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NUR4630 > Week 11: Multiple trauma > Flashcards

Week 11: Multiple trauma Flashcards

1
Q

trauma epidemiology

A
  • Leading cause of death in the first 4 decades
  • 150,000 deaths annually in the US
  • Permanent disability 3 times the mortality rate
  • Trauma related dollar costs exceed $400 billion annually
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2
Q

Trimodal death distribution

A
  • First peak instantly (brain, heart, large vessel injury)
  • Second peak minutes to hours
  • Third peak days to weeks (sepsis, MSOF)
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3
Q

ATLS focuses on the second peak…..Deaths from:

A
  • TBI, Epidurals, Subdurals, IPH…
  • Basilar skull fractures, orbital fractures, NEO complex injury…
  • Penetrating neck injuries…
  • Spinal cord syndromes…
  • Cardiac tamponade, tension pneumothorax, massive hemothorax, esophageal injury, diaphragmatic herniation, flail chest, sucking chest wounds, pulmonary contusion, tracheobronchial injuries, penetrating heart injury, aortic arch injuries …
  • Liver laceration, splenic ruptures, pancreatico-duodenal injuries, retroperitoneal injuries
  • Bladder rupture, renal contusion, renal laceration, urethral injury…
  • Pelvic fractures, femur fractures, humerus fractures…
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4
Q

tension pneumo thorax

A

lung completely collapses. That lung presses against the good lung and the heart

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5
Q

Concepts of ATLS

A
  • Treat the greatest threat to life first
  • The lack of a definitive diagnosis should never impede the application of an indicated treatment
  • A detailed history is not essential to begin the evaluation
  • “ABCDE” approach
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6
Q

flail chest

A

multiple ribs by each other that are compromised and the lung doesn’t expand correctly. Pt. has paradoxical chest movement

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7
Q

The trauma system includes:

A
  • EMS: goal to stabilize and get them to the hospital
  • emergency Physicians/NP’s/Nurses
  • trauma surgery team
  • *Best is Trauma Center level 1*: all the time have a special group of people who are trained to help
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8
Q

Trauma roles

A
  • Trauma captain: person running the show, either physician or APNP who specializes in trauma
  • Interventionalists
  • Nurses
  • Recorder
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9
Q

prepping for trauma pt. to arrive

A
  • warm the room to 99 degrees
  • have foleys, ngs, intubation, iv supplies, EKG 12 lead, call ct and have them on standby, get portable xray ready, pharmacy on standby, bloodbank, lab
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10
Q

nurses roles in trauma

A
  • nurse on the left: ABCDE assessment, 12 lead ekg, vital signs, foley insertion (unless trauma to genital area, or bladder is ruptured)
  • nurse on the right: IV access, start admin of fluids, blood draws, assessment of the extremities and the trunk (determine if chest tube is needed: decreased breath sounds one or both sides, tracheal deviation, crepitus or subq emphysema, hypoxia)
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11
Q

primary survey

A

Patients are assessed and treatment priorities established based on their injuries, vital signs, and injury mechanisms
ABCDEs of trauma care
A Airway and c-spine protection
B Breathing and ventilation
C Circulation with hemorrhage control
D Disability/Neurologic status
E Exposure/Environmental control

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12
Q

How do we evaluate survey

A

Airway should be assessed for patency

  • Is the patient able to communicate verbally?
  • Inspect for any foreign bodies
  • Examine for stridor, hoarseness, gurgling, pooled secrecretions or blood

Assume c-spine injury in patients with multisystem trauma

  • C-spine clearance is both clinical and radiographic
  • C-collar should remain in place until patient can cooperate with clinical exam

pg 214 (maxillary traumas)

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13
Q

maxiallry trauma worst ones

A

Lefort injuries (1-3) 2&3 are the worst. Sputum will be blood tinged, facial swelling, CSF through the nose, tachypnea/tachycardia

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14
Q

airway interventions

A
  • Supplemental oxygen
  • Suction (can increase swelling and secretions, though)
  • Chin lift/jaw thrust (bridge to intubation)
  • Oral/nasal airways (if you think there is trauma in that area)

Definitive airways

  • RSI (rapid sequence intubation) for agitated patients with c-spine immobilization
  • ETI for comatose patients (GCS<8)
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15
Q

once et tube is in place do what?

A
  • ascultate and look for co2 (yellow yes)
  • get an xray
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16
Q

What can we look for clinically to assess a patient’s ‘breathing’ status?

