Trauma Flashcards
Mechanisms of traumatic injury
Exchange of forces between environment & person
* Mechanical/kinetic (blunt or penetrating injury)
* Thermal (heat or cold)
* Chemical (acid or alkaline)
* Radiant
* Electrical
* Oxygen deprivation (smoke inhalation, drowning)
Aetiology of fractures
Direct force: trauma occurs in the region directly acted on by the force (fall, crush, impact) that leads to multple fractures, open injury, soft tissue damage, tendon contusion
Indirect force: trauma occurs in a region away from the direct force (transmitting or rotational force) e.g. compression fracture on T12 from falling n your hip
* fractures are usually oblique or compressive, tendon injury sprain
Types of skull fractures
- Linear
- Depressed
- Diastatic
- Basillar
Linear skull fracture
- Most common
- Linear fracture that doesnt involve bone movement
- Usually no interventions
Depressed skull fractures
- Part of the skull is sunken, with or without scalp damage
- May require surgery to correct deformity
Diastatic skull fracture
- Fracture along the suture lines - they become widened
- More common in infants and newborns
Basilar skull fractures
- FRacture of one of the bones of the base of the skull (occipital, temporal etc)
- Most serious
- Pt usually have eye bruises (racoon eyes), bruise behind ear, CSF from nose/ears
Le Fort I Maxillary fracture
- Transverse fracture above the teeth (along the ‘mustache’)
Le Fort II maxillary fracture
- Pyramid fracture (apex above the bridge of the nose)
Le Fort III maxillary fracture
- complete craniofacial disruption, that involves fracture up to the infraorbital rims
- Significant force (e.g. baseball bat)
Sternal fracture
- Usually caused by deceleration injury or blunt chest trauma (MVA)
Rib fractures
Fracture to one or multiple ribs that can cause:
* Respiratory splinting (reduced inspiration due to pain, resulting in atelectasis & pneumonia)
* Flail chest
* Penetration (pneumothorax, hemothorax)
Flail chest
- Atleast 2 fractures per rib in atleast 2 ribs, that creates free segments that is unable to control lung expansion
- This section moves paradoxically to the rest of the chest
- Lung expansion is compromised, causing SOB & pain, and may require ventilation if segments are large enough
Haemothorax
- Blood in the pleural space from the chest wall, lung parenchyma, heart or great vessels
- Usually due to blunt or penetrating trauma
On exam: absent breath sounds, dull percussion, haemodynamic instability
Treatment: chest tube/thoracostomy
Pneumothorax
- Air or gas in the pleural cavity that leads to impaired oxygenation, ventillation and/or lung collapse
- Caused by chest injury (trauma or medical procedures involving needles into the chest), ruptured air blisters that develop on top of the lung, mechanical ventilation (causes an air imbalance)
- Increased risk in COPD, smoking, males, ventilation, history
Open pneumothorax
- Large open chest wall defect that causes rapid equilibration of atmospheric and intrathoracic pressure that impairs oxygenation & ventilation
Treatment: three sided occlusive dressing (prevents tension pneumothorax), chest tube
Tension pneumothorax
- Severe form of pneumothorax where the injured tissue forms a one-way valve allowing air inflow into pleual space with inhalation
- The lung collapses, and the increasing pressure causes a mediastinum shift that compresses the other lung and venous return to the heart
- Leads to hypoxia, reduced venous return & output, CV collapse and respiratory insufficiency
Resp symptoms: absent breath sounds, distended neck veins, tracheal shift
treatment: needle decompression, tube thoracostomy
Pulmonary contusion
- Injury to lung parenchyma that causes oedema and blood collecting in alveolar spaces
- This impairs gas exchange, decreased lung compliance and increased pulmonary resistance
- Inflammatory reaction to blood in the lungs causes ARDS
Cardiac tamponade
- When a buildup in the pericardial cavity (pericardial effusion - serous, blood, chylous) compresses on the heart and impairs functioning
- This is due to trauma, inflammation, infection, autoimmune disorders
- Reduced ventricular filling & cardiac output, and reduced systemic venous return due to right sided collapse
