the clots from breaking down by keeping fibrin strands around longer to maintain the clot and thus helps to prevent internal bleeding and ultimately prevent death from hemorrhage
188
When is survival benefit greatest to admin TXA
Within the first hour
189
What is the dose for TXA
1 Gram in 100ml NS or LR as soon as possible but no later than 3 hours after injury
190
TXA should be administered over what time frame
10 minutes
191
What temperature range should TXA be stored at
59-86F
192
What is used to crease the blood volume following severe loss of blood or loss of plasma
Colloids (volume expanders)
193
What is used as maintenance fluids to correct body fluids and electrolyte deficits
Crystalloids - contain sodium/potassium/calcium/chloride
194
What is the mainstay IV therapy in prehospital settings
Crystalloids
195
What are the most common Crystalloid aka isotonic solutions
LR
NS
D5W
196
Isotonic have a tonicity equal to what
Body plasma
197
When is placement of an IO indicated
3 failed venous attempts Or 90 seconds
Or
In cases where it is likely to fail and speed is of the essence
198
What are contraindications of IO placement
Ipsilateral fracture or crush injury
Previous ortho procedure
Previous IO attempt in same bone
INFECTION AT INSERTION POINT
Inability to locate landmark
199
What are complications of an IO
Tibial fracture, especially in small framed people
Compartment syndrome
Osteomyelitis
Skin necrosis
200
If the patient is still in the fight and needs mild to moderate pain treatment what is given
Combat wound medication pack
- Tylenol 625mg 2 tabs PO q8hrs
- Meloxicam 7.5-15mg PO daily
201
If the patient is in moderate to severe pain and is not in shock and not in Resp distress and is not at risk for either, what medication can be given
Oral transmuscosal fentanyl citrate 800ug placed between the cheek and the gum and instruct the patient not to chew
202
If the patient is in moderate to severe pain and is in shock/Resp distress what medication is given
Ketamine 50mg IM or IN with repeat dose every 30 minutes or 20mg IV/IO every 20 minutes
203
What can be given at an alternate to OTFC if IV access has been established
Morphine 5mg IV
MAX DOSE IS 15MG
Reasses in 10 minutes
204
If given morphine, what should you have on hand
Naloxone IV/IM/SubQ 0.4-2mg may repeat dose every 2-3 minutes
205
What can be used for nausea after admin of narcotics
Ondanestron
4mg PO/IV/IM q8 hours as needed
206
If the patient is able to tolerate oral medication what antibiotic should be used
Moxifloxacin 400mg IV/PO q24 hours
207
If the patient is in shock or unconscious what antibiotic is given
Ertapenum 1G IV q24hrs
208
What are the other AMAL antibiotics that could be given
Levofloxacin 750mg IV/PO q24h
Cefazolin 1 Gram IV every 8 hours for 7 days
Ceftriaxone 2 grams IV q24h
209
What is are the leading causes of traumatic brain injuries
Motor vehicle collision
Falls in the elderly
210
What structure does the brain stem and spinal cord pass through
Foramen magnum
211
What are the meninge layers of the brain
Dura mater - epidural space
Pia mater - closely adhered to the brain
Arachnoid membrane - layered on top of blood vessels
212
What are the regions of the brain
Cerebrum
Cerebellum
Brain stem
213
What surrounds the brain and functions as a cushion to the brain
Cerebrospinal fluid (150mL)
214
What controls pupillary constriction. Crosses the surface of tentorium and hemorrhage or edema that leads to herniation of brain will compress the nerve and lead to pupillary dilation
Cranial nerve III (oculomotor)
215
What are the two biggest predictors of poor outcome in head trauma
Amount of time spent with ICP >20mmHg and
Time spent with systolic b/p <90. A single episode of hypotension can lead to worse outcome
216
It is essential to keep spo2 above what
90%
217
Increased ICP can lead to cardiovascular changes and a response known as cushings reflex. What is cushings triad
Elevated BP
Bradycardia
Abnormal breathing (Cheyenne stokes)
218
In secondary assessment what is the single most important observation
Constant continuous observation of mental status
219
What is bleeding between skull and dura mater and what might cause this
Epidural hematoma - usually low velocity blow to temporal bone
WATCH FOR DILATED, SLUGGISH NON REACTIVE PUPIL
220
