Trauma Management 1 Flashcards
Trauma Systems, MOI, Soft Tissue, Burns
What is trauma?
involves injury to the person by any outside force.
Explain KE and PE
KE is energy in motion PE is stored energy
What is the Law of Conservation?
energy can neither be created or destroyed
Is Mass or Velocity a bigger contributor to injuries in an accident? AKA who would fair worse: 140lbs woman travelling 50mph or a 210lbs man travelling 25mph.
Velocity is a bigger contributor. KE= 1/2mv^2
What are the five types of MVCs?
Front End
Rear End
Rollover
Lateral/T Bone
Rotational/Quarter panel
What are the injuries associated with Front End MVC?
Pt’s will go down and under (aka knee hits dashboard) or up and over (aka head strikes roof or windshield, chest strikes steering column).
Pt may take deep breath beforehand and rupture lungs.
Also may fx larynx if throat strikes steering wheel.
What are the injuries associated with Rear End MVC?
Whiplash injuries
What are the injuries associated with Rollover MVC?
Pt most likely to be ejected. Many strike points on body as car rolls.
What are the injuries associated with Lateral MVC?
Pt’s on same side of force suffer greatest damage. Head snaps violently downward towards force. Injuries to chest/pelvis/lower extremities. Likely pneumothorax.
What are the injuries associated with rotational MVC?
Injuries vary widely and depend upon strike point, seat belt usage, and velocity.
What are the four types of impacts in a motorcycle accident?
Head On
Angular impact
Laying the bike down
Ejection
What are the injuries from head on motorcycle MVC?
bilateral femur fx possible tib/fib fx
What are the injuries from angular impact on motorcycle MVC?
Extensive ortho damage to leg
What are the injuries from laying the bike down MVC?
possible abrasions and road rash
What are three predominant MOI in Vehicle vs Ped?
- Car strikes individual (lower extremity injury) 2. Upper body and head strike car hood 3. Sudden acceleration throws body away from car, pt strikes the ground
What are the five important things to know from fall patients?
Height of Fall Position
Upon Impact Area over which impact dissipated
Surface Pt Landed on
Physical condition of Pt before fall (osteoporosis, etc)
What are examples of low/medium/high velocity injuries?
Low= stab wounds, penetrations from falls
Medium= shotguns and handguns
High= rifles
Explain the factors to consider when assessing GSW pt’s.
Type of firearm
Velocity of bullet physical design- jacketed tend to mushroom and cause more damage size of projectile- larger bullets tend to tumble and cause more damage. smaller bullets tend to ricochet.
distance of pt from muzzle anatomy struck by bullet
What are the stages of blast injuries?
Primary Secondary Tertiary Quaternary Quinary
Explain stages of blast injuries.
Primary- initial shock wave
Secondary- shrapnel thrown by explosion
Tertiary- injuries due to impact with other object
Quaternary- burns, crush injuries, or inhalation injuries
Quinary- long term damage from contaminants
What affects the speed, duration, pressure of blast shock waves?
Size of explosive charge (larger explosions travel faster and stay longer)
Nature of surrounding medium (travel faster through water)
Distance from explosion ( farther away from explosion means slower the shock wave, longer duration, and lower likelihood of injury)
Presence/absence of reflecting surfaces (pressure waves reflected off solid objects, aka walls, tend to amplify damage)
Explain the major components of the trauma pt assessment.
Scene safety
Primary survey
- ABCDE or CABDE
- AVPU
- MOI
- Spinal precautions
- Rapid exam
- Txp decisions
Hx -SAMPLE/OPQRST
Secondary Assessment -Isolated or Multisystem
What is the trauma lethal triad?
Acidosis Hypothermia Coagulopathy
What is the Waddell Triad?
Children turn toward vehicle causing initially injuries to pelvis and femur injuries,
followed by intrathoracic injuries from striking grille,
and finally head injury when head strikes vehicle and pavement after being thrown.
