Trauma Flashcards
Trimodal distribution of peak incidence of trauma mortality
1) Prehospital: devastating head, vascular injuries
2) Minutes to hours after ED arrival: major head, chest, abdominal injuries
3) ICU: SIRS, sepsis, multi-system organ failure
Characteristics of Level 1 Trauma Centers
1) 24 hr availability of surgeons in all specialties
2) 24 hr availability of neuroradiology & hemodialysis
3) Program to establish & monitor effect of injury prevention & education efforts
4) Organized trauma research program
Two-person spinal stabilization technique
1) One provider devotes undivided attention to maintaining in-line immobilization & preventing excessive movement of c-spine
2) One provider manages the airway
Which trauma patients might need intubation?
Comatose
Agitated
What should we remember about nasal airways re: head trauma?
Don’t put a nasal airway in a suspected basilar skull fracture! Don’t put ANYTHING in the nose of a suspected basilar skull fracture! That’s gonna go in their BRAAAAAAIN!
5 NEXUS criteria for omitting cervical spinal imaging
If the patient meets ALL of the following, there is little need for c-spine imaging:
1) No posterior midline c-spine tenderness
2) No evidence of intoxication
3) Alert mental status
4) No focal neurologic deficits
5) No painful distracting injuries
* *Failure to meet any one criterion indicates need for c-spine imaging**
The Canadian c-spine rule:
1) High risk factor that mandates radiography (Age ≥ 65 or dangerous mechanism or paresthesias in extremities)? If yes, radiography. If no, move on to 2.
2) Any low-risk factor that allows safe assessment of ROM (simple rear end MVC, sitting position in the ED, ambulatory at any time, delayed onset of neck pain, absence of midline c-spine tenderness? If no, radiography. If yes, move on to 3.
3) Able to rotate neck actively? 45º L and R. If no, radiography. If yes, CONGRATS! NO RADIOGRAPHY!
Plain radiography may miss how many fractures?
Up to 15% of all c-spine fractures
Class I Hemmorhage
Blood loss: Up to 750 Blood loss %: Up to 15% Pulse (bpm): < 100 BP: Normal Pulse pressure: Normal or increased
Class II Hemmorhage
Blood loss: 750-1500 Blood loss %: 15-30% Pulse (bpm): 100-120 BP: Normal Pulse pressure: Decreased
Class III Hemmorhage
Blood loss: 1500-2000 Blood loss %: 30-40% Pulse (bpm): 120-140 BP: Decreased Pulse pressure: Decreased
Class IV Hemmorhage
Blood loss: > 2000 Blood loss %: > 40% Pulse (bpm): > 140 BP: Decreased Pulse pressure: Decreased
Suspect intraperitoneal bleeding or pericardial tamponade? What exam are we gonna use?
FAST exam! “Focused assessment with sonography for trauma”
Penetrating trauma patient already in shock: rush them to OR or not?
Yes! “Consensus that early operative intervention in patients experiencing penetrating trauma who are in shock results in better outcomes” (Tintinalli)
Colloids versus crystalloids?
“Three decades of study have failed to demonstrate an advantage of colloid therapy over crystalloid infusion.” (Tintinalli)
If you need to do a subclavian stick on a trauma patient, where should you stick?
Most often is best to stick the same side as the injury if possible
Remember if you see a “Fuzzy Image” upon X-Ray…
…may be a hint to look for a vascular injury
Penetrating injuries such as a bullet often require what sort of surgery?
Exploratory, to track pattern of injury
True or false: In an adult in a blunt trauma, the degree of hematuria may not necessarily be associated with the degree of injury.
True
True or false: a Glasgow coma scale of 15 excludes the possibility of traumatic brain injury.
False.
Principal efforts in brain-injured patients should…
…be directed toward resuscitation to maintain normal cerebral perfusion.
Traumatic brain injury (TBI) is defined as…
…impairment in brain function as a result of mechanical force.
How is TBI classified?
Based on clinical assessment of a patient’s level of consciousness with little or no regard to the actual underlying injury.
What might result from the way TBI is classified?
Two patients might have the same TBI classification despite dramatically different pathophysiology.
