trauma Flashcards
trauma timeline
-initially die from catatrophic injury
-1-3 hrs:
-pelvic fractures- bleed significant
-long bone fx- 2-3U of blood each
-points of fixation on the bowel- pyloric sphincter, terminal ileum, ascending and descending bowl -> prone to deceleration injury
-pancreas- compression against spine -> transected
A 72-year-old man with a past medical history of atrial fibrillation on apixaban(Eliquis), hypertension on enalapril (Vasotec), and hypothyroidism on levothyroxine (Synthroid) was struck on the driver’s side of his car after running a red light. A passenger in the car, his 69-year-old wife was deceased at the scene, and he was a prolonged extrication from the vehicle by fire rescue. He was transported to the emergency department by EMS and in the field his Glasgow Coma Scale was E2, V4, V5. Vitals were 173 cm (68 in), weight is 65.9 kg (145 lbs), and body mass index is 22.0 kg/m2. Temperature is 36.7°C (98.0°F), pulse rate is 120/min and regular, respirations are 24/min and labored, and blood pressure is initially 90/60 mmHg in the field.
-afib- decrease in 25% of the CO
-levothyroxine- 7 day half life
-c-spine collar- CT / MRI to clear -> CT doesnt r/o ligamentous (longitudinal) disruption
-ligamentous injury = fx
-pale + poor capillary refill - shock
-anytime someone else in the collision died -> SEVERE -> assume everyone has life threatening injury
-pain and mobility when the pelvis is pressed- unstable pelvis -> minimum 2 pelvic fractures -> look at sacroiliac joints for displacement
-leg is shortened and externally rotated- hip fracture, pelvic, femur fracture
-NEUROVASCULAR IS MOST IMPORTANT
priorities in trauma- ABCDE
-Airway and C-Spine
-Breathing and ventilation
-Circulation with hemorrhage control
-Disability: Neurological Status
-Exposure/Environmental Control- undress, and roll -> look everywhere
-make sure its warm to prevent hypothermia -> aluminum cap
-temp with foley
-2 mins
what to YOU do in trauma
-Cap, Gown, Gloves, Mask, Shoe Covers, Face Shield/Eye Covers
-Do not stop to identify specific injuries!
-Always head towards definitive management even if that means transfer to level 1 center
-Start with Standard Precautions!!- blood exposure
-Primary Survey and Resuscitation start simultaneously
-18g or larger IVs in both arms
-Preparation/Primary Survey/Reevaluation; Detailed Secondary Survey; Reevaluation/Definitive Care
-10-second screen: What’s your name? What happened?
-Appropriate response confirms: ABCD
primary survey
- = GCS and Pupillary Reaction
-Look at abdomen, roll patient, etc.
-May take 24 hrs to start secondary survey if you go to OR
-Takes 2 minutes for Primary Survey
-Primary Survey priorities are same for ALL patients!
-Special populations need to be dealt with: elderly, infants and children, pregnant women, obese, athletes (tachy can be 70-80)
-Establish Airway and protect the C Spine: watch for occult injury, progressive loss, equipment failure, inability to intubate (no crepitus, vocalization, etc.)
-intubate- if cant talk or penetrating injury to neck -> tracheostomy
airway and breathing
-resp rate, chest movement, air entry, oxygen saturation
-look at work of breathing- dyssynchronous -> is it airway or ventilation problem
-Is it an airway or a ventilation problem?
-Iatrogenic PTX or tension PTX (from central line) -> Always look for it and think about it especially with BP drop after positive pressure ventilation is initiated.
-intubation and you press to push air in -> if there is resistance -> suspect tension pneumothorax
Circulation/Hemorrhage Control
-assess for organ perfusion
-level of consciousness
-skin color and temperature
-pulse rate and character
-Watch for pacers- cant compensate for hemorrhages -> increase pacer setting
-beta-blockers, calcium channel blockers, conditioned athletes, etc.