Explain Level I, II, III, IV hospital trauma rankings.
l- comprehensive resource. 24 hour surgery coverage. II- able to start definitive care for all injured pt’s. 24 hour immediate surgery coverage. III- able to assess and stabilize injured pt’s. 24 hour immediate care by ER docs and prompt surgery availability. IV- available to provide ATLS before pt transfer. Basic ED functions
When do you utilize air medical services? (6)
extended period required to extricate
access pt distance to trauma center is >20-25miles
Pt needs ALS and no ALS ground available
Traffic slows pt transport time
Multiple pt’s that will overwhelm local resources MCI
Trauma Criteria- Physiologic conditions
GCS = 13 at any point during pt contact time
SBP <90 at any point (<110 in elderly over 65yo)
RR outside of 10-30
Trauma Criteria- Anatomic Criteria (9)
Any penetrating trauma to head/neck/torso/proximal extremities
Chest trauma and fx 2+ proximal long bone fx
Crush injury to any extremity
Degloving injury
Pulseless extremity
Amputation proximal to wrist or ankle
Pelvic instability
Open or depressed skull fx
Paralysis
Trauma Criteria- MOI Criteria
Fall > 3x body height in kids or >20ft in adults
Car vs Ped/Bicycle when person is thrown/run over/hit a >20mph
Motorcycle crash speeds >20mph
Car crash involving:
- intrusion into compartment >12inch
- ejection from vehicle
- death of another occupant in same vehicle
Trauma Criteria- Special considerations
Pt >55yo
Pt is pregnant
Burns of any kind with other trauma
Pt takes anticoags or has bleeding disorder
EMS provider judgment
What are the layers of skin?
Epidermis Dermis Subcutaneous tissue
What are the functions of skin? (5)
Protects from injury
Temperature regulation
Fluid regulation
Sensation
Inflammatory response
How does skin function with the immune system?
responds to wounds with inflammation, which cause redness, increased warmth, and painful swelling.
Blood vessels dilate and fluids leak to damaged tissues. This allows more nutrients, oxygen, and WBCs to injury site.
Explain closed vs open injuries.
closed wounds don’t have a break in skin, open wounds do.
Explain the process of wound healing.
- Hemostasis: cessation of bleeding through blood vessel constriction and platelet plugs. 2. Inflammation: WBCs migrate to site of injury via capillary leakage/chemotactic factors/mast cells (histamine). 3. Epithelialization: new skin cells are layed down 4, Neovascularization: new capillaries bud from intact capillaries 5. Collagen synthesis: collagen synthesizes to bring stability to wound and close open tissue.
What alters the process of wound healing?
certain medications: NSAIDs, corticosteroids, anticoags
skin tension lines can make wounds harder to heal
high risk wounds: bites, imbedded objects
abnormal scar formation- too much collagen produced
pressure injuries: bedridden
What wounds require closure?
Lips Face Eyebrows
Gaping wounds over tension lines
Degloving Ring injuries
Skin tears
How do we treat closed wounds?
Rest Ice Compression Elevate Splint
How do we treat open wounds
control bleeding keep wound as clean as possible
What are the implications of improperly applied dressings?