What is blood between dura and arachnoid membrane and what typically causes this
Subdural hematoma - MVC or falls
221
If a patient complains of having the worst headache of their life with nausea/vomiting, dizziness, seizures or may have meningeal signs what might this be
Subarachnoid hemorrhage (SAH)
222
After a mild tbi/concussion what is the minimal recovery period
24 hours
223
What are red flags to look out for in someone who had a concussion/ mild tbi
Deteriorating level of consciousness
Double vision
Increased restlessness, combative or agitated behavior
Repeated vomiting
Seizures
Weakness/tingle in arms or legs
Severe or worsening headache
Unsteady on feet
One pupil larger or smaller than the other
Changes in hearing, vision or taste
Repeated episodes of blacking out or passing out
224
What is part of the 24 hour rest period following a concussion
Rest with extremely limited cognitive activity (no reading, video games, word puzzles)
Limit physical activities to only daily living activities
Avoid work, exercise, reading or driving
Avoid caffeine/alcohol
225
What pain management can be used in someone with a concussion
Acetaminophen every 6 hours, for 48 hours
After 48, may use naproxen as needed
AVOID TRAMADOL, FIORICET AND NARCOTICS
226
for concussion management what is stage one
If symptom free during exertion testing and this is their first concussion in the last 12 months then return to duty
227
What is stage 2 in concussion management
If symptom free following 5 days of stage 2 activity then progress to stages 3/4/5 each for 24 hours and if symptom free during this, perform exertion testing and if no symptoms then return to duty
228
What is stage 3 in concussion management
Light tasks no longer than 60 minutes
Heavy tasks no longer than 30 minutes
229
What is stage 4 of concussion management
Can wear PPE
Light activity no longer than 90 minutes
Heavy activity no longer than 40 minutes
230
If there are 3 or more documented concussions and/or TBI in the past 12 months then what will you do
Stage 1 rest and refer to neurology
231
Hypothermia is defines as a core temperature below what
95F
232
What is the core temp of someone who has mild hypothermia
90-95F
233
What is the core temp of someone who has moderate hypothermia
82-90F
234
What is the core temp of someone who has severe hypothermia
Below 82F
235
What are the most common mechanisms of accidental hypothermia
Convective heat loss to cold air
Conductive heat loss to water
236
What heart arrhythmia may be present in someone with moderate hypothermia
A Fib
237
What heart arrhythmia may be present in someone with severe hypothermia
V fib/tach/asystole
238
Many standard thermometers only read to minimum of what degrees
93F
239
What are the two most important lab studies of someone who has hypothermia
Finger stick glucose
ECG to look for OSBORNE WAVES
240
How is someone with mild hypothermia rewarmed
Passive external warming - blanket
241
What rewarming is used for someone with moderate and refractory mild hypothermia
Active external rewarming - hypothermia blanket
242
What rewarming method is used in someone with severe and some cases of refractory moderate hypothermia
Active internal rewarming
243
Blood loss of 15-30 percent (750ml to 1500ml) is considered what class of hemorrhage
Class II
244
If a radial pulse is felt, what is the assumed pressure
>80mmhg
245
If a femoral pulse is felt what is the assumed pressure
>70mmhg
246
If a carotid pulse is felt what is the assumed pressure
>60mmhg
247
What are signs of a basilar skull fracture
Bruising around the eyes
Bruising behind the ears
248
What is the most commonly injured organ in blunt trauma
Spleen
249
what is the second most commonly injured organ in blunt trauma
liver
250
what is the 5 systematic steps to assess life threatening injuries in primary survey for TCCC
MARCH
251
what is the primary survey in ATLS
focus is airway breathing and circulation
252
what is a head to toe physical examination to include a reassessment of vital signs
secondary assessment
253
how is history obtained in a trauma patient
AMPLE
allergies
medications/supplements
past medical illness/injuries
last meal
events
254
what is hemotympanum and/or distruption of the auditory canal suggestive of
basilar skull fracture
255
what patients are at risk for compartment syndrome
those with fractures or crush injuries.
