Trauma Flashcards
Triage categories can change based upon what
Number of injured
Available resources
Nature and extent of injuries
Change in patients condition
Hostile threat in the area
How do you define multiple casualties
The number of patients and the severities of their injuries do NOT exceed the resources and capabilities
How do you define mass casualties
The number of patients and the severities of their injuries DO exceed the resources and capabilities
What are the five principles of triage
Degree of life threat posed by the injuries sustained
Injury severity
Salvageability
Resources
Time, distance, and environment
Which principal of triage entails looking at each patient in a total global fashion
Injury severity
When is application of triage principles used
Decisions made are based on the best information available at the time
A large number of patients into small manageable groups
Mode of evacuating and transporting patients
What are the categories of military triage
Delayed
Immediate
Minimal
Expectant
Define the immediate military triage category
Needs lifesaving interventions within minutes up to 2 hours on arrival to avoid death or major disability
What are examples of an immediate patient
Penetrating chest wound WITH respiratory distress
Torso, neck, or pelvis injuries WITH shock
Threatened loss of limb
Retrobulbar hematoma (threat to loss of sight)
Define the delayed military triage category
Requires medical attention but CAN wait
What are examples of a delayed patient
Moderate to severe burns with less than 20% of total body surface area (greater than 20% is immediate)
Define the minimal triage category
Can be treated with self aid, buddy aid, or corpsman aid
Define the expectant military triage category
Require complicated treatments that may not improve life expectancy
What is the fourth stripe on the tag - casualties are dead or non-salvageable and entails no care is needed
Black (deceased/expectant)
What is the third stripe on the tag - casualties have minor injuries and will need minimal care
Green (minimal)
What is the second stripe on the tag - casualties are in the most need of care and/or transport to a higher echelon of care
Red (immediate)
What is the first stripe on the tag - casualties will need care, but in no hurry
Yellow (delayed)
What is primary triage
Simple and quickly categorizing patients; identifying and stop life threats. Breaks patients down into more manageable patients
Immediate life sustaining care and situation awareness are part of what triage
Primary triage
What is secondary triage
Allows for adjustment on patient response, to direct more in-depth treatment and prepare for a nine-line medical evacuation request
What is tertiary triage
Continued management of patients where more complicated procedures should be weighed against situation
Early trauma deaths are due to disruptions in one, or all, of the three bodily systems - what are those
The respiratory system
The vascular system
Or the central nervous system
What is combat stress
Rapid identification and immediate segregation of stress casualties from injured patients will improve the odds of a rapid recovery
What are the categories of combat stress
Light stress
Heavy stress
Define light stress
Immediate return to duty or return to unit or unit’s non combat support element with duty limitations or rest
Define heavy stress
Send to combat stress control restoration center for up to 3 days reconstitution
What is the pneumonic used where resources and tactical situations allow
BICEP:
Brief
Immediate
Central
Expectant
Proximal
Simple
Or refer
Define brief from “BICEP”
Keep interventions to 3 days or less of rest, food and reconditioning
Define immediate from “BICEP”
Treat as soon as symptoms are recognized. Do not delay ***
Define central from “BICEP”
Keep in one area for mutual support and identity as service member
Define expectant from “BICEP”
Reaffirm that we expect them to return to duty after brief rest; normalize the reaction and their duty to return to their duty
Define proximal from “BICEP”
Keep them as close as possible to the unit
Define simple from “BICEP”
Do not engage in psychotherapy… address the present stress response and situation only, using rest, limited catharsis and brief support
Define the “or refer” of “BICEP”
Must be referred to a facility that is better quipped or staffed for care
Define level 1 echelon of care
First medical care military personnel receive. Includes immediate life-saving measures, disease and non-battle injury prevention and care, combat and operational stress control (COSC), patient location and acquisition.
What treatment is provided by level 1 echelon of care
Self-aid and buddy aid
Combat life saver
Medical personnel
Examples include: BAS, cruisers, destroyers
What is level 2 echelon of care
Initial resuscitative care is primary objective of care - saving life, limb and when necessary - stabilization for evacuation to level 3
What are examples of level 2 echelon of care
CRTS: LHD (largest medical capability), LHA, CVN
MEDBN - provides surgical care for the MEF (Consists of 1 HQ company and 3 surgical companies)
STP (shock trauma platoon) - a small forward unit with one physician supporting the MEF
FRSS (forward resuscitative surgical suite)
What is R2LM and R2E and what echelon of care do they fall under
R2LM - Role 2 Light Maneuver; light, highly mobile medical units designed to support lane maneuver formations
R2E - role 2 enhanced; provides basic secondary healthcare built around primary surgery, intensive care unit, and ward beds
Define level 3 echelon of care
The highest level of care available within a combat zone - advanced resuscitative care is the primary objective of care