-catheter to see fluid status -> DO NOT catheterize if pelvic fracture -> can make partial urethral tear into a full
-pressure on bleeding, restore volume, reassess patient
-After 1L of crystalloid go quickly to blood products
-Pit falls: Elderly, children, athletes, and medications
-Cardiac arrests in children are usually respiratory related
-Bradycardic child is a dying child!!
disability
GCS and Pupillary Response (1 minute): Base line and trending are important. Observe for neurologic deterioration!
-serial assess
resuscitation
-Protect and secure airway, ventilate and oxygenate, stop bleeding/resuscitation, protect from hypothermia.
-CT SCAN is after secondary assessment!!!!!!!!
-Primary Adjuncts:
Vitals, ABGs, Pulse Ox, Foley, NGT, UO, ECG, CXR, Pelvic films, FAST, DPL
-EFAST- includes lung sliding -> pneumothorax
-BLUNT TRAUMA- EVERYONE GETS CHEST XR AND PELVIC FILM
-DPL- diagnostic peritoneal lavage- infraumbilical incision -> peritoneum catheter and instill L of IV fluid -> and take it out -> look for blood, lipase, WBC, particulate matter
-rarely done
secondary survey
-helicopter transfer to level 1 trauma center if needed
-burn pts - be careful- gastric distention can increase (if no NG tube) and push up the diaphragm and cause the heart to kink
-started when patient is stable. The complete history and physical exam.
-History, physical head to toe, complete neuro, special dx tests, reevaluation
-AMPLE mnemonic.
-Head: external exam, scalp palpation, complete eye and ear exam, include visual acuity.
-Maxillofacial: bony crepitus, deformity, malocclusion
-Cervical Spine & Neck: look for bruising, swelling, ecchymosis, tracheal deviation, hematoma, may need to remove the collar to do this. Stridor, bruits can also be present. Can lead to progressive airway obstruction.
-Chest: Inspect, Palpate, Percuss, Auscultate, X-Rays.
Abdomen: Inspect/Auscultate, Palpate/Percuss, Reevaluate, Special Studies.
-Perineum/Rectum/Vagina: rectal exam is optional but needed in specific conditions (pelvic trauma, blood in meatus, head or spine trauma). Sphincter tone, high riding prostate, etc.
-Pelvis: X-ray is diagnostic about 90% of the time: pain, leg length unequal, instability, x-rays as needed.
-Extremities: contusion, deformity, perfusion, N/V status, x-rays as needed.
-MSK: you can lose significant blood from MSK injuries, miss fractures, soft tissue of ligamentous injuries. compartment syndrome -> Don’t be overwhelmed by what you see; get overwhelmed by what you don’t see!
-Neuro: Brain: GCS, pupil size and reaction, lateralizing signs, frequent reevaluation, prevent secondary injury.
-Spine: whole spine, tenderness and swelling, step off, complete motor and sensory, reflexes, imaging studies.
-Log roll the patient and leave them in a neutral spine position once it is evaluated.
-Special Diagnostic Tests: CT Scan but watch for patient deterioration, delay of transfer, deterioration during transfer, poor communication.
-Minimizing missed injuries. Reevaluate at 24 hours. High index of suspicion, frequent reevaluation is clue.
-Pain management: most appropriate is intravenous route. If BP is high morphine works better.
intervention
-1. Airway and Ventilatory Management.
-Key point is to prevent hypoxia; ventilate and oxygenate. This takes
priority over everything else.
-CT Scan: “The Doughnut of Death”.
-Maxillary, Mouth, Mandible, Neck (Hanging Injuries).
-Epiglottitis in adults present with tenderness over hyoid area.
-How do you know the airway is adequate? AO, talking, no evidence of injury of head or neck, assess and reassess for deterioration.
-Mechanism of injury provides the index of suspicion.
-When to intervene: impending airway, need ventilation, preserve airway
-Tube below the vocal cords = definitive airway
-4Ps- protect airway (aspiration), preserve (hematoma, allergic rxn), pulmonary failure (cant ventilate, pulmonary contusion- not rib fractures), pulmonary toileting (secretions)
-flail chest mc with pulmonary contusion
-Basic adjuncts, jaw thrust! -> never chin lift!!!
