Trauma Flashcards
ABCs
Airway (with C spine precautions - assume C spine injury until proven otherwise)
Breathing and vent
Circulation/Control of hemorrhage
Disability (neuro status)
Exposure/Environment control
Foley
Airway and C-spine
Assess patency
use jaw thrust or chin lift initially to open it up
Clear foreign bodies
Insert oral or nasal airway when needed
Intubate obtunded/unconscious patients
Surg airway = cricothyroidotomy - when unable to intubate
Patent airway
speaks in full sentences
B/l breath sounds
Just give O2
Urgent airway
Has patent airway now but maybe not forever. Will need intervention soon
Expanding hematoma
Cutaneous emphysema (rice crispies in skin)
Give BVM
Emergent airway
GCS
Breathing and ventilation
Do they need ventilations or a ventilator?
Monitor SpO2 and End tidal CO2 (for intubated patients should be about 40)
What might alter ventilation?
Hemothorax, pneumothorax, flail chest, pulm contusion
Normal RR 12-20
Control of hemorrhage
2 large bore IVs (14 or 16 gauge)
Draw blood samples at time of IV catheter placement
Assess cap refill, pulse, skin color
Control life-threatening bleeds using direct pressure
Are they in shock?
- sys BP
Disability
Rapid neuro exam
Establish pupillary size and reactivity and level of consciousness using AVPU or GCS
AVPU
Alert
Verbal
Pain
Unresponsive
Exposure/Environment/Extra
Undress the patient
Foley
Contraindicated when transection of urethra is suspected like in pelvic fracture. If suspected get retrograde urethrogram first
Examine prostate and genitals before foley insertion
Gastric intubation
NGT or OGT may reduce aspiration risk. If cribiform is fractured used OGT
IV fluid
Start with up to 2L of isotonic crystalloid (NS or LR)
Peds should get IV bolus 20cc/kg
3:1 rule. Total amount of crystalloid volume needed acutely to replace blood loss.
Use warm fluids whenever possible
Shock in the trauma setting
Hemorrhage Tension Pneumo Pericardial Tamponade Contractility issues Vasomotor
Hemorrhage signs
Bleeding patient with flat neck veins. Low Hgb/Hct. High HR (compensation)
Dx: May beed to do FAST
Tx: 2 large bore IV
Dump fluid and blood into them (T/C, IVF, Blood). Fix the hole. All on the way to the OR
Tension pneumo signs
1 - needle decompression in 2nd IC space (goal is to relieve IVC not re-inflate lung). This is NOT a chest tube.
Hole in pleura creates a flap. When pt breathes in, air gets into pleural space. When they exhale it gets trapped
Affected lung collapses. Replaced inside the space with air.
Air compresses IVC
Engorged neck veins
Absent lung sounds on affected side
Hyperresonant
Induces tracheal deviation away from affected side
F/u with chest tube (thoracostomy)
Pericardial tamponade signs
RV is looser/floppier than LV so it collapses. We cannot fill. Basically a diastolic HF.
Engorged neck veins
Clear lung sounds
Beck’s triad = distant heart sounds, JVD, hypotension
Dx: FAST
Tx: Pericardialcentesis
Contractility issues signs
Pt will have engorged neck veins
Also with pulm edema
Dx = Echo or FAST
Tx = medically manage
Vasomotor shock signs
Normal response to shock is to increase SVR therefore preload, HR, contracility issues generally cause cold extremities
HERE, we get vasodilation leading to warm extremities despite low BP.
Dx: depends on mechanism
TX: give back what they’re lacking (ANS tone) with vasopressors
Secondary survey
Stage in trauma eval after all the ABC business
Get trauma history (AMPLE history)
Allergies Meds/Mechanism of injury PMH/Pregnant? Last meal Events surrounding mechanism of injury
Head to toe eval
How is body water distributed?
2/3 intracellular
1/3 extracellular
- 1/4 intravascular
- 3/4 extravascular
Basilar skull fracture
Look for Battle sign - bruising around eyes and behind ears
Runny nose - that’s CSF actually coming out!
Get CT
Epidural hematoma
MMA breaks and starts to bleed. Space btw skull and dura fills with blood. Will get big enough and push on brain.
Initial LOC
Lucid period
Death
“Walk, talk, and die syndrome”
Dx: Get CT (lens-shaped)
Tx: Craniotomy
“Epi was a horrible class that I thought would be easy. I’m glad I can look at it through the lens of time now.”
Acute subdural
Young patient. May be sign of abuse in baby.
Usually need a HUGE trauma like MVAs.
Blood fills btw brain and dura
Course = trauma then coma then death
Dx: CT (crescent shaped).