What categories are TBI currently classified into?
Based on the Glasgow Coma Scale:
1) Mild: GCS of 14-15
2) Moderate: GCS of 9-13
3) Severe: GCS of 3-8
Three primary goals of management for patients with moderate to severe TBI
1) Prevent further secondary brain injury
2) Identify treatable mass lesions
3) Identify other life-threatening injuries
Ways to prevent secondary brain injury:
Correcting or preventing: 1) hypoxemia 2) hypotension 3) anemia 4) hyperglycemia 5) hyperthermia and 6) evacuating intracranial masses
Some studies have shown worse outcomes when TBI patients are intubated in the pre-hospital setting. What is one reason this might be?
Postintubation hyperventilation during transport.
DO NOT HYPERVENTILATE YOUR PATIENT. Their brains don’t like that.
When taking a history of TBI:
1) Reconstruct mechanism of injury to determine potential severity
2) Assess for extracranial injuries
3) Obtain details of mechanism of injury
4) Patient’s condition before & after the trauma
5) Medical history & meds (especially anticoags!)
6) Intoxication
7) Symptoms after the injury: nausea, vomiting, headache, memory impairment, visual/auditory symptoms
Symptom checklists are helpful! Acute Concussion Evaluation, ED version v 1.4 is recommended
The goal of ED resuscitation in TBI…
…is to prevent secondary insult and potentially slow the expansion of the underlying injury.
Which TBI patients require prompt airway control?
Severe TBI, or GCS ≤ 8
In-line cervical spine stabilization should be maintained until…
…c-spine injury is definitively excluded.
What are the recommended agents for rapid-sequence intubation in TBI cases?
Induction: etomidate & propofol
Neuromuscular blockers: succinylcholine & rocuronium
What are the benefits of etomidate for intubation in TBI patients?
1) Rapid onset (45 seconds)
2) Short duration of action (3-5 minutes)
3) Good hemodynamic profile
May have neuroprotective properties & reduce ICP. Continuous infusions may cause adrenal suppression, but single dose does not.
What are the benefits of propofol for intubation in TBI patients?
1) Rapid onset & recover
2) Strong anti-seizure properties
Boluses CAN cause hypotension & it should be used with caution in patients with labile BP or inadequate fluid resuscitation.
What are the benefits of succinylcholine & rocuronium for intubation in TBI patients?
Short acting! Extended paralysis is not recommended first tier for elevated ICP (only refractory). Long-term paralysis impedes neurologic exams, limits the ability to detect changes in neuro status, and may increase risk of pneumonia.
What is arguably the most important secondary insult in TBI patients?
Hypotension & subsequent ischemia of vulnerable & injured neuronal tissue can exacerbate the underlying secondary cascade & lead to expansion of injury & worse outcomes.
Due to the importance of maintaining adequate perfusion pressure:
Aggressive fluid resuscitation may be required to prevent hypotension & secondary brain injury.
But if we throw a ton of fluid at our TBI patient, aren’t we going to increase ICP?
No! Adequate fluid resuscitation does not increase ICP, & guidelines recommend an SBP > 90.
What are the recommendations for MAP in a TBI patient?
There are no official ones, but most studies in the guidelines recommend MAP > 80.
What is “relative hypotension”?
A concept often overlooked in TBI. It is normal-range BP, but still too low to adequately perfuse the injured brain.
Hypertension is an important finding in a TBI patient. Why?
If it’s not because of inadequate pain control, it could be an indicator of Cushing reflex, which is increased ICP in a patient with head injury.
The “neurologic vital sign”
The Glasgow Coma Scale
The GCS interpretation can be complicated by:
1) intoxicants
2) sedating therapies
3) evolution of the patient’s condition
New Orleans Head CT Clinical Decision Rules
GCS 15
- Headache
- Vomiting
- Age >60 years
- Intoxication
- Persistent antegrade amnesia
- Evidence of trauma above clavicles
- Seizure
Presence of any one finding indicates need for CT scan
Canadian Head CT Clinical Decision Rules
GCS 13-15
- GCS < 15 at 2 hours
- Suspected open or depressed skull fracture
- Any sign of basal skull fracture
- > 1 episode of vomiting
- Retrograde amnesia > 30 minutes
- Dangerous mechanism (fall > 3 ft, pedestrian vs MV)
- Age ≥65 years
The New Orleans & Canadian Head CT decision rules do not apply to what groups?