-15 L via nasal cannula then a BVM or NRB mask 15 L; no desaturation policy is what is now being observed
-less desat when NRB removed for ET
-Scott Weingart (Mt. Sinai)
-Be prepared for the difficult airway.
-Laryngeal mouth airway is for ventilation not intubation so it can be used when intubation is not initially possible.
LEMON
-for difficult intubation
-Look
-Evaluation 3-3-2
-Mallampati score- open mouth - 3/4 difficult
-Obstruction
-Neck mobility
-1- see entire soft palate
-2- see uvula
-3- only base of uvula
-4- no soft palate seen
MOANS
-assess anatomy and physiology
-Mask seal
-Obesity
-Age
-No teeth
-Stiff lungs/chest wall
BURP
-backward
-upward
-rightward
-pressure
-to try and get someones airway open
palpation
-key for assessing mid face fractures
last result airway
-kids- needle
-adults- open
DOPE
-dislodged
-obstructed
-pneumothorax
-equipment -if there is problem -> remove ventilator -> bag them
-Know when tube is in place
-Most important is visualizing the tube going through the cords
-CO2 capnography, CXR, auscultation.
-end tidal CO2 capnography
-positive end expiratory pressure (PEEP)- give amble bag with PEEP valve -> alveoli will collapse otherwise
- if PEEP >10 - give -> mimics what the ventilator is giving
shock classification
-Class I (up to 15%): no measurable changes occur in BP, HR, pulse pressure or RR.
-Class II (15-30%): 750 – 1500 ml tachycardia, tachypnea, decreased pulse pressure (catecholamines).
-Class III (30-40%): 15000 – 2000 ml. Potentially catastrophic blood loss, almost always with the signs of inadequate perfusion. This is usually the least amount that causes a drop in SBP.
-Class IV (> 40%): Immediately Life Threatening! Very narrow pulse pressure or unobtainable diastolic.
shock
-You don’t want to miss shock, especially in its early stages.
-Narrowing of pulse pressure is concerning
-Generalized hypoperfusion- problem with O2 delivery, catecholamines, hypoxia -> Cellular death
-altered LOC, cold diaphoretic, tachycardia, tachypnea or slow respirations, hypotension, decreased urinary output
-folley gives info about perfusion to kidneys
-Profound metabolic acidosis (high lactate) will result in airway management
-if lactate doesnt clear after resuscitation - you missed something (usually dead bowel)
-Hypovolemic (blood or fluid loss) vs non-hemorrrhagic shock
-T-PTX, tamponade, cardiogenic, neurogenic (spinal cord transection), septic from vasodilation (perforated esophagus)
-neurogenic- phenylephrine
shock intervention
-Locating Bleeding: PE, chest x-ray, pelvic x-ray, FAST/DPL - anechoic areas in abdomen
-Shock: hemostatic resuscitation, angiographic embolization, splint fractures!, hemostatic agents, operation, reduce pelvic volume (tape feet together pointed inwards), direct pressure/tourniquet.
-What can be done about shock?
-Fluid (blood is best), vascular access, type, volume, balanced, monitor response, prevent hypothermia
-hypothermia causes coagulopathy
-neurogenic- phenylephrine
shock pearls
-Responses to Fluid: Rapid Response, Transient Response (respond to tx and decline once stopped), Minimal or No Response (catastrophic)
-Lack of tachypnea may be due to drugs, alcohol, or head trauma. It is also an indication for ventilatory support, not just for metabolic acidosis.
-Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)- thru groin into aorta - balloon and stop bleeding
-Do not equate BP with cardiac output or perfusion- can be due to vasocontriction
-Hemoglobin and hematocrit values are misleading, as they have not equilibrated- once you give fluids it shows the deficiency
-7 and 21 is the trigger unless ACS- 8 and 24!!!!!!!!!!!!!!!!!!!!!!!
thoracic trauma
-Hypoxia, hypercarbia (hypoventilation), and acidosis often result from chest injuries -> All result in inadequate tissue perfusion
-periphery vasodilate, lungs vasoconstrict - match VQ
-Airway/Breathing: T-PTX, Open PTX, Flail Chest and Contusion, Massive Hemothorax.
