Trauma Flashcards
What is ATLS
Advanced Trauma Life Support
ATLS Primary Assesment
ABCDE
- A: Airway
- B: Breathing
- C: Circulation
- D: Disability
- E: Exposure
A: Airway - what are we looking for?
- Airway noises
- Position of head
- Foreign Body
- Fluids / Secretions
- Edema
- Aspirations
A: Airway - How do we treat it?
- Suction #1
- open
- secure
- O2
A: Airway - Securing the airway?
Combitube - EMS usually uses this
Intubation
What is a combitube?
Dual lumen tube. Distal portion is placed into the esophagus and a ballon is inflated. The proximal balloon is inflated in the oral cavit. The distal balloon helps reduce aspiration while ventilaiton is achieved by the proximal balloon.
B: Breathing - what are we looking for?
- Look - Listen - Feel
- Respiratory rate and effort
- Breath and any sounds assocated
- Subcu emphysema
- symmetry of chest movements
- tracheal deviation
- jugular vein distention
- cyanosis
- TBI induced respiratory depression
- Shock
- Hypothermia
- Aspiriation
- Pulmonary Contusion (R-L shuting)
- Smoke inhalation (bronchospams)
B: Breathing - how do we treat it?
- Supplemental O2
- Pneumothorax decompression
- Inhalation therapy
- ventilation if needed
C: Circulation - what are we looking for?
- HR
- BP
- capillary refill
- bleeding
- skin color
- diuresis
Shock!!!
C: Circulation - how do we treat
- IV or IO access
- control bleeding
- fluids
- drugs
- transfusion
C: Circulation - assessment ↦ Chest
- CT of chest
- Chest tube output
- CXR
C: Circulation - Treatment ↦ Chest
- Observe
- Surgery
C: Circulation - assessment ↦ Abdomen
- Ultrasound FAST scan
- Abdominal CT
- Physcial Exam
C: Circulation - treatment ↦ Abdomen
- Observe
- Surgical ligation
- angiography
C: Circulation - assessment ↦ retroperitoneum
- Angiogram
- CT Scan
C: Circulation - treatment ↦ retroperitoneum
Angiogram
C: Circulation - assessment ↦ long bones
- Physical exam
- X-ray of bones
C: Circulation - treatment ↦long bones
- fix fx
- ligation
C: Circulation - assessment ↦ outside the body
Physcial exam
C: Circulation - treatment ↦ outside the body
Applied pressure
ligation
D: Disability - what are we looking for?
- AVPU / GCS
- reactivity and symetry of pupils
- Glucose level
- C-Spine / stabilization
D: Disability - how do we treat
- Glucose if hypo
- insulin if hyper
- antidotes
AVPU?
- Alert = awake
- Verbal = responds to verbal stim only
- Pain = responds to pain stim only
- Unresponsive
GCS Quick Numbers
- 3-8 = severe
- 9-12 = Moderate
- 13-15 = Mild
E: Exposure - what are we looking for?
- Head to toe exam
- History
- Temp
- Injuries
- Drug abuse?
- Infection?
E: Exposure - how do we treat
- Identify the cause
- thermo-management
- NG tube
- Compartment syndrome
- Antibiotics
Levels of urgency to send to surgery
- Airway: Cricothyroidotomy
- Control exsanguination: Ex-Lap, Ex Thoracotomy, Pelvic Ex-Fix
- Intracrania Mass: Epidural hematoma, subdural hematoma with midline shift
- Sepsis / Loss of limb / Loss of eyesight / Continued hemorrhage (not massive amounts)
- Early patient mobilization / cosmetic
Adam’s secondary assessment: SAMPPLLE
- Signs and symptoms
- Allergies
- Medications
- Past Medical History
- Pictures (CXR, CT, U/S)
- Last meal
- Lab values
- Events
FAST Scan: What is it?
