Trauma Flashcards by Kris Dobie

Newton’s Laws of motion

1) Object at motion will stay in motion unless acted upon by an external force.

2) F = ma (mass x acceleration)

3) For every action there is an equal and opposite reaction.

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Le Fort Fractures

Require significant force
Cause significant bleeding

1) Separation of hard palate from upper maxilla (horizontal injury)
2) Pyramidal injury
3) Very extensive transverse injury. Ominous

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Trauma Circulation Assessment

Identify life threats and control bleeding

Analyze cardiac output - MAP
…maintain MAP at 60mmHg

Evaluate HR
… 120 = decompensated shock

Pale/white legs = ominous sign for hemorrhaging

BP is a waste of time
…Class III blood loss (30-40%) to cause a drop in BP

Shock index = HR/SBP - Concern > 0.9

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Blood Loss

Class 1 through 3

**Class 3:
Apparent physiologic changes:

1500-2000mL blood loss (30-40%)
Pulse >120
Decreased BP
Decreased urine output

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**Glasgow Coma Scale Adult/Child*

Eye Opening
Spontaneous 4
To Voice 3
To pain 2
None 1

Verbal Response
Oriented 5
Confused 4
Inapp. words 3
Incomprehensible 2
None 1

Motor Response
Follows commands 6
Localizes pain 5
Withdraws 4
Flexion 3
Extension 2
None 1

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Revised Trauma Score

GCS pts SBP pts RR pts
15-13 4 >89 4 10-29 4
12-9 3 76-89 3 >29 3
8-6 2 50-75 2 6-9 2
5-4 1 1-49 1 1-5 1
3 0 0 0 0 0

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Penetrating trauma

Stab wounds - what kind of weapon?

GSW - leading cause of death 15-25yrs
…know caliber of the round if possible
…high velocity rounds travel >2000fps

Permissive hypotension
Maintain MAP at 60 mmHg

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Glasgow Coma Scale Infant

Eye Opening
Spontaneous 4
To Voice 3
To pain 2
None 1

Verbal Response
Coos/Babbles 5
Irritable cries 4
Cries to pain 3
Moans to pain 2
None 1

Motor Response
Spontaneous + purposeful 6
Withdraws from touch 5
Withdraws from pain 4
Abnormal flexion posture 3
Abnormal extension posture 2
None 1

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Cardiac Tamponade (trauma)

Beck’s Triade

*Narrowing Pulse PRessure
*JVD
*Muffled heart tones
*CXR - widened mediastinum

Can be confirmed via ultrasound

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Tension Pneumothorax (trauma)

Severe respiratory distress
Decreased or absent breath sounds
Subcutaneous air
JVD
High plateau pressure
Trachial shift is a LATE finding
VS changes = LATE sign

Tx:
Needle decompression
…2nd ICS, mid-clavicular or 4-5 anterior axillary line

Chest tube - 4th - 5th ICS

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Hemothorax (trauma)

Decreased breath sounds
Midline trachea
Flat neck veinns
Decreased LOC

TX:
Chest tube
Fluid replacement/PRBC/FFP
Chest tube should be clamped at 1500cc initial output to avoid re-expansion pulmonary edema.

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Flail Chest

Paradoxical movement
Respiratory distress
Tachypnea - shallow breath
Grunting
Accessory muscle use
Chest pain

TX:
Self-splinting
Intubation
Place injured side down
Be aggressive with pain management

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Spleen injuries

Grade 1-5
1-3 may not require surgical intervention

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Liver injuries

Grade 1-6

Liver injuries of grades 5-6 are always fatal

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Abdominal Trauma

Multi-organ injuries will require surgical intervention regardless of severity

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Colon or bowel trauma

Severe trauma can occur without penetration
ie trauma from seatbelts

Aorta trauma

20% of MVA fatalities have aortic involvement.

