TRauma Ch 30 Flashcards
1 cause of death for 1-44yos
Trauma
Leading cause of death for 17-33yos
Suicide
Law that states a body at rest will remain at rest, unless acted on by an outside force. Similarly, an object in motion, will remain in motion, until acted upon by an outside force.
Newton’s 1st law of motion
Law that states the force that an object can exert is equal to the product of its mass & acceleration/deceleration. The greater and object mass and/or acceleration, the greater the force that needs to be applied to change the objects course or stop it.
Newton’s 2nd law of motion
Law that states that energy can be neither created nor destroyed; it can only change form.
Law of Conservation of Energy
Height of falls that gives you a high index of suspicion
Adults: 15ft or 3x’s pts height
Child: 2x’s pt height
Or ground level fall w/LOC
Hypotension & lack of JVD in supine pt is an indication of…..
Hypovolemia
What temp does something have to be to cause damage to the skin?
111 degrees Fahrenheit
The study of physiology & mechanics of living organisms
Biomechanics
The study of the relationship among speed, mass, direction, of force, & physical injury caused by these factors.
Kinetics
Which organs are easily compressed?
Organs w/gas in them
Which organs are less compressible?
Liquid containing organs
How much blood can you lose w/pelvic fx?
1500ml-2,000ml
Treat w/fluids, titrate to effect
The speed at which an object travels in a given unit of time.
Velocity
The downward acceleration that is imparted to any object moving towards the earth, caused by the effect of earth’s mass.
Gravity
Energy from motion….
Mechanical energy
Is found in the force of 2 moving vehicles colliding
Kinetic energy
Energy stored in an object
Potential
Such as a brick sitting on the ledge of a building,
The gravity would be the potential energy source. It is converted to kinetic energy if the object falls.
What type of energy is found in explosive’s or reaction from an ingested or medically delivered agent or drug?
Chemical Energy
What type of energy is transferred from hotter sources than the body?
Thermal Energy
(Flames, hot water, steam)
What type of energy is transferred from electrocution or lightening strikes?
Electrical Energy
What type of energy results from sudden changes in pressure, such as flying or scuba diving?
Barometric Energy
How to determine “Force”
Mass X Acceleration/Deceleration
Amount of force that is unsurvivable
37 G force
Injuries from Head-On Impacts
Head Injuries
Cervical Spine Injuries
Torn Aorta
Tearing or Shearing injuries to internal injuries
Crush & compression injuries
Injuries from “Down-and-under pathways”
Knees
Femur
Pelvis
Tibia/Fibula
Injuries from “Up-and Over Pathway”?
Head Injuries
C-Spine Injury
Laryngeal Fractures
Soft Tissue Injuries
How to assess for disability?
GCS
Pupil Size, equality, & reactivity
Evaluate pulse, motor, & sensation in extremities
BG will be slightly elevated, pupils will be slightly dilated, following trauma, d/t…
Fight or Flight
Closed Head injury w/ICP, what is the 2 most important things you can do for these pts?
Never let systolic BP get below 90
Never let O2 SAT get below 90.
Elevate head at least 30 degrees.
Contraindications for Lactated Ringers:
Crush Injury Pts (Potassium, intracellular) crush will send potassium into blood, you don’t want to add more potassium to the blood
Renal Pts
Benefits of LR, especially in burns….
Lactate - body detox’s it and turns it into bicarb
Trauma Lethal Triad
Acidosis
Coagulopathy
Hypothermia (cold blood doesn’t clot)
Criteria for Trauma Center
GCS - 13 or less
SBP of less than 90
RR of less than 10
Penetrating wounds to head/neck/torso/extremities
Chest instability
2 or more long bone fx’s
Crushed/Mangled Extremity
Amputation proximal to wrist/ankle
Pelvic Fx’s
Skull Fx’s
Paralysis
Criteria to consider MOI w/high index of suspicion:
Falls: more than 2x height, or what they land on, LOC
High-Risk MVC
Pedestrian/Bicycle vs car
Motorcycle crash at more than 20mph
Special Considerations for Trauma Centers:
Older than 55YO
Children to Ped appropriate facility
Anticoagulant use
Pregnancy
Burns
Provider Judgement
When making transport decisions, what factors will you take into consideration?