What are examples of level 3 echelon of care
Fleet hospitals, fleet ships (USNS comfort/mercy)
Define level 4 echelon of care
Definitive medical care is the primary objective at this level
What is an example of level 4 echelon of care
OCONUS hospital - NH Yokosuka
Define level 5 echelon of care
Restorative and rehabilitative care is the primary objective of care at this level
What is an example of level 5 echelon of care
CONUS hospital - NMCSD
What is a MEDEVAC
Timely, efficient movement and en route care provided by medical personnel to the wounded being evacuated from the battlefield to the MTF
What is a CASEVAC
Movement of casualties from the point of injury to medical treatment by non-medical personnel (may not receive en route medical care
What is AE
Aeromedical evacuation - generally utilizes USAF fixed-winged aircraft to move sick or injured personnel within the theater of operations (intra-theater) or between two theaters (Inter-theater)
What litters are used to transport casualties
Standard litter - prefabricated and may have accessories to be used with them
Stokes litter - most commonly used litter onboard ships
SKED litter - compact and lightweight transport system
Improvised litter - made from various materials
What are methods of ground evacuation
M997 Ambulance: protection for crew and patients
M1035 Ambulance: removable soft top
MK 23 7 ton: non-medical vehicle that may be utilized for casualty transport when available
What are the methods of air evacuation
UH-60A Blackhawk
UH-60B Seahawk
CH-46 Sea Knight
CH-53 D/E Sea Stallion
CH-1 Huey
MV-22 Osprey
C-2 Greyhound
P-3 Orion
C-130 Hercules
What are the MEDEVAC/CASEVAC priorities
Urgent - casualty must be evacuated within 2 hours in order to save life, limb or eyesight
Priority - casualty must be evacuated within 4 hours or condition could worsen
Routine - casualty must be evacuated within 24 hours for further care
What are examples of an urgent MEDEVAC/CASEEVAC
Cardio respiratory distress
Uncontrolled hemorrhage
Shock not responding to IV therapy
Head injuries with signs of increased ICP
Extremities with neurovascular compromise
What are examples of a priority MEDEVAC/CASEVAC
Flail chest segments without respiratory compromise
Open fractures
Spinal injuries
Major burns
What are examples of routine MEDEVAC/CASEVAC
Minor to moderate burns
Simple, closed fractures
Minor open wounds
Terminal casualties
What is line 3 of the 9 line
Number of patients by precedence:
A - urgent
C - priority
D - routine
What is line 4 of the 9 line
Special equipment needed
A - none
B - hoist
C - extraction equipment
D - ventilator
What is line 7 of the 9 line
Method of marking pickup site
A - panels
B - pyrotechnics ***
C - smoke
D - none
E - other
The MIST report consists of what categories
Mechanism of Injury
Injuries sustained
Signs/symptoms
Treatment
What states that every object will remain at rest or in uniform motion unless compelled to change its state by the action of an external force
Newton’s first law - commonly known as inertia
What is Newton’s second law
Builds on the first and further defines a force (F) as equal to the product of the mass (M) and acceleration (A): F=ma
Force = mass x acceleration/deceleration
What forms can energy take
Mechanical
Thermal
Electrical
Chemical
Who first proposed that the kinetic energy possessed by the bullet was dissipated in four ways
Theodore Kocher
What are the ways a bullet is dissipated
Heat
Energy used to move tissue radically outward
Energy used to form a primary path by direct crush of the tissue
What is cavitation
When a solid object strikes the human body or when the body is in motion and strikes a stationary object, the tissue particles are knocked out of their normal position creating a hole or cavity
What is the momentary stretch or movements of tissue away from the path of the bullet
The temporary cavity (think a vaccine)
What forms at the time of impact and is caused by compression or tearing of tissue, but it does not necessarily rebound to its original shape and can be seen later
The permanent cavity (think GSW)
What is the deviation of the projectile in its longitudinal axis from the straight line of flight
Yaw
What is the forward rotation around the center of mass
Tumbling
What is a mushrooming of the projectile that increases the diameter of the projectile, usually by a factor of 2, increases the surface area, and, hence, the tissue contact area by four times; hollow point, soft nose, and dum-dum bullets all promise deformation
Deformation
What is multiple projectiles can weaken the tissue in multiple places and enhance the damage rendered by cavitation. This usually occurs in high-velocity misses
Fragmentation
What are the energy levels of projectiles
Low
Medium
High
What is an example of a low level energy projectile
Knives, needles, ice picks
What is an example of medium energy projectiles
9 mm
What is an example of a high energy level of projectiles
.44 magnum
Elastic tissue tolerate damage better than non-elastic organs, what are examples of each organ group
Elastic tissue - bowel and lung
Non-elastic tissue - heart, liver, kidney and brain
The approach to thoracic injuries typically depends upon the mechanism, severity, and the location of injury, list examples of each
Mechanism - penetrating vs. blunt
Severity - life threatening vs. stable
Location of injury - chest wall vs. pleura vs. lung
What categories are blast injuries subdivided into
Primary - remember perforated tympanic membrane
Secondary - flying debris/fragments
Tertiary - body displacement
Quaternary - burns
What are the TCCC approved tourniquets
Combat application tourniquets (C.A.T.)
