Trauma Management 2 Flashcards
Explain the difference bw head trauma, head injury and TBI.
Head trauma- general term inclusive of both head injury and TBI
Head Injury- traumatic insult to head that results in injury of soft tissue of scalp or skull, does not include face.
TBI- impairment of brain fxn caused by external force that causes physical/social/emotional changes
What are the major regions of the brain?
What are the fxns of the major regions of the brain?
- cerebrum
- cerebral cortex
- cerebellum
- brainstem
- diencephalon
- pons
- medulla
- corpus callosum
Cerebrum- largest portion of brain, responsible for higher fxn/thought
Cerebral cortex- largest part of cerebrum, regulates voluntary skeletal movement, level of awareness
Cerebellum- maintains posture and equilibrium, skilled motions
Brainstem- crucial for vitals fxns (RAS-awareness)
Diencephalon-relays motor and sensory signals
Pons- regulates breathing and REM
Medulla- controls automatic fxns like HR and RR
What are the 4 different lobes and their fxns?
Frontal lobe: voluntary motions, personality and judgment
Parietal lobe: processes sensory info from skin and joints, responsible for proprioception
Temporal lobe: speech center, hearing, taste, smell, long term memory
Occipital lobe: processes visual information from optic nerve
What are the meninges?
They are a protective layer around the entire brain and spinal cord.
Dura mater –>Arachnoid –> Pia mater
Explain epidural hematoma.
Occurs bw dura mater and skull
Usually caused by a rupture of middle meningeal artery
Explain subdural hematoma
Occurs bw dura and arachnoid
Usually caused by rupture of bridging veins in bw these layers
Explain subarachnoid hemorrhage.
Occurs below arachnoid membrane.
Bleed directly into brain.
What do we look for in assessing a basilar skull fx?
- Blood and CSF leaking from ears, nose, both
- Raccoon eyes*
- Battle Sign*
*late signs
Cervical plexus
C1-5
innervates the diaphragm
Brachial plexus
C5-T1
Controls upper extremities
Lumbar plexus
L1-L4
Supplies skin and muscles of abdominal wall, external genitalia, part of lower limbs
Sacral plexus
L4-S4
Supplies buttocks, perineum, most of lower limbs
SCI at of below ___ may disrupt flow of sympathetic stimulation communication.
T6
How do we handle pt assessment for head and spine trauma? Any special considerations?
ABCDE
consider C spine
consider aggressive airway
consider neurogenic shock
do neuro exam
assess for ICP/abnormal posturing
consider backboarding
always place hands on pt for assessment
Signs of cerebral herniation
Unequal pupils
bilateral fixed dilated pupils
Decerebrate posturing/no motor response to px
GCS <9 that drops by 2+ points
What are the S/S of head injury?
DCAP
Visible fx
Battle sign
Raccoon eyes
CSF ears/nose
What EtCO2 do we ventilate head injury pt at?
30-35mm Hg
When would you want to start an IV in the case of head or SCI and use lots of fluids?
- establish 18g IV with LR
- do not give glucose unless known hypoglycemia
- only administer fluids on needed basis when hypotensive <90
- neurogenic pt’s may not require fluids so much as vagolytic drugs (atropine) and pressors or TCP
- watch for pulmonary edema
What are some specific assessments we do with SCI?
CMS in all extremeties
AVPU/serial GCS
Spinal immobilization
Pupils
check for chest trauma/fx
check for posturing
watch for hypo/hypertension
Stroke neuro exam
ask about sensation/pins and needles/numbness
**if pt unresponsive, but responsive to painful stimuli
–>grimaces, flexes limbs not likely to have SCI
Dermatome map
Explain skull fx types
Basilar- fx to base of skull.
Linear- closed, non displaced fx usually due to blunt trauma
Depressed- multiple fx in one area as result of blunt trauma with depression or dent in skull. can be concurrent with basilar fx. usually profound deficits seen
Open- brain tissue exposed
Closed- brain tissue not exposed
What is the difference bw primary and secondary injury? Give some MOI examples.