Tx: Keep ICP low (hypervent, raise bed head, mannitol). Pray.
Chronic subdural
Older patients or alcoholics
Shrunken brain = stretched veins. Tearing of bridging veins from minor trauma or an old trauma maybe weeks ago.
HA then progressive dementia.
Dx: CT (crescent shaped)
Tx: Craniotomy
This is why all patients with dementia should get a CT
Why should all patients with dementia get a CT?
Could just be chronic subdural hematoma
Ways to reduce ICP
Hyperventilation
Raise head of bed
Mannitol
Concussion
Sports injury
LOC
Amnesia (retrograde)
CT is normal
Tx: Go home but only if patient has family to keep them up. Keep them awake for 24 hrs
Diffuse Axonal Injury
Patient who had angular trauma like a car accident where car spun a lot
Presents with coma
CT shows blurring of grey-white junction
Tx = pray
Neck zones
Zone 1 = lowest. Below cricoid and above clavicle (most conservative)
Zone 2 = middle (lots of surgery here)
Zone 3 = above angle of mandible (some surgery)
When does penetrating trauma to the neck always lead to surgical exploration?
All cases where there is:
Expanding hematoma
Deteriorating vitals
Clear signs of esophageal or tracheal injury (coughing or spitting blood)
GSW to middle neck
GSW to middle neck (zone 2)
surgery always
GSW to lower neck (zone 1)
Arteriography, esophagogram (water soluble then barium if negative), esophogoscopy, and bronchoscopy before surgery to decide approach
GSW to upper neck (zone 3)
Arteriogram. If abnormal then surgery
Stab wounds to all zones
Arteriogram and U/S
Looking for expanding hematoma or active bleeding
Why is surgery uncommon for zones 1 and 3?
Blood supply is hard to control in these regions.
ALS (tract)
Pain and temperature.
lateral spinal cord, anterior
Crosses over before ascending
DCML
Vibration/Position
Dorsal, medial
Crosses over in brainstem
Motor tracts
Upper extremity more medial than lower extremity. Lateral spinal cord.
Cord Syndrome
Patient with FND
- ED, urine/fecal incont, erection that doesn’t stop
Dx = MRI
Initial trauma doesn’t do the damage. It’s the edema around it. Therefore, you can really skip the MRI and just give them dexamethasone (decadron)
Complete transection of spinal cord
At the site of the lesion you lose LMNs - paralysis
Below the site you lose UMNs - upgoing Babinsky and hyperreflexia
All sensory is lost and all pain/temp is lost.
Basically nothing works below the lesion
Hemisection
Ipsilateral loss of motor and sensory (vib/position)
Contralateral loss of pain/temp
Sharp knife trauma
Anterior Cord lesion
Burst fractures of the vertebral bodies.
Loss of motor function and loss of pain/temp on both sides distal to injury
Preserved vibration/position sense
Central Cord Syndrome
Patient is elderly with forced hyperextension of the neck (rear-end collision). There is paralysis and burning pain in upper extremities with preserved functions in lower extremities
Sort of like syrinx - cape-like distribution. May expand to include ALS.
management of spinal cord injuries
MRI: CT is easier to do if we only need to see bones.
Some think high dose steroids right after the injury may help
Pericardial tamponade - more detail
Usually seen with penetrating thoracic trauma, but blunt can cause it too.
Tachycardia, muffled heart sounds, JVD, hypotension and electrical alternans on ECG (alternating heights of R in QRS complexes)
Dx with cardiac U/S as part of FAST
Requires immediate decompression via needle pericardiocentesis, pericardial window or thoracotomy with manual decompression
Clinically apparent tamponade may result from 60-100ml of blood
Blunt cardiac trauma
Usually secondary to MVAs, fall from heights, crush injury, blast injury, direct violent trauma
Get a screening ECG
How should pericardium be opened?
anterior and parallel to phrenic nerve (longitudinally)
Pneumothorax
Can be from penetrating trauma or blunt trauma that caused a rib fracture
Air in pleural space
Usually asymptomatic. Maybe Chest pain.
Dyspnea
Hyperresonance of affected side
Decreased breath sounds of affected side
Dx: upright CXR - absence of lung markings where the lung has collapsed. Vertical lung shadow.
Tx: Tube thoracostomy in upper lung. Confirm placement with CXR
Tension pneumothorax
Air enters pleural space and cannot escape. Causes total ipsilateral lung collapse and mediastinal shift, impairing venous return and thus decreasing cardiac output resulting in shock
Same signs as pneumothorax PLUS tracheal deviation away from affected side
Dx should be clinical - don’t wait on the CXR to start treatment
Tx: immediate needle decompression followed by tube thoracostomy
Hemothorax
Dyspnea
Dullness to percussion
Reduced breath sounds
Lung compressed upward so there is an air-fluid level.
