Trauma Flashcards
Triage: mechanism of injury that makes something a “major trauma”
- Falls >20 ft (adult)
- Falls 2x height of child
- High risk auto: intrusion, ejection, death of occupant, vehicle data high risk
- Auto-bike: thrown, run-over, >20mph
- Motorcycle: >20mph
Triage: clinical info that makes something a “major trauma”
- Penetration injury to head/neck/torso/proximal extremities
- ≥2 long bone fx
- Amputations, crushed, mangled extremity
- Burns + multi-trauma
- Paralysis
- GSC ≤13
- SBP <90
- RR <10 or >29 or vent support needed
What is the 1st, 2nd, and 3rd peak in the trimodal death distribution?
1st: immediate
2nd: minutes - hours
3rd: days - weeks
What are the causes of death in the 1st peak of the trimodal death distribution?
- High C spine
- Brain injury
- Great vessel injury
How do we treat pt. the 1st peak of the trimodal death distribution?
Prevention!
What are the causes of death in the 2nd peak of the trimodal death distribution?
- Intracranial injury
- Pelvic fx
- Abd & lung injuries
How do we treat pt. the 2nd peak of the trimodal death distribution?
Good pre-hospital and ATLS care
What are the causes of death in the 3rd peak of the trimodal death distribution?
- Sepsis
- MSOF
How do we treat pt. the 3rd peak of the trimodal death distribution?
Good ATLS & inpt. care
Injuries are the #__ reason for death in persons <45 and #__ leading cause of death overall
1; #3
Injuries: ___ are minor, ___ are moderate
1/2; 1/3
Trauma related mortality is __%
5
What 3 types of injuries have the highest case fatality rate?
- Suffocation
- Drowning/submersion
- Firearms
3 leading causes of trauma injury
- Falls (esp children <7, elderly >75)
- MVC (esp adolescents, young adults)
- Firearm (12-22yo)
Most likely cause of shock in trauma pt.
Hemorrhage
Class I hemorrhage:
Blood loss: up to 750ml, up to 15% Pulse rate: <100 BP: normal PP: normal or increased RR: 14-20 UO: >30ml/hr Cognition: slightly anxious Fluid replacement: crystalloid
Class II hemorrhage:
Blood loss: 750-1000ml, 15-30% Pulse rate: >100 BP: normal PP: decreased RR: 20-30 UO: 20-30ml/hr Cognition: mildly anxious Fluid replacement: crystalloid
Class III hemorrhage:
Blood loss: 1500-2000ml, 30-40% Pulse rate: >120 BP: decreased PP: decreased RR: 30-40 UO: 5-15 Cognition: anxious, confused Fluid replacement: crystalloid + blood
Class IV hemorrhage:
Blood loss: >2000ml, >40% Pulse rate: >140 BP: decreased PP: decreased RR: >35 UO: negligible Cognition: confused, lethargic Fluid replacement: crystalloid + blood
Hemorrhage general trends as it increases in severity (Class I-IV)
Blood loss (ml, %): ↑ Pulse rate:↑ BP: ↓ PP: ↓ RR: ↑ UO: ↓ Cognition: anxious → confused → lethargic Fluid replacement: add blood to crystalloid in class III
Mechanism of injury: frontal impact of MVC
Suspected injury pattern:
- Cervical spine fx
- Anterior flail chest
- Myocardial contusion
- PTX
- Traumatic aortic disruption
- Lacerated spleen/liver
- Posterior fx or dislocation of hip or knee
Mechanism of injury: side impact
Suspected injury pattern:
- Contralateral neck sprain
- Cervical spine fx
- Lateral flail chest
- PTX
- Traumatic aortic disruption
- Diaphragmatic rupture
- Fx spleen/liver/kidney
- Pelvis fx
Mechanism of injury: rear impact
Suspected injury pattern:
- Cervical spine injury
- Soft tissue neck injury
Mechanism of injury: ejection
Suspected injury pattern:
Greater risk for all injury mechanisms
Mechanism of injury: MVC vs. pedestrian
Suspected injury pattern:
- Head injury
- Traumatic aortic disruption
- Abd visceral injuries
- Fractured LE/pelvis
Who gets a C collar?