A

*Airway patency alone does not ensure adequate ventilation

*Inspect, palpate, and auscultate

  • Deviated trachea, crepitus, flail chest, sucking chest wound, absence of breath sounds, decreased, or diminished, in and out wheezing (or lost all together)

*CXR to evaluate lung fields

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17
Q
A

flail chest, 2 or more ribs broken in a row, pain, most likely intubate and manage the pain. Now movement toward surgical intervention to stabilize the ribs

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18
Q
A

subcutaneous emphysema: been some type of trama that has allowed air to get into subq tissue, like pneumo. Would need a chest tube

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19
Q

breathing interventions

A
  • Ventilate with 100% oxygen
  • Needle decompression if tension pneumothorax suspected: only if severe, then insert chest tube after
  • Chest tubes for pneumothorax / hemothorax
  • Occlusive dressing to sucking chest wound
  • If intubated, evaluate ETT position
20
Q

type of chest tube?

A
  • more lateral, at 5th intercostal space: for fluid (draining blood)
  • for pneumo, it’s the 2nd intercostal space, anterior
21
Q

what’s going on, what do we need to do?

A
  • lung field on right is wiped out
  • heart is being pushed over
  • trachea is deviated
  • TENSION PNEUMOTHORAX
  • Needle decompression needed with this as well as subsequent chest tube placement
  • You will find trachae deviated away from pneumothorax, tachypnea, tachycardia, cardiac output decreased, narrowed pulse pressure, crepitus
22
Q

which way will the trachae deviate with a pneumothorax

A

away from the pneumothorax

23
Q

circulation

A

*Hemorrhagic shock should be assumed in any hypotensive trauma patient
*Rapid assessment of hemodynamic status

  • Level of consciousness
  • Skin color
  • Pulses in four extremities
  • Blood pressure and pulse pressure
24
Q

if you can’t get a bp manually, what do you do?

A

palpatory pressure. Inflate the cuff until you get radial pulse return

25
Q

inraosseus injection

A
  • when you can’t get IV access, go through the bone.
  • flat size of tibial bone
  • aspirate for bone marrow to confirm placement
  • secure site
  • reassess for infiltration for swelling or oozing
  • can infuse up to 125 cc’s an hour
26
Q

circulation interventions

A

*Cardiac monitor
*Apply pressure to sites of external hemorrhage
*Establish IV access

  • 2 large bore IVs (at least 18 guage for potential of giving blood)
  • Central lines if indicated

*Cardiac tamponade decompression if indicated
*Volume resuscitation

  • Have blood ready if needed
  • Level One infusers available (put volume into machine which compresses it to push it in very fast, like a PRBc’s in 2 minutes for the whole bag. Also warms the fluid).
  • Foley catheter to monitor resuscitation
27
Q

classes of blood loss (pg 223)

A
  • class 1: mild blood loss. May not even be symptomatic less than 15
  • class 2: 15-30% blood loss, systolic not greatly affected, drip in MAP
  • class 3: 30-40% blood loss. See a drop 20mmhg in BP. Tachy above 120
  • class 4: more than 40% blood loss. Significant tachycardia, significant drops, MAP less than 60
28
Q

fluid resuscitation

A
  • 2 liters isotonic solution first
  • followed by as need the 2:1:1 ratio (2 prbs, 1 ffp, 1 platelets)
  • pediatrics: based on weight 20ml/kg x 2 of isotonic solution. Need at lease 2 liters of this before you think about blood.
29
Q

disability

A

Abbreviated neurological exam

  • Level of consciousness
  • Pupil size and reactivity
  • Motor function
  • GCS: Utilized to determine severity of injury. Guide for urgency of head CT and ICP monitoring
  • AVPU scale: looking at their level of conciousness. A: alert, responding to verbal stimuli. V: they’re responding to verbal stimuli (not alert) P:** Only respond to painful stimuli **U: no response to even painful stimuli
30
Q

disability interventions

A

Spinal cord injury

  • High dose steroids if within 8 hours

ICP monitor- Neurosurgical consultation
Elevated ICP

  • Head of bed elevated
  • Mannitol
  • Hyperventilation
  • Emergent decompression
31
Q

exposure

A
  • Complete disrobing of patient
  • Logroll to inspect back
  • Rectal temperature
  • Warm blankets/external warming device to prevent hypothermia
32
Q
A
  • giving large volume fluids
  • a line in place
  • intubation
  • cspine immobilized
33
Q

28 yo M involved in a high speed motorcycle accident. He was not wearing a helmet. He is groaning and utters, “my belly”, “uggghhh.”

HR 134 BP 87/42 RR 32 SaO2 89% on 100% facemask

Brief initial exam: pt is drowsy but arousable to voice, has large hematoma over L parietal scalp, airway is patent, decreased breath sounds over R chest, diffuse abdominal tenderness, obvious deformity to L ankle

What are the management priorities at this time?

