Trauma, Burns, and Sepsis Flashcards
How is the initial airway evaluation performed? What signs are looked for?
determine whether the airway is clear or obstructed.
If a patient can talk, the airway is patent, at least at that particular moment.
Signs of airway obstruction include stridor, hoarseness, and evidence of increased airway resistance such as respiratory retractions (retraction of the soft tissues between the ribs during inspiration) and use of accessory respiratory muscles.
- Clear visually
- gag reflex indicates that the upper airway is most likely clear.
How are trauma patients evaluated initially in the ED?
primary survey for trauma patients. Most clinicians reassess patients again before proceeding to the secondary survey
Continual reassessment - is necessary during trauma surveys, looking for cardiovascular instability and other Significant changes, particularly neurologic changes.
ATLS initial evaluation recommends?
Airway
Breathing (ventilation)
Circulation
Disability (neurologic deficit)
Environment; expose patient (i.e., remove all clothing)
Blunt trauma may lead to what complication? How should it be managed?
Blunt trauma may also cause laryngeal edema, which may be mild when the patient is first admitted to the emergency department but become worse in the next few minutes or hours.
Hoarseness, a change in voice, or stridor are clues to this condition. If laryngeal edema is suspected, intubation is necessary, before airway obstruction occurs.
What are the indications for intubation?
–Laryngeal edema
- inadequate respiratory effort
- severely depressed mental status
- a Glasgow Coma Score of eight or less
- inability to protect the airway
- severely compromised respiratory mechanics
Treatment for simple pneumothorax?
treatment is insertion of a large-diameter chest tube. It is important to insert a finger into the pleural space prior to inserting the tube to be certain that it is in the correct space.
What is the management of a chest tube?
Youwouldplaceawatersealwithsuctionandtoallowreinflationofthelung. Serial CXRs are necessary. Removal of the tube may occur when the lung is fully inflated and no fur ther air leak is apparent.
examination indicates a laceration on the chest wall that penetrates through to the lung and “sucks” air as it moves in and out
during respiration. What is it? What is the treatment?
sucking chest wound. It should be sealed with an occlusive dressing, and a chest tube should be inserted at a different location.
After insertion of the chest tube and repeating the CXR, the lung does not fully inflate.
Either the chest tube is in the wrong location or not functioning properly. Tubes can be erroneously inserted into the subcutaneous tissues, have air leaks at their connections, or “clot off”
After insertion of a chest tube, a large amount of air continues to leak into the chest tube over the next 6 hours, and the lung remains only partially inflated.
major airway injury with disruption of a bronchus or the trachea . sometimes apparent on bronchoscopy, requires a thoracotomy and partial lung resection to repair the injury.
Can a small pneumothorax be observed
As long as it is small. Uncomplicated. Not enlarging there is no chest injury. There is no fluid in the plural space
If a surgery is required, a chest tube is always necessary, otherwise a small pneumothorax may turn into a tension pneumothorax.
You clear the airway of the patient in Case 1 2.1 . Absent breath sounds in the right chest are notable. The patient has a BP of 80/60 mm Hg. Distended neck veins are present.
hypotension and absent breath sounds, the suspected problem is a tension pneumothorax.
Treatment for tension pneumothorax?
If immediate insertion of a chest tube is not possible, needle aspiration of the left chest is nec essary. With a diagnosis of tension pneumothorax, the patient should experience immediate improvement in BP.
A patient presents with hypotension, normal breath sounds, distended neck veins. What is it? What is the treatment?
Pericardial tamponade. or myocardial contusion (usually causes arrhythmias)
Emergent pericardiocentesis or pericardial ultrasound examination, if immediately available in the trauma resuscitation unit, is necessary.
After initial drainage, the patient should go to the operating room for a pericardiaI window and examination of the pericardial contents to stop the source of bleeding
How is the initial blood loss estimated based on the patients presentation?
Blood losses of less than 15 % cause few physiologic changes;
losses of 15%-30% cause mild changes, including tachy cardia and increased pulse pressure.
Losses of 30%-40% cause severe changes in vital signs including hypotension, tachycardia, and decreased mentation.
Which stage of hemorrhage requires a blood transfusion?
Patients who suffer blood losses of 15%-30% (Class II) usually require blood transfusion, and those who suffer blood losses of 30%-40% (Class III) almost always require transfusion.
How is the adequacy of resuscitation determined?
Signs of adequate initial resuscitation include acceptable urine output and improvement in heart rate, mental status, and BP.
Other physiological variables to follow: anaerobic metabolism as measured by correction of lactic acidosis and normalization of venous oxygen saturation.
What do you do if a patient remains hypotensive despite adequate fluid resuscitation?
When a patient continues to remain hypotensive and unstable despite adequate fluid resuscitation, the most important priority is a search for the underlying cause. Urgent laparotomy or thoracotomy may be indicated.