Primary- actual injury to brain as direct result of insult. Aka GSW, blunt trauma.
Secondary- damage to brain tissue as result of primary injury that bleeds into brain and swelling. can also include abscess, infection, hypoxia, etc.
Explain ICP
Skull is not capable of expanding for swelling brain post injury. The brain swells regardless of skulls capacity to expand, and it begins to take up what available space there is in the cranium. It takes up CSF space, occludes small blood vessels, increasing ICP. As pressure grows, brain recognizes it is hypoxic as a result. To combat this brain sends order to increase BP. In contrast carotid sinuses recognize that BP is increasing they did not call for, and order HR to slow down. This cycle continues, and pressure in skull worsens as the brain tries to maintain CP. As pressure grows, brain has no choice but to herniate out foramen magnum. Breathing centers and HR are sacrificed, ventilation is impaired, acidosis grows. Pupils will change. Pt will vomit out of nowhere with no previous complaint of nausea. Cushings triad is seen.
How do we determine MAP?
MAP= pulse pressure difference/3 + diastolic
Cerebral perfusion formula
CPP= MAP-ICP
ICP numbers
0-15
minimum CPP
60
Uncal herniation
most common brain herniation
part of temporal lobe moves laterally and then down
Early signs of ICP
Seizure
vomit without previous nausea
HA
ALOC
Explain cerebral concussion and what to look for.
occurs when teh brain is jarred in the skull.
usually caused by rapid acceleration-deceleration
produces shearing injuries caused by rotational/angular forces
seen with MVCs, falls, sports
S/S: HA, amnesia, confusion, dizzy
if suspected, all pt need eval
check A/O
Explain diffuse axonal injuries and what to look for
diagnosable only in hospital
more extensive damage to brain than concussion
axons can be sheared and torn
often not survivable
causes permanent damage
watch for unresponsiveness, especially >6 hours
watch for airway compromise
probable life flight
How does an epidural hematoma present?
initially lose consciousness
regain consciousness
have period of lucidity
lose consciousness after ICP increases
common to see unequal pupils
How does a subdural hematoma present?
does not become apparent for a few weeks after initial trauma due to venous bleeding
may present stroke-like
How does a intracerebral hematoma present?
depends on ICP and size of injury.
How does a subarachnoid hemorrhage present?
sudden severe HA
stiff neck
ALOC
seizure
N/V
posturing
Explain thermal management of brain injuries
do not let head injury pt become overheated.
do not cover with blanket if ambient temp >70
What are some pharmacology treatments to consider for head injury?
control seizures
RSI meds
some med control may order lasix or mannitol
Le Forte Fx
Explain flexion injuries and MOI
head whips forward suddenly
can fx atlas and axis or dislocate them
could tear spinal cord
seen with MVC or sports
Explain rotation with flexion and MOI
flexion when combined with rotation of head happens with lateral MVC impact or football tackle or assault.
can cause severe C1/2 injuries
Explain hyperextension and MOI
can occur anywhere in spine
most common in cervical area
can cause hangman’s fx- fx of C2 that causes bilateral fx of pedicles. unstable fx that does not usually injure spinal cord.
Explain vertical compression and MOI
also known as axial loading
common in cervical and lumbar areas
compression force comes from above
usually hitting head on roof of vehicle, or jumping with locked knees
usually fairly stable injury
What is primary SCI?
ANY CORD INJURY RESULTING DIRECTLY FROM THE TRAUMATIC EVENT
can be complete or partial
What is secondary SCI?
cord swelling as a result of trauma leading to temporary loss of neurological fxn distal to injury
Explain complete vs incomplete SCI
Complete SCI- complete disruption of all tracts of spinal cord with permanent loss of all cord mediated fxns below level of injury.
