Trauma - Exam 2 Flashcards
What are the components of the primary survey? What are the components of the secondary survey? What should you do if there is any change in pt’s status?
Primary Survey:
Airway
Breathing
Circulation
Disability
Exposure
Secondary Survey:
Head to Toe Physical
History as able (AMPLE)
need to start over again at AIRWAY
_____ is a good indicator if the patient has ABCD intact. When should you do a primary survey?
if the pt can hold a conversation, then ABCD is usually intact
with the first 10-90 seconds!!
What things should you be looking for as you are assessing a pt’s airway? When should you intubate?
Foreign Bodies (Teeth)
Facial, Mandibular, tracheal or laryngeal fractures
Fluids: Blood, Mucus, Water (Suction)
need to remove obstructions while keeping the cervical spine motion restricted-> assume cervical spine injury until it has been ruled out
GCS less than 8 = intubate
What are some reasons why a combative patient might be combative?
Combative patients can be intoxicated, but often represent respiratory failure / airway / breathing problems!
**Draw the GCS coma scale
What is the definition of a definitive airway? What type of pts get a definitive airway automatically?
a tube placed in the trachea with the cuff inflated below the vocal cords, the tube connected to a form of oxygen-enriched assisted ventilation, and the airway secured in place with an appropriate stabilizing method OR surgical airway is also definitive
significant facial or neck swelling or burns -> because the airway will swell
Are LMA and King airways definitive?
NO! good field options but not definitive airways
How should you assess a pt’s breathing as part of the primary survey?
expose chest wall!! watch for even rise and fall of the chest
Ascultate - are breath sounds equal and present?
What is the difference between Oxygenation and ventilation?
Oxygenation - getting oxygen into the blood stream, increases partial pressure of oxygen on ABG -> INHALATION
Ventilation - moving air in and out of the lungs, reduces PCO2 on ABG -> EXHALATION
For breathing, most trauma pts will have either _____ or ______
definitive airway
have supplemental oxygen via mask with bag and pulse oximeter
What are the options to control external bleeding? What if the skull is bleeding?
Significant Direct pressure
Tourniquet-> needs to be tight!!
staples with skull bleeding
hypotension is a trauma pt is ________ until proven otherwirse. What should you think if the HR is high and the BP is low?
hemorrhage
high HR with low BP think hemorrhagic shock!!
During circulation, if there is obvious blood coming from somewhere, where should you think to look first?
Chest
Abdomen / Retroperitoneum
Pelvis
Long Bones
look in these 4 quadrants if there is obvious bleeding!
What imaging should you order next to find the source of the bleeding?
FAST ultrasound exam or CXR / pelvic XR gotten bedside in a trauma
As part of circulation, what is the protocol for replenishment?
need to get 2 large bore IVs (if you cannot then IO)
1L of warmed NS/LR then switch to blood products
______ is used to prevent the body from breaking down blood clots. What is the regimen?
Tranexamic Acid
Severely ill patients receive a 1,000 mg IV bolus and then receive 1,000 mg IV over the next 8 hours
What should you do if the pt comes in on a spinal board? What are the criteria to remove the c-spine collar? Can you remove the c-collar in an intoxicated pt?
Remove from board quickly
no localized pain
no neuro deficit
no head injury
not intoxicated
or if negative imaging
NO!! cannot remove c-collar in an intoxicated pt even if there is negative imaging
What should be included as part of your neuro exam in a trauma pt?
GCS
EOMs
Pupillary size and shape
Roll pt and palpate entire spine for tenderness/step off
Rectal exam
AMS?
What should you assume if the trauma pt presents with AMS? What are some other things you should consider?
it is CNS related until proven otherwise
alcohol, drugs, hypoglycemia, sepsis, hypercapnia, DKA, hyperammonemia
What is the correct way to remove a pt from a spinal board?
one person stabilizes the head and two other criss cross hands at the pt’s hip and rolls them towards themself
What is the final step in the primary survey?
E: Exposure
completely undress pt and cover with warmed blankets, warm fluids but normal temp blood products
What are the monitoring requirements for a trauma pt? When are foley caths indicated?
All patients should be placed on a monitor with cardiac monitoring, Pulse oximetry, BP monitor, CXR, Pelvis XR
Foley contraindicated if blood at urinary meatus or concern for urethral injury, pelvic fracture, perineal ecchymosis
decompress stomach
Where does fluid collect in the RUQ?
Morrison’s pouch: space between liver and Right kidney
Where does fluid collect in the LUQ?
Splenorenal recess: between the spleen and the Left kidney
Where does fluid collect in the pelvic view?
pouch of Douglas: behind the bladder, behind the uterus
Where does fluid collect in the chest?
around the heart in the pericardium
When should you think about transferring a pt? What should you NOT wait for when deciding whether or not to transfer a pt? Can only transfer _______ pts
After completion of primary survey, should have an idea of whether or not your facility can safely treat this pt or not.
