Trauma Flashcards
what is the prognosis of the majority of trauma patients?
*Immediate Within Minutes (50%)– trauma due to widespread brain damage and/or rupture of heart or great vessels
* Within Hours (30%)– “The Golden Hour” – An injured person has about 60 minutes in which traumatic care can improve survival rate.
* Within Days (20%)– Sepsis and multi-organ failure
when do the majority of trauma deaths occur?
at the scene or within 1st hr
Levels of Trauma
- Level 1 – Provides total care for every aspect of injury; research leader
- Level 2 – Provides definitive care for a wide range of traumatic complexities (pts needing Cardiac Sx, hemodialysis and microvascular Sx are stabilized in level 2 and then passed to level 1)
- Level 3 – Provides initial stabilization and treatment; care of uncomplicated patients
- Level 4 – Provides initial stabilization; transfers all trauma patients for definitive care
Parkview and Lutheran handle level ___ trauma
2
Should primary and secondary surverys be conducted before or after the pt reaches the hospital?
After they get IN the hospital
What is the Primary Survey?
ABCDE
Airway
Breathing
Circulation
Disability
Exposure/Environment
2 goals: Identify life threatening injury quickly, provide stabilization when identified.
ABCDE
Airway
talking = patent airway
Unconscious -> Intubation (GCS<8)
Conscious + CANT talk -> check airway (FB rmvl, suction, identify frx)
Assess face/neck injuries
C-spine collar immobilization
Swelling (hematoma/edema) -> compress airway.
Bleeding, nasopharygngeal blood -> aspiration
Crepitus = direct laryngeal or tracheal injury
Burns -> airway edema
Inhalation injury -> hypoxia
youre thinking about intubating but arent sure, wdyd?
INTUBATE
ABCDE
are airway or chest/pulm (breathing) traumatic injuries MC?
Chest/pulm (breathing) injuries are more common
ABCDE
Breathing
- listen to breath sounds
- assess resp effort (rate, muscle use)
- assess O2 Sat
- r/o tension pneumo, flail chest, open pneumotheroax, hemothorax
- give O2 (SpO2 >95%)
- Stabile -> CXR
ABCDE - Breathing
Indications for Mechanical Ventilation
RR >___ or <____
O2 <____% despite supp O2
- Respiratory Rate >35 or <6
- Oxygen desaturation to <90% despite supplemental O2
- Cardiopulmonary arrest
Why can’t you give Succhinycholine to a pt who has crush injuries and burns?
Natural Hyperkalemia after trauma + Succhinycholine induced Hyperkalemia = cardiac arrest
How to do rapid sequence intubation (RSI)
Induction agent (eg. Ketamine or Etomidate) followed by a paralytic agent (eg. Rocuronium or Succinylcholine).
OOA: 1 min
What is this? Trmnt?
tracheal deviation, uneven chest, absent breath sounds, hemodynamic compromise.
Tension Pneumothorax
Immediately perform needle decompression in 2nd intercostal space along midclavicular line. Followed by tube thoracostomy
Trmnt for flail chest
Often associated with underlying pulmonary contusion.
Trmnt: supportive +/- mechanical ventilation
Trmnt for open pneumo due to stab wound
Rapid equilibration of atmospheric and intrathoracic pressure
for impaired oxygenation and ventilation
Trmnt for hemothorax
LARGE tube thoracostomy and replacement of blood products
you start to do a needle decompression and blood is coming out. wdyd?
get a large tube
the blood will clot in the small needle diameter
ABCDE
Circulation
- asses color, mental state, cap refill
- feel peripheral pulses and check vitals on monitor
- r/o MC places to bleed out -> hemorrhagic shock (chest, abd, retroperitoneum, hip, femur, cranium (small kids)
- r/o obstructive shock (cardiac tamponade, tension pneumo)
- direct pressure on external bleeds
- IV access (2 large bore peripheral IVs 18g or larger, Intraosseous line, or central line)
- Start with isotonic crystalloid (consider blood transfusion)
- emergent trmnt based on underlying injury
Peripheral pulses SBP
Carotid >60 mmHg
Femoral >70 mmHg
Radial >80 mmHg
Dorsalis pedis >90 mmHg
ABCDE
Circulation FAST Exam
(Which regions do you US to check for ascites?)
- RUQ (Morrison’s pouch) - in b/w liver & kidney
- Subxiphoid
- LUQ
- Suprapubic (pouch of Douglas) - below the bladder
ABCDE
Disability
- Assess Level of consciousness using AVPU (alert, voic, pain, unresponsive), or Glasgow Coma Scale (GCS)
- Pupillary Fn
- Four extremity Movement (brain/spinal cord injury)
- External signs of head/neck trauma
- If patient is in any way altered -> check blood glucose (Pts with medical illness can have trauma precipitated by the medical problem)
- Assess for life threatening neurological injury
Penetrating cranial injury
Intracranial hemorrhage (Subdural hematoma, epidural hematoma, traumatic sub-arachnoid hemorrhage, intraparenchymal hemorrhage, or intraventricular bleed)
Diffuse axonal injury
High spinal cord injury
Glasgow Coma Scale (GCS)
“4 eyes”
“Jackson 5”
“V6 motor”
Scoring
3 = unresponsive (Dead)
8 = Intubate
15 = Gucci (fully responding)
If GCS is <_____ = INTUBATE
8
Order a STAT ____ for a low GCS score
Cranial image
doesnt say which study specifically
ABCDE - Disability
How to r/o a cervical spine injury
ABCDE
Environment/Exposure
- Remove clothing/covering.
- Look at the patient’s skin
- Avoid hypothermia (use a warm trauma bay, warm with fluids or blankets, transfuse blood if needed)
- Perform a complete head to toe exam (esp axilla, back, back of head, neck)
- Cover them up again
Primary Survery Points
- Do the Primary survey first
- Do it the same way every time
- Identify specific life threatening issues and treat simultaneously
- Know the differential diagnoses of the ABCDEs
- Following the survey, know if you need to transfer
- If something changes during exam, return to A, and redo the survey
Special Population Considerations:
Children
Pregnancy
Elderly
- Children: Different anatomic variables. They will have more anterior airways. They may not have as many fractured bones given flexible nature.
- Pregnancy: Higher circulating volumes, gravid uterus
- Eldery: comorbidities, may be on blood thinners, have less physiologic reserve.
Secondary Survery
Does not begin until primary survey is finished
Use AMPLEM history
* Allergies
* Medication
* Past surgical/medical history
* Medication
* Last meal
* Events
* Mechanism (blunt, penetrating, burn/inhalation)
Secondary Survery
Look for what on PE?
Spine (check cervical, thoracic, lumbar spine for deformities, step-offs, areas of tenderness)
Head and scalp (depressed skull fractures)
Maxillofacial
C-spine/neck
Chest
Abdomen (Bruising/distension, penetration)
Perineum/genitalia
Extremities
Neurologic
Flank discoloration = grey turners (think retroperitoneal bleed)
This flank discoloration found during Secondary Survery is a concern for _____
Flank discoloration = grey turners (think retroperitoneal bleed)
Following Survey
following is a verb in this “PA is to follow or FU”
- Consider Pan-Scan (CT it ALL -> Head, C-spine, Chest, Abd/Pelvis)
- Obtain specific imaging (spine, extremity)
- Stabilize and transfer to definitive care center if needed
- Trauma patients must be evaluated continuously
- Patients should improve as they go
- Sudden decompensation -> go back to A again and do primary survey all over again (double it and give it to the next person)
- Tertiary survey refers to rounding on the patient