Incomplete SCI- pt retains some degree of cord mediated fxn below injury site
Explain anterior cord syndrome
results from disruption of anterior region of cord
usually result of flexion injury
will have motor and sensory loss inferior to injury
Explain central cord syndrome
associated with hyperextension injuries of cervical spine
loss of upper extremity fxn with intact lower extremity
Explain posterior cord syndrome
likely with extension injuries
decreased sensation to light touch and proprioception
Explain Brown Sequard syndrome
also known as lateral cord syndrome
damage to one side of cord via distraction or penetrating trauma
leads to loss of motor/light touch/vibration on side of/inferior to injury
leads to loss of px and temperature sensation on side opposite injury
Explain Cuda equina syndrome
caued by lesions in L1-2 area
effects lower extremities and bowel
numbness
low back px
What is neurogenic shock?
caused by spinal injuries
causes widespread vasodilation of vessels below site of inury
leads to hypovolemia
pt will be pale and diaphoretic superior to injury and dry warm inferior to it
hypotensive with bradycardia due to loss of sympathetic tone
What is spinal shock?
temporary local neuro cdxn that occurs immediately after spinal trauma
swelling on cord produces disruption of nerve conduction
What is Autonomic Dysreflexia and how do we tx it?
late complication of SCI
occurs at injuries above T4-T6
loss of parasympathetic system
present with huge uncompensated cardiovascular response caused by sympathetic stimulation below injury site
rise of >20mmHg above normal BP and SCI indicate AD
S/S: seizure, HA, blurred vision, anxiety, bradycardia, flushing above injury site, chills with no fever, bronchospasm, constipation, full bladders, kinked foley
Tx: remove restricting clothes, unkink foley, may need to reduce BP with vasodilators or labetalol
Explain the mechanics of ventilation in relation to chest trauma
The primary fxn of thorax is to maintain oxygenation and ventilation as well as circulation.
the systems require an environment free from disruptions and complications; chest trauma disrupts this and can cause life threatening ventilation problems.
aka broken ribs –> shallow breathing due to px causes decreased ventilation
What is the assessment process for pt’s with chest trauma?
ABCDE
AVPU
Sick/Not Sick
IAPP for Chest
Deadly dozen of Chest injuries
airway obstruction
broncial disruption
diaphragmatic tear
esophageal injury
open pneumo
tension pneumo
hemothorax
flail chest
cardiac tamponade
traumatic aortic disruption
myocardial contusion
pulmonary contusion
What does lack of JVD in supine position mean?
in combination with shock signs, may suggest hypovolemia
Chest percussion significance of dull vs hyperresonance
dull=blood in chest
hyperresonance= increased air in chest
What can muffled heart tones signify?
can indicate tension pneumo or cardiac tamponade
Tx of chest trauma basics
Focus on maitaining airway, oxygenation/ventilation, and supporting circulation.
if facial injuries, don’t nasotrach intubate
if tracheal injuries, don’t intubate
give appropriate ventilation- don’t overinflate!
IV fluids
other than RSI drugs, only other drug to consider is px management
How do we manage flail chest?
IAPP
pt may splint and make it hard to observe
s/s include shock, hypoxia, shallow breathing
Goal is spO2 >95% with supp O2 or PPV
-if not maintaining consider intubation
consider px management for better ventilation
How do we manage rib fx?
s/s of pleuritic chest px and mild dyspnea
may see chest tenderness, crepitus, subcut emphysema
ABCDE
give O2 if needed
have pt hold pillow or blanket over affected ribs
px management
How do we manage sternal fx?
px over anterior part of chest
DCAP on palpation
EKG due to possible myocardial contusion
ABCs
px management
How do we manage clavicle fx?
skin tents
splint with sling and swathe
cold pack
px management
How do we assess and tx simple pneumo?
frequent with blunt trauma
S/S: mild dyspnea, pleuritic chest px on one side, diminished/unequal breath sounds
as pneumo grows, s/s get worse –> shock, ALOC, absent breathe sounds
maintain ABCs and provide O2
monitor closely
How do we manage and tx open pneumo?
