trauma and surgical skills Flashcards
what are the ABCDEs of trauma management
Airway/c spine protection
Breathing/life threatening chest injury
Circulation/stop the bleeding
Disability/intracranial mass lesion
Exposure/Environment/body temp
what is the leading cause of death in the first four decades of life
trauma
other causes of rapid death:
- major CV injury
- major neuro injurt
- -we cant do much with causes of rapid deaths, so we approach with prevention
list some causes of early death (2-4 hours post injury)
bleeding from organs (liver, spleen, kidney)
bleeding into the skull/CNS injury
orthopedic injury (long bones, pelvis)
airway compromise and pneumo/hemothoraces
**therapeutic interventions can somewhat prevent deaths from these injuries
what causes late deaths (2-3 week post injury)
infectious mechanisms
multiple organ dysfunction
what does TEAM stand for
Trauma Evaluation And Management
what are the precepts of TEAM approach
**Treat the greatest threat to life first
Definitive diagnosis is less important
Physiologic approach
**Time is of the essence
Do no further harm
what is the TEAM sequence
- rapid primary survey/resuscitation of vital functions simultaneously
- -ABCDEs
- -adjuncts - detailed secondary survey/re-evaluations of vital functions simultaneously
- -head to toe
- -adjuncts - safe transfer
- definitive care
how do you perform a primary survey generally
- assess airway patency
- assess breathing adequacy
- assess organ perfusion
- assess neuro disability/responsiveness
- assess exposures/environment
how do you assess airway patency in a primary survey
listen/look for gurgling, stridor, ventilation and oxygenation
how do you assess breathing adequacy in a primary survey
chest rise–synchronous, equal?
breath sounds and air entry
rate/effort
color/sensorium
adjunct–> CXR (great screening test for airway compromise)
example of problem–> tension pneumothorax will show decreased breath sounds, hypotension, hyperresonance, JVP change, tracheal deviation
how do you assess organ perfusion in a primary survey
loss of consciousness (brain)
skin color and temp
pulse rate and character
heart sounds and ECG
tachy? –> seen at 15% of blood loss
vasoconstriction?
hypotension? –> seen at 30% blood loss
how do you assess neuro disability/responsiveness in a primary survey
GCS (EVM-456)
seizure activity or abnormal movements
how do you assess exposures/environment in a primary survey
observe the entire patient
keep then adequately warm
list some adjuncts to a primary survey
- monitoring
- vital signs
- ABCs
- ECG
- pulse ox
- end tidal CO2 - diagnostic tools
- chest/pelvis xray
- c spine xray when appropriate
- DPL
- FAST
what are the main points of trauma resuscitation
- if in doubt, establish a definitive airway
- oxygen for all trauma patients
- chest tube may be definitive for chest trauma
- stop the bleeding!
- two large calibre IVs
- prevent hypothermia
how should you manage bleeding in a trauma patient thats causing shock?
stop it
use direct pressure or operation but avoid blind clamping
- -assess breath sounds and use CXR for thoracic bleed
- -pelvic xray for pelvic bleed (most bleeds in this area are from a pelvic fracture)
- -peritoneal U/S for abdo bleeding (FAST)
what are the components of a secondary survey
AMPLE history
head to toe physical exam (including complete neuro exam)
special diagnostic tests
re-evaluation
what is an AMPLE history
Allergies Meds Past illnesses/surgery Last meal Events/environment
on your head to toe physical exam in your secondary survey, what should you focus on in the:
head
GCS
neuro
on your head to toe physical exam in your secondary survey, what should you focus on in the:
cspine
tenderness, motor/sensory exam
xray
on your head to toe physical exam in your secondary survey, what should you focus on in the:
neck
airway injury (stridor, hoarseness, crepitus)
blunt (usually occult) or penetrating injury
on your head to toe physical exam in your secondary survey, what should you focus on in the:
chest
CXR
inspect, auscultate, palpate etc
re evaluate frequently
on your head to toe physical exam in your secondary survey, what should you focus on in the:
abdomen
hard to physically and radiologically examine but still do it
re eval frequently (can take a lot of blood before there are signs)
special tests–> DPL and FAST, CT if hemodynamucally stable
on your head to toe physical exam in your secondary survey, what should you focus on in the:
CNS
motor and sensory exam with imaging as indicated
record this well, often over time to see if improvement or worsening and how fast
what are the goals of re-evaluation in the trauma setting
minimize missed injuries
recognizing patient deterioration
when do you use mayo scissors?
heavy, hard, thick tissue as well as sutures, gauze, tubes etc
when do you use metzenbaum scissors
tissue dissection and fine work only
do not cut sutures or other materials with mets
name an absorbable stitch
vicryl
what are the most commonly used non absorbable materials in surgery
silk
linen
cotton
polyester
(silk absorbs after 2 years)
what are the three basic techniques for local anesthesia
infiltration
field block
nerve block
describe infiltration local anesthesia
0.5-1% lidocaine/xylocaine is injected throughout the area where the operation is planned
25 gauge needle (1/2 inch) is used to raise a skin wheal
underlying layers of tissue are then infiltrated with the use of a larger, longer needle (22 gauge, 1-1/2 inch)
describe field block anesthesia
field of surgery blocked by infiltration of xylocaine around the field of surgery
describe nerve block anesthesia
- formation of skin wheal with 25 gauge needle
- insertion of a longer needle through the wheal to the targeted nerve–> when needle reaches nerve, patient feels paresthesia along nerve distribution–> then needle withdrawn 2-3 mm
- aspirate the needle to make sure needle not in a blood vessel
- inject 2-5 mL of 1-2% solution in the area surrounding the nerve
how do you achieve temporary hemostasis
- digital pressure on the bleeding point
- pressing supplying areas proximal to the bleeding point
- pressing major arteries proximal to the bleeding area using pressure points
- using a tourniquet (for no more than 2 hours, and released and reapplied every 1-2 min)
- applying tamponade
how do you achieve permanent hemostasis
- ligate the artery
- sew the artery back together
- apply a biological or synthetic hemostatic material to seal the lac
- electrocoagualation of the bleeding point
- use of clips
- chemical or biological agents to vasoconstrict and coagulate
advantage of vertical mattress suture
covers deep wounds with no dead space and also everts edges for optimal healing