Time
Extent of Injuries
LZ’s
Extended extrication time
Terrain
Distance to trauma center is over 20-25 mins
Pt needs ALS, & no ALS ground level is available
Traffic Conditions
Trauma Center capability
Stroke Volume X Heart Rate
Cardiac Output
How much blood can you lose before you can no longer compensate?
20%
Normal ejection fraction
55-70%
Anytime your QRS gets over 170, what will your ejection fraction be?
Below 50%
Plasma makes up how much of the blood volume?
55%
Plasma is made up of …
Clotting factors
Proteins
Calcium
What carries blood away from the heart?
Arteries
What transport blood back to the heart?
Veins
RAAS - System
Renin
Angiotensin
Aldosterone
Syndrome
Endocrine system responds to changes by secreting what?
Aldosterone - Retains sodium in blood
ADH
3 steps of hemostasis….
Vasoconstriction
Platelet Aggregations
Fibrin Formation
Fibrin/Fibrinolytics
Hemophilia 8-9 - Christmas factor - Know about hemophilia
Inadequate blood volume is what type of shock?
Hypovolemic Shock
Compensated Shock (Class I & II)
Decompensated Shock
Irreversible Shock
Signs of Compensated Shock
Signs of of Decompensated Shock
Oliguria - less than 500ml per day
Estimated blood loss with each bone break…
Radius/Ulna - 250ea
Humerus - 500ml ea
Femur - 1500ml ea
LEAN - ET tube adm.
Double dosage + Flush
Lidocaine 100mg
Epi
Atropine
Narcan
Skins role in maintaining homeostasis in the body…
Protection
Temp & Fluid Regulation
Sensory nerves
Responds to injury w/inflammation
Pts with burns may have trouble with…..
Thermoregulation
Inability to sweat
Impaired vasoconstriction & vasodilation
Little or no melanin (at risk for sunburns)
Inability to grow hair
Little or no sensation
Which layer of skin contains nerve endings, blood vessels, sweat glands, and hair follicles?
Dermis
Which layer is the thick layer of connective tissue between the dermis & underlying bone & muscle?
Subcutaneous
What occurs becuase of fluid loss across damaged skin & series of volume shifts within the body (Intravascular volume oozes into the interstitial spaces?
Hypovolemic shock
What limits distribution of O2 & glucose & hampers the ability to remove waste products?
Shock
What temp can cause thermal burns?
118 degrees F, 47.8 degrees Celsius
The severity of the burns directly correlates with what?
Temperature
Concentration
Duration of exposure
(More severe for trapped pts in an enclosed space w/toxins)
Type of burn that only involves the epidermis; skin is red & swollen, usually no blisters, will heal in 2-3 weeks….
Superficial
Which type of burn involves dermis & epidermis?
Partial Thickness
Which type of burn destroys both layers of skin; the skin is unable to self-regenerate, may appear white & waxy, or brown & leathery, or charred; sensory nerves are destroyed?
Full-Thickness Burns
Which type of burn involves all layers of the skin, along with fat, muscle, bone, or internal organs? Sensory nerves are destroyed & may lead to debilitating/disfiguring injuries.
Subdermal burns
Most fire related deaths are caused from….
Smoke/Superheated gas inhalations
Exposure to fire smoke causes:
Thermal burns to airway
Hypoxia
Tissue damage
What binds to receptors sites 250x’s more easily than O2?
Carbon Monoxide
Signs of airway involment from fire/smoke…
Hoarseness
Cough
Stridor
Singed facial/nasal hair
Facial burns
Anyone with suspected burn to airway could benefit from humidified O2.
Treatment for burn victims
Listen to stridor, Early Intubation could be life saving!!
Fluid Rescusitation.
Do not delay transport to try multiple IV attempts.
Rule of 9’s for adult:
Which parts are 9?
Which parts are 18?
