Truama Truama Truama Flashcards
Top three causes of death following trauma
Head injury
Chest injury
Major vascular injury
What was the trauma act of 1990
U.S. Congress passed the Trauma Care Systems Planning and Development Act
Designated Trauma centers are certified based on their commitment of personnel & resources to maintain readiness to treat critically injured patients
TYpe 1 vs type 2 RR failure
Type 1 respiratory failure
->Hypoxia without hypercapnia
Conditions that affect oxygenation but not necessarily ventilation
-> PNA, PE
Treatment focuses on optimizing oxygenation
Type 2 respiratory failure -> Hypoxia with hypercapnia Conditions that affect ventilation COPD -> Treatment focuses on optimizing oxygenation & supporting ventilation
7 P’s of RSI
Preparation Pre-oxygenation Pre-treatment Paralysis with Induction!! Protection and Positioning Placement of the tube/proof Post intubation management
How many breaths do you need for pre ox for RSI
Administer 100% oxygen for 3 minutes, using a NRB mask supplied with 15 L/min of oxygen
(Or 8 vital capacity breaths)
CAn children less than 12 get cric?
NO!
MC surgical site infection with Vanc resistance
Enterococcus fasciem
What is the BMZ
complex region of the extracellular matrix
Connects basal cells of epidermis with papillary dermis
->interdigitate with epidermal projections – “rete ridges”
significant role in burn wound healing
epithelialized wounds undergo blistering until:
->the anchoring structures of the BMZ mature
Burn Calc (9s)
Head 9
Front Torso: 18
Back: 18
Arms: 9 each
Legs 18 each
Deep vs superficial partial thickness burns
Superficial partial-thickness:
Typically pink, moist, and painful
Heal within 2 to 3 weeks, without scarring or functional impairment
Deep partial-thickness:
Extend into the reticular layer of the dermis
Typically a mottled pink-and-white, dry, and variably painful.
Prognosis of deep partial thickness burns
If they do not become infected,
typically heal in 3-8 weeks, with severe scarring, contraction, & loss of function
If a partial-thickness burn has not healed by 3 weeks,
surgical excision and skin grafting may be required
Do ABX help Burns?
All topical antibiotics retard wound healing
should be used only on deep second- or third-degree burns or wounds
MGMT for Superficial burns to the face
can be treated open with an antibacterial ointment
Systemic antibiotic prophylaxis
plays no role in the management of acute burn wounds
Cream for Burns to the ears
Sulfamylon
For burns to the ears. Prone to chondritis.
Painful topical
Best type of gradt for the face, neck and hands
Full thickness sheet graft
define burn shock
both a hypovolemic and a cellular shock
decreased cardiac output, increased extracellular fluid, decreased plasma volume, and oliguria
How do we decrease catabolism in burn pts
Controlled use of a beta-blocker has been shown to decrease catabolism
insulin, growth hormones, and testosterone analogues
shown to both decrease catabolism and increase anabolism
What kind of necrosis do acids and alkaline burns cause
Acids- coagulation necrosis
Alkaline- liquefaction necrosis
Tx for chemical burns
Remove clothing from burned area
Irrigate with copious amounts of running water
Elevate and dress
Splint in position of function
MGMT for chord biting burns
Normally no surgery/debridement needed immediately
Splint to avoid contracture
Reconstruction of the mouth after healed
Partial thickness burns greater than _____ should be sent to a burn center
10 %
What does ADC VAN DIS MAL mean
Admit
Dx
Condition
Vitals
Activity
Nursing orders
Diet
IVF
Special Tests
Meds
Allergies
Labs
3 stages of wound healing
inflammation, migration/proliferation, and maturation
Wound healing: 80% of original tensile strength is reached by 6-8 weeks
Healing time for abrasions
If left to heal by secondary intention -
should close within 7 to 14 days
When should we remoce debris from abrasions
traumatic tattooing if not debrided within 24-48 hours
Healing approach for punctures
They are typically left open,
treated with wound care,
and allowed to heal by secondary intention
Secondary closure reduces the risk of infection !
