Trauma Flashcards
Leading causes of injury-related death
- MVC (blunt trauma)
- suicide (penetrating trauma)
- falls (blunt trauma)
Immediate death causes
seconds-minute
- Severe CNS injury
- hemorrhage
early death causes
min-hrs (2-4hr)
- hemorrhage
- severe TBI
late death causes
late (2 weeks)
- sepsis
- MOF (multisystem organ failure)
What is the golden hour?
when most potentially preventable deaths from trauma— most likely immediate-early death (hemorrhage, severe CNS injury, severe TBI)
Describe the trauma assessment
- Rapid primary evaluation
-ID and treat immediate life-threatening conditions - Resuscitation of vital functions
-Initiate treatment and monitor patient response - Detailed secondary assessment
-ID all injuries - Initiation of definitive care
stabilize and treat vs transfer or discharge
describe the primary survey
“ABCDE” approach to identify and treat the most life- threatening condition(s) first
airway/C spine control, breathing/ventilation, circulation/hemorrhage control, disability/neuro, exposure/environmental control
*Address any problems identified BEFORE continuing the assessment
FIND the bleeding, STOP the bleeding
describe resuscitation (step 2) in the trauma assessment
- Administer O2, IV access, control hemorrhage
2. Address life-threatening conditions
what is the secondary survey
Brief history, more thorough physical exam
- SAMPLE History (brief, from pt, family or EMS)
- Head-to-toe exam (ID all injuries, log-roll the pt)
- Continued monitoring
- Additional Imaging
What are life-threatening conditions that are found in the primary assessment and that need to be addressed
- Inadequate airway
- Pneumothorax – tension, open
- Hemothorax
- Cardiac tamponade
- Hemorrhage – internal, external
How do you provide appropriate resuscitation?
- Monitor VS
- Protect airway
- Improve ventilation, oxygenation
- Control bleeding
- Prevent hypothermia
- Maintain adequate tissue perfusion
How to manage the airway (in primary assessment)
- look for signs of inadequate airway/obstruction
2. secure the airway (incubate, trach)
Signs of inadequate airway or obstruction
- Noisy breathing = obstructed breathing
- Cyanosis (late finding)
- AMS (agitated vs obtunded/somnolent)
Injuries associated with compromised/obstructed airway:
- TBI, altered LOC
- Maxillofacial trauma
- Penetrating neck trauma
- Blunt neck trauma
types of airway maintenance
- Chin-lift maneuver
- jaw-thrust maneuver: higher risk of spinal cord injury due to hyperextension of the spine
- Airway adjuncts (oropharyngeal or nasopharyngeal airway)
Indications for a definitive airway (ET intubation or surgical airway):
- Airway or breathing compromise (present or predicted)
- Unprotected airway
- GCS less than 8
- Combative or uncooperative patients who can’t otherwise be managed safely*
*get neuro exam PRIOR to chemical paralysis for intubation
Who do you want to immobilize with a C collar for C spine control:
- Unconscious or GCS less than 8
- Significant head/facial injuries
- Neurological deficit (Weakness, numbness, paresthesia’s)
- Neck pain, tenderness, limited ROM
- High risk mechanism of injury (Auto/ped, bicycle crash, MVA, falls)
*NEXUS and Canandian C-spine rules
NEXUS criteria for low probability of injury**
- no midline tenderness
- no focal neuro deficit
- normal alterness
- no intoxication
- no painful distracting injury**
- if Yes to any of these– need a C collar
- TO get the C collar off– need imaging!
Canadian criteria for detecting clinically important cervical spine injury: High risk factors
- age ove 65
- fall over 1 meter
- axial loading injury
- high speed MVC/rollover/ejection
- motorized recreational vehicle or bike collision
- presence of paresthesia
Canadian criteria for detecting clinically important cervical spine injury: low risk factors
- simple rear-end MVC
- not pushed into oncoming traffic
- not hit by a large bus or truck
- no rollover
- not hit by high-speed vehicle - sitting position in the ED
- ambulatory anytime
- delayed onset of neck pain
- no midline cervical tenderness
if someone comes in with a C collar and no NEXUS criteria what can you do?
can clear them after primary and secondary assessment if dont’ meet NEXUS criteria
How do you control the C-spine
In-line stabilization → hard collar → long board → sandbags and strap
*Logroll patient while maintaining head and c-spine immobilization
How do you assess breathing/ventilation
- VS: decrease BP, increased HR, RR can vary, decreased O2 sat, AMS
- Look: Accessory muscle use, sporadic respirations, asymmetric chest rise/fall, open chest wounds
- Listen: Absent breath sounds, dull (PTX) or hyperresonance percussion notes
- Feel: Crepitus, chest wall deformity, tracheal deviation
Hypotension can occur with:
- tension ptx,
- cardiac tamponade,
- hemorrhagic shock,
- neurogenic shock
AMS can occur with
- hypercarbia (obtunded, somnolent) vs
2. hypoxic (agitated)
What are initial resuscitative measures?