Pelvic trauma

Anterior/posterior compression (crushing forces)
Lateral compression (crushing or side impact)
Vertical sheer (ominous - often fatal)…high falls or head-on accidents

Treatment:
compression of pelvis (ie pelvic binder)
Check for blood at the meatus
Ask pt to lift each leg (likely no fx if they can lift legs)

REBOA

Resuscitative Endovascular Balloon Occlusion of the Aorta

Zone 3 is primary tx area
Vertical sheer pelvic fractures
Liver/spleen injuries

Burn Classification

Adult rule of 9’s
Head: 9%
Arms: 9% each
Legs: 18% each
Chest: 18%
Back: 18%
Perineum: 1%

Pediatric rule of 9’s
Head: 18%
Chest: 18%
Back: 18%
Arms: 9% each
Legs: 13.5% each

Burn airway factors

Exposure time
Types of toxic fumes exposed to
Concentration of fumes
Severity of thermal injury
Concomitant trauma/injuries
Pre-existing medical conditions

Burns lower airway

Injuries below the glottic opening are technically chemical burns

Carbon particles adhere to mucosa
Cilia impairment prevents removal of foreign matter
Cell membrane damage occurs
Inflammatory reaction
Increased pulmonary blood flow
Edema formation worsens
Impacts lung compliance and oxygenation

Burns conscious vs unconscious

Unconscious patients tend to have more severe lower airway burns

Circumferential 2nd and 3rd degree burns

…Cause a loss of elasticity in chest wall tissue
Causes increased work of berthing to maintain adequate tidal volume
Will see increase in peak pressures
Escharotomy is the appropriate course
…W technique usually prehospital

Fluid resuscitation in burn patients

End organ perfusion Adult urine output: 0.5 - 1 mL/kg/hr Rhabdo: 1-2 mL/kg/hr Pediatrics < 10 kg: 2 mL/kg/hr Pediatrics >10 kg: 1 mL/kg/hr HR < 130 SBP > 90

Parkland formula

Outdated but know it pt kg x TBSA x 4mL = volume/24 hrs 1/2 total volume in first 8 hrs

Consensus Formula

Now the standard for burn fluid resuscitation pt kg x TBSA x 2-4 mL = volume/24 hrs 1/2 over first 8 hrs 1/4 over next 8 hrs 1/4 over final 8 hrs Adults: 2 mL/kg Peds: 3 mL/kg Electrical burns: 4 mL/kg

American Burn Association fluid resuscitation

Adult: (TBSA x kg) / 8 = rate (mL/hr) Peds: (TBSA x kg x 1.5) / 8 = rate (mL/hr)

Burn Fluid Resuscitation and urine output

At hospital, fluid rate should be adjusted based on urine output; with a target of approximately 0.5 mL/kg for adults, and 1 mL/kg for peds > 10kg Urine output in excess of these levels indicates over-resuscitation

Fluid choice in burns

Crystalloids Isotonic crystalloids are preferred for initial fluid resuscitation LACTATED RINGER'S always first priority

**Burn electrolyte imbalance**

Phase 1: 0-36 hrs Hyponatremia (because we give too much volume) Hyperkalemia (leakage from cells to bloodstream) Intravascular loss Increased vascular permeability Interstitial osmotic pressure increase Phase 2: 3-7 days Hypernatremia Hypokalemia Hypophosphatemia Hypomagnesemia Hypocalcemia Caused by reabsorption of cellular edema Urinary retention based on overstimulation of ADH

Electrical injuries

First component "Hidden injury" Generated heat along the path it travels through the body. Damages nerves, blood cells, and muscle Second component Injury from arcing Third component Flash burn from power source or from clothing ignition Fourth component Trauma as a result of intense muscle spasm

Electrical injuries (secondary)

Pulmonary Assess for presence of these burns that could restrict chest wall movement Any associated inhalation injury? Associated traumatic injury? Renal Muscle damage; myoglobin release from muscle damage; myoglobin is tough on kidneys and can lead to rhabdomylosis.

Electrical injuries rhabo

Extensive muscle damage often causes myoglobinuria If left untreated, results in acute tubular necrosis and renal failure. Treatment: FLuid, fluid, more fluid! Monitor urine output: 1-2mL/kg/hr NaHCO3 to alkalinize the urine Mannitol Diuretic

A patient requiring massive PRBC transfusion should be monitored for which electrolyte abnormality?

Hyperkalemia

A basilar skull fracture is often associated with...?

seventh cranial nerve palsy

How would a right-sided tension pneumothorax present?

Tracheal deviation toward the left, and diminished or absent breath sounds on the right.

Death within minutes of multi-system trauma is most often a result of?

Great vessel laceration