Focused Assessment with Sonography in Trauma is a rapid bedside ultrasound examination performed by surgeons, emergency physicians, and paramedics as a screening test for blood around the heart (pericardial effusion) or abdominal organs (hemoperitoneum) after trauma.
FAST Scan Order: 1-6
- Pericardium
- RUQ
- LUQ
- Suprapubic
- R Anterior thoracic
- L Anterior thoracic
FAST: Pericardium ↦ what are we looking for and where?
Subxiphoid
Aimed U/S at heart just inferior and (to the patients) right of xiphoid cartilage.
Looking for cardiac tamponade cause by effusion
FAST: RUQ ↦ what are we looking for and where?
Looking for blood from liver and right sided retroperitoneal bleeding
FAST: LUQ ↦ what are we looking for and where?
Splenic/Pancreatic and retroperitoneal bleeding in LUQ
FAST: Suprapublic ↦ what are we looking for and where?
looking for blood in and around the bladder in the pelvis
FAST: R/L Anterior Thoracic ↦ what are we looking for and where?
Looking for presence of pneumo or hemothorax
Indications for intubation in trauma
CARD-IFF
- Cardiac or Respiratory arrest
- Airway protection
- Respiratory insufficiency
- Deep sedation or high narcs
- ICP too high, hyperventilation required
- FiO2 100% for CO posioning
- Facilitate workup for intoxicated or uncooperative patient
Ultrasound for NPO: Transducers
Adults: Curvilinear
Pedi: Linear
Ultrasound for NPO: Transducer positioning
Supine
Transducer long axis in subxiphoid
Fan right to left to get view of antrum
Repeat in Right lateral decubitus
Ultrasound for NPO: Stomach Layers
Ultrasound for NPO: Anatomy
Ultrasound for NPO: Empty Stomach
Ultrasound for NPO: Fluid in Stomach
Hypoechoic
Stary night effect = carbinated
Ultrasound for NPO: Solid in Stomach
Hyperechoic and shadow
Ultrasound for NPO: Fluid and Solid in Stomach
Hyper and Hypoechoic
Ultrasound aspiration risk: No fluid in antrum in supine
Low risk
Ultrasound aspiration risk: Just fluid in right lateral but not supine
Low risk
Ultrasound aspiration risk: Fluid in both supine and right lateral
Higher risk
Ultrasound aspiration risk: Solid matter in either supine or right lateral
Higher risk
Signs of tension pneumo
- Increased airway pressure
- Jugular distension
- Hypotension
- tachycardia
Emergency airway: Percutaneous Translaryngeal Ventilation
technically this is oxygenation only
6 steps
- Hyperextend neck, palpate cricothyroid membrane
- With a 14ga angiocath on a saline filled syringe. Insert the needle caudally at a 30-45°
- Aspirate as you advance, stop once air bubbles are seen
- Advance catheter to the hub into the trachea
- Remove needle
- Attach to O2 supply then start oxygenation
Emergency airway: Melker Percutaneous Cricothyrotomy
This is ventilation
4 step
- Palpate cricothyroid membrane and advance needle at 45° in caudal direction. Aspiriate with saline filled syrine for air bubbles.
- Advance catheter then remove needle. Thread guidewire through catheter into trachea. Remove catheter
- Knick the skin at guidewire entry
- Place dilator into the airway catheter and thread over guidewire. Advance until level with skin. Remove guidewire and dilator. Secure
One Unit of PRBC will raise Hg and Hct by how much?
One unit = 350 mL
Hg 1 g/dL
Hct 3%
When should we transfuse PRBC?
Hg < 6 g/dL
When Hg 6-10 consider patient status before transfusion. Bleeding, ishemia, IV volume status, or inadequate oxygenation
One Unit of platelets will raise plt # by how much?
One unit = 200-250 mL
5-10,000 μL
ABO compatability not needed
One Unit of FFP will raise clotting factor by how much?
