Trauma Flashcards
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.
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
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
Blood Loss
Class 1 through 3
**Class 3:
Apparent physiologic changes:
1500-2000mL blood loss (30-40%)
Pulse >120
Decreased BP
Decreased urine output
**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
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
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
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
Cardiac Tamponade (trauma)
Beck’s Triade
*Narrowing Pulse PRessure
*JVD
*Muffled heart tones
*CXR - widened mediastinum
Can be confirmed via ultrasound
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
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.
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
Spleen injuries
Grade 1-5
1-3 may not require surgical intervention
Liver injuries
Grade 1-6
Liver injuries of grades 5-6 are always fatal
Abdominal Trauma
Multi-organ injuries will require surgical intervention regardless of severity
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
1/8 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