tissue damage from tight dressing
Abrasion tx
do not clean cover lightly with sterile dressing
Laceration tx
control bleeding cover with sterile dressing
Puncture wound tx
look for entrance and exit wound treat swelling with ice control bleeding stabilize in place
Avulsion tx
if wound is contaminated, irrigate fold skin back into place dress with sterile gauze control bleeding
Amputation tx
control bleeding rinse off debris from amputated part wrap loosely in saline moistened gauze seal in plastic bag and keep cool
Bite tx
control all bleeding apply dry sterile dressing document and txp
High pressure injection injury tx (5)
irrigate open wounds
dress with sterile bandage
px meds
check cms
check for subcutaneous air
Facial and Neck Injuries Tx
*Control airway
- patency and protection
- 02 as needed
- Suction secretions
*Control bleeding
- if only one provider, control airway first
- use bulky dressing and direct pressure
- occlusive dressings for neck wounds
- Realign avulsed skin along face or neck to original position if possible
Thoracic Injuries Assessment 4 steps IAPP
4 Main steps:
Inspect
Auscultation (at least two sites, diminished sounds=pneumo)
Palpation (abnormalities or subcutaneous emphysema- indicative of tracheobronchial disruption)
Percussion Consider occlusive dressing for thoracic wounds
Abdominal lnjuries Tx
Be highly vigilant with these injuries Focus on potential injury to underlying organs and vessels –>Cullens Sign, Grey Turner Sign, distended abdomen, etc.
What is myositis?
inflammation of muscle due to injury or infection s/s: fatigue with exertion, muscle weakness, fever
Explain gangrene.
Gangrene is dead tissue due to interrupted blood supply to tissue.
It can be dry or wet.
Wet gangrene develops quickly and causes sepsis.
Dry gangrene can develop over months.
Smokers and diabetics the most susceptible.
Many causes.
Basic tx unless sepsis present.
Explain tetanus.
Tetanus is caused by Clostridium, which produces a potent toxin –> muscle contractions. Rapid transport
Explain necrotizing fascitis
NF is a complication of Strep, causing tissue death. S/S: warm tissue, redness, fever, night sweats, fever, chills, N/V, diarrhea. Rapid transport and surgical debriedment needed.
Explain paronychia
Infection of cuticle.
Explain flexor tenosunovitis.
infection usually caused by penetrating trauma to hand, usually sheath of the tendons that flex the fingers. S/S: inability to extend involved finger, px, swelling along tendon path. Common in pt with RA and overuse injury
Explain the anatomy of the surface of the eye
Cornea- cover anterior portion of pupil
Pupil- hole in iris that light passes through
Lens- focuses light on retina to form image, behind pupil and iris
Retina- receives light and converts it to electrical signal
Fovea- most light sensitive area of retina
Optic nerve- receives electrical signal
Optic disk- blind spot of eye
Sclera- white of eye
Aqueous Humor- anterior chamber of eye fluid; can be replenished
Vitreous humor- posterior chamber of eye fluid; cannot be replenished
Lacrimal Gland- under upper eyelid on lateral edge, drips tears into eye
Conjunctiva- underside of each eyelid
Explain the pathophys of burn injuries
Burns are soft tisue injuries resulting from sudden and violent release of energy. Burns can occur from a release of heat in the form of fire, energy from chemical rxns, or radiation released from radioactive substances. Damage to skin in such a profound way also affects body systems other than just the skin:
- Airway burns compromising respiratory system
- fluid shifts can lead to hypovolemia and cardiovascular compromise
- destruction of skin opens pt up to massive infection risk that overtaxes the immune system.
- Hypothermia and shock
What is the pathophys of burn hypovolemic shock?
Hypovolemic shock is the most profound systemic response to a burn.
- Occurs because of fluid loss across damaged skin and series of volume shifts within the rest of the body
- capillaries become leaky due to histamine and other mediators released.
- this allows intravasular volume to ooze out of circulation into interstitial spaces.
- cells of normal tissues take in increased water and salt from fluid surrounding them
- as BP falls, HR increases and vasoconstriction occurs, limiting blood flow further, increasing shock.
- massive fluid shifts and electrolyte imbalances cause N/V
- adequate fluid replacement NECESSARY
What are the S/S of hypovolemic shock?
cold or clammy skin
pale skin
rapid, shallow breathing
rapid heart rate
confusion
weakness
weak pulse
blue lips and fingernails
lightheadedness
loss of consciousness
What are the five types of thermal burns?