EVERYONE in major trauma
__% of unconscious trauma pt. have a serious C-spine injury
10%
What fraction of spine injuries are cervical?
2/3
What cervical vertebrae are most commonly affected?
C2, C5
Presumptive evidence for an unstable c-spine fx
Para or quadriplegia
1 reason for fetal demise
Maternal shock/death
CV changes during pregnancy that conceal shock
- CO increases
- Plasma volume increases
- Blood loss directs blood away from uterus
Fetus is most vulnerable to radiation in what trimester
1st
When to admit a pregnant pt. after trauma
- Bleeding
- Cramping
- Amniotic fluid leak
- Hypovolemia
- Fetal distress concerns
If a fetuses EGA is _____, the mothers is referred to OB care after initial trauma eval (major trauma has been ruled out)
> 20 wks
If a fetuses EGA is _____, the mothers remains in the ED for monitoring (major trauma has been ruled out)
<20 wks
In what ways do pediatric airways differ from adult airways?
- Large tongue
- Glottis more anterior & superior
- Occiput is large, slight flexion is supine (place rolled towel/pad under neck or shoulders to achieve extension)
M/C cause of death in children
MVC
M/C pediatric injury
Falls
If children do not respond to a 40cc/kg fluid bolus, what should they be given
10cc/kg bolus of PRBC’s
Children are more susceptible to what two “environmental” conditions
Hypotheramia, hypoglycemia
Factors that make pt. difficult to intubate
- Obesity
- Short neck
- Large incisors, tongue
- Narrow mouth
- Limited neck mobility
Mallampati Class I (what’s visible)
Soft palate, uvula, fauces, tonsilar pillars
Mallampati Class II (what’s visible)
Soft palate, uvula, fauces
Mallampati Class III (what’s visible)
Soft palate, base of uvula
*considered difficult to intubate
Mallampati Class IV (what’s visible)
Hard palate only
*considered difficult to intubate
Indications for RSI
- GCS <9 w/ gag reflex
- Facial trauma
- Head injury, stroke
- Burn pt. w/ airway involvement
- Resp exhaustions (asthma, CHF, COPD w/ hypoxia, & failure of non-invasive support)
- Overdose w/ AMS
- COVID-19
7 P’s of RSI
- Preparation
- Pre-oxygen w/ 100% O2 for 4-5min
- Pre-medicate (etomidate or midazolam)
- Paralytic (succinylcholine or rocuronium)
- Pass tube
- Proof of placement (listen, CXR, EtCO2)
- Post intubation care (secure tube, ventilate)
Highest risk age for both TBI and SC injury
15-24yo
ETOH present in ~__% of TBI
50%
Primary brain injury vs. secondary brain injury
1 = direct insult 2 = cellular damage following 1
What is cerebral autoregulation?
Allows for constant cerebral blood flow across a range of arterial pressure (as long as BBB is maintained)
How does an increase in PCO2 (d/t apnea, respiratory depression following TBI) affect……
- CBF
- ICP
- CPP
- CBF ↑
- ICP ↑ (also ↑ d/t edema, expanding mass)
- CPP ↓
What is the Monroe-Kelli Doctrine
= Total volume of the brain parenchyma, cerebrospinal fluid, and blood remains constant
- Least compressible is brain
- CSF first to decrease (& venous flow)
- Blood may decrease, but maintains adequate perfusion d/t autoregulation
- herniation begins after you can’t let off anymore CSF or venous blood
How does increased ICP affect BP and HR? What is this phenomena called?
↑ BP, ↓ HR
= Cushing’s reflex
How to reduce ICP?
