trauma Flashcards
pneumothorax
collapsed lung; occurs when air leaks into pleural space
primary blast injury
direct effects of pressure waves cause injury mainly to HOLLOW ORGANS
secondary blast injury
results from FLYING DEBRIS striking person
tertiary blast injury
results from PERSON striking another OBJECT
the golden hour
first 60 seconds after the occurrence of multi-system trauma; victims chances of survival are greatest if they receive definitive care within the first hour after injury
definitive care
where problems can be fixed (surgeon, OR)
primary survey
identify, detect, address life-threatening situations
trauma adults vs peds
child:
- smaller airway (nose + mouth)
- trachea narrow/softer/more flexible
- tongue occupies larger space
nasopharyngeal airway appropriate when…
gag reflex intact and no blunt face trauma
oropharyngeal airway appropriate when…
no gag reflex
ABCDE
a irway/cervical spine b reathing c irculation d isability e xposure
airway for spontaneously breathing patient
non-rebreather
airway for patient requiring ventilatory assistance
bag-valve-mask + appropriate airway adjunct + 100% oxygen
airway for significantly impaired consciousness
endotracheal tube + mechanical ventilation
external hemorrhage
usually obvious, best controlled with firm, direct pressure on bleeding site with thick, dry dressing material
internal hemorrhage
more hidden complication that must be suspected in injured patients or those who present in shock states
AVPU
a lert
v oice, responsive to
p ain, responsive to
u nresponsive
GCS
intubate!
intraosseous access: humerus has same flow rate as
subclavian vessel
central line access appropriate for trauma patient when?
once patient is stabilized - MUST be done under sterile technique
appropriate PRBC for men/women 55+
O+
appropriate PRBC for peds and women
O-
coagulopathy
abnormalities of clotting
- likely due to activation of protein C pathway; exacerbated by hypothermia
- can be reversed with vitamin K or FFP, but small window of opportunity after injury
- anticoagulants (warfarin) significantly increase risk
6 Ps of rapid sequence intubation
p reparation / preoxygenate
p remedicate (lidocaine to prevent gag for low ICP)
p aralysis & sedation
p assing the tube
p roof of placement
p ostintubation management
preferred method of intubation & why (trauma)
endotracheal tube
- good control of airway
- prevents aspiration
cricothyroidotomy
surgical airway when intubation via nose or mouth is not possible.
- higher than tracheostomy
shock types 3Ps
hypovolemic - preload
cardiogenic - pump
obstructive - pipes
hypovolemic shock
loss of circulating blood, plasma, other bodily fluids
hypovolemic shock: causes
- traumatic, thermal injury
- excessive vomiting, diarrhea
- vaginal, GI bleeding
- diuresis
hypovolemic shock: treatment goals
- ensure adequate oxygenation, ventilation, perfusion
- STOP VOLUME LOSS & restore
five areas we bleed into
chest abdomen retroperitoneum pelvis long bones/soft tissue
beware hypocalcemia, how & prevention consideration?