One unit = 200-250 mL
2-3%
ABO needed / Rh not
One Unit of cryoprecipitate will raise fibrinogen by how much?
One unit = 10-20 mL
5-7 mg/dL
ABO compatability not needed
Minimum IV sizes for blood admin
Adult 20 ga
Pedi 24 ga
What is something all shocks have in common?
Hypotension and decreased CO
Name the 4 shocks
DOC-H
- Distributive
- Obstructive
- Cardiogenic
- Hypovolemic
Hypovolemic shock: Define
Not enought fluid in circulation
Obstructive Shock: Define
blood is blocked, usually by a pulmonary emolism or collapse lung
Cardiogenic shock: Define
Heart can not pump enough blood to meet demand. Think heart attack
Distributive Shock: Define
When the blood vessels lose tone and organ perfusion is reduced
3 Different Distributive Shocks
- Neurogenic
- Anaphylactic
- Septic
The two steps to shock: Macro and Mircocirculatory
- Macro: vascoconstriction and catecholamine surge
- Micro: Ischemic cells take up interstitial fluid ⇀ cellular edema ⇀constricting capillary flow ⇀ more ischemia ⇀ free radical and lactate production
What does lactate do to contractability?
Decrease it
Hemorrhagic shock stages: detailed
5 total
Stage 1: mild/stable
Stage 2: Moderate/stabilized (responsive to fluid test)
Stage 3: Hypotensive shock (not responsive to fluid test)
Stage 4: Shock with heart and brain ischemia (≥40% blood loss)
Stage 5: Cardiac arrest by exsanguination
Hemorrhagic shock stages: Overview
Stage 1: Stable HS
Stage 2: Stabilized, compensated HS
Stage 3: Progressive, Unstable
Stage 4: Critical HS, impending cardiac arrest
Stage 5: Cardiac arrest by exsanguination
HS = Hemorrhagic Shock
What 9 goals do we have for early resuscitation goals in hemorrhagic shock?
CHAPPS-NNF
- Core temp > 35°C
- Hematocrit 25-30%
- Adequate anesthesia and analgesia
- Platelets > 50,000
- Prevent lactate increase
- SBP 80-100 mmHg
- Normal PT and PTT
- Normal ionized calcium
- Functional pulse ox
What are the two lactate levels Adam gives?
Normal: < 2mmol/L
Acidosis: > 5mmol/L
Why don’t we just give fluids to help with volume in a trauma situation?
We aren’t incresing RBC’s and oxygen delivery
Causing dilutional anemia and coagulapathy
Normal calcium levels (Total and Ionized)
- Total: 8.6-10.3 mg/dL
- Ionized: 4.6-5.2 mg/dL
What does ionized mean?
free in serum and available for use by the body
Adams obession with the 16ga IV
Not much time is gained from the 14 ga angiocath or 6 Fr sheath introducer
Rapid transfuser benefits
WAARRP-FC
- Warms Fluids
- Accurate recording of volumes and pressures
- Able to pump through multiple lines
- Rates up to 1500 mL/min
- Reservoir allows mixing of products
- Portable for travel
- Fail-safe to prevent air infusion
- Compatable with all fluids and blood products execpt platelets
Rapid transfuser: Fluids and Blood products
- Crystalloid
- Colloids
- PRBC’s
- Washed Salvaged Blood
- FFP
Prothrombin Time (PT)
Extrinsic pathway (INR)
11.5-14.5 sec
Partial Prothrombin Time (PPT)
Intrinsic pathway
24.5-35.2 secs
Thrombin Time
Time to clot once thrombin added
22.1-31.2 secs
Activated CLotting Time (ACT)
Test tube reagent clotting
70-180 sec
Platelets
Pure count in blood
150-450K
P2Y12
Plavix inhibition test
180-376 PRU
What is INR?