Special operations forces tourniquet - tactical (SOFT-T)
Emergency and military tourniquet (EMT)
What can be used as a temporary measure and works most of the time for external bleeding and can even be used for carotid and femoral bleeding
Direct pressure
What are the TCCC approved hemostatic agent
Combat gauze
Celox gauze or chito gauze - active ingredient is chotosan, a mucoadhesive, it functions independent of the coagulation cascade
XStat - best for deep narrow tract junctional wounds
What are the locations of junctional wounds
Groin
Buttocks
Perineum
Axillae
Base of the neck
Extremities
What are the CoTCCC Junctional tourniquets
Combat ready clamp
Junctional emergency treatment tool
SAM junctional tourniquet
What is the primary involuntary respiratory center
Medulla
What is connected to the respiratory muscles by the vagus nerve
The pons
Primary control centers come from the medulla and pons; what is this called
Neural control
What factors increase and decrease respirations
Increases respirations: body temperature, emotion, pain, hypoxia, acidosis, stimulant drugs
Deceases respirations: depressant drugs, sleeping agents, drugs like morphine
What is anoxia
There is no oxygen available at all
What is hypoxia
Literally means “deficient in oxygen”, that is an abnormally low oxygen availability to the body or an individual tissue or organ
What is hypoxemia
Insufficient oxygenation; that is decreased partial pressure of oxygen in blood
True or false: All trauma casualties should receive appropriate ventilator support with supplemental oxygen to ensure that hypoxia is corrected or averted entirely
True
What are indications for oxygen therapy
Cardiac and respiratory arrest
Hypoxemia
Hypotension
Low cardiac output and metabolic acidosis
Respiratory distress
When is hyperbaric oxygen used
For decompression illness (the “bends”)
Carbon monoxide poisoning
Why is Sellick’s maneuver helpful
Aids in preventing aspiration, particularly during BVM ventilation
Prevention of gastric aspiration is one of the key components in airway maintenance
Which maneuver improves the visualization of the larynx structures and eases the intubation
BURP maneuver
What is an indication to apply an OPA on a patient
Casualty who are unable to maintain their airway
What is a complication to using an OPA
Due to gag reflex stimulation, use of the OPA may lead to gagging, vomiting, and laryngospasm in casualties who are conscious
What are complications to using an NPA
Bleeding cause by insertion may be a complication
Inserting the NPA into the brain with a basilar skull fracture
Nasal turbinate injury
What is an i-Gel
A supraglottic airway
What is a contraindication to doing endotracheal intubation
Cervical fractures
What are complications of endotracheal intubation
Hypoxemia from prolonged intubation attempts
Trauma to the airway with resultant hemorrhage
Right mainstem bronchus intubation
Esophageal intubation
Vomiting leading to aspiration
Loose or broken teeth
Injury to vocal cords
What is the sniffing position
The head is extended, and the neck is flexed
What is also known as a blind insertion airway device (BIAD) often used in the pre-hospital, emergency setting
The Combitube - esophageal tracheal airway
What is an indication to use the combitube airway
Airway management in trapped patients
What is a contraindication of using the combitube airway
Patients with known esophageal pathology
Patients with intact gag reflexes
What are complications os using the combitube airway
Increased incidence of sore throat, dysphasia and upper airway hematoma when compared to endotracheal intubation and LMA
Esophageal rupture is a rare complication but has been described
May be partially preventable by avoiding over-inflation of the distal and proximal cuffs
Confirm tube placement of the combitube airway can be confirmed using what
End tidal CO2 detector or esophageal bulb device
What does not provide a definitive airway, and proper placement of the device is difficullt without appropriate training
The LMA
What are complications of using an LMA
Aspiration, because LMA does not completely prevent regurgitation and protect the trachea
Layngospasm
Sore throat
What is not a definitive airway device and plans to provide a definitive airway are necessary
LTA
What are complications of using an LTA
The laryngeal tube may be displaced during repositioning the patients head and neck for operation
Aspiration
Poor seal with inability to ventilate
What is the purpose for doing surgical cricothyrotomy
To provide an emergency breathing passage for a patient whose airway is closed by:
Traumatic injury to the neck
Burn inhalation injuries
By closing of the airway due to an allergic reaction to bee or wasp stings
Or by unconsciousness
What is considered a technique of “last resort” in prehospital airway management
Surgical cricothyrotomy
What are indications to performing surgical cricothyrotomy
Massive midface trauma precluding the use of BVM device
Inability to control the airway using less invasive maneuvers
Ongoing tracheobronchial hemorrhage
What is a contraindication to performing surgical cricothyrotomy
casulaties with acute laryngeal disease of traumatic or infectious origin
What are complications of performing a surgical cricothyrotomy
Prolonged procedure time
Hemorrhage
Aspiration
Misplaced or false passage of the ET tube
Injury to neck structures or vessels
Perforation of the esophagus
The longer the period of use, the greater the risk of complications
True or false: with the non-dominant hand to immobilize the thyroid cartilage and hold the skin taut over the membrane. Make a 3cm vertical incision centered over the cricothyroid membrane
True
A surgical cricothyrotomy can be left in place for how long
24 hours but should be replaced within that time period by a formal tracheotomy performed in a higher level of care
Needle decompression should be performed when what criteria is met
Evidence of worsening respiratory distress or difficulty with BVM device
Decrease or absent breath sounds
Decompressed shock (SBP <90 mm Hg)
What is a simple pneumothorax
A collapsed lung caused by the rupture of a congenitally weak area lung
I.e. spontaneous pneumothorax
When does a simple pneumothorax usually occur
Young white males
Age 16 to 25 year olds
Those who possess a very lanky, thin, runners build
Spontaneous simple pneumothorax occur WITH or WITHOUT evidence of trauma
WITHOUT
What is released air that becomes trapped within the subcutaneous tissue. Feels like “rice crispies” underneath the skin