1) People taking anticoags
2) Children
These populations were excluded from validation studies
The New Orleans & Canadian Heat CT studies found that certain elements of the H&P have relatively more significance. What is one?
Nausea & vomiting have significance comparable to loss of consciousness re: a positive CT finding.
Indications for head CT in mild TBI without loss of consciousness
#GCS < 15 #Focal neurologic findings #Vomiting > 2 times #Moderate to severe headache #Age > 65 years #Physical signs of basilar skull fracture #Coagulopathy #Dangerous mechanism of injury (e.g. fall > 4 ft)
Indications for head CT in mild TBI with loss of consciousness or amnesia
#Intoxication (drug or ETOH) #Physical evidence above clavicles #Persistent amnesia #Post-traumatic seizures
An ICP of [what value] increases subsequent morbidity & mortality?
> 20
Indicators of increased ICP
#Headache #Nausea/vomiting #Seizure #Lethargy #Hypertension #Bradycardia #Agonal respirations
Indicators of impending transtentorial herniation
DANGER, WILL ROBINSON!
#Unilateral or bilateral pupillary dilation #Hemiparesis #Motor posturing #Progressive neurologic deterioration (declining GCS scores)
I am hoping you didn’t have to be told ANY of those.
When a TBI patient does have signs/symptoms of ICP, what can be done to lower it in the ED?
#Ventilation to maintain PaCO2 at 35-40 & O2 sat at > 95% #Adequate sedation (helps with relaxation & prevention of gagging on ET tube) #HOB at > 30 to increase CSF outflow (reverse Trendelenberg is nice) #Stop & prevention of seizures #Mannitol for patients who are not hypotensive
Mannitol considerations
#Osmotic diuretic that can reduce ICP, improve cerebral blood flow #Reduces ICP in 30 minutes #Expands plasma volume #Initially reduces hypotension #Some authors advocate starting at low end of range #Net intravascular volume loss bc it's a DIURETIC, so monitor I&O.
Scalp lacerations are important because
they can cause some SERIOUS blood loss!
Anyone suspected of having a skull fracture requires…
…a CT of the head. BIG SURPRISE.
Skull fractures are categorized by
1) Location (basilar vs. skull convexity)
2) Pattern (linear, depressed, comminuted)
3) Open or closed
Most common CT abnormality in patients with moderate to severe TBI?
Traumatic subarachnoid hemorrage
What’s the best time frame for detecting traumatic subarachnoid hemorrage on CT?
6-8 hours post-injury
Epidural hematoma
Blood collects in the potential space between skull & dura mater
Epidural hematoma is usually shaped like what on CT?
Biconvex (football shaped)
The key to reducing morbidity/mortality from epidural hematoma is…
…early recognition & evacuation!
Subdural hematoma
Hematoma formation between the dura mater & arachnoid
What causes a subdural hematoma?
Sudden acceleration-deceleration of brain parenchyma with tearing of the bridging veins. They collect more slowly than epidural hematoma because of venous origin.
What 3 populations are at higher risk for acute subdural hematoma because of brain atrophy?
#Elderly #Alcoholics #Children < 2 years old
Help! I have a subdural hematoma! Is it acute or chronic?
Well, if it’s < 14 days from injury, it’s acute. If it’s been more than that, it’s chronic!
Diffuse axonal injury
Disruption of axonal fibers in the white matter & brainstem caused by sudden deceleration.
What are some causes of diffuse axonal injury?
#Motor vehicle crashes #Shaken baby syndrome #Blunt trauma
What are some hallmarks of diffuse axonal injury?
#Edema can develop rapidly #Can result in devastating, irreversible neuro deficits
What are some treatments for diffuse axonal injury?
They're very limited but we try to prevent secondary damage by: #Reducing cerebral edema #Limiting pathologic increase in ICP
