Trauma part 1 Flashcards
Trauma is the leading cause of death between
1-45 years of age in the US
Receiving care at _______ reduces mortality from unintentional injury by ________
level 1 trauma center; 25%
WHO estimates trauma is the leading cause of death world wide between
15-44 years of age
The initial evaluation of a trauma patient includes
Rapid overview- initial impression, ABCs
Primary survey
secondary survey
Describe the rapid overview.
takes a few seconds is patient stable or unstable
ABC’s
inability to oxygenate–> brain injury & death within 5-10 minutes
Inability to oxygenate leads to*****
brain injury & death within 5-10 minutes**
The primary survey involves
rapid evaluation for functions crucial to survival and includes ABCDE (airway patency, breathing, circulation, disability, and exposure)
The secondary survey involves
detailed and systemic evaluation of each anatomic region & continued resuscitation if needed
Describe ABCDE in detail:
airway patency- obstruction
breathing- high flow oxygen, trachea midline, flail chest (3 or more fractured segments of ribs), tension pneumothorax due to air leaking from the lung, or chest wall into the pleural space, massive hemothorax >1500 cc blood
circulation- skin temp, color, 2 large bore IVs
disability (neuro) mentation- GCS
exposure- take it off
Describe the components of the glasgow coma score
eye-opening response
verbal response
motor response
Describe how to assign an eye-opening response.
4= spontaneous 3= to speech 2= to pain 1= none
Describe how to assign verbal response
5= oriented to name 4= confused 3= inappropriate words 2= incomprehensible sounds 1= none
Describe how to assign motor response
6= follows commands 5= localizes to painful stimuli 4= withdraws from painful stimuli 3= abnormal flexion (decorticate posturing) 2= abnormal extension (decerebrate posturing) 1= none
Describe the step of exposure.
final step of primary survey and includes complete exposure of the patient
removal of clothing and turning to examine
includes a brief head-to-toe search for visible injuries or deformities
The secondary survey begins after
critical life saving actions have begun:
- intubation
- chest tube placement
- fluid resuscitation
The focus for the secondary survey is:
history of injury**
allergies, medications, last oral intake*
focused medical & surgical history*****
In terms of the airway evaluation, most trauma patients require:
assisted or controlled ventilation
self-inflating bag with a non-rebreathing valve is sufficient after intubation and for transport
100% oxygen is necessary until ABG is complete
When performing an airway evaluation, assume
patient absolutely requires an airway & cannot be re-awakened electively**
The airway evaluation involves:
the diagnosis of trauma to the airway & surrounding tissue
anticipates the respiratory consequences
contemplates airway management maneuvers
Airway obstruction considerations include:
airway edema/direct airway injury cervical deformity cervical hematoma foreign bodies dyspnea, hoarseness, stridor, dysphonia subcutaneous emphysema & crepitation hemoptysis/active oral bleeding/copious secretions tracheal deviation jugular vein distention hemodynamic condition
If someone is bleeding, the airway device of choice is
not fiberoptic b/c the camera will be obscured
Nasal intubations are prone to
increased blood in the airway & nasal trauma
If considering a nasal intubation, ensure that
there is no basilar skull fracture
-assess for Battle’s sign, racoon eye, CSF leak, bruising around ears
also cannot nasally intubate with Lafort 3
Considerations for AW management include:
oxygen administration chin lift & jaw thrust full stomach clearing of oropharyngeal airway oral & nasal airway*** (smaller tube= increased resistance) immobilization of cervical spine tracheal intubation if ventilation is inadequate consider AW adjuncts to secure AW
If a trauma patient arrives intubated,
always check ETT placement via breath sounds & capnometry
remember if hypotensive may not see a lot of CO2
Airway management techniques for the trauma patient include:
DL, bougie, video laryngoscopy, awake fiberoptic, RSI vs. MRSI, cricoid pressure??- can sometimes impede visualization & ventilation, manual in line cervical stabilization, surgical cricothyrotomy/trach
Indication for ETT intubation includes:
cardiac or respiratory arrest
respiratory insufficiency/deteriorating condition
airway protection
need for deep sedation or analgesia (pain control)
GCS <8
delivery of 100% FiO2 in presence of carbon monoxide poisoning
facilitate work-up in an uncooperative or intoxicated patient
transient hyperventilation required
Describe considerations with a tracheotomy over a cricothyroidotomy.
takes longer to perform
requires neck extension which may cause extended neck trauma if cervical injury is present
Describe considerations with a cricothyroidotomy over a tracheotomy.