Do NOT wait for imaging or labs
STABLE! pts must be stable enough for transfer
When should you preform the secondary survey?
After Primary Survey, Resuscitative efforts are underway, and improvement of the patient’s vital functions demonstrated then Head to Toe Physical Exam
What does AMPLE stand for?
Allergies - primarily medication
Medications - Currently used
Past Medical hx / Pregnancy Status
Last Meal
Events and Environment leading to the injury
What is the inclusion criteria for the Canadian CT head rule? What does it help you decide?
helps to decide which patients need a head CT if they have a minor head injury
any signs of basilar skull fracture or dangerous mechanisms automatically gets head CT
What are the Canadian head CT rules to get a head CT?
What is the decision making tool for kiddos whether or not to order a head CT? **What is the required observation time?
Pcarn
**Observation time is 4-6 hours from onset of trauma
What does the GCS score need to be in a kiddo to automatically get a CT? What are the other 2 signs?
less than or equal to 14
AMS
signs of skull fx
Consider looking at this PCARN chart again. **What type of hematoma on a kiddo is FINE and is NOT an indication to get a CT?
frontal hematoma on a kiddo is fine but any other hematoma is grounds to get a CT
What should the pt’s MAP be in a head injury?
BP MAP (Above 80: Generally 50-150)
What is the classic sign of uncal hernation?
Remember that Ipsilateral pupillary dilation associated with contralateral hemiparesis is the classic sign of uncal herniation
Depressed skull upon palpation
Hemotympanum, Battle Signs, Racoon Eyes, Clear Rhinorrhea
What am I? What should you do next?
skull fx
Admit to Neurosurgery and IV Ceftriaxone per NS recommendation
What is the tx for a linear, non-depressed skull fx?
observe for 4-6 hours and discharge with NS follow-up.
What should you assume if a skull/facial fracture is present?
assume cervical fracture is also present.
What am I? How would the pt present? What artery is involved?
Epidural hematoma
Concussion to diffuse axonal injuries with LUCID (lucEd) Interval
Often tear of Middle MeningEal Artery, Egg shaped on CT
What am I? How will the pt present?
subdural hematoma
Concussion to diffuse axonal injuries
crescent shaped on CT
Are epidural or subdural hematomas have worse outcomes? Which one is MC?
subdural is both more common and more deadly than epidural
What is the tx for an epidural/subdural hematoma?
What needs to be included as part of the neuro exam for neck/spine trauma?
GCS, Mentation
Cranial nerve deficits / Pupillary response to light (2) / EOM (3,4,6)
Sensation deficits
Movement difficulties
HA, dizzy, seizure, tingling, numbness, weakness, trouble moving, change in mentation, balance, speaking difficulties?
Know the common dermatomes
C7: middle finger
When is the NEXUS criteria used? What are the 5 criteria?
used in LOW probability cases, if all criteria are a NO then do NOT need to get cervical imaging
What is neurogenic shock? What level? What is the treatment?
loss of vasomotor tone and sympathetic innervation to the heart
(Above T6) often causes hypotension and bradycardia.
Tx: Fluid, Vasopressors, atropine
What is spinal shock? What is important to note?
Flaccidity (Loss of muscle tone) and loss of reflexes that occur below level of injury immediately AFTER Spinal Cord Injury usually due to SWELLING
**After a period of time, symptoms resolve.
What are the 4 different types of spinal cord syndromes?
Brown-Sequard
Central
Anterior
Posterior
________ usually caused by penetrating trauma directly into the cord - loss of motor function on same side as injury, but sensation on contralateral side
Brown-Sequard
______ usually occurs with a hyperextension injury in a pt who falls from ground level hitting their face with pre-existing cervical stenosis
central
_______ Causes loss of pain and temperature sensation as well as motor function - usually paraplegia - worst prognosis for recovery - Usually from ischemia
anterior
_____ Loss of sensory function but preservation of motor function
posterior
What is an atlanto-occipital dislocation? What is happening internally?
Brainstem / Cervical spine junction injury. Internal decapitation
Ligamentous separation of cervical spine from the brainstem
most will die or be vent dependent
shaken baby syndrome
The atlas is ____. What is the MOI for atlas fracture? Are they stable?
C1
Usually from axial loading or falling onto head
Unstable - rigid cervical collar.
The axis is _____. What are the 3 types? Which one(s) are stable?
C2 (the bone that sticks up)
Type I, II and III
type I is stable
type II and III are unstable
What type?
axis (C2) type I
stable fx
What type?