1. Flame Burn- open fire burn
2. Scald Burn*- hot liquid caused
3. Contact Burn*- contact with hot object
4. Steam Burn- topical scald burn
- may cause supraglottic trauma from inhalation
- or may (rarely) cause subglottic trauma
5. Flash Burn- from explosions or lightning strikes
*common abuse burns in kids and elderly
What are the signs of intentional burns?
unusual hx patterns
burns with formed shapes
unusual patterns
atypical burn locations
-genitalia, buttocks, and thighs
What are the burn zones from worst to furthest?
Zone of Coagulation: little or no blood flow to the injured tissue in the area affected.
Zone of Stasis: decreased blood flow and inflammation adjacent to coagulation area; most likely to undergo necrosis within 24-48 hours.
Zone of Hyperemia: least effected
Explain the superficial burns.
aka 1st degree burn
example: sunburn
only the epidermis is effected and skin will be red/hot to touch, swollen and painful.
when touched skin will blanch and then return to red color
Explain partial thickness burns.
involves the epidermis
can be further divided into moderate or deep partial thickness
- Moderate partial thickness involves only superficial dermis with most hair follicles remaining intact. Skin will be red with fluid blisters. Redness will blanch and return to red.
- Deep partial thickness involves blisters and damage deeper into dermis. It damages hair follicles and sweat glands. May destroy some pain receptors.
Explain full thickness burns.
involve the entriety of the epidermis and the dermis, burning all the way down to the basement membrane.
Skin will appear white, waxy, charred, or leathery. It is dry, hard and tighter than normal skin.
Can tighten to point of acting as tourniquet, and can hamper breathing if on chest.
Will not feel px except for on outer edges of the burn
Explain the pathophys of inhalation burns.
Inhalation of superheated air can cuase airway burns. Airway lining swells, sometimes to the point that it closes off the airway completely. Epiglottis, layrnx, and pharynx often take brunt of gas heat and sustain worst trauma. Pt will require aggressive airway managment.
Be cognizant of CO in smoke burns, along with superheated air. Be careful with pt with soot around mouth and nose. Cyanide and HCl are also concerns with smoke, but [] usually not high enough to cause severe damage.
What is the primary survey for burn pts?
ABCDE
- burn pt that is combative=hypoxic until proven otherwise
- unresponsive burn pt= look for other deadly injury
- Airway is KING
- Look for S/S of airway involvement:
1. hoarseness
2. cough
3. stridor
4. singed nasal/facial hair
5. facial burns
6. black sputum/lips
7. hx of burn in enclosed space - consider early intubation due to laryngeal edema
- listen to lung sounds
- preexisting lung disease may cause bronchospasm, give Beta 2 agonist drugs
- IV access and fluids
- after airway and breathing controlled, assess extent of burns
Rule of Nines
Lund Browder Chart
Explain secondary survey with burn pt’s.
Check for other injuries
If pt is in shock, look for other source of shock
Observe for circumfrential burns of chest, neck, extremities
Check CMS in extremities
Vitals which include EtCO2
Explain what major burns are.
Burns of hands/feet/major joints/gentialia
circumferential burns
full thickness bursn >10% TBSA
Partial burns >25% 10-50yo
Partial burns >20% <10yo or >50yo
inhalation injury
burns with fx or trauma
high voltage electrical burn
chemical burn
Explain moderate burn classification
Full thickness burns 2-10% TBSA
Partial thickness burns 15-25% TBSA 10-50yo
Partial thickness burns 10-20% TBSA <10yo or >50yo
Superficial burn >50% TBSA
Low voltage electrical burn
Major burn characteristics absent
Explain minor burns
full thickness covering <2% TBSA
Partial thickness burns <15% TBSA 10-50yo
Partial thickness burns <10% TBSA <10yo or >50yo
Superficial burns <50%
What are the burns should be taken to specialty center?
Partial thickness >10% TBSA
Burns of face, hands, feet, genital area, major joints
full thickness in any age group
electrical burns
lightning strikes
chemical burns
inhalation burns
burn injuries with preexsisting cdxns that prolong healing
burns and concomitant trauma/fx
What are the phases of definitive burn care?