Each arm is 9 (4.5 front, 4.5 back)
Torso & back, each 18
Legs 18 (9 front, 9 back)
Rule of 9’s for Peds:
Which parts are 9?
Which parts are 13.5 or 16.5?
Which parts are 18?
Arms: 9 (4.5 front, 4.5 back)
Head 18 (baby) 12 (child)
Legs 13.5 (baby) 16.5 (child)
Burns involving hands/feet/face/genitalia
Full thickness for than 10% of TBSA
25% or more TBSA Under 10yo, over 50YO
High voltage Electrical burns
Chemical burns
Are classified as what type burns?
Major
Superficial burns covering more than 50% of TBSA
Low voltage electrical burns
Full thickness burns involving 2-10% of TBSA
15-25% TBSA for under 10yo or 55YO & older
Are classified as what type burns?
Moderate
Full thickness burns covering less than 2% of TBSA
Superficial burns less than 50% of TBSA
Classified as what type of burn?
Minor
Only treat burns, once what is managed?
Airway
How to treat burns?
Cold compresses (no ice, ointments, or creams)
Apply dry, sterile, non adherent dressings.
Wounds associated with electrical burns….
Entrance & Exit wounds
(400 deaths & 4,400 injuries per year)
What type of internal injuries are associated with electrical burns?
Asphyxia
Cardiac Arrest
Nervous System Disruption
Which nerve constricts the pupils & is responsible for motion of the eyeball?
Occulomotor
Which nerve provides the sense of vision?
Optic
How many permanent teeth do we have?
32
LeFort fx’s
Numbness of the chin, inability to open the mouth, or TMJ dislocations could indicate what type fx?
Mandibular
Massive facial swelling, instability of mid facial bones, or elongated appearance of the face could indicate what type fx?
Maxillary
Infraorbital hypoesthesia, enophthalmos tramaticus, massive nasal discharge & CSF, impaired vision, & paralysis of upward gaze could indicate what type fx?
Orbital
Flattened appearance of face, paralysis of upward gaze, or loss of sensation over cheek, nose & upper lip could indicate what type of fx?
Zygomatic
Bleeding into the anterior chamber that obscures vision?
Hyphema
If hyphema or rupture of the globe is suspected, you should….
Take spinal precautions
Do not try & manipulate or reposition it
How to treat eye burn caused by UV light?
Sterile, moist pad & eye shield
Cool compress
Supine position
How long do you irrigate chemical eye burns?
5 mins
Ruptured eardrums can be caused from….
Direct blows
Foreign bodies
Pressure-related injuries
How to treat ear injuries….
Dressing between ear & scalp
roll gauze
Ice pack
Treatment for ear avulsion….
Partially Avulsed:
Realign ear into position
Slightly moistened bandage (normal saline)
Completely Avulsed:
Wrap ear into saline moistened gauze
Place in plastic bag
Place bag on ice
To reimplant an Avulsed tooth…..
Place tooth back in its socket
Have the pt bite down to hold it in place.
How to care for an Avulsed tooth…
1.) handle by crown only
2.) rinse too w/milk or normal saline
3.) Place tooth in cold milk
4.) wrap in cling film
5.) transport tooth with pt
Zones for neck injuries…..
Zone I - lower neck, clavicle area
Zone II - soft tissue, chin area
Zone III - upper neck, mouth area
Stretching or tearing of ligaments…
Sprain
Stretching or tearing of muscle or tendon…
Strain
●Protects underlying tissue from injury
●Aids in temperature regulation
●Prevents excessive water loss
●Acts as sense organ
●Responds to injuries with inflammation
Skin
●Nerve endings
●Blood vessels
●Sweat glands
●Hair follicles
●Sebaceous glands
Dermis
Common blood thinner names….
Warfarin
Coumadin
Eliquis
Plavix
The bodies naturally blood-clotting mechanism.
Hemostasis
Horizontal fx of the maxilla that involves the hard palate & the inferior maxilla, separating it from the rest of the face.
