Trauma

Question 1

What is trauma?

Answer 1

Any impact force that will cause physical injury
-results in activation of the hypothalamic-pituitary-adrenal axis resulting in immunological and metabolic responses
-ex: motor vehicle accidents, falls, animal-animal or animal-human interactions

Question 2

What is the most important thing when a trauma patient arrived to ER?

Answer 2

TRIAGE
-treat the most critical patients first (those with problem with ABCs)

Question 3

T/F: you can triage over the phone

Answer 3

True- also can guide owner in starting trt
- ex: pressure on bleeding wounds

Question 4

Describe a triage exam

Answer 4

-rapidly evaluate the circulation, respiratory tract and CNS (especially mentation)
-not a complete physical exam
-be aware that polytrauma patients may appear ok but deteriorate/decompensate quickly

Question 5

What is the second leading cause of death in animals?

Answer 5

Trauma
-young male dogs most affected
-polytrauma most common (72% of cases)

*need to reevaluate these patients very frequently

Question 6

What is the most important factor in the prognosis of shock patients?

Answer 6

Time until intervention

Question 7

What is the main type of shock seen with trauma?

Answer 7

Hypovolemic (hemorrhagic)
-can also be distributive or hypoxic

Question 8

Describe the pathophysiology of hemorrhagic shock

Answer 8

-decreased CO and mean arterial pressure leads to the activation of the neuroendocrine stress response
-this leads to release of pituitary hormones, increased sympathoadrenal activity, pancreatic hypersecretion and activation of inflammation
-as cells and tissues become deprived of oxygen, anaerobic metabolism starts, there is an increase in blood lactate, an overproduction of oxygen radicals and other toxic metabolites and cellular injury

Question 9

T/F: you should consider re-ultrasounding a patient after fluid therapy

Answer 9

True- may reveal hemoabdomen

Question 10

If a trauma patient is anemic, but there is no obvious signs of blood loss on Afast/Tfast, where may the blood be lost to?

Answer 10

They may be bleeding into a fracture!

Question 11

Describe the general approach to a polytrauma patient

Answer 11

-first perform a thorough evaluation of tissue oxygen debt, tissue perfusion, hypoxemia and if SIRS/MODS may be present (CBC, clotting times, lactate)
-start with stabilization and resuscitation and try to improve and restore tissue perfusion

Question 12

When are signs of shock from hypovolemia obvious based on physical exam?

Answer 12

After 15% of blood is lost

Question 13

If you cannot feel the dorsal pedal arteries, what may this indicate? What about the femoral pulse?

Answer 13

BP <60 in dogs, <70 in cats

Femoral- if you cant feel BP <90

Question 14

T/F: before beginning fluid therapy on a patient in shock, you should be sure to get a blood pressure reading

Answer 14

False- if patient is displaying signs, start therapy!
- can try to get a singular BP, but there are more important things

Question 15

What are some things that thoracic trauma may cause?

Answer 15

Hypoxia and decreased oxygen delivery
- most common injuries are pulmonary contusions and pneumothorax, but could also be hemothorax, rib fractures, flail chest and diaphragmatic hernia
-need to monitor respiratory rate and effort in these patients

Question 16

What is flail chest?

Answer 16

Indicates 3+ rib fractures
- can see skin moving into the chest cavity
- not always surgical- may just require time and pain management to heal

Question 17

What should be your approach in a respiratory trauma patient?

Answer 17

-if patient is dyspneic, provide flow by oxygen
-check SpO2
-lung auscultation
-TFAST
-CPR if undergone respiratory arrest
-perform advanced imaging only once the patient is more stable

Question 17

What is the approach to neurologic workup in trauma patients?

Answer 17

This is the third system that should be evaluated after CV and respiratory systems
- assess for TBI, spinal trauma
- assess level of consciousness, brain stem reflexes and motor responses
- for non-ambulatory patients, try to pinpoint if the problem is neurologic or orthopedic in origin

Question 17

What should be the 4th system worked up in trauma patients?

Answer 17

Urinary
- check serum creatinine and BUN, USG
- advanced imaging to see if there is a tear in urethra or bladder (contrast imaging)

Question 18

What is normal urine output?

Answer 18

1-2 ml/kg/h minimum

Question 19

At what ratio of abdominal fluid to serum creatinine do you suspect that there is a uroabdomen?

Answer 19

abdominal fluid has creatinine 2x that of blood

Question 20

When can you pursue external stabilization in the case of a fracture?

Answer 20

If it is a distal long bone fracture

Question 21

What should be the first procedure done if an unstable patient comes in?

Answer 21

Place IV catheter and pull blood
- allows for fluid therapy to initiated quickly

Question 22

What should your initial fluid therapy look like for a shock patient?

Answer 22

10-30 ml/kg over 20-30 min of LRS

Dont use 90 mL- more likely to fluid overload the patient

Question 23

What is the best fluid option for patients with traumatic brain injury?

Answer 23

Hypertonic saline

Question 24

What are some of the main concerns with giving too much fluids to trauma patients?

Answer 24

Displacing blood clots, worsening hemorrhage
-not realistic to keep below normal BP for too long as we often dont get these patients to surgery very fast

Question 25

Describe acute traumatic coagulopathy

Answer 25

-a syndrome that may contribute to ongoing hemorrhage
-need for blood transfusion
-not simply a dilutional or consumptive coagulopathy
-secondary to an imbalance of the equilibrium between procoagulant factors, anticoagulant factors, platelets, endothelium and fibrinolysis
-may be characterized by factor 5 inhibition, dysfibrinogenemia, systemic anticoagulation, impaired platelet function and hyperfibrinolysis
-treat with tranexamic acid and epsilon aminocaproic acid- to avoid fibrinolysis (prevents clots from breaking off from wall)