-Circulation: Massive Hemothorax, Cardiac Tamponade
-Secondary Survey: 8 potentially lethal injuries to look for: Simple PTX, hemothorax, pulmonary contusion, tracheobronchial injury, blunt cardiac injury, traumatic aortic disruption, blunt esophageal injury, traumatic diaphragmatic injury (MC on L side)- due to distention
-Must have an index of suspicion and recognize presentation for all of them.
-General anesthesia and positive-pressure ventilation should NOT be administered in pt with traumatic PTX until chest tube inserted.
-Look for: tachypnea, respiratory distress, hypoxia, tracheal deviation, abnormal breath sounds, percussion abnormalities, and chest wall deformity
-Airway obstruction is rare- air in soft tissues of neck, hoarseness, sub-Q emphysema, intubate cautiously, tracheostomy
-TX:
-90% of pneumothorax dont need OR
-Watch for CT insertion with > 1500 ml (1.5L) of blood on return; or > 200 ml/hour x 3 hours -> SURGERY
-VATs
-Resuscitative Thoracostomy: PENETRATING thoracic injury arriving with PEA- vital signs at scene and lost on the way to hospital
-NOT BLUNT- nothing can be done
-5th ICS on left side -> open all around -> vascular clamp on the aorta
abdominal and pelvic trauma
-Once hypothermia, acidosis, and coagulopathy set in; pt will do poorly.
-Blunt vs Penetrating Trauma are main mechanisms.
-Blunt: Spleen, Liver, Small Bowel, Pelvis.
-Penetrating: Stab: liver, small bowel, diaphragm, colon. GSW: small bowel, colon, liver, abdominal vascular structures, Overpressure injuries from blast effect.
-Get a surgeon on board early in the management of abdominal and pelvic injuries.
-Anterior abdomen as high as T4 and as low as the pelvis diaphragmatic excursion -> can get pneumo still
-Flank and back present challenges to dx
-Blunt: Speed, point of impact, intrusion, deployment of safety devices, extrication, patient position, ejection, kind of vehicle.
-Penetrating: type of weapon, distance, # and location of wounds.
-Explosion is combined penetrating -and blunt force injury. Proximity is the key to the injury in explosions.
-Any organ is at risk with penetrating injuries.
-Do not go by entrance and exits as you cannot connect lines linearly. Thinks pitch, yaw, roll and cavitation effects.
-Stab wounds- dont know length of or how the knife was manipulated internally
abdominal and pelvic trauma imaging
-once stable….
-Pan scan in < 5 minutes. Can also use as adjuncts: urethrogram, cystogram, IVP, GI studies.
-DPL, FAST, CT Scans. All beneficial in the right hands.
-Negative scans do not rule out injuries nor do they completely rule them in.
-Lower chest rooms. Serial exams, thoracoscopy, laparoscopy, or CT scans,
-Anterior stab wounds: wound exploration, DPL, or serial exams
-scope in and look at underside -> if not peritoneum violation -> no surgery
-Back and flank stab wounds: DPL. Serial exams, or double or triple contrast CT scans.
-Serial FAST exams are very useful.
abdominal and pelvic trauma dx
-gastric tube, foley catheter (if no urethral trauma) -> dont want distention
-Urethral, perineal, and rectal examination
-Vaginal and gluteal examination may also be indicated.
-FAST vs DPL- Special approach for DPL in special populations.
-Factors compromising exam: rib, spine, pelvic fractures, brain and spinal cord, alcohol and other drugs -> serial exams
-!!!!Do not repeat pelvic distraction maneuvers -> 1 time exam bc of the risk
-Hematuria is dx of injury- SHITTT -> stones, hematologic, infection, tumor, trauma, TB
-Urinary catheters are a must for decompression prior to DPL, monitor urine output, watch for pelvic fractures
-Blood of out of vagina or rectum- make you vigilant for pelvic injury
-Posterior urethral injury: Pelvic fracture. Anterior urethral injury: Straddle Injury.
-G-Tube: Orally, decompress prior to DPL. Watch with basilar skull, facial fractures. Battle’s sign, Raccoon sigh, otorrhea are all warning signs.