Dx: CXR shows horizontal air-fluid level
Tx: Thoracostomy in lower lung.
We need to figure out if bleed is from peripheral or pulmonary artery. Pulm vasculature is lower pressure and stops on its own.
Look at chest tube output - If 1500cc initial drainage OR 600cc in 6hrs go to surgery (thoracotomy)
25% of hemothorax cases have associated pneumothorax
75% of hemothorax cases are associated with extrathoracic injuries
Indications for thoracotomy
1500cc initial drainage from chest tube
200cc/hr for 4hrs continued drainage
- Thoracic great vessel injury
- Esophageal injury
- Patients who decompensate after initial stabilization
Sucking chest wound
ONLY from penetrating trauma from the outside (not ribs)
Breathe in: air enters
Exhale: flap closes. Air gets stuck
May get a tension pneumo
Pt = trauma, dyspnea, tension pneumo
Dx: Visual inspection
Tx: Occlusive dressing taped on 3 sides to create our own valve. THEN chest tube to drain whatever air is left.
Rib fracture
Blunt trauma usually
Can induce ANY of the penetrating traumas
CP that makes them splint - won’t breathe much. Reduced breathing leads to higher risk for atelectasis and pneumonia
Dx = CXR Tx = pain control (avoid tons of opiates) balanced with breathing
Flail chest
Flail chest is an indication for looking for problems inside the chest
HUGE blunt trauma - requires 2+ ribs broken in 2+ places
Paradoxical movement
Dx = visual inspection and CXR Tx = weights/binders to align it. Maybe surgical placement of a plate
What are the indications for investigating for problems WITHIN the chest?
Flail chest
Sternal fracture
Scapular fracture
Investigate for: Aortic dissection, pulmonary contusion and myocardial contusion
Pulmonary contusion
Get CXR - normal initially. All of a sudden the pt gets dyspnea and pulm edema
Takes 48h from trauma for CXR to show b/l whiteout
This is a non-cardiogenic pulmonary edema - a lot like ARDS
Tx = avoid crystalloids. Give colloids BUT really we treat with PEEP (push fluid back into leaky capillaries)
Myocardial contusion
Dx: prophylactic EKG and troponin
Tx: Control HF and arrythmias with MONA BASH
Aortic dissection
High speed MVAs. Torn at ligamentum arteriosum due to inertia
Patient is either DOA (total tear) or if tear is incomplete there is an adventitial hematoma
Dx: CXR - This determines index of suspicion
- If widened mediastinum, tearing CP radiating to back or dif BPs on exam then index is very high.
THEN do CT. If index is high and CT is negative do angiogram. If index is low and CT negative stop.
Tx = surgical repair. Get systolic BP as low as you can first.
Seat-belt sign
ecchymotic area found in distribution of lower anterior abdominal wall and can be associated with perforation of bladder or bowel as well as lumbar distraction fracture (Chance Fracture)
Cullen’s sign
Periumbilical ecchymosis is indicative of intraperitoneal hemorrhage
Grey-Turner sign
Flank ecchymosis indicative of retroperitoneal hemorrhage
Kehr’s sign
L shoulder or neck pain secondary to splenic rupture
Increases in trandelenburg position or with LUQ palpation
Caused by irritation of diaphragm
GSW to abdomen
All go to ex-lap
Knife to abdomen treatment
If you see:
Evisceration
Peritoneal signs
Shock
GO TO EX-LAP
If you probe the wound and cannot enter peritoneum then watch/wait. If you can enter then GO TO EX-LAP
How much blood can each compartment hold?
Head = 50cc Chest = 500cc Abdomen = 1500cc Pelvis = 2000cc Thighs = 1000cc each Ankles = 200cc each Arms = 100cc each Forearms = 50cc each
Anything below nipple and above knee then can kill you
Blunt trauma to abdomen
We need to know if patient is bleeding or not
Get FAST or CT
If bleeding then Ex-Lap
FAST
Positive if free fluid is demonstrated in abdomen
4 views used to search for free fluid (presumed to be blood in trauma patient) that collects in dependent areas and appears as hypoechoic on US
1) Morrison’s pouch (RUQ) - btw liver and kidney
2) Splenorenal recess (LUQ) - btw spleen and kidney
3) Pouch of Douglas - above rectum “bladder view”
4) Subxiphoid and parasternal views - looks for hemopericardium
Pros/Cons to FAST
Pros: Fast, noninvasive, 80-95% sensitive for intra-abdominal blood
Cons: user dependent, low specificity for individual organ injury
What are some potential iatrogenic causes of great vessel injuries?
