Trauma and Surgical Management Flashcards
Model trauma care systems
- Prevention
- Access
- Acute hospital care
- Rehabilitation
- Research activities
regional resource, state-of-the-science care, education, outreach, and research
Level I
provides care for trauma patients and transfer to Level I if needed
Level II
community hospital where no Level I or II exists
Level III
provides advanced trauma life support (ATLS)
and transfer
Level IV
Primary prevention
prevent the event
• Driving safety classes
• Speed limits
• Campaigns to not drink and drive
Secondary prevention
minimize the impact of the traumatic event • Seat belt use • Airbags • Car seats • Helmets
Tertiary prevention
maximize patient outcomes after a traumatic event through emergency response systems, medical care, and rehabilitation
Trauma Team
- Similar to code team
• Team members preassigned
• Trauma surgeons, emergency department physicians, and specialists
• Nurses
• Ancillary services: radiologic technologists, laboratory
technicians, respiratory therapists, and social workers
TRAUMA TRIAGE
- Essential for determining if patient needs to be transferred to a Level I trauma center
- Made by prehospital personnel
- Criteria in place to guide decision
- ABCs and lifesaving interventions
- Ground versus air transport
DISASTER AND MASS CASUALTY MANAGEMENT
- A sudden event that overwhelms EMS, hospitals, community resources
- Environmental, man-made, terrorism-related
- Internal disaster
- Disaster protocols
- Disaster debriefing
MECHANISMS OF INJURY
- Knowledge helps to identify potential problems
- Uncontrolled source of energy
- Kinetic energy
- Thermal, chemical, electrical, radiation, blast
BLUNT TRAUMA
• Severity depends on kinetic energy dissipated to the body
• Common vehicular trauma, assault with blunt objects, falls, and sports
- Acceleration
- Deceleration
- Shearing
- Crushing
- Compression
PENETRATING TRAUMA
- Impalement of foreign objects into the body
- Stab wounds are low-velocity injuries
- Ballistic trauma (e.g., gunshot injuries)
- Medium velocity: handguns, some rifles
- High velocity: assault and hunting rifles
- Velocity and missile (bullet) determine tissue damage
- Cavitation
BLAST TRAUMA
• Blunt and penetrating trauma • Tissue and organ injury • Gas-containing organ injury (e.g., eardrums, lungs, intestines) • Blast injury: • Primary • Secondary • Tertiary • Quaternary
PREHOSPITAL CARE/TRANSPORT
- Emergency stabilization and quick transport
- ABCs (with cervical stabilization)
- IV access and fluid administration
- Hemorrhage control
- Fracture stabilization
EMERGENCY CARE PHASE
• Prehospital data obtained
• Trauma unit in emergency department must always be
in a state of readiness
• Trauma surgeon must be present upon patient arrival, in the operating room, and during critical care interventions
PRIMARY SURVEY
- Done in 1 to 2 minutes
- Airway patency (with C-spine immobile)
- Breathing effectiveness
- Circulation, including hemorrhage and pulses
- Disability (overview of neurological status)
- Expose the patient, remove clothing, warm patient and trauma room
- Identify life-threatening injuries accurately to establish priorities
SECONDARY SURVEY
• Performed after life-threatening injuries are identified and treated
• Examination of all body systems:
• Full set of vital signs; focused interventions, family
presence
• Give comfort measures
• History and more thorough head-to-toe assessment
• Inspect posterior surfaces
• Maintain C-spine immobilization until cleared by x-ray
• X-ray studies (as determined by injury)
• Laboratory studies
• Tetanus toxoid administration
• Specialty physician consults
RESUSCITATION PHASE
- Time from injury to stabilization
- Focus: To establish effective circulatory volume
- ABCDEs
MAINTAIN AIRWAY PATENCY
- Many factors affect the airway (e.g., facial fractures, bleeding, vomiting, decreased sensorium)
- Open airway
- Jaw thrust or chin lift
- Nasopharyngeal or oropharyngeal airways
- Laryngeal mask airways (LMA)
- Endotracheal intubation
- Cricothyrotomy
- Facial fracture
- Unable to intubate
- Facial or upper airway burns
- Oropharyngeal hemorrhage
INEFFECTIVE BREATHING
- Ongoing assessment is essential
- Respiratory status
- Arterial blood gases (ABGs)
- Chest x-rays
- Computed tomography (CT) imaging
- Improve ventilation and gas exchange
Ineffective Breathing: Tension pneumothorax Interventions
- Needle decompression
- Prepare for chest tube insertion on affected side.
Ineffective Breathing: Pneumothorax interventions
Prepare for chest tube insertion on affected side.
Ineffective Breathing: Open chest wound interventions
- Seal the wound with an occlusive dressing and tape on three sides.
- Prepare for chest tube insertion on affected side.
Pulmonary contusion interventions
Prepare for early intubation and mechanical ventilation.
Flail chest interventions
- Prepare for early intubation and mechanical ventilation.
- Administer analgesics as ordered.
Spinal cord injury interventions
1) Avoid hyperextension or rotation of the patient’s neck.
2) Observe ventilatory effort and use of accessory muscles.
3) Maintain complete spinal immobilization.
4) Monitor for signs of distributive (neurogenic) shock.
Decreased level of consciousness interventions
1) Position the patient’s head midline with the head of the bed elevated.
2) Anticipate a computed tomography scan.
3) Implement interventions to prevent aspiration.
4) Prepare for intubation and mechanical ventilation.
Massive hemothorax interventions
1) Prepare for chest tube insertion on affected side.
2) Administer blood or blood products as ordered.
3) Anticipate and prepare for emergency open thoracotomy.
IMPAIRED GAS EXCHANGE
• Supplemental oxygen or mechanical ventilation
• Ongoing assessment:
- Oxygen saturation
- Respiratory status (rate, work of breathing, depth of ventilation, breath sounds)
- Secretion removal
CIRCULATION: HYPOVOLEMIA
• Hypovolemic shock: Acute blood loss - External hemorrhage - Internal hemorrhage • Ongoing assessment of vital signs, urine output, mental status, and hemodynamic parameters • Early rapid identification of cause
Treatment of hypovolemia
1) Stop bleeding
2) Venous access
• Two large-bore IVs
• Intraosseous IV access
• Central line may be needed
3) Administration of crystalloids and blood products
• Lactated Ringer’s is fluid of choice
• Blood administration is based on response to initial fluid resuscitation and laboratory values
• Autotransfusion an option
RESPONSE TO TREATMENT
- Rapid responders
- Transient responders: Patient is still bleeding; surgery needed
- Minimal or no responders: Emergent surgical intervention is needed to stop bleeding
ONGOING SIGNS AND SYMPTOMS OF SHOCK
- Tachycardia, tachypnea
- Narrowing pulse pressure
- Falling PaO2
- Decreasing urine output
- Increased serum lactate levels
- Falling hematocrit