What are this patient’s possible injuries?

What are the interventions that need to happen now?

A

. Always ABCDE first!

  • A – airway patent; go to NRB mask, frequent reassessment, don’t forget proper C-spine immobilization. May need intubation
  • B – tachypnea, decr. BS, hypoxia (? PTX, hemothorax); consider needle decompression , CXR, then chest tube
  • C- hypotensive, tachycardic (? Tension PTX v. massive hemothorax v. intraabdominal hemorrhage, ? Pelvic fractures); needs large bore IV v. CVL, IVF, blood available. (fluid resucitation)
  • D – do quick GCS, pupils, motor assessment
  • E – exposure, blankets
34
Q

secondary survey

A

F: vital signs & family members

G: give comfort comfort to your patient.

H: head to toe assessment & history

I: insepcting the posterior surfaces

  • Ample history:Allergies, medications, PMH, last meal, events
  • Physical exam from head to toe, including rectal exam
  • Frequent reassessment of vitals
  • Diagnostic studies at this time simultaneously: X-rays, lab work, CT orders if indicated, FAST exam
35
Q
A

seatbelt sign (seatbelt injury). Seatbelt can rupture the bladder.

36
Q

diagnostic aids

A
  • Standard trauma labs: CBC, K, Cr, PTT, Utox, EtOH, ABG
  • Standard trauma radiographs: CXR, pelvis, lateral C-spine (traditionally)
  • CT/FAST scans
  • Pt must be monitored in radiology
  • Pt should only go to radiology if stable
37
Q
A
  • simple pneumothorax
  • a classic line tells you that there’s air there. Means that potential pleural space had become a real space
38
Q
A
  • widened mediastinum, cardiac tampenade. Know there’s fluid collecting around the heart.
  • there’s also a chest tube on the right side. lateral and low, so it’s probably for blood
39
Q

What is this and what do you worry about?

A

bilateral pubic ramus fractures and sacroiliac joint disruption. Worry about fatty and blood emobli.

40
Q

abdominal trauma

A
  • Common source of traumatic injury
  • Mechanism is important: Bike accident over the handlebars, MVC with steering wheel trauma
  • High suspicion with tachycardia, hypotension, and abdominal tenderness
  • Can be asymptomatic early on
  • FAST exam can be early screening tool
  • Look for distension, tenderness, seatbelt marks, penetrating trauma, retroperitoneal ecchymosis
  • Be suspicious of free fluid without evidence of solid organ injury
  • *Treat with rapid fluid hydration and fast exam
  • Bruising retroperitoneal : liver/kidney, pain in shoulder: spleen
41
Q

Splenic Injury

A
  • Most commonly injured organ in blunt trauma
  • Often associated with other injuries
  • Left lower rib pain may be indicative
  • Often can be managed non-operatively
42
Q

liver injury

A
  • Second most common solid organ injury
  • Can be difficult to manage surgically
  • Often associated with other abdominal injuries
43
Q
A
  • diaphragmatic hernia
  • heart is pushed over because bowel is pushing on it
  • May only see the nasogastric tube appear to be coiled in the lung.
    Left > right due to liver protection of the diaphragm.
  • more common on the left side
44
Q

hollow viscous injury

A
  • Injury can involve stomach, bowel, or mesentery
  • Symptoms are a result from a combination of blood loss and peritoneal contamination
  • Small bowel and colon injuries result most often from penetrating trauma
  • Deceleration injuries can result in bucket-handle tears of mesentery
  • Free fluid without solid organ injury is a hollow viscus injury until proven otherwise
45
Q

ct scan in trauma

A
  • Abdominal CT scan visualizes solid organs and vessels well
  • CT does NOT see hollow viscus, duodenum, diaphram, or omentum well
  • Some recent surgery literature advocates whole body scans on all trauma: Keep in mind that there is an increase in mortality related to cancer from CT scans
46
Q

fast exam

A
  • Focused Abdominal Scanning in Trauma
  • 4 views: Cardiac, RUQ, LUQ, suprapubic looking at liver, spleen, bladder, heart
  • Goal: evaluate for free fluid
47
Q

non-accidental trauma

A
  • Key is SUSPICION!!!
  • Incongruent stories of mechanism
  • Delay in seeking treatment
  • Multiple stages of injuries
  • Pattern Injuries
  • Multiple hospital visits
  • Injury mechanism beyond the scope of the age of child (6week old rolled over off the bed)
  • Bite marks, submersion injury, cigarette burns

NUR4630 (34 decks)

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