- Administer O2 by NC or bag-mask
- Obtain portable CXR
- Obtain definitive airway if inadequate ventilation
- Adequate Airway ≠ Adequate Ventilation
It is important to ID and address life threatening conditions. Common respiratory life threatening conditions to address when assessing breathing and ventilation in your primary survey includes:
- Tension pneumothorax
- Open pneumothorax
- Massive Hemothorax
- Flail chest
Signs and Sx of tension pneumothorax
- Absent breath sounds
- Tracheal deviation
- Hypoxia
- ↓BP
Signs and Sx of open pneumothorax
- “Sucking” chest wound
- Decreased breath sounds
- Hypoxia and hypercarbia
Dx: CXR or CT
Signs and Sx of hemothorax
- Decreased (but not absent) breath sounds
- Dullness to percussion
- ↓BP
tx of tension pneumothorax
Immediate needle decompression →
Chest Tube placement
tx of open pneumothorax
Occlusive dressing on 3 sides → Chest Tube placement
tx of hemothorax
Chest Tube placement
Needs for airway protection
- Severe maxillofacial fractures
- Risk of obstruction (Neck hematoma, Laryngeal or tracheal injury, Stridor)
- Risk for aspiration (bleeding, vomiting)
- Unconscious, GCS less than 8, Agitated/combative
Needs for ventilation or oxygenation
- Inadequate respiratory efforts (Tachypnea, Hypoxia or Hypercarbia, Cyanosis)
- Massive blood loss and need for volume resuscitation
- Severe closed head injury (to temporarily control ICP with hyperventilation)
- apnea (neuromuscular paralysis, unconscious)
When assessing circulation check:
- hypovolemia, shock, external hemorrhage
- VS and mental status: ↓BP, ↑HR, ↑RR, AMS
- Diminished pulses, delayed cap refill, ↑JVD
- Abnormal or muffled heart tones
- Cyanosis, cool and clammy skin
- Unstable pelvis
- Long bone fx – deformity, soft tissue swelling
What is Becks triad?
signs for cardiac tamponade
- muffled heart tone
- elevated JVD
- hypotension
Consider all injured patients who show signs of shock to have ___
hemorrhagic shock
*if trauma pt has soft BP–> do not give pressors until r/o hemorrhage
signs of hemorrhagic shock
- ↓BP,
- ↑HR,
- ↑RR,
- cool extremities,
- ↓cap refill,
- ↓UOP
5 areas where life threatening hemorrhage can occur
- Chest – hemothorax, cardiac tamponade
- Abdomen – intraperitoneal, retroperitoneal
- Pelvis – unstable pelvic fx, pelvic hematoma
- Thigh – long bone fx
- Floor – external bleeding
Initial resuscitative measures:
- STOP THE BLEEDING (possibly OR, stabilize fx)
- CXR and Pelvis x-ray
- FAST exam
- IV access – 2 large-bore peripheral IV’s, central line
- Volume resuscitation – 2 liter bolus of warmed IVF, blood products if needed
- Prevent hypothermia
signs and sx of cardiac tamponade
- Beck’s triad, pulsus paradoxis
2. Dx: FAST or US
tx of cardiac tamponade
pericardiocentesis
signs and sx of hemoperitoneum
- ↓BP, +/- abd distension
2. Dx: FAST or DPL
tx of hemoperitoneum
damage control laparotomy
signs and sx of unstable pelvis
- Crepitus, ↓BP
2. Dx: Pelvis X-ray
tx of unstable pelvis
pelvic binder
tx of external hemorrhage
direct pressure
tourniquet if amputation
What is the abbreviated/gross neuro exam
- Level of consciousness – GCS or AVPU*
- Pupils – PERRLA, anisocoria, lateralizing signs
- Motor/Sensory function* – movement of extremities, gross sensory function
How should you do a pelvic binder
Pressure point over greater trochanter!