“sucking” chest wound
as air is drawn into pleuritic space, lung is unable to fully expand
will find wound or impaled object on exam
pt will be tachycardic/pnea and restless
placed gloved hand over wound
apply occlusive dressing
place on high flow O2
may require intubation if spO2 doesnot improve
usually won’t proceed to tension pneumo
Explain pathophys of tension pneumo
life threatening
can result from open or closed
lung collapses and mediastinum moves away from injured side
pulmonary shunting occurs
CO decreases as intrathoracic pressure increases
–>compression of heart and vena cava, reduces preload
–> HR increases in attempt to increase CO
How do we assess and tx tension pneumo?
s/s: absent breath sounds, unequal chest rise, pulsus paradoxus, tachycardia, VT/VF, JVD, narrow pulse pressure, tracheal deviation
supplemental O2
IAPP
occlusive dressings if needed
needle decompression
Needle decompression site
2nd or 3rd intercostal space midclavicular line on affected side
or fifth intercostal space slight anterior/midaxillary
go above rib 3 (avoids nerve bundles)
How do we assess and tx hemothorax?
S/S: ventilatory insufficiency (hypoxia, agitation, anxiety, tachypnea, dyspnea) and hypovolemic shock (tachycardia, cool, clammy, hypotension).
there will be a lack of tracheal deviation, hemoptysis, dull chest with percussion, neck veins will be flat
supplemental O2
(2) 18g IV
fluids to limit hypotension
consider intubation as needed
How do we assess and tx pulmonary contusion?
ventilation can be impaired due to px and injury damage
s/s of impaired respiration
consider O2 or PPV
caution with fluids due to edema–> use small boluses
small amounts of px management to increase ventilation but not cause resp depression
Explain assessment/management of cardiac tamponade.
Becks triad: muffled heart tones, hypotension, JVD
electrical alternans on EKG
breath sounds will be equal and there will be no tracheal deviation
ABCs
give O2
IV fluds
rapid txp
Explain assessment/management of myocardial contusion
sharp retrosternal chest px
may hear crackles with lung sounds
EKG
-PAC, Sinus tach, Afib, PVCs, new RBBB, AV block, ST changes
supportive care
-O2, IV fluids, EKG
Explain assessment/management of myocardial rupture
present with edema or cardiac tamponade
supportive care/ABCs
rapid txp
Explain assessment/management of commotio cordis
direct blow to heart during repolarization
may be unresponsive and apneic
may have seizure
tx what is present
Explain assessment/management of traumatic aortic disruption
common result of MVC or falls
most often tearing px behind sternum or scapula
also hypovolemia, dyspnea, ALOC
difference in pulses bw extremities
ABCs
gradual fluids to maintain BP
no pressors
rapid txp
Explain assessment/management of penetrating wounds of great vessels
common with penetrating injuries
can cause 6 P’s
tx for hypovolemic shock
ABC support
IV fluids
Explain assessment/management of diaphragmatic injury
most injuries occur on left side
s/s: hypotension, bowel sounds in chest, chest px, absence of breath sounds, possible N/V, abdominal px
ABC support
IV
possible nasogastric decompression
Explain assessment/management of esophageal injury
rapidly fatal
s/s: pleuritic chest px, px with swallowing or flexion of neck
ABC support
Explain assessment/management of tracheobronchial injury
seen with severe deceleration injury
rapidly progresses to tension pneumo
can be mild to severe s/s of resp compromise
s/s: hoarseness, dyspnea, tachypnea, hemoptysis, pneumo
ABCs
try to manage with PPV since intubation is discouraged
bag gentle and slow
Explain assessment/management of traumatic asphyxiation
caused by sudden and forceful compression of thoracic
aka unrestrained driver hitting steering column or ped vs vehicle/wall
ABCs
spine precautions
supp O2 or intubation
IV access (2) 18g
rapid txp
Explain the abdominal quadrants and their organs
What are the solid organs of the abdomen?
liver
spleen
pancreas
What are the hollow organs of the abdomen?
stomach
bladder
gallbladder
intestines
What is a complication of a hollow organ bursting?