is contraindicated in those younger than 12 years old
laryngeal damage precludes the ability to perform a cricothyroidotomy
A surgical cricothyroidotomy can be used for
up to 72 hours then must be converted to a tracheotomy
A cricothyrotomy will be considered when there is
massive facial trauma/hemorrhage supraglottic foreign body obstruction angioneurotic edema inhalational thermal injury epiglottitis/croup
______ is a consideration for ALL trauma patients and impacts AW intervention
full stomach*
-time not available to allow pharmacologic intervention to decrease gastric contents and acidity
Safe technique for securing the airway for trauma patients includes:
RSI with cricoid pressure & manual in-line stabilization (cricoid pressure no longer a class I recommendation) awake intubation with topical anesthesia (consider loss of protective reflexes) and sedation LMA use is contraindicated as a definitive airway
________ use is contraindicated* as a definitive airway
LMA
Describe the induction agents that may potentially be used and their dosages.
etomidate: 0.2-0.3 mg/kg IV
ketamine 2-4 mg/kg IV
ketamine 4-10 mg/kg IM
propofol 2 mg/kg IV
Describe the neuromuscular blocking drugs.
succinylcholine 1-1.5 mg/kg IV
-30 sec onset, fasciculate, 5-12 min. duration
rocuronium 1.2 mg/kg IV
-30-60 sec onset, may need gentle mask vent (MRSI), 60-90 min. duration
There is a high suspicion for cervical injury if victim has experienced:
a fall
MVA
diving accident
Cervical spine injuries & AW management include:
semi-rigid collar, sandbags, and backboard provide best stabilization
manual inline stabilization best for AW management
stabilization is maintained until cervical injury is ruled out
orotracheal intubation is most desirable
Ruling out need for cervical stabilization includes:
XR of cervical spine that is clean &
pt cannot be obtunded or under the influence of drugs or alcohol and must be able to say they are not having pain
With head, open eye, & major vessel injuries, ensure that
adequate oxygenation and ventilation occur
deep anesthesia & profound relaxation prior to airway manipulation & intubation
Without sufficient depth of anesthesia, patients with head, open eye, or major vessel injuries:
hypertension
coughing/bucking
increased ICP, IOP, & intravascular pressure
Describe considerations with maxillofacial injuries & AW managmenet:
bloody & debris in the oropharyngeal cavity may predispose the patient to- complete or partial AW obstruction
aspiration of teeth or foreign bodies
serious AW compromise may present within a few hours of penetrating facial trauma
consider limitation of mandibular movement and trismus
AW management technique is based on the presenting condition
Cervical airway injuries may result from
blunt or penetration trauma
With cervical airway injuries, intubation of the trachea should be with a
fiberoptic scope or AW should be established surgically
Damage from a penetrating injury to the cervical spine depends on 3 interactive factors:
type of wounding instrument
velocity at time of impact
characteristics of tissue thru which it passes
Clinical signs of penetrating injury include
escape of air, hemoptysis, and coughing
Blunt injury may result from
direct impact, deceleration, shearing, and rotary forces- laryngotracheal damage
Clinical signs of blunt injury include
hoarseness, muffled voice, dyspnea, stridor, dysphagia, cervical pain & tenderness, flattening of the thyroid cartilage
Factors that alter respiration and interfere with breathing and pulmonary gas exchange after trauma include:
tension pneumothorax flail chest open pneumothorax hemothorax pulmonary contusion diaphragmatic rupture chest wall splinting
A hemothorax is
presence of blood in pleural cavity
Hallmark symptoms of a hemothorax include
hypotension, hypoxemia, tachycardia, increased CV
Anesthetic considerations for a patient with a hemothorax include
may need 1 lung ventilation
intubate first with a regular tube
The treatment for a hemothorax includes
eliminate and correct problem
-will likely need a chest tube
A pneumothorax is a
disruption of the parietal or visceral pleura- presence of gas within the pleural space
Pneumothorax types include
simple
communicating
tension- requires needle decompression
Treatment for a pneumothorax is a
chest tube if pneumothorax >20% lung collapse
A tension pneumothorax occurs with
rib fractures and barotrauma due to mechanical ventilation
Hallmark symptoms of a tension pneumothorax include
hypotension, hypoxemia, tachycardia, increased CVP, tracheal deviation, diminished BS on the affected side
Decompression of a tension pneumothorax occurs by
16G or bigger needle between 2nd and 3rd rib on midclavicular line
Flail chest results from
comminuted fractures of at least 3 ribs
rib fractures associated with costrochondral separation
sternal fracture
A flail chest may result in
respiratory insufficiency and hypoxemia over several hours with deterioration of CXR and ABG
The treatment for flail chest is
consider pain management (intercostal blocks, give oxygen, CPAP or Bipap) over mechanical ventilation
Hemorrhage is the most common cause of
traumatic hypotension and shock in trauma patients
Circulatory failure leads to
inadequate vital organ perfusion and oxygen delivery
Resuscitation in the circulatory shock state refers to the
restoration of normal circulating blood volume, normal vascular tone, and normal tissue perfusion