Factors that influence the neuro exam:
- EtOH,
- drugs of abuse,
- narcotic pain medication,
- sedation,
- hypoglycemia,
- hypoxia/hypercarbia
Describe the GCS
- Eye opening (4= spontaneous, 1= no eye opening)
- verbal response (5= oriented 1= no verbal response)
- motor response (6= obeys command, 1= no response)
Total score range: 3-15
4= spontaneous, orient
**ALWAYS ROUND UP and always reassess to track progression/regression
describe the eye opening scoring for GCS
4= spontaneous 3= to verbal stimuli 2= to pain stimuli 1= no eye opening
describe the verbal response scoring for GCS for adults
5= oriented 4= confused 3= inappropriate words 2= incomprehensible 1= no verbal response
describe the motor response scoring for GCS for adults
6= obeys commands 5= localized pain 4= withdraws to pain 3= abnormal flexion 2= abnormal extension 1= no response
How do you assess AVPU?
- Alert – awake, responsive, oriented, talking
- Verbal – unresponsive at first but will respond to loud verbal stimulus (speak, grunt, groan, or gaze)
- Painful – patient does not respond to verbal stimuli but to painful stimuli (sternal rub, pinch)
- Unresponsive – patient does not respond to painful or verbal stimuli
When assessing exposure you want to undress the pt for complete exam but you want to avoid hypothermia. Do this by:
- Warm blankets
- Warm fluids and blood
- Warm room
- Control hemorrhage
**Don’t want a bleeding person cold!!
Goals of resuscitation
- Definitive airway
- Improve ventilation
- Control bleeding
- Volume resuscitation
- Prevent hypothermia
- Treat life-threatening conditions
- Tension ptx, open ptx, hemothorax, external bleeding…
Initial resuscitative measures and interventions:
- Administer 100% O2
- Resuscitate blood volume (IVF, blood products)
- Gastric decompression (NGT, OGT)
- Monitor urine output (Foley catheter)
- Prevent hypothermia (Warm blankets, Warmed IVF)
- Pulse Ox
- IV access (Peripheral +/- central)
- EKG monitoring
- Draw labs (CBC, BMP, venous lactate, TEG, tox screen, T&C)
- Rapid imaging (Portable X-rays → CXR, Pelvis, OR Bedside FAST exam)
What is your trauma lab panel?
- CBC,
- BMP,
- venous lactate,
- TEG,
- tox screen,
- T and C
What is a FAST screen and what is it used for?
FAST = Focused Assessment with Sonography for Trauma = beside ultrasound in trauma
- recognizing intraperitoneal bleeding in hypotensive patients who need an emergent laparotomy
- diagnosing cardiac injuries from penetrating trauma
- identifying a hemothorax or pneumothorax in trauma patients
Describe the history taking for a secondary survey
- Age, sex, neuro status, pt. complaints, VS, MOI
- Treatment/interventions by EMS
SAMPLE History
- Signs/symptoms
- Allergies
- Medications (Anticoagulants, insulin, β-blockers, pain meds)
- Previous medical/surgical history
- Last oral intake (Time)
- Events /Environment surrounding the injury
What PE components should you do for the secondary survey
- Head/face
- Neck
- Chest
- Abdomen
- Pelvis and perineum
- Extremities
- Spine and Neuro
important components of the head/face exam in the secondary survey:
- HEENT
- Periorbital soft tissue injuries
- Blood/CSF leak, hemotympanum (basilar skull fx)
- Intraoral injuries, loose teeth
important components of the neck exam in the secondary survey:
- Penetrating wounds
- Subcutaneous emphysema (seen w/ injuries to lung and trachea)
- Tracheal deviation
- Neck vein appearance (JVD)
important components of the chest exam in the secondary survey:
- Clavicles and chest wall for tenderness, deformity, crepitus, wounds
- Breath sounds and heart tones
important components of the abdominal exam in the secondary survey:
- Seatbelt sign or evidence of blunt trauma
- Penetrating wounds
- Tenderness, distension
important components of the pelvis and perineum exam in the secondary survey:
- Rectal examination
- Perineal trauma
- Palpate femoral pulses
- Blood in the uretheral meatus
important components of the extremities exam in the secondary survey:
- fx
- peripheral pulses
- soft tissue injury
important components of the spine and neuro exam in the secondary survey:
- Log roll the patient
- Inspect for trauma or deformity
- Palpate for step-off, tenderness, deformity
- Assess sensory/motor function
What further imaging may be indicated for definitive care?
- CT scan: head, C-spine, T/L spine, C/A/P+, CTA neck (get for possible C spine injury)
- plain films (mainly for extremities) (chest and pelvis XR in primary survey)
*non-contrast CT are not as specific for bleeding
Always perform a ___ before transferring a patient!
Primary survey
*make sure they are stable or if they need an airway or transfusion
How do you determine disposition of a trauma patient?