Subcutaneous emphysema
Hemothorax occurs when blood enters the pleural space. Because this space can accommodate how much liquid
2500 and 3000 ml, hemothorax can represent a source of significant blood loss
The mechanisms resulting in hemothorax are the same as those causing the various types of pneumothorax. The bleeding may come from where
The chest wall musculature, the intercostal vessels, the lung parenchyma, pulmonary vessels, or the great vessels of the chest
The primary cause of hemothorax is lung laceration or laceration of an intercostal vessel or internal mammary artery due to what
Either penetrating or blunt trauma
What are the indications for performing a chest tube
Drainage of large pneumothorax
Drainage of hemothorax
After needle decompression of a tension pneumothorax
Pleural effusion
Emphysema
Simple/closed pneumothorax
Open pneumothorax
What are contraindications to placing a chest tube
Infection over insertion site
Uncontrolled bleeding
No contraindication if the procedure is emergent
What is a flail chest
The breaking of 2 or more ribs in 2 or more places
What are some signs/symptoms of a patient with a flail chest
Shortness of breath
Paradoxical chest movement
Bruising/swelling of affected chest area
Crepitus
What is the chief physiological abnormality of a pulmonary contusion
Prevention of gas exchange because no air enters these alveoli; blood and edema fluid in the tissue between the alveoli further impedes gas exchange in the alveoli that are ventilated
Fresh whole blood contains all the functional components required by the body such as what
Red blood cells
Platelets
Plasma
FWB has a shelf life of what
24-48 hours for collected FWB
All males can receive what blood at any time
O positive or
O negative
All females of childbearing age receive what blood
O negative - unless it is a matter of life and death and there is no O negative blood available
Why can females only receive O negative blood
It can induce what is termed Rh disease
If the female becomes pregnant with an Rh-positive baby, then 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
What is class III hemorrhagic shock
Class III - 30% of blood loss
1500-2000 ml of blood loss
>120 pulse rate per minute
Decreased blood pressure
30-40 respirations per minute
Urine output 5-15 ml per hour
Level of consciousness exhibiting confused demeanor
What is class IV shock
Class IV - >40% of blood loss
>2000 ml of blood loss
>140 pulse rate per minute
Decreased blood pressure
>35 respirations per minute
Urine output negligible
LOC exhibiting lethargic demeanor
absent radial pulse/SBP below 80 mm Hg
If you were to encounter a patient with citrate toxicity, how do you manage the patient
Recommendation is to give 1 amp of calcium glaucoma temperature every 4 units of FWB to avoid toxicity and hypocalcemia
How do you manage patients with a febrile non-hemolytic reaction
Treat as you would any other fever with 1 gram of Tylenol PO every 8 hours
What should be filled out prior to blood transfusion and record vital signs every 10-15 minutes during transfusion
Fill out the back of the TCCC card or an SF 518
How often are vitals being assessed for a patient undergoing a blood transfusion
Record baseline vitals and continue to record them through and following the transfusion at minimum every 15 minutes. For the first 15 minutes of the transfusion, record them every 5 minutes
If a casualty is anticipated to need a significant volume of blood transfusion due to what would TXA be given
Hemorrhagic shock
One or more amputations
Penetrating torso trauma
Evidence of severe bleeding
What is TXA
Tranexamic acid
What is the administration for TXA
Survival benefits are greater when given within 1 hour of injury
Administer 1 gram of TXA in 100 ml normal saline or lactated ringers as soon as possible, but not later 3 hours after injury
When administering TXA is should be administered over 10 minutes
What is a side effect of administering TXA
Hypotension with rapid IV infusion, seizures, visual changes
What is storage and handling of TXA
Recommended temperature range for storage: 59 - 86 F
What are the types of solutions IV fluids come in
Colloids
Crystalloids (isotonic, hypotonic, hypertonic)
Blood ad blood products
When the crystalloid contains the amount of electrolytes as the plasma, it is referred to as what
Isotonic
If a crystalloid contains more electrolytes than the body plasma, it is more concentrated and referred to as what
Hypertonic
True or false: placement of an intraosseous needle is indicated during traumatic situations when attempts at venous access fail (3 attempts or 90 seconds) or in cases where it is likely to fail, and speed is of the essence
True
What are some contraindications of IO placement
Ipsilateral fracture or crush injury of an extremity
Previous orthopedic procedure near the selected insertion site
Previous IOVA attempts in the same bone
Infection at the selected insertion site
Inability to locate landmarks
Brittle bones
How do you flush an IO
Two 10ml syringes for aspirating medullary contents and flushing with normal saline
What are complications of an IO
Tibial fracture, especially in small framed people
Compartment syndrome
Osteomyelitis
Skin necrosis
What do you give to a patient in mild to moderate pain and casualty IS still able to fight
Tylenol
Meloxicam (Mobic) - for moderate pain: 7.5 to 15 mg PO daily
What do you give to a patient in moderate to severe pain and casualty is NOT in shock or respiratory distress and is not at significant risk of developing either
Oral transmucosal fentanyl citrate (OTFC): 800 ug
What do you give to a patient in moderate to severe pain and casualty IS in shock or respiratory distress or casualty is at significant risk of developing either
Ketamine: 50 mg IM with repeat dose every 30 minutes/ 20 mg IV and repeat every 20 minutes
Often has side effect of vivid hallucinations
What is an alternative to OTFC if IV access has been established
Morphine: 5 mg IV/IO, max of 15 mg
What are the TCCC antibiotic recommendations
Moxifloxacin (Avelox): 400 mg IV/IO q 24 hours
Ertapenem (Invanz): 1 gram IV q 24 hours
Levofloxacin (Levaquin): 750 mg IV/PO q 24 hours
Cefazolin (Ancef, Kefzol): 1 gram IV every 8 hours for 7 days
Ceftriaxone (Rocephin) 2 grams IV every 12 hours
What is the small opening for blood vessels and nerves to pass in the skull
Foramina
What is it called where the brain stem and spinal cord passes
Foramen magnum ***
What is the layers that cover the brain
Meninges