-NO MANDATORY BLOOD TESTS PRIOR TO URGENT LAPAROTOMY!!
-Hemodynamically abnormal: Type and cross match, coag studies; ETOH and drug testing, urine for blood.
-Quick chest and pelvic films, especially in the blunt trauma. You can see metal and glass but not wood.
abdominal and pelvic trauma tx
-Who needs a laparotomy (OR): HD unstable, free air, diaphragmatic rupture, peritonitis (voluntary guarding or rebound should be explored), evisceration, positive FAST, DPL, CT
-Gun shot wounds = Early operation!
-1500 pounds/sq inch to crack the pelvis!
-Look at each orifice with pelvic injuries.
-Pelvic Fracture Management: AB as usual, C wrap the binder around the trochanteric level, angiography, fixation, pelvic packing. Twist and tie to the sheet to hold it in place.
-pelvic fracture causes a pelvic hematoma -> zone 3- pelvis
-never enter pelvic hematoma without control of the bleed -> usually internal iliac artery bleed - CT angiography and embolization first
AASR grade and type of injury: spleen grade
spleen grading
-adults- splenectomy
-kids- try to save it
-3-5 -> OR
hepatic laceration
-hepatic avulsion
-1-3 - monitor with embolization and conversative
-4-6- embolization and/or surgery
-surgery isnt that great
-can do partial hepatectomy
le fort fractures
-le fort 3- cranial facial dissociation - everything unstable- intubation bc sliding can block airway
-never place a NG
-if basilar skull fx- check sugar bc CSF has sugar in it
intraparenchymal bleed
-ventricular hemorrhage
-parenchymal bleed
-small epidural hematoma on the right !
-shift
-drain
intraventricular hemorrhage
-management- external ventricular drain (EVD)
-bedside
-drain blood or csf
-control ICP
sternum fracture
-area of heart will have significant blunt thoracic trauma
-stunned myocardium
-multiple rib fracture
-pneumo and hemothorax
-MC rib fracture 5-9
-flail segments- 2 areas of rib fracture with at least 3 ribs
-in with inspiration and out with expiration
-negative pressure in pleural space
-huge pneumothorax
-mediastinum shifted
-heart shifted to right
-chest tube in place
-hemothorax on the left
-hemo and large pneumo -> reexpansion pulmonary edema
-diaphragmatic hernia
-stomach in the chest
-air fluid level
-heart shifted to right
-rapid increase in intraabdominal pressure
-left diaphragm rupture
-gastric bubble
-huge tension pneumothorax
-right side
-FAST
-blood in pericardium
-blood = black
-tamponade
-pelvic fracture
-diastasis
-open book fracture- left and right pelvic separate
-multiple fractures
-damage the bladder
-sheet around it and bring it together
-separation of the SI joint
-right is in tract
-can cause significant bleeding
-pelvic angiogram -> embolization prior
hip fractures
-femoral head
-femoral neck- cartilage problem -> arthritis, avascular necrosis
-intertrochanteric fracture- easy to repair -> but deformity
-shortened leg with external rotation
-document neuro status before
-extremities are last priority -> pelvis is first priority (as far as fractures)
-uneven legs, pulseless, foot drop
-long bone fractures -> high risk for fat embolism syndrome (fat breaks off marrow) and flies up to lungs
-morrisons pouch
-area of space between liver and right kidney
-anechoic area
-sub-hepatic space
EFAST
-1. heart- will kill you first
-RUQ, LUQ
-pelvic
-both lungs- lung sliding- r/o pneumothorax, and fluid for hemothorax
-unstable w/ blunt abdominal injury -> FAST/DPL -> OR
-+FAST, stable with abdominal injury -> CT
-unstable penetrating gunshot wound (penetrating) -> OR
-neg FAST -> DPL+ -> OR
-not specific, not good for solid or hollow organ injury
-sensitive for free fluid
debakey 1, 2, and 3 aortic dissections
-must be surgically corrected
-3- medically
-NEVER use hydralazine for 3 -> use nicardipine
-debakey 1+2 = injury to aortic root, +/- intimal tears
-debakey 3 = tears distal to left subclavian (descending)