Le Fort I fracture
A fracture w/ a pyramidal shape, involves the nasal bone & inferior maxilla.
Le Fort II fracture
Fracture of all mid facial bones, separating the entire mid face from the cranium…
Le Fort III Fracture
Le Forte III fracture with a concurrent frontal bone fracture
Le Forte IV fracture
Excessive collagen formation can occur if healing phases are not balanced, leads to …..
Hypertrophic Scar
Keloid
Fluid Resucitation Formula
2-4ml X body weight X Percentage of TBSA
Electrical Burn should receive around 4L. Thermal burns should be……
Less
The first half of fluid administration should be administered within what time?
8hrs from the time the pt was INJURED
What part of the eye is most often injured from thermal burns?
Eyelid
The central area of skin that sustains the most damage.
There is little or no blood flow to the injured tissue in the area, resulting in necrotic tissue in this area.
Zone of Coagulation
Peripheral area surrounding the zone of coagulation has decreased blood flow & inflammation. May undergo necrosis within 24/48hrs, if perfusion is compromised by hypovolemic shock. The care you provide will be crucial to whether these cells survive or not.
Zone of Stasis
The area least affected by thermal injury. In this area, the cells will typically recover in 7-10 days, so long as perfusion is adequate & infection is controlled.
Zone of Hyperemia
Why no moist dressings on burns?
Loss of fluids, decreased thermoregulation, cool blanket will make them shiver
4th, 5th, & 6th degree burns, all layers on skin have been damaged, along with layers of fat, muscle, bone, or internal organs.
Subdermal Burns
Highly water-soluble gases (ammonia) primarily affect which part of the airway…..
Upper Airway - And are usually immediate
Moderately water-soluble gases (chlorine) primarily affect which part of the airway…..
Depends on concentration, effects may be immediate or delayed
Slightly water-soluble gases (phosgene, nitrogen dioxide) primarily affect which part of the airway…..
Inflammation & pulmonary edema at the alveolar level, effects may occur hours or days after exposure.
How to treat Hydroflouric Acid (used in drain cleaners) burn….
Calcium Gluconate topical gel is the preferred treatment.
Exposure of 6%-8% of TBSA to a concentration of 50% of HF acid will likely cause death.
How to prevent lightening related injuries ….
●Don’t be the tallest conductor.
●Don’t stand under or near the tallest conductor.
●Take shelter in a substantial structure.
●Avoid touching good conductors.
Skin can protect the body from what type of radiation?
Alpha
Protective clothing can protect the body from what type of radiation?
Beta
Gamma radiation requires what to be protected from it?
Several inches of lead or concrete
How to test or orbit fx?
H tests - have pt follow your finger
Occulomotor nerve - Responsible for eye movement is which cranial nerve?
III
Optic nerve - Responsible for vision is which cranial nerve?
II
Floaters in vision could be….
Broken blood vessel
Or retina detachment
Or strenuous physical exertion
Where in the mouth are the Incisors, Canine, Premolars, & molars?
Molars - 12 total - 3 back teeth, 3 on each side, top & back
Premolars - 8 total - 2 teeth just in front of the molars
Incisors - 8 total - 4 up top, 4 on bottom
Canine - 4 total - teeth between the Incisors & Premolars, 2 top, 2 bottom
Eyes that don’t track together….
Disconjucate gaze
Symptoms of Ocular Injury:
●Visual loss
●Double vision
●Severe eye pain
●A foreign body sensation
Size of Spinal Cord
1/2in in diameter, about 18ins long.
33 vertebrae.
How many bones in skull?
How many bones in face?
How many bones in ears?
28
14
3
Means same side….
Ipsilateral
Which part of the brain controls personality & voluntary motor action?
Frontal lobe
When is the ONLY time hyperventilation is appropriating?
Cerebral herniation
ICP
Cushing’s
The diaphragm attaches to which ribs anteriorly?
The lower 6
What are the primary physiologic functions of the thorax?
Maintaining oxygenation/ventilation
Maintain circulation
Alveolar collapse that prevents the use of the portion of the lung for ventilation & oxygenation. Reduces the surface area available for gas exchange.