What is inside the skull and is made of a tough fibrous layer and has epidural space (potential space)
Dura mater
What is closely adhered to the brain
Pia mater
What is layered on top of blood vessels adhered to pia
Arachnoid membranes
What are the regions of the brain
Cerebrum
Cerebellum
Brain stem
What is the brain surrounded by that is produced in the ventricular system and functions to cushion the brain
Cerebrospinal fluid (CSF) - approx. 150ml
What controls pupillary constriction and crosses surface of tentorium
Cranial nerve III (oculomotor) - hemorrhage or edema that leads to herniation of the brain will compress the nerve leading to pupillary dilation
What is CPP
Cerebral perfusion pressure
What are the biggest predictors of poor outcome in head trauma
Amount of time spent with ICP >20 mmHg (usually below 15mmHg)
Time spent with systolic BP <90mmHg. A single episode of hypotension can lead to a worse outcome
What is assessing for adequate airway and ventilator effort is crucial in early stages
Breathing
Essential to keep SpO2 >90mmHg
What is Cushings triad
Refers to elevated systolic BP, bradycardia and abnormal respirations (Cheyne-stokes)
When should a patient be intubated
GCS <8
Depressed vs non depressed skull fractures
Depressed can often be palpated and may require surgical intervention
When should a Basilar skull fracture be suspected
Suspect if CSF drainage or delayed (several hours) findings of periorbital ecchymosis or battle signs are seen
What is a hyphema
Blood in anterior orbit
How is a concussion defined
A head injury from a hit, blow or jolt to the head that:
Briefly knocks you out
May affect your ability to remember information before, during, or after the event
Makes you feel dazed (bell rung)
Where is an epidural hematoma, how could it happen, and what should you watch for
Bleeding between skull and dura mater
Usually happens from low velocity blow to temporal bone
Watch for dilated, sluggish non-reactive pupil
Where is a sub Duran hematoma, and what does this usually happen from
Account for 30% of severe brain injuries
Happens from MVC and falls
Blood collects between dura and arachnoid membrane
How is a subarachnoid hemorrhage described as and what are the signs and symptoms
Commonly associated with ruptured cerebral aneurysm and onset of worst headache of life
Signs and symptoms: severe HA
Nausea/vomiting
Dizziness
May have meningeal signs***
Seizures
What is the recovery period after a mild concussion/TBI
24-hour minimal recovery period
What are red flags of a mild concussion/TBI
Deteriorating LOC
Double vision
Increased restlessness, combative, or agitated behavior
Repeated vomiting
Seizures
Weakness or tingling in arms or legs
Severe or worsening headache
Unsteady on feet
One pupil larger or smaller than the other
Changes in hearing, taste or vision
Repeated episodes of blacking out/passing out
How should an aggressive headache be managed
Use acetaminophen every 6 hours, for 48 hours - after 48 hours, may use Naproxen as needed
Avoid tramadol, fioricet, and narcotics
How is an initial concussion patient managed
Mandatory 24 hour rest period
Reevaluate after 24 hours
If a patient is symptom free at rest after a TBI/concussion, what should be performed next
Exertional testing
If symptom free during exertional testing and first concussion in the past 12 months - return to duty
If sx free during exertional testing and second concussion in the past 12 months - stage 2 light routine activity for the next 5 days
What are the do’s and don’t’s of Stage 2 light routine activity
May wear uniform and boots, can do stuff no longer than 30 minutes
DO NOT: drink alcohol, play video games, do resistance training or repetitive lifting, do sit-ups, push-ups, or pull-ups, go to crowded areas where you may be bumped into
For a patient that was symptom free following 5 days of Stage 2 activity, what is the next step
Patient may progress through stages 3, 4, and 5 for 24 hours each
What are the do’s and don’t’s of Stage 3 light occupation-oriented activity
May perform activities for no longer than 60 minutes - lift/carry objects less than 20 lbs
May perform activities for no longer than 30 minutes - gently expose to light and noise
DO NOT: drink alcohol, drive, play video games, do resistance training or relative lifting, go to crowded places, participate in combative or contact sports
What are the do’s and don’t’s of stage 4 moderate activity
You may wear PPE
Can perform activities for no longer than 90 minutes - brisk walk, light resistance training
Can perform activities for no longer than 40 minutes - play video games
DO NOT: drink alcohol, participate in combative or contact sports, drive
What are the do’s and don’t’s of Stage 5 Intensive activity
Resume normal routine and exercise, participate in normal military routine
DO NOT: drink alcohol, participate in combative or contact sports, go outside the wire in a combat zone
If symptoms develop/return during any stage of mild concussion/TBI recovery, what should be done
Patient must restart protocol and start at Stage 1 (rest), provide sx management, refer to rehabilitation provider
Where should a patient be referred to if there are 3 or more documented concussions in the past 12 months
Stage 1 rest and refer to Neurology for a comprehensive work-up with imaging and assessment
What are the temperature stages of hypothermia
Mild: 90 - 95 F
Moderate: 82-90 F
Severe: below 82 F
How do patients present in each stage of hypothermia
Cold stressed (not hypothermic) - temp is 95 - 98.6 F… they’re okay, just cold
Mild hypothermia: alert but mental status may be altered, shivering present, not able to care for self
Moderate hypothermia: decreased LOC, could be conscious or unconscious, with or without shivering
Severe/profound hypothermia: unconscious, NOT shivering
What is vaporization of water through both insensible losses and sweat
Evaporation
What is emission of infrared electromagnetic energy
Radiation
What is direct transfer of heat to an adjacent, cooler object
Conduction
What is direct transfer of heat to convective currents of air or water
Convection
What are the most common mechanisms of accidental hypothermia
Convective heat loss to cold air and conductive heat loss to water
What symptoms may be present for a patient with moderate hypothermia
At lower ends of temp, loss of shivering, dysrythmias (A fib), and dilated pupils below 29 C
What symptoms may be present in a patient with severe hypothermia
Pulmonary edema, oliguria, hypotension, bradycardia, ventricular dysrhythmias (V fib/tach/asystole)