Raise HOB, IV mannitol
Causes of TBI
- Concussion (mTBI)
- Epidural, subdural, intra-cranial, SAH hemorrhage
- Cerebral contusion
- Diffuse axonal injury
- Penetrating cranial injury
- Skull fx
Adult head CT indications
Head trauma +…….
- GCS <15 after 2 hours
- GCS<13
- Skull fx
- Age >65
- LOC >5 or anterograde amnesia
- Dangerous mech
- Recurrent vomiting
- Alcohol intox
- Pt. on anticoags/antiplts
Epidural hematoma (mech, presentation, dx, tx)
Mech: direct blow to temporal region
Presentation: LOC, return to consciousness, then AMS (lucid interval), dilated + fixed ipsilateral pupil (uncal herniation)
Dx: lenticular lesion on CT
Tx: emergent craniotomy & clot evac
Subdural hematoma (mech, presentation, dx, tx)
Mech: falls, acceleration, deceleration
Presentation: focal deficits, depressed MS
Dx: cresent shaped lesion on CT
Tx: emergent craniotomy & clot evac if decompensation
Which has poorer prognosis: epidural or subdural?
Subdural
Decorticate positioning represents ________ lesion and pt. demonstrates ______ of the UE
Hemispheric lesion; flexion
Decerebrate positioning represensts ________ lesion and pt. demonstrates ______ of the UE
Brainstem lesion; extension
If a neck injury violates the platysma muscle, what is the next step in mgmt
Consult surgery
Neck injury - zone I
Extends from manubrium of the sternum to the bottom of the cricoid
Neck injury - zone II
Extends from bottom of cricoid through the body of the mandible
Neck injury - zone III
Above the body of the mandible
Management of zone I, III injuries
Testing to r/o injury (CT, angio, esophageal studies)
Management of zone II injuries
Surgical exploration, routine or selective testing
What functions do you lose with…..
Central cord lesion
Anterior cord lesion
Brown Sequard
Central: motor (UE >)
Anterior: paralysis, pain & temp
Brown Sequard: ipsilateral motor, contralateral pain & temp.
SC injuries above what cervical vertebrae require mechanical ventilation and why?
C4
Phrenic n. (supplies diaphragm) is innervated by C3-5
Indication for operative thoracotomy w/ a hemothorax
- Initial tube drainage >20 cc/kg or 1500 cc
- Continued bleeding > 7 cc/kg/hr for 3-4 hr
- Persistent hypotension despite resuscitation
- Lack of lung re-expansion
M/C potentially lethal chest injury
Pulmonary contusion
1 and #2 solid organ injury
#1 spleen #2 liver
Indications for immediate laparotomy w/ blunt abd trauma
- Hypotensive pt. w/ peritoneal signs
- (+) FAST US w/ hypotension
- Free air (abd or retroperitoneum)
GSW most often injure
Large & small bowel
Stab wounds most often injure
Liver & small bowel
Indications for immediate laparotomy w/ penetrating abd trauma
- Hemodynamic instability
- Any GSW
- Peritoneal signs
- Evisceration
- Signs of fascial penetration (do NOT prob wound)
Mechanism of most GU trauma
Blunt
Indication for CT in penetrating renal trauma
Any hematuria
Indication for CT in blunt renal trauma
- Frank ecchymosis
- Gross hematuria
- BP <90
- Known abd injury
Indications for surgery/embolization in renal trauma
- Expanding/pulsatile/non-contained hematoma
- Renal avulsion
Tx of renal injury w/ contusion & micro hematuria
D/C, UA in 1 wk
Tx of renal injury w/ gross hematuria or high grade
Admit for ob
M/C GU injury in kids
Renal contusion
When do we use CT in kids w/ GU injury
> 50 RBC/HPF
What type of bladder injury is M/C and how is it managed?
Extraperitoneal - place foley
What is the most important part of your exam with penetrating extremity trauma
Assessing arterial injury
“Hard signs” of penetrating extremity trauma
- Absent/diminished pulses
- Obvious arterial injury
- Expanding hematoma
- Bruit/thrill
- Distal ischemia