Becks triad: distended jugular veins, hypotension, muffled heart sounds
Treatment: pericardiocentesis, thoracotomy
Aortic disruption
- Complete or incomplete transection of the aorta, usually due to deceleration, frontal or side impacts, falls
- The proximal thoracic aorta is at greatest risk due to the highly mobile aortic arch moving against the fixed descening aorta, or due to compression with sternum or spine
Ruptured diaphragm
- Injury by direct blow that increases intra-abnominal pressure or by rib laceration
Hepatic injury
- Very prone to injury due to being large and fixed in position
- Commonly injured and the most common cause of death in abdominal injury
- Damage usually by blunt trauma, which can lacerate under pressure (within a capsule) or by hematoma
Splenic injury
- Relatively protected by the ribs but can be injured in rapid deceleration, blunt blow, penetration, or during emergency operations
Pelvic fractures
Are relatively uncommon
* Stable: one break in pelvic ring, bones in place, little bleeding (heals several weeks after surgery)
* Unstable: two or more breaks, mod/sev bleeding (life threatening, organ damage, long rehab)
Signs & symptoms
NB: dependent on type of injury
* Bleeding
* Pain
* Increased RR, shallow breathing, accessory muscles
* Low sats
* Low UO
* Skin: cool, pale, clammy, low turgor
* Hypotension
* Tachy, thread pulse
* Low GCS, anxious
* arrhythmias
* HTN to pain
Trauma assessment steps
- Prep: team assembly, equipment check
- Triage: sort by acuity
- Primary survey: quickly identify life threatening injuries & treat
- Secondary survey: full history & physical exam
- Monitor & evaluate
- Transfer (ICU, ward, OT)
Airway
- Airway patency (obstructed by injury, oedema, secretions or unable to keep open due to low consciousness)
- NB noisy respirations, hoarse voice = upper airway injury
Interventions
* Suction
* Chin lift/jaw thrust
* NP airway
* Oxygen (NRBM), bag valve, ETT, emergency cricothyrotomy (immediate airway access, avoid vocal cords & thyroid)
C-Spine immobilisation
Keep patient in precautions until cleared by radiography
* Rigid spinal collar for neutral head position and/or spinal board for lower spine in-line immobilisation
* Log rolls
* Use blocks, rolled towels, tape
Clearance:
* A&O
* Not intoxicated
* No tenderness at spinous processes
* No focal neurological deficits
* No distracting injuries
* Painless ROM of neck
Breathing
- Full respiratory assessment (RR, rhythm, expansion, TD, accessory muscles, paradoxial movements, auscultation - air entry, sounds, palpation)
Injuries to look for
* Tension pneumothorax
* Haemothorax
* Flail chest
* Open pneumothorax
Circulation
Complete evaluation of HR, BP, CRT, heart auscultation, ECG
Assess for shock
* Haemorrhagic (assume first)
* Obstructive (tamponade, T pneumothorax)
* Neurogenic (SC injury)
Intervention
* 2x large IV to correct hypovolemia
* Stop bleeding (pressure, close lacerations)
* Close fractured with pelvic binder & immobilise fractures
* Cardiac monitoring, BP monitoring
Disability
Baseline neuro exam (GCS)
* Pupillary exam (dilation = herniation)
* AVPU
* Movement & sensation
BGL
Pupil asymmetry, no reflexes, hemiplegia = increased ICP & herniation risk
Exposure
- Remove clothing, examine for other injuries including back (log roll if needed)
- Avoid hypothermia
Supine hypotensive syndrome
Condition in pregnancy women > 20 weeks where enlarged uterus with foetus & fluid compress IVC, decreasing venous return & CO
* Keep in left lateral position
Diagnostic tests
- XR, CT, US, MRI, cross match bloods, blood alcohol level, drug screen, pregnancy test
- U&E, FBC including HB, WCC & platelets, coag profile (aPTT & INR) LFT, ABGs
Nursing care
- Frequent vitals monitoring including ECG & heat-toe assessment
- IDC
- NGT (decompression & aspiration prevention)
- Ventilation management
- Pain manegement
- Blood tranfusions
- IV therapy
- Temp management (warmed fluids, blankets, heated lamps)
- Family & psychpsocial care
- Liaise with med team, OT, PT, social work, radiology, pastoral care, psych
Fluid therapy
Use of crystalloids or colloids to restore intravascular volume by increasing oncotic pressure, moving fluid in = increases CVP, CO, SV, BP, UO, perfusion
Crystalloids