Many standard thermometers only read to a minimum temp of what
93 F
What labs should be collected for a hypothermic patient
Finger stick glucose
ECG (Osborne waves)
How is mild hypothermia treated
Passive external warming
How is moderate and refractory mild hypothermia treated
Active external rewarming
How is a severe hypothermic patient treated
Active internal rewarding and possibly extracorporeal rewarming
The primary survey for both ATLS and TCCC consists of what
5 systematic steps to assess life threatening injuries with slight variations
What is the TCCC primary survey
M - massive hemorrhage
A - airway
R - respirations
C - circulation
H - head trauma/hypothermia
What is a class I hemorrhage
Loss of up to 15% (about 750ml) of circulating blood volume - tolerated well in healthy patients
What is a class II hemorrhage
Blood loss of 15-30% (about 750-1500ml) of total blood volume - results in tachycardia and narrowed pulse pressure
What is a class III hemorrhage
Blood loss increases beyond 30% (1500ml) - worsening hypotension, tachycardia, peripheral hypoperfusion and decline in mental status
What is a class IV hemorrhage
Blood loss greater than 40% (2L) - the ability of the body to compensate has reached its limits and hemodynamic decompensation is imminent without effective resuscitation
When assessing respirations, what findings warrant immediate intervention
Needle thoracostomy for tension pneumothorax
Insertion of large-bore chest tubes to relieve hemopneumothorax
Application of an occlusive dressing to a sucking chest wound
When assessing circulation, what should be assessed for hemodynamic status
Consciousness, skin color and presence and magnitude of peripheral pulses
Formal BP should NOT be performed at this point in the survey - important information can be rapidly obtained regarding perfusion and oxygenation from the level of consciousness, pulse, skin color and capillary refill
What are the expected palpable pulses of a patient
Radial pulse: pressure >80mmHg
Femoral pulse: pressure >70mmHg
Carotid pulse: pressure >60mmHg
What is the lowest and normal score for a GCS
Lowest score: 3
Normal score: 15
Intubation: <8 - indicates severe head injury/coma
What is the pneumonic used to collect the history of a trauma patient
A - allergies
M- medications and supplements
P - past medical illnesses and injuries
L - last meal
E - events associated to the injury
What is hemotympanum
Disruption of the auditory canal on otoscopic exam are additional findings suggestive of a basilar skull fracture (blood behind the TM) - CSF leaking from the ear is confirmatory
What does the presence of bruising around the eyes (raccoon eyes) or behind the ears (battle signs) indicate
Basilar skull fracture
What is the most commonly injured organ in blunt trauma
The spleen
What is the second most common solid organ injury
The liver
Hollow viscous injuries can involve what
Stomach, bowel, or mesentary
What may develop insidiously, and every patient with an injured extremity should be at risk, particularly those with fractures and crush injuries
Compartment syndrome
What presents as the first sign of ischemia and should be aggressively evaluated
Pain - frequent reevaluation of the extremity is essential and if compartment syndrome is present, a fasciotomy should be performed
For crush injuries, what should be considered
Rhabdomyolysis
When should transportation begins for a trauma patient
MEDEVAC/CASEVAC should begin as soon as the patient is stabilized and packaged or when operationally possible
What is an ongoing assessment
After the primary survey and initial care are complete, the patient should be continuously monitored
What is the definition of anaphylaxis
Defined by airway compromise or hypotension, is obviously a true medical emergency and must be rapidly assessed and treated
What are triggers for anaphylaxis
Drugs
Food
Additives
Toxins
Chemicals
What is a classic presentation of an allergic reaction
Pruritis
Flushing
Urticaria
What is progression of an allergic reaction
Throat fullness
Anxiety
Chest tightness, SOB, lightheadedness
What are signs and symptoms of a severe allergic reaction
Loss of consciousness
Cardiorespiratory arrest
When do signs and symptoms begin of an allergic exposure
Begin within 60 minutes
The faster the onset, the more severe the reaction
What is the management of a patient in anaphylaxis
The single most important step in treatment is the rapid administration of EPINEPHRINE
What are 2nd line therapies for a patient in anaphylaxis
Corticosteroids: Methylprednisolone (Solumedrol) 125mg IM/IV daily x2 days
Antihistamines: loratidine (Claritin) 10mg, Clarinex 5mg, Allegra 60mg twice a day, Zyrtec 10mg, Benadryl 25050mg IV (Preferred Agent)
What is the preferred mNgement of n allergic bronchospasm
Nebulized albuterol (SABA) - 5mg every 15-30 minutes
Smoke inhalation injury usually effects what
Upper airway
Trachea
Pulmonary parenchyma
Alveoli
What causes smoke inhalation injuries
Caused by heat, smoke, or chemicals
Fire is the leading cause of smoke inhalation injuries
Upper airway injuries due to smoke inhalation usually effect what
Above the vocal cords - usually due to thermal injuries
Leads to erythema, ulcers and edema
Injury can cause impaired ciliary function as well
Can lead to airway compromise
Tracheobronchial tree injuries is usually caused by what
Caused by chemicals in the smoke and can lead to pulmonary edema and subsequent mismatches in ventilation and perfusion within the lungs
Where is a parenchymal injury usually located and what does it mean
Injury to the lung tissue, usually a delayed process - results in alveolar collapse and impaired oxygenation, risk for pneumonia
What is systemic toxicity caused by
Caused by breathing toxic substances
What are the most relevant gases that cause systemic toxicity
Carbon monoxide
Hydrogen cyanide
What are some symptoms of the upper airway when dealing with systemic toxicity
Dyspnea of the upper airway and clinical findings of: soot around nares, carbonaceous sputum, obvious burns to neck and face, stridor, drooling, dysphonia
When should a chest x-ray be done for a patient with smoke inhalation
Typically obtained early in the course - may be normal initially however, it is useful as a baseline
When should an EKG be collected on a patient with smoke inhalation injury
Useful in any patient being evaluated for toxicological purposes
What can lead to myocardial ischemia
CO poisoning
What is the first step to treating a patient with smoke inhalation injuries