Can a closed head injury cause hypotension?
A closed head injury typically does not cause hypotension as a result of the Cushing reflex.
Explain the Cushing reflex?
ischemic brain sends a sympathetic nervous system message to the peripheral circu lation to vasoconstrict, which maintains a normal or increased BP and thus regulates per fusion to the brain. Bradycardia also results, because the vagus nerves are unaffected by this message and respond to the increased BP with parasympathetic stimulation to the heart, causing the decreased heart rate.
How do you evaluate a cervical spine when the patient is awake and alert?
Cervical spine precautions include neck immobilization with a collar or a board, as used by paramedics. If no stabilization is in place, it is necessary to maintain in-line cervical stabilization
palpation of the neck along the posterior aspect to detect
tenderness, deformity, or other abnormalities. In addition, a rapid assessment of the basic motor and sensory function of the arms and legs is necessary.
Ask the patient to move his fingers and toes.
Lateral cervical spine radiograph
How do you evaluate the cervical spine of a patient who is comatose?
Cannot clear the cervical spine. Some surgeons will order a cervical spine MRI
The patient has loss of neurological function below the neck
neurologic deficits, radiologic abnormalities, or cervical spine tenderness are present, then a cervical spine injury should be suspected.
continued cervical spine precautions, a neurosurgical consultation, complete evaluation with imaging, and immediate administration of steroids to maximize recovery of the neurologic loss due to damage caused by edema to the adjacent areas of the spinal cord. Intubation requires extreme caution
Patient has priapism after a motor vehicle accident. What is it?
Priapism is a finding in patients with a fresh spinal cord injury. Other findings include loss of anal sphincter tone, loss of vasomotor tone, and bradycardia due to loss of pe ripheral sympathetic activity and intestinal ileus.
25-year-old man presents with a stab wound to the left chest lateral to the nipple. He is ver bally complaining of pain. His vital signs are BP, 120/60 mm Hg; heart rate, 90 beats/min; and respiratory rate, 20 breaths/min. What is it? Management?
very likely that the pleural space has been violated and that a hemopneumothorax exists.
Chest tube insertion or tube thoracostomy (> or =38F) should occur in the left side, fifth intercostal space.
You perform a tube thoracostomy, and 1700 mL of blood is evacuated. What is the next step in management?
emergent thoracotomy is usually based on where the stab wound is located (e.g., close to a vital structure such as the heart or great vessels) and the initial volume of blood evacuated. Generally, if a tube thoracostomy is placed with 1500 mL evacuated in a brief amount of time, a thoracotomy should be performed to evaluate for lung hilar injury or an injury to the heart.
When does a patient require a thoracotomy?
Usually, a blood loss of greater than 200 mL/hr for 3 hours also requires thoracotomy to evaluate the injury.
Stab want just below left nipple. What is the next step in management?
Diaphragmatic injuries may be missed on initial survey, because herniation of intra-abdominal contents into the thorax may not occur in the initial period. For this reason, if suspicion of a diaphragmatic injury is high, exploration throughout the abdomen for related injuries, in cluding the stomach, small bowel, colon, pancreas, and other visceral organs, is necessary.
One is abdominal expiration justified?
Exploration of the abdomen is justified in patients with obvious, penetrating injuries such as gunshot wounds or deep penetrating lacerations, as well as in unstable patients with a rapidly expanding (distending) abdomen o r severe abdominal pain.
What is DPL? When is it most useful?
Diagnostic peritoneal lavage - small midline incision is made and the peritoneum is opened. The urinary bladder must be emptied prior to this test to avoid injury to the bladder. If 10 mL or more of gross blood is encountered on opening the peritoneum, the test is positive, and the ab domen is closed.
A positive DPL is an indication for exploration.
DPL is most useful in situations in which the diagnosis of abdominal injury is not clear and hemodynamic instability is present.
What are the drawbacks to a diagnostic peritoneal lavage?
may miss injuries to retroperitoneal structures such as the duodenum and pancreas if there is no communication between the injury and the peri toneal cavity.
What is a FAST test? When is it useful?
focused assessment with sonography for trauma (FAST). Complete an ultrasound examination of the four quadrants of the abdomen to check for the presence of fluid. Fluid, presumably blood, indicates the presence of an in jured organ.
technique is particularly useful for detecting blood and pericardial effusion
When is CT preferred over FAST and DPL?
CT scanning is used in stable patients with unclear abdominal injuries or a mechanism of injury that warrants further investigation.
A patient complains of severe diffuse abdominal pain. What is the best next step in management?
Severe pain, which is a sign of Significant irritation to the peritoneum from blood or in testinal contents, is an indication for exploration without further tests. In centers with FAST ultrasound examination or CT scanners in the trauma receiving unit, either FAST or CT is a useful method for determining whether fluid is present in the peritoneal cav ity, which would confirm an injury.