- calcium citrate added to banked blood to prevent clotting
- consider calcium administration after every 4th unit of PRBCs
permissive hypotension
administration of only enough blood volume for vital organ perfusion in order to avoid dislodging clots
- SBP ~90 adequate/permissive
- controversial
electrolyte imbalances in hypovolemic shock
- hyperkalemia (cell lysis)
- hypocalcemia (calcium citrate in banked blood)
- acid/base imbalance (liver converts citrate to bicarbonate)
deadly triad
acidosis, coagulopathy, hypothermia
cardiogenic shock
impaired heart muscle leads to poor pumping action, decreased cardiac output
cardiogenic shock: causes
- myocardial infarction
- cardiomyopathy
- severe blunt cardiac injury
cardiogenic shock: s/s
- dyspnea
- tachycardia
- hypotension
- rales
- altered mental status
- distended neck veins
cardiogenic shock: management
same as heart failure! reduce preload, afterload; support pump
obstructive shock
obstruction impairs blood flow in or out of the heart, which leads to decrease in cardiac output - form of cardiogenic shock
obstructive shock: causes
tension pneumothorax, cardiac tamponade - 2 largest causes
- pulmonary embolism
- aortic aneurysm
obstructive shock: clinical presentation
varies with cause –
- chest, back pain
- distended neck veins
- dyspnea
- tachycardia
- hypotension
- cyanosis
- muffled heart sounds
obstructive shock: management
TREAT UNDERLYING CAUSE
- chest decompression
- pericardiocentesis
- embolectomy
- surgical repair
distributive shock
occurs in response to reduction in the systemic vascular resistance, mainly due to vasodilation
- NO CHANGE IN VOLUME - just size of vasculature
3 types: neurogenic, septic, anaphylactic
neurogenic shock
a type of distributive shock
- loss of vasomotor tone r/t loss of vasomotor sympathetic regulation
- can resolve within 48 hours
neurogenic shock: causes
- outflow from vasomotor center inhibited
- parasympathetic response increases, causes vasodilation
- spinal cord injuries at or above T6
neurogenic shock: presentation
- bradycardia
- warm, dry skin
- hypotension
- poikilothermia (lose all body temp and adapt to temp of environment
poikilothermia
inability to maintain core body temperature independent of ambient temperature (adapt to temp of environment)
- seen in neurogenic shock
septic shock
type of distributive shock - loss of vascular tone r/t toxins, invading microorganisms
inflammatory response
septic shock: inflammatory response
inflammatory response causes acute vascular, cellular response - neutrophils migrate to injury site - VASODILATION - increased CAPILLARY permeability - FIBRINOGEN CLOT develops - MAST CELLS release vasoactive mediators
septic shock: management
fluid resuscitation, antibiotics, vasopressors, inotropic support
shock evaluation: perfusion status
mental status, pulses, BP, UOP
poor man’s cardiac output
urinary output (no urine = sucky cardiac output)
shock evaluation: resolution of anaerobic metabolism
lactate levels!
normal lactate range
shock evaluation: lactate levels significance
- build up is an indirect measurement of oxygen debt
- also monitors resuscitation, tissue perfusion
- excess –> metabolic acidosis
shock: lactate clearance how?
- all body cells except RBCs can clear
- via volume resuscitation
indirect measurement of oxygen debt
lactate levels
one of the most commonly seen minor head injuries
concussion
concussion
traumatic reversible deficit with or without temporary loss of consciousness with some amnesia
- lasts minutes to hours
- CT normal
concussion: cause
strong, rapid acceleration - deceleration stimulus or sudden blow to skull
concussion: s/s
- LOC after injury
- dizziness, headache
- nausea, vomiting
- amnesia, asking same questions over and over
secondary impact syndrome
concussion/head injury before first concussion is resolved results in significant longterm complications, cognitive issues
hematoma
localized collection of blood outside blood vessels, usually in liquid form within tissue
ecchymosis
hematoma > 10 mm
type of purpura
not necessarily caused by trauma
bruise
caused by trauma, always
purpura
red or purple discoloration of skin that do not blanch when pressure is applied
petechia
1 - 2mm spot on skin caused by minor bleed; type of purpura
epidural hematoma
collection of blood between skull and dura
- ARTERIAL bleed under high pressure, does not tamponade –> increased ICP
- rapid onset!
epidural hematoma: s/s
RAPID!
