Week 11: Multiple trauma Flashcards
trauma epidemiology
- 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
Trimodal death distribution
- First peak instantly (brain, heart, large vessel injury)
- Second peak minutes to hours
- Third peak days to weeks (sepsis, MSOF)
ATLS focuses on the second peak…..Deaths from:
- 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…
tension pneumo thorax
lung completely collapses. That lung presses against the good lung and the heart
Concepts of ATLS
- 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
flail chest
multiple ribs by each other that are compromised and the lung doesn’t expand correctly. Pt. has paradoxical chest movement
The trauma system includes:
- 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
Trauma roles
- Trauma captain: person running the show, either physician or APNP who specializes in trauma
- Interventionalists
- Nurses
- Recorder
prepping for trauma pt. to arrive
- 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
nurses roles in trauma
- 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)
primary survey
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
How do we evaluate survey
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)
maxiallry trauma worst ones
Lefort injuries (1-3) 2&3 are the worst. Sputum will be blood tinged, facial swelling, CSF through the nose, tachypnea/tachycardia
airway interventions
- 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)
once et tube is in place do what?
- ascultate and look for co2 (yellow yes)
- get an xray
What can we look for clinically to assess a patient’s ‘breathing’ status?
*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
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
subcutaneous emphysema: been some type of trama that has allowed air to get into subq tissue, like pneumo. Would need a chest tube
breathing interventions
- 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
type of chest tube?
- more lateral, at 5th intercostal space: for fluid (draining blood)
- for pneumo, it’s the 2nd intercostal space, anterior
what’s going on, what do we need to do?
- 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
which way will the trachae deviate with a pneumothorax
away from the pneumothorax
circulation
*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
if you can’t get a bp manually, what do you do?
palpatory pressure. Inflate the cuff until you get radial pulse return
inraosseus injection
- 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
circulation interventions
*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
classes of blood loss (pg 223)
- 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
fluid resuscitation
- 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.
disability
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
disability interventions
Spinal cord injury
- High dose steroids if within 8 hours
ICP monitor- Neurosurgical consultation
Elevated ICP
- Head of bed elevated
- Mannitol
- Hyperventilation
- Emergent decompression
exposure
- Complete disrobing of patient
- Logroll to inspect back
- Rectal temperature
- Warm blankets/external warming device to prevent hypothermia
- giving large volume fluids
- a line in place
- intubation
- cspine immobilized
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?
. 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
secondary survey
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
seatbelt sign (seatbelt injury). Seatbelt can rupture the bladder.
diagnostic aids
- 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
- simple pneumothorax
- a classic line tells you that there’s air there. Means that potential pleural space had become a real space
- 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
What is this and what do you worry about?
bilateral pubic ramus fractures and sacroiliac joint disruption. Worry about fatty and blood emobli.
abdominal trauma
- 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
Splenic Injury
- 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
liver injury
- Second most common solid organ injury
- Can be difficult to manage surgically
- Often associated with other abdominal injuries
- 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
hollow viscous injury
- 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
ct scan in trauma
- 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
fast exam
- Focused Abdominal Scanning in Trauma
- 4 views: Cardiac, RUQ, LUQ, suprapubic looking at liver, spleen, bladder, heart
- Goal: evaluate for free fluid
non-accidental trauma
- 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