Rescue from source and limit exposure time - ABCs and ATLS protocols with frequent re-assessment
What should be performed if a patient has signs of thermal injury to the airway
Intubation is indicated
What are the steps of treatment for a smoke inhalation injury patient after intubation
Provide 100% O2
IV fluids for burns
Inhaled bronchodilators for bronchospasm (albuterol)
Prevent hypothermia
What is the definition of rhabdomyolysis
Striated muscle breakdown
What are some causes of rhabdomyolysis
Trauma
Crush injuries
Prolonged restraints or immobilization
Compartment syndrome
Electrical injuries
What are causes of exertional rhabdomyolysis
Individual is not conditioned (new recruits)
Hot, humid conditions
Impaired sweating
Seizures and delirium tremens
Meth and cocaine use
What are causes of non-exertional rhabdomyolysis
Coma induced by drugs
Medications
Toxins
What are common symptoms and exam findings for a patient with rhabdomyolysis
Muscle tenderness
Edema
Muscle weakness
Dark urine (dark honey/coca cola)
Altered mental status may occur from underlying etiology
What are some differentials for a patient with rhabdomyolysis
Compartment syndrome
Crush injury
Meth/cocaine use
DVT
Heat cramps
What labs should be drawn on a patient with rhabdomyolysis
Elevation in CK (Hallmark) typically fivefold increase from normal
UA dipstick is usually positive fr blood
Electrolyte abnormalities (hyperkalemia)
EKG to evaluate electrolyte abnormalities (causes peaked T waves)
What is the treatment for a patient with rhabdomyolysis
Large volume IV resuscitation (1.5L/hr) to maintain 2ml/kg/hr urine output
Usually can be maintained on platform if no AMS and maintaining above ^
If AMS, temp >105, or unresponsive to IV fluids then need to immediate MEDEVAC
Some patients may have progressive renal failure and require hemodialysis
What are complications of rhabdomyolysis
Acute renal failure, acute kidney injury
Compartment syndrome
Electrolyte abnormalities
Cardiac arrhythmias
Death
What are the three sections of the Glasgow Coma Scale
Eye opening response
Verbal response
Motor response
What is being scaled and what are the scores respectively for eye opening response
Eyes open spontaneously - 4 points
Eyes open to verbal command, speech, or shout - 3 points
Eyes open to pain (not applied to face) - 2 points
No eye opening - 1 point
What is being scaled and what are the scores respectively for verbal response
Oriented - 5 points
Confused conversation, but able to answer questions - 4 points
Inappropriate responses, words discernible - 3 points
Incomprehensible sounds or speech - 2 points
No verbal response - 1 point
What is being scaled and what are the scores respectively for motor response
Obeys commands for movement - 6 points
Purposeful movement to painful stimuli - 5 points
Withdraws from pain - 4 points
Abnormal (spastic) flexion, decorticate posture - 3 points
Extensor (rigid) response, decerebrate posture - 2 points
No motor response - 1 point
What is the definition of triage and its meaning in French
The process of prioritizing patient treatment during mass casualty events based on their need for or likely benefit from immediate medical attention
French word “to sort”
How are patients managed for care under fire during triage in TCCC
Get the patients who are not clearly dead to cover if possible - continue with the mission/fight and gain fire superiority
How are patients managed for tactical field care during triage in TCCC
Perform an initial rapid assessment of the casualty for triage purposes (should not take more than 1 minute per patient)……
A casualty collection point should be quickly chosen based on what
Proximity to patients
Proximity to vehicle access
Proximity to HLZ (helicopter landing zone)
Geography, safety “geographic triage”
What is tested in ISR safety model, widely fielded in the DoD and recommended by the CoTCCC first choice
Combat gauze
What may be used when combat gauze is not available and has the active ingredient of chotosan
Celox gauze/chito gauze
What is the first expanding wound dressing FDA-cleared for life threatening junctional bleeding
XStat (best for deep narrow tract junctional wounds)
Where should a tourniquet be placed
Apply 2-3 inches above bleeding site - if unable to identify site, apply “high and tight” - if still unable to control, apply 2nd tourniquet directly above the first or directly below if “high and tight”
How long should hemostatic dressings be applied for
At least 3 minutes of direct pressure
What is a non-invasive method allowing the monitoring of the saturation of a patient’s hemoglobin
Pulse oximeter
What are the indications for oxygen therapy
All trauma casualties should receive appropriate ventilator support with supplemental oxygen to ensure hypoxia is corrected or avoided
If oxygen saturation is 94% or lower, the patient is hypoxia and needs to be treated quickly
What gives 100% oxygen at an increased pressure of 3 atm
Hyperbaric oxygen
What are examples of manual airway maneuvers
Head tilt/chin lift
Jaw thrust maneuver
Sellick’s maneuver
BURP maneuver
What is the most frequently used artificial airway device and its complication
OPA - complication due to gag reflex stimulation
What are the disadvantages of the NPA
Smaller size
the risk of nasal bleeding during insertion
Cannot be used if a basilar skull fracture is suspected
What is the preferred supraglottic airway because it makes it simpler to use and avoids the need for cuff inflation and monitoring
I-Gel (supraglottic airway)
According to ATLS, what is the preferred definitive airway
Tracheal intubation through the mouth using direct layngoscopy
What is a complication of endotracheal intubation
Hypoxemia from prolonged intubation attempts
What is an indication to use the Combitube airway
Airway management in trapped patients
What is the difference between performing a needle cricothyrotomy and surgical cricothyrotomy
Needle - a syringe with a needle attached is used to make a puncture hole through the cricothyroid membrane
Surgical - incision is made through the cricothyroid membrane in order to place tubing for ventilating the patient
What type of pneumothorax presents with air in the pleural space
Simple (closed) pneumothorax
What are the anatomical landmarks for performing a simple pneumothorax decompression
Mid-clavicular line
Sternum
Jugular notch
2nd intercostal space
Second rib
Clavicle
What are the signs and symptoms of a patient that presents with a hemothorax
Anxiety/restlessness
Chest pain
Tachypnea
Signs of shock (pallor, confusion, hypotension)