International Normalized Ratio
makes each PT test standardized
TBI anestetic goals
- Maintain CPP (80-100mmHg)
- Treat increased ICP (20 mmHG and above)
- Avoid hypoxemia
- Avoid hyper and hypocapnea
- Avoid hyper and hypoglycemia
Which steroid is contraindicated in TBI?
125mg or more of methylprednisolone
Toxicology: Cannabis
Acute: drowsy, possible MI or arrythmias
Chronic: cough and respiratory issues, possible heart ischemia
Withdrawal med: Benzos
Toxicology: Cocaine
Acute: vasoconstriction, hyperthermia, tachy, hypertension, arrhythmias, stroke, cardiomyopathy, seizure Chronic: Epistaxs, bowel ischemia, aspiration pneumonia, pulmonary htn Withdrawl med: propranolol
Acute: mydriasis or dilated pupils
these folks are catecholomine depleted so we would need to use Epi not ephedrine if they go hypotensive
Toxicology: Heroin
Acute: slow bretahing, brady, nausea
Chronic: Abcesses, endocarditis, liver and renal dz, pulmonaey edmea, pulmoary emobilisms
Withdrawal Med: Methodone
Acute: miosis or constricted pupils
Toxicology: Ketamine
Acute: Hallucinations, increased BP, slow breathing
Chronic: Stomach pain, cystitis
Withdrawl meds: none
Toxicology: MDMA
Acute: Increased HR and BP, teeth clenching, hyperthermia, rhabdo, hyponatermia, ESLD, ESRD, CHF
Chronic: Anxiety and aggression
Whithdrawl meds: antidepressants
Toxicology: Meth
Acute: High energy, tachypnea, tachycardia, hypertension, hyperthermia
Chronic: Violent, dental issues, anxiety
Whidrawal: Antidepressnats
Like cocaine, catecholamine depleted
Toxicology: Herbal meds
Basic jist, platelet inhibition so increased bleeding time
TEG: full name and breakdown
Thromboelastography
Thrombo: thrombus or clot
Elast: ability to change
Graphy: record of
St Luke’s Process for TEG
- Call blood bank
- draw sample and put in blue top
- date and time tube
- send asap
- Initial results in 15 mins
- complete in 30-45
Componets of a TEG
5 things
- Reaction time (R time)
- Kinetics time (K Time)
- Alpha angle
- Maximum amplitude (MA)
- Lysis at 30 mins (LY30)
R time or Reaction Time
- Start of clot formation
- Normal is 5-10 mins
- Prolonged R time indicates a deficient coagulation factors
- Treatment: FFP
K time or Kinetics time
- Time from end of R time to when a clot reaches an amplitude of 20mm
- Measures strength of clot
- Normal is 1-3 mins
- Prolonged K time indicates fibrinogen deficiency
- Treatment: Cryoprecipitate
Alpha angle
- Speed of fibrin accumulation
- Normal is 53-72 degrees
- Low angle indicates fibrinogen deficiency
- Treatment: Cryoprecipitate
MA or Maximum amplitude
- Measures the strength of fully formed clot
- Normal value is 50-70mm
- Lower value indicates a platelet deficiency
- Treatment: Platelets or DDVAP
LY30 or Lysis 30
- Measures fibrinolysis after 30 mins
- Normal is 0-8%
- higher numbers indicate hyper fibrinolytic
- Treatment: TXA
TEG picture examples
Benefits of TEG
WRTS
- Whole blood used
- Real time results
- Treatment guide
- Shows if patient is clotting
Limitations of TEG
FUN-DV
- Familiarity with results
- Uremia, vW Dz, or aspirirn not indicated
- Needs frequent calibration
- Doesn’t test platelet adhesion
- Venous coagulaiton only
DIC
Disseminated Intravascular Coagulation
TACO
Transfusion associated circulatory overload
More blood is administered than the CO can account for
TRALI
Transfucsion related acute lung injury
Similar to ARDS
Usually from plt/FFP admin