- initial period of unconsciousness
- lucid interval (classic, not always present): awake then rapid decline to unconsciousness
- pupils: unilateral, fixed, dilated
- paresis, paralysis: contralateral progression to posturing
- cushing’s response LATE
paresis
weakness of voluntary movement or partial loss of voluntary movement
cushing’s response
late sign of epidural hematoma, physiological response to increased intracranial pressure
triad:
- systolic hypertension
- irregular breathing
- bradycardia
subdural hematoma
collection of VENOUS blood between dura matter and subarachnoid layer of meninges; GRADUAL onset
acute, subacute, chronic
subdural hematoma: acute presentation timeframe
subdural hematoma: subacute presentation timeframe
2 - 14 days
subdural hematoma: chronic presentation timeframe
> 14 days
subdural hematoma: acute s/s
- headache, drowsy, confusion
- STEADY decline in LOC
- unilateral pupil dilation + lack of response to light
- contralateral hemiparesis
hemiparesis
weakness on one side of body
subdural hematoma: chronic s/s
- gradual, non-specific changes
- alteration in mentation
- hemiparesis
- papilledema
- dilated pupil, sluggish to light
papilledema
optic disc swelling in response to ICP
hematoma treatment x8
- monitor neuro
- manage BP
- elevate HOB to improve venous, CSF return
- quiet environment
- sedation, analgesics, anticonvulsants
- decompression of cranial vault to decrease ICP
- prepare for emergency surgery: clot evacuation or coiling procedure
- maximize O2, ventilation
axial loading
direct trauma to head or feet
spinal cord injuries common in what age range?
15 - 35yo
enopthalmos
posterior displacement of eyeball due to changes in orbit (bone) or muscle
nasal trauma common in
children!
with nasal trauma, clear drainage or blood tinged drainage should be considered…
CSF
malocclusion
wonky shutting teeth
neck trauma management tends to be…
surgical evaluation and repair
fractures of ribs 10 - 12 associated with…
liver and spleen injuries
most frequently injured organ
spleen
- may be associated with rib fracture or lower left chest trauma
Kehr’s sign
referred pain to left shoulder from spleen injury
kidney injury nota bene
usually occurs with other injuries, not alone
- right kidney lower than left because liver!
- hard to detect since inside retroperitoneal space
grey turner’s sign
bruising to flanks indicative of kidney injury
cullen’s sign
bruising around umbilicus due to kidney injury
pancreas injury usually associated with
duodenal injury and blunt trauma
- management is rarely surgical
colon injuries mostly due to
penetrating trauma
population more prone to stomach trauma
pediatrics
common finding in stomach/bowel injury
blood in ng/og aspirate
stomach/bowel injury management x2
- surgical! examine entire length because if not fixed, peritonitis
- bowel rest
where is the bladder in adults?
pelvis
where is the bladder in peds?
abdomen
most common bladder injury
extraperitoneal rupture, highly associated with pelvic fracture
- injury at bladder neck, contents spill into peritoneal cavity
bladder injury typically due to
blunt trauma
extraperitoneal bladder rupture
most common
highly associated with pelvic fracture
pain with urination
intraperitoneal bladder rupture
at top of bladder due to increased pressure from bottom
penetrating trauma
hematuria, inability to void
urethra classic triad
- inability to void
- blood at urinary meatus
- distended palpable bladder
bloody urinary meatus?
DON’T PLACE A DAMN FOLEY
second most common cause of death in multi-system trauma patients
pelvic fracture
blood loss in pelvic fractures
3L+ loss or more due to injured vessels, typically VENOUS
once pelvis examined and determined to be unstable…
DO NOT MANUALLY EXAMINE AGAIN
long bone trauma management
assess distal CMS p rotection r est i ce c ompress e levate r ehab
deadly dozen
lethal six
- airway obstruction
- tension pneumothorax
- pericardial tamponade
- open pneumothorax
- massive pneumothorax
- flail chest
hidden six
- thoracic aortic disruption
- pulmonary contusion
- tracheobronchial injuries
- blunt cardiac injury (myocardial contusion)
- diaphragmatic tear
- esophageal injury
one of the major causes of trauma fatalities
airway obstruction (lethal six/deadly dozen)
tension pneumothorax
tear in visceral pleura allows air to enter potential space, pressure increases, lung collapses
- air rushes into pleural space during inhalation, but can’t come out during exhalation
- thoracic structures pushed to opposite side of chest
- obstructive shock: affects cardiac output; this is the difference between tension pneumothorax and plain pneumothorax
late sign of tension pneumothorax
tracheal deviation = dead
tension pneumothorax s/s
hyperresonance on percussion
tracheal deviation
and all the standards
main indication for chest decompression
tension pneumothorax
tension pneumothorax: management
- immediate decompression
- chest needle decomp is temporary
- chest tube placement is primary fix
pericardial tamponade
develops when tear in pericardial sac and an injury to one of the chambers of the heart or coronary vessels causes blood to collect in potential space
- usually due to penetrating, very rarely due to blunt
beck’s triad
- jugular distension
- hypotension
- muffled heart sounds
pulses paradoxus
radial pulses disappear during inspiration, due to drop in systolic > 10 mmHg
pericardial tamponade: s/s
beck's triad pulses paradoxus ST segment changes widened mediastinum pulseless electrical activity
pulseless electrical activity (PEA)
form of cardiac arrest, s/s of pericardial tamponade
pericardiocentesis
- fix for pericardial tamponade
- QUICKLY! or death due to decreased cardiac output
open thoracotomy
- fix for pericardial tamponade
- usually performed in CRASHING patient
- only with PENETRATING trauma
- low survivability rate
pericardial tamponade: fixes
- pericardiocentesis (QUICK!)