generally yields excellent aesthetic results
If Uncomplicated cellulitis
->Oral antibiotics
Healing MGMT for lacerations
Can be closed primarily
Ensure wound bed is clean
Close within 6-8 hours
Face may be left open for up to 24 hours
Do not close if debris left in wound or not HDS, If contamination then 2nd intention
Time frame to do fasciotomies in crush injuries
fasciotomies should be performed within 6 hours
Tx of Rhabdo and Renal failure in crush injuries
If an elevated serum CK, intravascular volume is stabilized, and urine flow is confirmed,
a forced mannitol-alkaline diuresis should be initiated
-prophylaxis against hyperkalemia and acute renal failure
If someone is bitten
What image must we order
X-rays must be obtained and wounds explored to evaluate for fractures or open joint injuries
Mgmt for bite If a joint capsule has been violated
the joint must be thoroughly cleaned
heal by secondary intention or delayed primary closure
Rabies prophylaxis treatment
What solutions should be used for wound irrigation
Only nontoxic solutions should be used for wound irrigation
Avoid irrigation with an antibiotic solution
Strong antiseptics should not be placed directly into the wound
->toxic to the tissues and impede healing
How does 2ndary intention work
Wound closure occurs by
granulation of the wound base,
contraction from the wound edges,
and reepithelialization
In any wound where cellulitis starts
Treat with
Oral ABX
MC agent of surgical site infections
S. Aureus
What is the threshold to start antimicrobianas ABX in chronic wounds
the wound should show signs of contracture and secondary wound closure within 2 weeks.
If not - Quantitative anaerobic and aerobic bacterial wound tissue culture
Topical antimicrobial treatment is recommended
systemic antibiotics are not effective
Excessive cautery of the superficial scalp can lead to…
Alopecia
Can you use active drains over skull fxs?
NEVER!
layers of the scalp from superficial to deep
Acronym SCALP from outside in
Skin Connective tissue (galea) Aponeurosa Loose areolar tissue Pericranium
Complications of basilar skull fxs
Vascular – epidural hematoma
CN deficits – III, IV, V
CSF leak – concern for meningitis
What is 2ndary brain injury
Secondary brain injury is the sequelae of primary brain injury.
First responders can intervene to reduce secondary brain injury by managing:
- Hypoxia
- Hypotension ->decreased cerebral blood flow
- Increased Intra-Cranial Pressure (ICP)
- Hyper or hypo-glycemia
- Seizures
Motor score less than 4?
Intubate
spontaneous hyperventilation (causing PaCO2 < 26 mm Hg)…
Immediately intubate
Indications for a ICP bolt
Indicated in all salvageable patients
with a GCS score of less than or equal to 8 (between 3-8)
with an abnormal head CT scan
Normal pupils should be within _____mm
1
NML pupil size in adults
Less than 4mm
Hyphema in head injury think
TBI
LAB eval for LOC
CBC
CoAgstudies
BMP/ CMP
ABG
Tox
Blood and CSF Cx
Thyroid Funtion and B12 assay
After structural lesions have been excluded, ____ should be performed in most patients with altered consciousness
EEG
Loss of grey white delineation on CT
Think
Cerebral edema
Artery asssoc with Epidural Hematoma
Middle Meningeal
Sodium goals in Head trauma
Na+ goals of 145 to 155 mEq/l
Rx to use in ICP to manage shock
Phenylephrine
Labs when giving mannitol
Serial measurements of serum sodium, serum osmolality, and renal function
Seizure prophylaxis in head truama
Levetiracetam (Keppra) for 7 days
Rx for Agitaion in head truama
Propofol + Fentanyl
Propofol better outcome than using Benzos + narcotic
Role of barbituates in ICP
Barbiturates - reserved for refractory elevated ICP
What causes cerebral salt wasting following a TBI
attributable to the release of brain natriuretic peptide
a potent vasodilator and natriuretic that is elevated in serum during the acute phase of TBI
Approach to penetrating abdominal trauma
May need surgery to evaluate for hollow organ injury
Exploratory laparotomy- open procedure
Exploratory laparoscopy- minimally invasive
Stable pt with a penetrating abdominal trauma =
Diagnostic Laparoscopy
Indications for Ex lap in Blount trauma
peritonitis, ongoing intra-abdominal hemorrhage, and the presence of other known associated injuries
Penetrating injury to the abdomen + shock =
Ex lap
Is peritonitis after blunt abdominal trauma common?