CVP line or CP placement
Intra-aortic balloon pump placement
Overinflation of Swan-Ganz
What is the mortality associated with traumatic aortic rupture?
90% die at scene
another 50% die within 24h
How can you detect an injury to innominate or subclavian arteries?
Absent/low upper extremity pulses and BP
Increased lower extremity pulses
What are some possible sources of bleeding detected by FAST?
1 = ruptured liver
- ligamentum teres tears from inertia
- Tx = repair or lobectomy. Can do pringle (grab hepatoduodenal ligament and cut off hepatic artery/portal vein)
Ruptured spleen
- massive bleed
- has a capsule so repair is pretty easy
- if you can fix it save it
- if not sacrifice it - remember to vaccinate against encapsulated organisms
Ruptured diaphragm
- BS in thorax
- Kehr’s sign
- Get CXR
- Tx = surg
Pelvic trauma
Major MVA/Fall to break a pelvis
Use hip-rocking maneuver - will always be broken in 2 places. Can move it in 2 directions at once with extreme pain
Look for urethral injuries - high riding prostate, blood at meatus. Get an IV pyelogram and avoid foley.
May require prophylactic protoscopy to rule out rectal injury
Dx = CT (the same one we got during FAST)
Tx = give them blood and track H/H
Do NOT operate. Let the hip heal first.
25 yo F presents after high speed MVA with dyspnea and tachycardia. Local bruising over right side of chest. CXR shows a right upper lobe consolidation.
Pulmonary contusion.
First degree burn
Like a sunburn
Erythema, warm, tender
No blisters
Second degree burn
Erythema, warm, tender
Blisters
Third degree burn
Deeper than dermis (into fascia or muscle)
Painless
Surrounded by 2nd degree burns
White/charred lesions
Chemical burn
Alkali or acidic
Alkali are worse
Either on the skin - never buffer. just irrigate a ton
OR swallowed - never vomit. CAN buffer here bc it’s in stomach
Respiratory burns
Closed fire/explosion
Chemicals/smoke inhaled and may burn larynx.
Eventual edema can block the airway
Look for soot on nostrils/mouth
Dx = bronchoscopy
Tx = intubation
Electrical burns
Lightning strikes or touching high voltage wires
Entrance and exit wounds
Can cause arrhythmias
Can burn muscle in contact with bone (bones conduct electricity well). This can cause rhabdo.
Can act on nerves as well and generate muscle contractions that can cause posterior dislocation of shoulder
Dx = check CK. If positive get creatinine
Tx = IVF and mannitol
Circumferential burns
No matter the source
Initially blood vessel is patent. THEN cut off by eschar
Watch for signs of vascular compromise.
Dx = clinical Tx = cut the eschar at bedside (it's 3rd degree so it won't hurt)
Parkland formula
Tells us how much fluid we need to give burn patients
(%BSA involved)(kg body weight)(4cc) = fluids lost
Add that number of cc’s of LR to 2000cc of D5W
Replace the total as: 50% in first 8hrs. 50% in next 16hrs.
Rule of 9s
ONLY count 2nd/3rd degree burns
Whole head = 9% Chest front = 9% Upper back = 9% Abdomen front = 9% Lower back = 9% Leg front = 9% x 2 Leg back = 9% x 2 Arm = 9% x 2
Total = 99%
Genitalia = 1%
Rabies algorithm
Animal bite… was it a wild animal?
Wild: Capture it and kill it. Look at its brain. If you see signs of rabies or you couldnt catch the animal then vaccinate (vaccine + IgG)
Domestic: Observe the animal. If you see signs of rabies then vaccine + IgG
If never see signs of rabies then nothing needs to be done
bee sting
Anaphylaxis?
Yes: SubQ Epi 1:1000 + H1/H2 blockers
No: remove stinger
Snake bite
Signs it’s venomous: slit-like eyes, cobra cowl, rattlers
Patient will have skin changes, erythema and lots of PAINNN if it’s venomous.
Dx = clinical Tx = anti-venom
Black widow bite
Pt has bite and abdominal pain OR enzymatic evidence of pancreatitis**
Dx = it's pretty much too late Tx = IVF and IV Calcium to treat the pancreatitis
Brown recluse bite
Attic. Old boxes. Southern USA.
Starts off with small dot of erythema
Progresses to necrotic ulcer with ring of erythema
Dx = clinical Tx = debridement over and over. Skin grafting when toxin has resolved
Human bite
WORST ONE
Sex act or fist fight
Shady story
Dx = clinical and shady story
Tx = Debride, explore wound and irrigate a ton THEN give Abx (amoxicillin or augmentin)