- pain is the first sign of ischemia and should be aggressively evaluated
- if there is suspcion then compartment pressures should be measured or fasciotomy performed
256
the primary survey is comprised of what
evaluation circulation, airway, c-spine, disability (mental status) and environmental exposures
257
secondary survey is what
includes a total evaluation of the patient from head to toe
258
when do signs and symptoms of anaphylaxis begin
within 60 minutes of exposure
259
after resolution of symptoms, what percentage of patients will have a reoccurrence within 12 hours after resolution of the first episode
21%
260
what is the most important step in the treatment of suspected anaphylaxis
rapid administration of epinephrine
261
what leads to erythema, ulcers, edema and causes impaired ciliary function of the upper airway
usually due to thermal injury
262
what leads to pulmonary edema and susequent mistatches in ventilation and perfusion of the lungs which can cause hypoxemia
tracheobronchial tree injury usually caused by chemicals in the smoke
263
what results in alveolar collapse and impaired oxygenation and puts the patient at risk for pneumonia
parenchymal injury
264
with carbon monoxide affinity for hemoglobin is how many times grater than oxygen
260 times greater than oxygen
265
what are important historical factors that should be obtained with a smoke inhalation patient
flame, smoke, fire
duration of exposure
enclosed space
associated loss of consciousness
266
what is the first step in treatment of a smoke inhalation patient
rescue from source and limit exposure time
267
what treatment is indicated if there are signs of thermal injury to the airway
intubation is indicated
268
what medications can be given for a smoke inhalation patient
albuterol - SABA
acute tx: 1-2 inhale every 2 hours for first 4 hours
maintenance (in combo with corticosteroid): 1-2 inhale q4-6hrs as needed MAX: 8 inhale
269
what are some causes of rhabdomyolysis
trauma/muscle compression
trauma
crush injury
prolonged restraints
compartment syndrome
electrical injuries
270
what are causes of exertional rhabdomyolysis
individual not conditioned (new recruits)
hot humid conditions
impaired sweating (heat stroke)
seizures and delirium tremens
meth and cocaine use
271
what are symptoms and exam findings of someone with rhabdo
muscle tenderness
edema
muscle weakness
DARK URINE *COCA COLA URINE*
altered mental staus may occur from underlying cause
272
what are lab findings of rhabdo
ELEVATION IN CK (hallmark)
UA dipstick positive for blood but no RBC on micro
HYPERKALEMIA - peaked T waves seen in EKG
273
what is the treatment for rhabdo
LArge volume IV fluid resuscitation to maintain 2mL/kg/hr urine output
if alt mental status, Temp > 105 or unresponsive to IV fluids then MEDEVAC
some patients may hav eprogreessive renal failure and reuire hemodialysis
274
what are some causes of non exertional rhabdo
coma induced by drugs
medications (statins)
Toxins (snake venom & CO)
275
what is it when contents of the muscle fibers leak into circulation and is a result of an injury/necrosis to the muscle fiber
rhabdomyolysis
276
what are the structures in the peritoneal cavity - the true abdomen
solid organs
portions of large intestine
most of the small intestine
female reproductive organs
277
GSW most commonly injure what organs
small bowel (50%)
colon (40%)
Liver (30%)
abdominal vessels (25%)
278
injuries most often associated in blunt abdominal trauma includes what structures**
Spleen (40-55%)**
Liver (35-45%)
Small bowel (5-10%)
279
what structures are located in the retroperitoneal space**
kidneys
ureters
inferior vena cava
aorta
pancreas
much of the duodenum
ascending descending colon and rectum
280
shock from intra-abdominal bleeding may present with what symptoms **
mild tachycardia with few other findings to severe tachycardia with pale, cool skin findings
281
if a seat belt sign is present what organ is likely to be damaged **
bowel
282
significant tenderness to percussion or pain with coughing on abdominal exam is a strong indicator for what
perotonitis
283
what is the primary treatment goal of someone with a crush injury
primary goal is to prevent ARF. Suspect, recognize and treat rhabdo
initiate therapy ASAP and establish IV access in a free arm or leg vein
284
what is given for fluid resuscitation in a crush injury victim
1 L should be given prior to extrication and up to 1 L/h (short extrication time) to a max of 6-10 L/d in prolonged entrapments
285
what is the most common sign of compartment syndrome
Paresthesia
pain
lower extremity is more prone
286
what is avulsed skin and subcutaneous fat off underlying structures, these areas can become ischemic and requires skin grafting
degloving injury
287
what is the gold standard imaging in a pelvic fracture
CT scan
288
in regard to third degree full thickness burns, what is adjacent to zone of necrosis, immediately after injury blood flow is stagnant
zone of stasis
289
what is the outermost zone of a third degree full thickness burn called
zone of hyperemia
290
what type of burn only involves the epidermis, is red and painful, will heal in about a week without a scar. and is not included when calculating the percentage of body surface burn
superficial burn
1st degree
291