NO !
Indicates: rupture of a hollow organ - duodenum, bladder, intestine, or gallbladder; pancreatic injury; presence of retroperitoneal blood
How does a hollow viscus organs injury look like on CT
May show “fat stranding”, pneumoperitoneum and free fluid as sequelae of hollow viscous organ injury
2 indications that make you think there may be a hollow viscus injury
The “seat-belt” sign
->more than doubled relative risk of small bowel injury
Flexion-distraction fractures of the spine (Chance fractures)
->suspicion for associated hollow viscus injury.
What can be done to decompress the stomach before Ex lap
Insert NG/OG tube to decompress stomach and avoid aspiration
What is the prevailing therapeutic strategy for blunt trauma
Conservative MGMT
Solid organ injury with evidence of active bleeding in the abdomen
Angiography
Must be stable
In a liver injury, Evidence of RUQ fluid collections or clinical deterioration =
CT to exclude a biloma, an abscess, necrosis, or hematoma
Post Dc imaging for Liver injury pts
4 to 8 weeks after injury
high-grade injuries should be reimaged at 3 months prior to return to contact sports
Prevailing Strategy to manage Spleen injuries
nonoperative management (NOM) has become the prevailing strategy for blunt splenic trauma
direct blow to the epigastrium Or bicycle handlebar to the epigastrium Or the steering wheel or a motor cycle handle bar is involved
+abdominal, back, or flank pain
Think
High Index of suspicion for Duodenal/ Panc Trauma
Retroperitoneal air, free intraperitoneal air, or obliteration of the psoas shadow
Think
Duodenal Rupture
Indications to perform a RUG
Blood at meatus
Scrotal hematoma
Blood on gloved finger after DRE (Rectal)
High riding prostate
Do not place bladder catheter if urethra injury suspected
If the FAST is negative In hemodynamically unstable patients with Pelvic trauma
Assume
pelvis is the source of the bleeding
Send to CT if stable, to evaluate
Arterial: angiographic embolization is necessary
Venous: operative placement of an external fixation device
Define Abdominal compartment syndrome
Post surgery -> increased fluid-> Results in increased peak airway pressures, decreased cardiac output, increased systemic vascular resistance
If the abdomen is closed,
->evaluate frequently for acidosis, decreased urine out put and increased lactate
Differnce between a Jackson Pratt and a Penrose Drain
Jackson Pratt drain :
- Grenade shaped vacuum container
- Closed system under suction
Penrose drain
- Rubber/latex drain
- Prevents wound healing and allows serous drainage
- Open and not under suction
Triangle of safety for Chest tubes
Medial border- pectoralis muscle
Lateral border- latissimus dorsi
Inferior border- 4-5th intercostal space
Criteria to remove a chest tube
No air leak on water seal
<200ml drainage in 24 hours
No PTX
Hard sings for penetrating neck injuries
Crepitus Hoarse Bloody Cough/ saliva Dyspnea Drool Stridor EXANDING HEMATOMA! HOTN
if a rectal injury is suspected – perform Sigmoidoscopy
Hards signs of arterial injuries
external bleeding, an expanding/pulsatile hematoma, absent distal pulses, a palpable thrill, an audible bruit, or signs of distal ischemia
Pelvic fx with no evidence of bleeding and the patient remains unstable
should be considered for external pelvic fixation and preperitoneal pelvic packing in the OR
followed by angioembolization
A GCS score lower than 9 and a lateralizing neurologic examination
indicate a significant risk that emergency craniotomy will be needed
CT scan of the head if hemodynamic stability permits
Gold standard to eval Vascualar Cerebral Injuries from blunt truama
CTA of the neck is considered the gold standard for initial screening
For patients with a concerning MOI or inconclusive findings on CT
a small amount of free fluid, mesenteric or bowel wall thickening=
Serial physical examinations are performed,
and amylase levels are checked
MGMT of blunt renal injury
Bed rest - until the urine becomes grossly clear
Foley catheter - until can void spontaneously
Consider Follow-up CT at 48 to 72 hours