- Initial eval and resuscitation: 1st 72 hours
- Initial wound excision and biolgoic closure: day 1-7
- Definitive wound closure: day 7- week 6
- Rehab, reconstruction, reintegration: entire hospitalization
What are some specific airway management techniques for burn pt’s?
Probable field intubation
Potential need for surgical cric
Use smaller tube than normally would
Most experienced medic first pass at intubation
Cool humidified O2
Supplemental O2 for inhaled toxins
What are specific fluid resuscitation for burn pt’s?
TBSA >20% will need fluid resuscitation
at least 18g IV
can start line in burned extremity
consider IO if IV not possible
check lung sounds to watch for fluid overload
Give LR soln
What are px management techniques for burn pt’s?
px meds should be given IV due to fluid shifts –> IM not reliable
keep in mind elderly, cirrhosis damage, and respiratory depression should influence narcotic choice
What is the Consensus/Parkland Formula?
2-4mL x KG x %TBSA
Example: 70kg man with 30% TBSA
2-4mL x 70 x 30= 4200-8400mL in first 24 hours
to determine 1st 8 hours of fluid divide mL by 2
to determine hourly rate for 1st 8 hours divide again by 8
Explain how we manage thermal burns.
Note skin cdxn
Note any other exsisting trauma
Cool any burns areas
Apply dry non adhesive dressing
Keep warm
Tx shock
Give fluids and px meds if needed
Cool nebulized air for inhalation injury
may need to be aggressive with airway
Chemical burn assessment and tx
determine TBSA
brush off any remaining dry powder
Flush with copious amounts of water
remove any garments that may have come into contact with agent
keep pt warm
Tx of dry lime
flush with overwhelming amounts of water after brushing off dry powder
Sodium metals tx
cover with oil to stop burning
Hydrofluoric acid tx
very pxful
3-5% TBSA can be fatal
sucks calcium out of body
can make calcium gel- 10mL calcium chloride mixed with water based lube to help with burn px
Gas or diesel fuel tx
flush with soapy water
may cause pt to be sleepy/coma
Hot tar tx
immerse in cold water
do not remove tar after cooled
Inhalation burn from toxic chemical tx
check for stridor/upper airway swelling
check for wheezing/edema/lower airway swelling
maintain spO2
Duo Neb
Aggressive airway management
Chemical burns for eye assessment and tx
flush with lots of water
remove contact lens
after irrigating, patch eye with light applied dressings
Electrical burns assessment and tx
when voltage is low it takes path of least resistance
-along blood vessels and nerves
when voltage is high it takes shortest path
initial damage greatest at entrance/exit point
AC more dangerous than DC
AC more likely to cause VF
asphyxia may result from prolonged contact
keep in mind possibility of c spine injury
defib soon if in arrest
look for fx
assess csm in all extremities
be mindful of rigid abdomens
ABCs
EKG
consider fluids for fluid shifts
consider sodium bicarb for acidosis
Supplemental O2
Lightning strike injuries assessment and tx
start cpr as needed
suspect c spine injury
jaw thrust
EKG
O2
18g IV run LR wide open
Cover burns with dry sterile dressing
Splint fx
if pt falls, immobilize spine
Radiation burns assessment and tx
scene safety
ABCDE
30% TBSA with radiation likely fatal
Decon before txp
irrigate open wounds
Explain special considerations for kids and the elderly when it comes to burns.
- kids have thin skin and delicate respiratory systems
- fluid resuscitation is challenging with kids- they may need more
- kids have poor glycogen stores, so may need dextrose; be sure to monitor their BG
- watch for child abuse
- elderly sensitive for toxic fumes
- elderly also have poor glucose stores, monitor!
- EKG with elderly
- watch for fluid overload with elderly when giving fluids