Frothy, blood sputum
Diminished breath sounds on the affected side
Tachycardia
Flat neck veins
What is the management of a flail chest patient
It is directed toward support of ventilation in addition to high flow oxygen such as BVM, IV fluids, analgesia to improve ventilation
What is drawn directly from an on-site donor and does not undergo processing into separate components
Fresh whole blood
What a was the first approved protocol in the ARMY for whole blood
Low titer O whole blood (LTOWB)
The human liver can process how many units of fresh whole blood without needing additional calcium
13 units
What is the recommended number of amps every 4 units of FWB to avoid toxicity and hypocalcemia
1 amp of calcium gluconate
In a patient with allergies or history of a previous allergic transfusion reaction, how much diphenhydramine and what route do you use
25-50mg IM/PO/IV (through a separate line) prophylactically before transfusion
If a casualty is anticipated to need a significant volume of blood transfusion, why would TXA be given
For:
Hemorrhagic shock
One or more amputations
Penetrating torso trauma
Evidence of severe bleeding
What is used to increase the blood volume following severe loss of blood (hemorrhage) or loss of plasma (severe burns)
Colloids (volume expanders)
How do expanders present
In dextran, plasma, and albumin
Colloids are expensive, have specific storage requirements, and have short shelf life (more suitable in hospital setting)
What are fluids that consist of water and dissolved crystals, such as salts and sugar and is used as maintenance fluids to correct body fluids and electrolyte deficit
Crystalloids - contain electrolytes (sodium, potassium, calcium, chloride) but lack the large proteins and molecules found in colloids
What is the equation for mean arterial pressure (MAP)
Systole + diastole x2/3 OR diastole + 1/3 pulse pressure
When performing a secondary survey for the head, what should be taken into consideration
Brisk bleeding from the scalp can be masked by thick hair, and a significant amount of blood may be lost before adequate evaluation is performed
What are the basic regions of the abdomen that are encompassed in the peritoneal cavity
Intrathoracic component
Retroperitoneum
The pelvic portion
What are the second line therapies for anaphylaxis
Methylprednisolone (Solumedrol) 125mg IM/IV daily x2 days
Antihistamines (block H1 and/or H2
Carbon monoxide has an affinity for hemoglobin by how much
260 times greater than oxygen
GSW most commonly injure what
Small bowel - 50%
Colon - 40%
Liver - 30%
Abdominal vessels - 25%
What injuries most often involved in blunt abdominal trauma include
Spleen - 40-55%
Liver - 35-45%
Small bowel - 5-10%
What are signs of compartment syndrome
Paresthesia (most common)
Pain (most common)
Pulselessness
Pallor
What is the gold standard imaging for a pelvic fracture
CT scan
What is a region of greatest destruction resulting in Necrosis and not capable of repair
Zone of coagulation - central zone
What is adjacent to zone of necrosis, immediately after injury blood flow is stagnant - cells are injured but not irreversible
Zone of stasis
What is the outermost zone - minimal cellular injury and characterized by increased blood flow secondary to inflammatory reaction initiated by the brain injury
Zone of hyperemia
What is a superficial burn
Used to be called first degree - involve only the EPIDERMIS, red and painful
What is a partial thickness burn
Involve epidermis and varying portions of the DERMIS - will appear as BLISTERS or denuded burned areas with glistening or wet appearing base
What is a full thickness burn
May have several appearances - most often appear thick, dry, white, and leathery regardless of skin color, thick leathery damaged skin referred to as eschar
When treating burns, how do you begin resuscitation
Use LR solution or similar
Continue during evacuation
Starting rate 500ml/hr for adults
What is the estimation of fluid resuscitation for the hourly fluid rate
Initial hourly rate = % TBSA burn x 10 ml/hr
What is the primary index of adequate resuscitation
UOP - important to avoid over or under resuscitation
Foley placement is essential part of the resuscitation process, what is the target UOP
0.5 ml/kg/hr
What are reasons for prolonged field care (PFC)
Long evac times
Indigenous capabilities
Requires different skills
Different environments
What are the three phases of PFC
Evaluation phase
Resuscitation phase
Transport phase
What is the evaluation phase of prolonged field care
A systematic approach priority to treat life threats in order of severity - resuscitation and life saving procedures, treat shock, completion or MARCH and upgrading stopgaps, initiate evacuation plan
What is the resuscitation phase of PFC
During this time, procedures and steps taken to normalize vitals and reverse physiological effects based on skill set available - lethal triad addressed of hypothermia, acidosis, coagulopathy + sepsis
What is the transport phase of PFC
Prevent hypothermia, secure patient and litter, splinting, monitors and cuffs, emergency meds, sedation pain, secure tubing, documentation of patient condition,response to therapy and treatment rendered
For sedation and pain management, what is the better capability
Additional training to provide sedation with ketamine and added midazolam (versed)
What should not be attempted for TQ’s in place longer than 6 hours unless it occurs at definitive care facility
Tourniquet conversion
What are the important timings for performing a tourniquet conversion
<2 hours is considered safe (attempt conversion)
2-6 hours is likely safe (attempt conversion)
>6 hours require caution (conversion not advised in PFC)
What is the fluid of choice for patients in hemorrhagic shock as well the capability to provide transfusion should be a basic capability of any clinician providing PFC
Fresh whole blood (FWB)
What is a very easy tool available to monitor the patient’s response and guide resuscitative efforts
Urine output (UOP)
What is the goal for adequate UOP
0.5-1 mg/kg/hr
This reflects adequate kidney perfusion and volume
What medications are given which produce a diminished sensation to pain without producing a loss of consciousness
Analgesia
What type of medication is the depression of a patients awareness to the environment and reduction of responsiveness - various levels including minimal, moderate and deep
Sedation
What medication can stable patients
Morphine
What medication can hemodynamically unstable patients get
Fentanyl or ketamine