Peritonitis from abdominal irritation and injury
What are some MOIs that are likely to cause closed abdomen injuries?
compression- direct blow from fixed object (seatbelt/airbag)
crushing- impact from steering column, dash
shearing-rapid deceleration from MVC or fall
Assessing abdominal/GU injuries
ABCDE
Assessing who is in need of rapid txp
Explain the ways a liver can be injured and S/S to expect.
most vulnerable organ
suspect injury with right sided trauma
sudden deceleration can cause dissection due to ligamentum teres
look for RUQ ecchymosis/tenderness
abdominal wall spasm
tenderness/guarding
hypotension
shock
Explain the ways a spleen can be injured and S/S expected.
falls, sports, and MVC
fx of 9th/10th ribs on ULQ
referred px to left shoulder (kehrs sign)
hypotension
shock
Explain the ways a pancreas canbe injured and S/S expected
most commonly injured by penetrating trauma
guarding/rebound tenderness
Explain the ways a diaphragm can be injured and S/S expected
injuries are rare
can be due to blunt trauma or penetrating trauma
most likely caused by MVC with lateral impact
bowel sounds in chest
dyspnea
chest px
Explain the ways the intestines can be injured and S/S expected
commonly injured from penetrating trauma
also severe blunt trauma (lap belt)
may present as back px
generalized abdominal px
Explain the ways a stomach can be injured and S/S expected
penetrating trauma
generalized abdominal px due to spillage of stomach acid into abdominal cavity
Explain the ways a kidney can be injured and S/S expected
trauma to back or flanks
MVCs or sports usually
px on inspiration in abdomen and flank area
penetrating renal trauma usually assoc with liver/lung/spleen
Management of abdominal injuries
ABCDE
spinal immobilization if indicated
IV
EKG
txp- rapid if indicated
Care for evisceration
wet sterile dressing over intestines
do not put in abdomen
can plastic wrap over dressing
secure intestines best you can
keep pt warm
tx for shock
What are abdominal vascular injuries?
rapid rates of blood loss
includes vena cava, superior phrenic artery, mesenteric vessels tears
mostly injured due to penetrating trauma
S/S of duodenal injury
later signs: abdominal px, fever, N/V
*suspect if child is thrown from bike and hits abdomen on handlebars
What are age associated changes in bones?
fx and dislocations associated with osteoarthritis, atrophy, weaknened proccesses of aging
What are injury predictions based on pathologic MOI?
fx in hip, spine, and wrist
degradation of joints or disks
What are the injury predictions for direct MOI?
fx of bone if direct hit
dislocation if near joint
contusion of soft tissues
penetrating trauma can cause fx
What are the injury predictions for indirect MOI?
knee striking dashboard, fx hip
fall that fx multiple bones up arm
twisting injuries result in fx, sprains, dislocations
Explain pathophys of fx.
force applied to bone exceeds its strength point, causing it to break.
Explain open vs closed fx
open fx breaks through skin
closed fx does not break skin barrier
What are the S/S of fx?
primary s/s is px
hearing snap or pop
deformity
shortening
swelling
ecchymosis
guarding
loss of use
tender to palpation
possible crepitus
exposed bone ends
Explain subluxation
partial dislocation
What is luxation
complete dislocation
Pathophys of dislocation
force of blow exceeds ligament and tendon strength, causing the joint to misalign
Explain ligament injuries/sprain
usually result from sudden twisting motions beyond ROM
also causes temporary subluxation
s/s: px, swelling, discoloration, reluctant to use
ROM typically limited by px not structural malformation
Explain strains
injury to muscle and or tendon resulting from violent muscle contarction or from excessive stretching
usually minor swelling
increased px
ligament vs tendon
ligament = bone to bone
tendon = bone to muscle
What are the fx classifications?