Balances isotonic solution that freely crosses capillary walls (quick plasma expansion but is short lived as they dont stay in the vessels as long as colloids - HL 30-60min)
* NS, CSL
Colloids
- Greater capacity to expand circulatory volume as they are larger molecules and stay in the bloodstream longer
- Gelofusin, albumin
- Risk of anaphylactic reactions in gelatins, mad cow disease
Hypovolemic shock
Rapid fluid loss that results in inadequate circulating volume & tissue perfusion
* Usually due to haemorrhaging (trauma, GI bleeds), burns
PP - compensatory stage
- SNS responds by increasing HR, contractility, peripheral vasoC, CO & vital organ shunting
- RAAS causes release of angiotensin & aldosterone = retain water and sodium
(renin converts angiotensinogen to angiotensin I, lungs convert I to II = vasoC to increase BP & aldosterone secretion) - water & sodium retention furthered by ADH production by P pituitary in response to low BP
- Lactic acidosis = hyperventilation & tachypnoea
- Bleeding stimulates coag cascade, contracting vessels, activating platelets & fibrin deposition to clot
S&S: hypotension, tachy, cool/pale skin, tachypnoea, oliguria, reduced LOC
PP - decompensated/progressive stage
- Na/k pumps start to fail, cells swell & rupture, and enzymes leak causing cell death
- Decreased CO, SV, venous return = impaired metabolism & perfusion
S&S: severe hypotension, comp tachy, severe peripherla shutdown, comp tachypnoea, sev oliguria, delirium/coma
PP - irreversible
- Unresponsive to therapy, irreversible MODS = death
Classes of haemorrhagic shock
Class I: 0-15% loss, minimal tachy, delayed CRT, no other changes
Class II: 15-30% loss, tachy, tachypnoea, low pulse, cool skin, delayed CRT
Class III: 30-40%, marked tachyp & tachy, low SBP, mental status changes, tranfusion required
Class IV: >40%, severe above, oliguria or no UO, LOC, immeasurable DBP, life threatening
Disseminated intravascular coagulation (DIC)
Complication of another condition that causes systemic activation of blood coagulation
* Widespread generation & desposition of fibrin = microvascular thrombi throughout the body that can lead to MODS
* At the same time, exhaustion of coag proteins leads to severe bleeding
= simultaneous clotting & bleeding problem
Treatment: original condition, blood transfusion, heparin, supportive treatment
Aetiology
Conditions that cause DIC are usually those that involve SIRS
* Sepsis & severe infection
* Trauma
* Organ inflammation & failure (pancreatitis, liver failure)
* Cancer
* Obstetric complications
* Transfusion rxs, transplant rejection
* Heat stroke & hyperthermia
Acute vs chronic DIC
Acute: over hours/days
* clotting first, then bleeding (but bleeding can be noticed first & is often severe)
* Emergency treatment
Chronic: develops slowly over weeks/months
* Lasts longer, not as quickly recognised, mostly clotting & usually no bleeding
* Sometimes no symptoms
S&S - clotting
- Chest pain/SOB (clots in lungs & heart)
- Pain/red/oedema in legs (deep vein)
- Headache/speech changes/paralysis/dizzy (brain)
- MI, lung & kidney problems, organ failure
S&S - bleeding
Internal
* hematuria
* malena
* headache, double vision, seizures (from the brain)
External
* underneath the skin from small wound or IV
* Mucosa (gums from brushing teeth)
* Excessive menstrual bleeding
* Bruising & small purple dots on the skin
* Nosebleeds/epistaxis w/o HTN
Rhabdomyolysis
Injury to skeletal muscle causes death of muscle fibres and release of toxic intracellular components (myoglobin) into plasma, which is harmful to kidneys
Aetiology
- Trauma
- Alcohol, drugs
- Heatstroke
- Infection
- Metabolic disorders
- Medications (antipsychotics, statins)
- Strenuous exercise
S&S of rhabdomyolysis
- Myalgias (muscle weakness)
- Generalised weakness & aching
- Dark urine
- Fever, N&V
Treatment
- IV fluid therapy to help kidneys & produce urine to prevent AKI
- Dialysis if severe
- Treat original cause
- Manage electrolyte abnormalities
- Manage complications (protein in urine, compartment syndrome, DIC)
Fentanyl
Route: IV, IM
Class: opioid analgesic
Mechanism: binds to mu receptors in brain to induce analgesia, euphoria, sedation
Effect: management of severe pain (stronger than morphine)
HL: 3.7
SE: respiratory depression, apnoea, rigitity, muscle twitching, constipation