Axis (C2) type II
unstable= Cervical Collar and Neurosurgery consult. Most will be admitted
What type?
axis (C2) type III
Cervical Collar and Neurosurgery consult. Most will be admitted
What is the MC fx and dislocation of C3-7?
Most flexibility and most common injury is C5
call neurosx!
What do you need to document in a neck/spine trauma?
Document complete [Loss of ALL motor and sensory function below a certain level] or incomplete paraplegia (Thoracic injury) or quadriplegia (cervical injury). Make sure to test both sides as there can be variance
____ should be the reflexive imaging of choice in kiddos with neck trauma. _____ should be ordered for spinal cord injury
xray (NOT CT)
MRI
If getting a _____ on an older adult, I reflexively order the ______ in most patients
CT brain
CT Cervical Spine
If a cervical spine fx is noted on imaging, what should you order next?
if + c-spine fx, need to go back and order Thoracic and Lumber spine CT
up to 10% of patients will have another spine fracture somewhere else
What are the 3 different zones of neck trauma?
What should you do if a pt has trauma to Zone 2 with stable vitals and airway? Unstable?
stable: CTA of neck
unstable: OR for Surgical exploration
How should you treat trauma in zone 3 of the neck?
Treat as Cranial Injury
CT Brain, CTA Head and Neck
How should you treat trauma in zone 1?
CXR often helpful
Often will need thoracic surgeon
What does “Rice Krispies” on palpation indicate for a pt with thoracic trauma?
Subcutaneous Emphysema
Subcutaneous emphysema is a condition where air becomes trapped in the tissues beneath the skin
What is this?
Yankauer-> used in suction
Where should you insert a chest tube?
Nipple line / Inframammary fold
in Males line up with nipple
moderate size incision superior to rib (Avoiding nerve bundle)
What should you do for a open pneumo, GSW/puncture or sucking chest wound?
Place 3 sided sterile dressing
Chest tube insertion remote from the injury
What are the criteria in a hemothorax that would indicate the pt needs to go directly to the OR?
> 1500 ml of blood return - direct to OR
Or, more than 200 mL/hour for >2 hours
Or, Blood transfusion required
How is a cardiac tamponade usually dx? What are the tx options?
found with FAST
Thoracotomy ASAP -> puncture into chest wall
Pericardiocentesis
_____ is the MC chest wall traumatic injury. Which are associated with abdominal trauma? What is the best way to dx?
rib fracture
9th, 10th, 11th associated with abdominal trauma
CT significantly more sensitive than XR (Rib xrays do NOT show up super well)
______ is associated with 50% mortality if less than 2 years old
<2 years old w/ >2 rib fx = 50% mortality
What is the tx for rib fx?
Pain Control
Incentive Spirometry
Oxygen if needed
What is the disposition for a rib fracture?
Admit to ICU 5 or more fx or Flail Chest
Admit Elderly with multiple fx
Consider admission for COPD or lung comorbidities
What is the biggest concern for internal bleed and solid organ injury in an abdominal trauma?
pneumoperitoneum from perforation of bowel.
What should you do in an abdominal trauma if there is pain on pelvic rock? ______ can indicate a spinal injury
if pain - pelvic binder or sheet to be placed -> should be placed ASIS to femur
penile erection
What is the tx in abdominal trauma with unstable vital signs?
OR without CT examination!!!
What are the indications for laparotomy in abdominal trauma?
Blunt trauma with hypotension and positive FAST
GSW to abdomen
Evisceration
Peritonitis
Free air under diaphragm or rupture of diaphragm
Bleeding from Stomach, rectum, GU tract after penetrating trauma
Abnormal CT of abdomen with concern for blood, air or injured organ
What should you do in a gunshot wound abdominal trauma?
need to search for entry and exit wounds!!
______ are classically found in unrestrained drivers in front impact MVC, direct blows to the abdomen, or bicycle handlebar injuries
duodenal injuries
_____ direct blow in LUQ, detected with elevated amylase; however, can have false positive with lab
pancreatic injuries
_______ seatbelt sign, not always associated with internal bleeding
hollow viscus injury
What needs to be included in the primary survey of a MSK trauma?
Pressure for Bleeds or tourniquet placement.
Fractures of long bones will need reduced if active hemorrhage
&traction splint - document N/V status before and after splinting
Pulses found in all 4 extremities and marked if difficult
______ MSK trauma is at high risk for significant blood loss, multiple organ failure, death
bilateral femur fx
What abx are given for MSK trauma? What is added for extensive soft tissue damage?
Cefazolin 2g IV for any OPEN fx
Vanc
______ is given for all burns or open wound pt if greater than 5 years since last dose in MSK trauma
Tdap
What 3 populations are at high risk for non-accidental trauma?
kiddos
elderly
pregnant pts
