Trauma Flashcards
leading causes of trauma mortality
- head trauma - 40%
- hemorrhagic shock
2-4% of blunt traumas have
concurrent C-Spine injuries
70% of blunt airway injuries
also have C-Spine injuries
flail chest diagnosed with
- two or more sites of at least three adjacent rib fractures
- rib fractures associated with costochondral separation or sternal fracture
open pneumothorax is a concern for
vascular air entrainment
definitive tx of trauma shock
operative control of bleeding
expect major bleeding with
- falls from greater than 6 feet
- high energy deceleration injury
- high velocity GSW
C/I to cricothyroidotomy
- children under 12 - permanent laryngeal damage may occur
- suspsected laryngeal trauma - uncorrectable airway trauma may occur
Blunt Airway Injury Symptoms
- hoarseness
- muffled voice
- dyspnea
- stridor
- dysphagia
- odynophagia
- cervical pain
- tenderness
- ecchymosis
- subQ emphysema
Airway management of blunt/penetrating airway trauma
- CT if feasible
- FOB or surgical airway
- Laryngeal damage precludes cricothyroidotomy - trach distal to penetrating wound
Interventions for tension pneumothorax
- needle decomprssion 2nd ICS at mid clavicular line - inferior border of 2ICS
- CT, mid-axillary line, 5th ICS
flail chest diagnosis
- 2 or more sites of at least 3 adjacent rib fractures
- rib fractures are either sternal fracture or costochondral separation
flail chest interventions
- will deteriorate over 3-6 hours
- ARDS is very likley if lung contusion >20%
- better to focus on analgesia and maintain adequate excursion and oxygenation
- may need epidural or thoracic paravertebral block
- evaluate for co-existing trauma (hemothorax, pneumothorax)
- Automatic intubation - NOT reccomended, O2 supplementation + Non invasive PPV
sx of tension pneumo
- cyanosis
- tachypnea
- hypotension
- neck vein distention
- tracheal deviation
- diminished breath sounds on affected sides
blunt thoracic trauma that arrives pulseless has survival rate of
<1%
Tachycardia may be absent in hypotensive trauma patients
- up to 30%
- because of Bezold-jarisch reflex
- increased vagal tone
- chronic cocaine use
injury without compensation of tachyardia
increases mortality
most consistent pediatric VS change for early volume loss
narrow pulse pressure
pediatric pts only decompensate after
35-40% of blood volume loss
Base Defecit
- -2 to -5: mild shock
- -6 to -9: moderate shock
- over -10: severe shock
lactate, free radicals, and other humoral factors released by ischemic cells
all act as negative inotropes
cardiac dysfunction in shock
is a late and often terminal sign.
Cardiac is preserved from ishcemia r/t neuroendocrine response to hemorrhagic shock.
Gut response to hemorrhagic shock
One of the earliest organs affected by hypoperfusion; may be the prime trigger of MSOF.
skeletal muscle response to shock
- release lactic acid adn ree radicals, tolerate ischemia better than other organs
no cross-match and severe hemorrhage:
- O+ positive PRBCs (except women of childbearing age)
- AB- FFP
normal lactate
- normal lactate = 0.5 to 1.5 mmol/L
- levels over 5 mmol/L = significant lactic acidosis
permissive hypotension not possible with
- TBI
- SCI
- elderly with chronic hypertension
administration of large volumes of LR/NS
administration of large volumes of lacatate/NS
- LR: increases lactate
- NS: increases base defecit
large volumes of crystalloid infusion found to be an independent cause of
- ARDS
- abdominal compartment syndrome
components of the coagulopathy of the trauma patient
-
ATC: acute trauma coagulopathy
- develops shortly after trauma and is caused by hyperfibrinolysis and severe tissue injury that releases tissue factors, which in turn activates the coagulation pathways
- this type of coagulopathy appears to be independent of hypothermia/diluation of factors
-
RAC: resuscitation associated coagulopathy
- caused by hypothermia, fluids, and possibly other resusctation related factors
Primary objective of the early management of brain trauma
prevent or alleviate the secondary injury process that may follow any complication that d ecreases the oxygen supply to the brain, inlcuding:
- systemic hypotension
- hypoxemia
- anemia
- raised ICP
- acidosis
- possibly hyperglycemia >200 mg/dL
Patients with GSC <8 have a 40% likelihood
of an intracranial hematoma
most important therapeutic maneuvers in brain injury patients:
avoid hypotension, hypoxemia, anemia, raised ICP, acidosis, glucose
normalize:
- BP - MAP >80 mmHg
- PaO2 >95%
- ICP <20 to 25 mmHg
- CPP at 50-70 mmHg (MAP - ICP)
preferred fluid for head trauma
NS > LR
- LR is slightly hypotonic
mannitol/hypertonic NS
- mannitol - 0.25 - 0.5 g/kg over 30-60 minutes
- hypertonic: 15%NS, 0.42ml/kg
most damaging insult to brain:
hypotension/hypoxia
brown-sequard syndrome
- ipsilateral motor and contralateral sensory defecit below the injury
tx for pericardial tamponade
- must maintain preload
- must maintain contractility
- prefer to evacuate under local anesthesia
s/sx of abdominal compartment syndrome
- tense, severely distended abdomen
- increased peak airway pressure
- CO2 retention
- oligura
- intra abdominal pressure >20-25 mmHg signals decrased perfusion and may require surgical decompresion
25% of pelvic fractures
- lead to major hemmorhage (major cause of mortality)
- exsanguination occurs in 1% of all injuries
- most cases, bleeding results from venous disruptions by fragments of bone
- approx 18-20% of pts havebleeding that does not stop (needs embolization)
R value =
- reaction time, initial fibrin formation
- rough approximateion of PT/aPTT/intrinsic clotting
problem here = coagulation factors, give FFP
K time
K time
- time taken to minimal sufficinet clot strenth
- depends on fibrinogen
- tx with Cryo (fibrinogen)
alpha angle
- slope between R and K
- fibrin build up and cross linking takes place
- depends mostly on fibrinogen level
- if problem: cryo
MA
maximum amplitude
- represents the utlimate strength of the fibrin clot, overall stability of the clot. Depends on fibrinogen and plt function
- if problem; plts and/or DDAVP
Protein C inhibits
- clotting factors V and VIII
- contributes to coagulopathy
- decreases the inhibition of TPA
FDP >40mg/mL
Is suggestive of DIC
cryoprecepitate contians
- factor 8
- fibrinogen (1)
- VWB
- fibronectin
- Factor 13
used primarily to replace fibrinogen
effects of hypothermia
- acidosis, hypotension, coagulopathy
- cardiac depression and ischemia
- arrthymias
- peripheral vasoconstriction
- impaired tissue oxygenation delivery
- elevated oxygen consumption during rewarming
- blunted responses to cathecholamines
- increased blood viscosisty
- elevated acidosis, electrolyte imbalances,
- reduced drug clearance
- infection
occult hypoperfusion syndrome
common in post operative trauma patients, particularly young ones.
Syndrome is characterized by a normal BP maintained by systemic vasoconstriction; decreased intravascular volume and CO and organ ischemia
kleihauer-Betke test
has fetal blood entered mom’s circulation?
If yes and Mom is Rh- carrying an Rh+ fetus, then give Rhogam.