transverse
oblique
spiral
comminuted
greestick
compression
pathologic
linear
segmental
stress
buckle
complete
depression
Explain the process of assessing musculoskeletal injury
ABCDE
c spine considerations
cms in extemities
splinting as needed
px management
6 P’s of musculoskeletal assessmentq
px
paralysis
paresthesias
pulselessness
pallor
pressure
Explain inspecting a musculoskeletal injury
look at joint above and below injury site
compare injured side to uninjured side
look for:
- deformity/angulation/shortening/rotation
- skin changes
- DCAP BTLS
- swelling
- muscle spasm
- abnormal limb position
- changed ROM
- color changes
- bleeding
Explain the relationship bw volume of hemorrhage and open/closed fx.
Total blood loss from fx can be significant.
direct pressure, splinting, IV fluids can help stabilize
highest potential blood loss fx- pelvis, femur
Explain px control in musculoskeletal injuries
assess px level
splinting
resting, elevation
apply ice
consider px management if above not helping
Explain general guidelines of splinting
visualize injury- remove clothes
assess CMS
cover any open wounds before splinting
do not push exposed bones back in
do not move before splinting done unless hazards exist
splint entire bone lengths if joint dislocated
support limb well while splinting
straighten limb if severely angulated
if pt is resistant to movement or reports severe px, splint in place
recheck cms
ice pack
Explain some special considerations with femur fx management
fx often causes muscle spasm, by applying traction, it reduces spasm and allows for normal muscle tension which enables bleeding to slow –>potential for lots of blood loss.
Basic management of peripheral nerve injury
shoulder girdle fx
midshaft humerus fx
elbow fx
forearm fx
wrist/hand fx
femur fx
knee fx
tib/fib fx
calcaneus fx
expose injury
assess cms
consider px management before moving limb
splint injury
ice
rest
elevation
Explain assessment and management of compartment syndrome
swelling or bleeding within a compartment that causes reduced blood flow to muscle and therefore ischemia
S/S severe px, tenderness, sensory changes
px described as searing or burning
px typically not relieved with narcotics
affected area may feel firm and look pale
look for 6 P’s
elevate limb to heart level
place cold packs
loosen clothes or splint
give IV fluids to flush kidneys
Explain the assessment and management of crush syndrome
occurs bc of prolonged compression that impairs circulation and metabolism
rhabdo ensues
occurs after 4-6h
release of tissues causes acidosis
renal failure severe complication
hyperK seen
assess ABCDE
give high flow O2
give IV fluids
EKG- watch for hyperK
can give Albuterol
calcium to stabilize heart if changes seen
sodium bicarb
rapid txp if needed
S/S of DVT
Swelling of extremity
warmth
px
S/S of PE
sudden dyspnea
pleuritic chest px
tachypnea
tachycardia
low grade fever
right side heart failure
shock
cardiac arrest
hx of recent surgery, prolonged immbolization
tx: ABCs, IV and fluids, rapid txp
S/S of fat embolism
begins 12-72 h after injury
tachycardia
dyspnea
tachypnea
pulmonary congestion
fever
petechiae
ALOC
organ dysfxn
Causes of pelvic fx
blunt trauma from MVCs, motorcycle crash, veh v ped
crush injuries
falls from high height
*if have pelvic fx, suspect abdominal and head trauma
Types of pelvic fx
lateral compression disruption
anterior-posterior compression disruption
vertical shear (falls)
straddle fx (fall and impact to perineum area)
open fx
S/S of pelvic ring disruption or fx
px can be minimal
difficulty bearing weight
profound shock
gross instability
diffuse pelvic/lower abdominal px
bruising
lacerations
shortening of limb
Tx pelvic ring disruption or fx
ABCs
spinal stabilization
IV access
IV fluids for open book fx
pelvic binder
Hip fx S/S
unable to bear weight
externally rotated shortened
can appear normal if not displaced
tenderness on palpation
swelling
deformity
bruising
px
How do we reduce ankle/finger/knee dislocation or fx
buddy system taping/pad for fingers
splint ankles and knee