- open thoracotomy (crashing/penetrating, low survivability)
open pneumothorax
sucking chest wound - occurs when opening from pleural space to outside of chest; air rushes in and increases intrapleural pressure resulting in the collapse of underlying lung tissue
open pneumothorax: clinical presentation
penetrating wound with bubbling appearance and sucking sound
massive pneumothorax
develop as result of collection of blood in pleural space (>1500mL)
- intercostal vessels most common source
- blunt or penetrating
massive pneumothorax: clinical presentation
shocky but FLAT jugular veins
shocky but FLAT jugular veins
massive pneumothorax presentation
chest tube thoracostomy
insertion of chest tube into pleural cavity to drain air, blood, bile, pus, or other fluids
flail chest
multiple rib fractures occurring in 2+ places along rib, resulting in floating segment that moves paradoxically with normal chest wall movement
- impairs oxygenation, ventilation
- classic with blunt trauma, especially steering wheel impact
flail chest: management
stabilize flail segment (bulky dressing, hand)
intubation, PEEP
pulmonary toilet
pulmonary toilet
procedures to clear mucus, secretions from airways
thoracic aortic disruption
results from rapid deceleration event
- 85 to 90% immediate death, survivors typically due to clot around tear
most common site of thoracic aortic disruption
arch where ligamentum arteriosum holds descending aorta in place
thoracic aortic disruption: clinical presentation
- DEAD
- upper extremity BP asymmetry
- widened pulse pressure
- loss of distal pulses
- harsh systolic murmur
pulmonary contusion
contusion of lung parenchyma resulting from blunt trauma, usually rapid deceleration leading to tissue destruction, hemorrhage, edema
- inflammatory process starts - leukocytes - fibrin clots
- significant cause of ARDS in trauam
significant cause of ARDS in trauma
pulmonary contusion
pulmonary contusion: clinical presentation
hypercarbia
hemoptysis
crackles
respiratory acidosis
pulmonary contusion: management
can’t fix, support to allow lungs to heal
- PEEP: maximize O2 or else acidotic
tracheobronchial injuries
results from tear, injury to one of the larger airways in bronchial tree; usually close to carina at bifurcation
- deceleration force, compression injury
- RARE
blunt cardiac injury
aka myocardial contusion; blunt trauma (penetrating possible too) directly affecting heart muscle impairs pumping
- force causes hemorrhage, edema, myocyte injury
- results in cell necrosis, scar formation
- right ventricle most common injury site
blunt cardiac injury: management
gotta let let body heal itself
- monitor for cardiogenic shock
- NO THROMBOLYTICS
diaphragmatic tear: presentation
- seen on CXR
- most commonly left side because right protected by liver
- bowel sounds in chest
- chest pain referred to shoulder
esophageal injury: MOI
penetrating - usually. GSW 95%
blunt - MVC 75 to 80%
esophageal injury: diagnosis
difficult to assess! use EGD or esphagogram
- poor outcome if not identified/corrected!
esophageal injury: clinical presentation
- subq air
- mediastinal air
- unexplained fever