- Determine if patient needs to be transferred (if the needs of the patient exceed the capabilities of the health care team or institution).
- If patient needs to be transferred, further efforts should be directed towards:
- Improving patient’s vital functions, avoid further dx testing that would not add to the resuscitation and only delay the transfer process
How do you clear a C collar
- ask about neck pain and numbness and tingling in hands/feet
- remove the collar
- palpate neck and clavicle for tenderness
- pain with ROM?
a state of severe systemic reduction in tissue perfusion characterized by decreased cellular oxygen delivery and utilization, as well as decreased removal of waste byproducts of metabolism
shock
Shock in the trauma patient is almost ALWAYS ____ shock
hemorrhagic
___ is the 2nd leading cause of death related to trauma (#1 ___)
Shock (hemorrhage)
TBI
Clinical manifestations of shock
- AMS
- decreased BP
- decreased pulses
- increased HR
- increased RR
- cool, clammy skin due to blood loss
- decreased UO
Causes of shock
The pump
1. intrinsic failure: cardiogenic, anaphylactic
2. extrinsic failure: tamponade, tension ptx
The pipes
3. Pipes get larger: anaphylactic, neurogenic, septic
4. Pipes get leaky: anaphylactic
The fluid in the pipes
5. Loss of fluid: hemorrhagic
Classifications of shock and associated pathogenesis:
- hypovolemic
- cardiogenic
- obstructive
- distributives
- neurogenic
- SIRS
- hypovolemic- decrease blood volume
- cardiogenic- pump failure
- obstructive- obstructive CV flow impaired diastolic filling, excessive afterload
- distributives- excessive vasodilation
- neurogenic- loss of sympathetic tone
- SIRS- increase vascular permeability, decreased circulating plasma volume
Trauma related etiology of hypovolemic shock
- hemorrhage
2. thermal injury
Trauma related etiology of cardiogenic shock
- CV disease
- papillary rupture
- cardiac contusion
Trauma related etiology of obstructive shock
- tension pneumothorax
- cardiac tamponade
- PE
- aortic dissection
Trauma related etiology of neurogenice shock
- spinal cord injury (T6 and above)
2. drugs (benzos, opioids)
Trauma related etiology of SIRS shock
- systemic inflammatory response
2. tissue injury
Almost all forms of shock include some component of hypovolemia, as a result of decreased ___
preload
common causes of internal and external hemorrhagic shock in patients
Internal - chest, abdomen, pelvis, long bone fx
External scalp, arterial injury
signs of neurogenic shock and spinal cord injury
- normal or decreased HR
2. focal neuro exam
Neurogenic shock vs hemorrhagic shock
neurogenic:
- decrease BP and HR
- warm and dry skin
- Euvolemic–> won’t respond to fluid resuscitation
- anormal neuro exam (paralysis, weakness, numbness, etc.)
Hemorrhagic:
- decrease BP, increased HR
- cool and pale skin
- hypovolemic–> responds to fluid resuscitation
- non-focal neuro exam
How much blood is lost with Class I, II, III and IV hemorrhagic shock
I: less than 750mL (less than 15%)
II: 750-1500mL (15-30%)
III: 1500-2000mL (30-40%
IV: over 2000mL (over 40%)
What is the pulse, BP, RR and UO with Class I hemorrhagic shock
HR: less than 100,
BP: nl,
RR 14-20,
UO over 30mL/hr
What is the pulse, BP, RR and UO with Class II hemorrhagic shock
HR: over 100,
BP: normal, decrease PP
RR 20-30
UO: 20-30mL/hr
What is the pulse, BP, RR and UO with Class III hemorrhagic shock
HR: over 120,
BP: decrased
RR 30-40
UO: 30-40mL/hr
What is the pulse, BP, RR and UO with Class IV hemorrhagic shock
HR: over 140,
BP: very decreased
RR over 35
UO: negligible
What is the mental status for Class I, II, III and IV hemorrhagic shock
I- normal
II- mildly anxious
III- anxious/confused
IV- confused/lethargic/coma
What is the volume replacement for Class I, II, III and IV hemorrhagic shock
I- crystalloid
II- crystalloid
III- crystalloid + blood
IV- crystalloid + blood
What is the lethal trial of shock
- coagulopathy
- acidosis
- hypothermia
What is the initial management of shock
- IV access (2 peripheral large bore IVs, central line)
- fluid resuscitation
- 2L IVF Warmed LR or NS
- Blood products
What blood do you give to trauma patients
- O Negative (reproductive aged females)
- O positive for all others
*Type and cross early in critical patients