what type of burn involves epidermis and varying portions of the DERMIS, will appear as blisters or denuded burned areas with glistening or wet appearing base
partial thickness burn
2nd degree
292
what type of burn appears thick, dry, white and leathery
full thickness burn
thick leathery damaged skin referred to as eschar
293
in a burn victim what is the starting rate for fluid resuscitation
starting rate 500ml/hr for adults
294
what is the initial hourly rate fluid resuscitation calculation
%TBSA burn x 10ml/hr
ex: 40% TBSA burn = 400ml/hr
295
when monitoring a burn patient, what is the target urine output
0.5ml/kg/hr
30mL
296
what is the single most reliable indicator of adequate resuscitation
uop
297
what are reasons for prolonged field care
long evac times
indigenous capabilities
requires different skills
different enviroments
298
what are the three phases of prolonged field care
evaluation phase
resuscitation phase
transport phase
299
what is the lethal triad
hypothermia
acidosis
coagulopathy
+sepsis
300
what should be done in the transport phase
prevent hypothermia
secure patient and litter
splinting
monitors and cuffs
emergency meds
sedation pain
secure tubing
document of patients condition, response to therapy and treatment rendered
301
in prolonged field care what is the goal for adequate urine output
UOP 0.5-1mg/kg/hr
302
what is a non invasive method allowing the monitoring of the saturation of a patients hemoglobin
pulse oximeter
303
according to ATLS what is the preferred definitive airway
tracheal intubation through the mouth using direct laryngoscopy
304
if there is a patient trappedm what is the indicated airway
esophageal tracheal combitube
305
what are the anatomical landmarks in a needle decompression
mid-clavicular line
sternum
jugular notch
2nd intercostal space
second rib
clavicle
306
a patient presents with tachypnea, pallow, hypotension, frothy bloody sputum, and flat neck veins. what might be the cause
hemothorax
307
for pain management of a flail chest patient what can you do
splint ribs with trauma bandage/triangle bandage
IV fluid bag on area and tape down
IV ketamine
308
what is fresh whole blood also referred to as and was the first approved protocol in the ARMY
LOW TITER O WHOLE BLOOD (LTOWB)
309
for a febrile non-hemolytic reaction what is the treatment
1 gram of tylenol PO/PR q8hr
310
how much blood is drawn into the bag
450ml (overfilling may cause clotting). a trip scale may be used or alternatively a 9.5 inch piece of 550 cord around the bag
311
in a patient who has had a previous allergic blood transfusion,, how will you proceed
give 25-50mg diphenhydramine IM/PO/IV in a seperate line
312
what are side effects of txa admin
hypotension with rapid IV infusion
seizures
visual changes
313
if TXA is given and patient is still bleeding out what can you do
admin a second infusion of 1 gram TXA after inital has been completed
314
what type of technique is used in an IO
sterile
315
what equipment is used to aspirate medullary contents in an IO
two 10mL syringes with normal saline
316
how is the mean artierial pressure calculated
systolic+dystolic x2/3 or diastolic + 1/3 pulse pressure
317
what is normal CPP (cerebral perfusion pressure)
70-80mmhg
CPP=MAP-ICP
318
what can brisk bleeding of the scalp be masked by
thick hair
319
in a patient who has anaphylaxis epi is given and what else
methylpredisolone (solumedrol) 125mg IM/IV daily x2 days
320
in Carbon monoxide the affinity for hemoglobin is how much greater than oxygen
260 times greater than oxygen
321
in full thickness burn what is the region of greatest destruction resulting in necrosis and not capable of repair called
zone of coagulation - central zone
322
what stage of prolonged field care is the lethal triad addressed
resusciatation phase
323
when should you NOT attempt to convert a TQ
for any TQ in place longer than 6 hours unless it occurs at definitive care
<2 hours = safe
2-6 hours = likely safe
>6 = requires caution, not advised
324
what is the better capability of sedation and pain management in prolonged field care
provide sedation with ketamine and added midazolam (Versed)
325
why do you put one additional TQ in place when converting a TQ
if the TQ already in place breaks during the conversion process, there is already a backup in place ready to be tightened
326
what is the fluid of choice for patients in hemorrhagic shock
Fresh whole blood
MAP of 65mmhg
adequate UOP at least 05cc/kg/hr
Adequate mentation (mental activity)
327
what is a common source of bleeding in a pelvic fracture
venous plexus
328
if a patient has a suspected pelvic fracture, blood from the meatus and swelling what will you do
retrograde urethral gram
329
patient has a GCS of 3, face swollen and gargling you already gave o2 and performed the jaw thrust what will you do next
suction
330
what is the landmark for placing a pelvic binder
greater trochanter
331
what other injury is likely when someone has a flail chest
pulmonary contusion
332
you've got a patient with a fracture and you have splint but before they are loaded into the medevac, what should be done
check neurovascular status
333
what is the target urine output for a burn
0.5mg/kg/hr
334
when can you d/c fluid resuscitation
hemodynamically stable and mental stability