Atelectasis
2 or more adjacent ribs that are fractured in 2 or more places
Flail chest
Once a flail segment has occurred, inspiration will cause a __________________ pressure within the thoracic cavity, drawing the flail segment toward the center of the chest.
Negative
When your pt has a flail segment, when the chest relaxes on expiration, it results in a __________________ pressure, forcing the flail segment away from the thoracic cavity.
Positive
An injury to the underlying lung tissue that inhibits the normal diffusion of oxygen and carbon dioxide.
Pulmonary contusion
The pressure waves generated by either penetrating or blunt trauma that disrupt the capillary-alveolar membrane, resulting in hemorrhage.
Spalling Effect
3 physical mechanisms that contribute to the formation of pulmonary contusion.
Implosion
Inertial effect
Spalling effect
Rib fractures can lead to ….
Inadequate ventilations
Self-splinting
Atelectasis
Infection from inadequate ventilations
Air under the skin
Subcutaneous emphysema
“Snap, crackle, pop, sensation, under the skin, during palpation”
What does subcutaneous emphysema indicate?
Pneumothorax
The accumulation of air or gas in the pleural cavity…..
Pneumothorax
Diminished breath sounds and what may be found on the affected side of a pneumothorax?
Hyper-resonance
A drop in BP upon inhalation
Pulsus paradoxus
These signs indicate what?
Unilateral, absent breath sounds
Unequal chest rise & fall
Pulsus paradoxus
Tachycardia
JVD
narrow pulse pressure
Tracheal deviation
Tension Pneumothorax
What condition would you need to do a needle decompression for? Where is it performed?
Tension Pneumo
2nd & 3rd rib, midclavicular
5th intercostal space, anterior axillary line
When hyperventilating a pt, what rate do you ventilate at?
Until Capno reads 25-45
How much fluid resuscitation?
20mg/kg up to Systolic of 90
What makes glucose necrotic?
It’s severely acidic
PH - 3.2-6.5
An area of the body innervated by sensor components of spinal nerves….
Dermatome
Which vertebrae (nerve root) controls the diaphragm?
C3-C5
Which vertebrae correlates with the nipple nine?
T4
T2-T7 controls intercostal muscles
Which vertebrae, nerve roots are responsible for bladder?
Sacral nerves
Which skull fx is most common?
Linear, will not be felt upon palpation
Tear in the dura mater, CSG drainage from the ears & nose, raccoon eyes and battle signs is what type of fx?
Basilar skull fx
Increase in ICP decreases….
MAP-ICP= cerebral perfusion pressure
And blood flow
Early warning signs of ICP:
Vomiting
Headache
AMS
Seizures
The most commonly broken bone in the body?
Clavicle
The umbilicus level is at the same level of which vertebrae?
T10
Most commonly broken ribs?
4-9
11-12 are the least commonly broken ribs
How many true ribs do we have?
7 set
Which rib does the diagram connect to?
6th
Major respiratory accessory muscles…
See pg 2055
Tidal Volume X RR =
Minute Volume
What is a physical sign that could be pneumothorax, volume overload, cardiac tamponade, or R-sided heart failure?
JVD
How to assess JVD?
Should be seated at least 45 degrees, should be 1/2 to 2/3 up from clavicle
Potential associated injuries with rib 4-9 fractures….
Aortic injury
Tracheobronchial injury
Pneumothorax
Vascular Injury
How large does the hole have to be to create a “sucking chest wound”?
2/3 of the trachea
Narrowing pulse pressures
Muffled heart tones
JVD
Hypotention
Are signs of what?
Cardiac Tamponade
(Beck’s Triad)
Cardiac Arrest caused by a direct blow to the thorax during repolarization…..
Commotio Cordis
What are the 3 layers of blood vessels?
Intima - Internal layer
Media - Middle/Muscle layer
Adventitia - Outside layer
MOI of diaphragm hernia
Abdominal Pressure
What causes traumatic asphyxia?
Sudden, forceful compression of the thoracic cavity
