Trauma Management

Question 1

Newton’s first law of motion

Answer 1

An object in motion will remain in motion, and an object at rest will remain at rest, unless active bond by a force

Question 2

Newtons second law of motion

Answer 2

Force = Mass x Acceleration (F=MA)

Question 3

Newtons third law of motion

Answer 3

For every action, there’s an equal and opposite reaction

Question 4

Le Fort fracture

Answer 4

Le Fort 1- mandible only
Le Fort 2- mandible and cheekbones
Le Fort 3- mandible, cheekbones and orbital bones.

Question 5

Circulation assessment

Answer 5

> identify life threats and bleeding control
cardiac output-maintain MAP of 60mmHg
evaluate HR— >120= decompensated shock
BP is a waste of time initially. 30-40% loss in blood volume is when you will see a drop in blood pressure. Class 3 Blood Loss(BL).
shock index= HR/SBP (>0.9 is bad)

Question 6

Blood loss classes

Answer 6

Class 1- <750mL, 15%, vitals normal
Class 2- 750-1500mL, 15-30%, mild tachycardia
Class 3- 1500-2000mL, 30-40%, HR>120, decreased BP
Class 4- >2L, >40%, HR >140, and decreased BP

Question 7

GCS(EVM)

Answer 7

E4, V5, M6

E- Spontaneous =4, Voice = 3, Pain = 2, None = 1

V- Oriented = 5, Confused = 4, Inappropriate words = 3, Incomprehensible sounds = 2, None = 1

M- Follows commands = 6, Localizes to pain = 5, Withdrawals = 4, Flexion = 3, Extension = 2, None = 1

Question 8

Becks Triad

Answer 8

1- narrow pulse pressure
2- JVD
3- muffled heart tones
*Only if X-ray is available- widened mediastinum on chest x-ray

Question 9

Causes of widened mediastinum

Answer 9

> Thoracic aortic aneurysm at the ascending and proximal descending aorta
Aortic dissection at the ascending and proximal descending aorta
Unfolding of the aorta
Traumatic aortic rupture
Hilar lymphadenopathy; infectious or malignant.
Mediastinal masses like lymphoma, seminoma and thymoma
Mediastinitis
Cardiac tamponade
fractured ribs or thoracic vertebrae

Question 10

Tension pneumothorax symptoms

Answer 10

> severe respiratory distress
decreased or absent breath sounds
tracheal shift(late find)
subcutaneous air
JVD
high CVP
Tx: needle decompression or chest tube in the 4-6th intercostal space.

Question 11

Hemothorax symptoms

Answer 11

> decreased breath sounds
midline trachea
flat neck veins
decreased LOC
Tx:
chest tube
fluid replacement(PRBC/FFP)
airway management
Chest tube should be clamped at 1500 cc initial output to avoid re-expansion pulmonary edema

Question 12

Flailed chest symptoms

Answer 12

> paradoxical movement
respiratory distress
tachypnea with shallow depth
grunting
accessory muscle use
chest pain
Tx:
Self splinting
intubation
place injured side down
aggressive pain management and treat for nausea

Question 13

What is the number one most commonly injured organ

Answer 13

Spleen
Grade 1-5(3-5 mean surgery or fatal)

Question 14

What is the second most common organ injury?

Answer 14

Liver
Grade 1-6(4-6 mean surgery or fatal)

Question 15

Colon or bowel trauma

Answer 15

Usually penetrative or tearing/ripping, and are complicated by infection/sepsis.
Requires surgical intervention

Question 16

Aortic trauma

Answer 16

18-20% of MVA fatalities have aortic involvement
Requires surgical intervention

Question 17

Pelvic trauma

Answer 17

Unstable
> anterior/ posterior compression- result from crushing forces.
> lateral compression- results results from side impact or crushing forces
> Vertical sheer- is most ominous and often fatal
Tx:
> compression of the pelvis(binder)
> check for blood at meatus
> Disrupted pelvis can hold 4L or 80% of blood volume.

Question 18

REBOA

Answer 18

Resuscitative Endovascular Balloon Occlusion of the Aorta

> inserted via art line
Placed as early as possible(ultrasound, guided)
zone 1- injuries above diaphragm max 1hr
zone 3- primary insertion site. Best for vertical sheer, liver/spleen lac. Max 4-6 hr
zone 2- OFF LIMITS!!

Question 19

Electrolyte imbalance phase 1

Answer 19

0-36hrs
>Hyponatremia and hyperkalemia
> intravascular loss
> increased vascular permeability
> cellular edema
> Interstitial osmotic pressure increase

Question 20

Electrolyte imbalance phase 2

Answer 20

3-7 days
>Hypernatremia, Hypokalemia, hypophosphatemia, hypomagnesemia, and hypocalcemia
> reabsorption of cellular edema
> Urinary retention — stimulation of ADH

Question 21

Burn classifications

Answer 21

First-degree burn— epidermis
Second-degree burn— dermis
Third-degree burn — hypodermis

Question 22

Rule of nines (Adult)

Answer 22

Head = 9%(front and back)
Chest = 18%
Back = 18%
Arms = 9% each
Legs = 18% each
Perineum = 1%

Palmer method— each area the size of the patient’s palm = 1%. Most accurate way of estimating percentage

Question 23

Rule of nines (Child)

Answer 23

Head = 18%(front and back)
Chest = 18%
Back = 18%
Arms = 9% each
Legs = 13.5% each
Perineum = 1%

Palmer method— each area the size of the patient’s palm = 1%. Most accurate way of estimating percentage

Question 24

Burn injury zones

Answer 24

> Zone of coagulation- where tissue death occurs
Zone of stasis- outside of the zone of coagulation, usually has limited perfusion but no tissue death occurs
Zone of Hyperemia- usually more superficial and just redness.

Question 25

Escharotomy vs Fasciotomy

Answer 25

Escharotomy is a superficial(first layer) cut to allow for lung expansion and proper perfusion.(no pain or bleeding)

Fasciotomy is performed if tissue perfusion does not return after Escharotomy.(surgical procedure)

Question 26

Fluid resuscitation

Answer 26

> Parkland formula:
kg x TBSA% x 4mL = volume/24hrs(half over first 8hrs)

> Consensus formula: (combo of Brooks and Parkland)
kg x TBSA% x 2-4mL = volume in 24hrs(half over first 8hrs)
2mL/kg for adults
3mL/kg for peds
4mL/kg for electrical burns

Volume based on urine output

LR for burn patients

Question 27

Electrical injury components

Answer 27

1- injury caused by current. Generates heat along path of current. Damages, nerves, blood vessels, and muscles.
2- injury from arcing(breathing hot gases in)
3- flash burn from power source, or from clothing igniting
4-trauma due to intense muscle spasm.

Question 28

Secondary injuries of electrical burns

Answer 28

> Pulmonary- assess for inhalation injury, or restricted chest movement.
Renal- muscle damage leads to myoglobin release, which leads to rhabdo

Question 29

Rhabdomyolysis

Answer 29

Caused by massive muscle damage. If left untreated result in acute tubular, necrosis and renal failure.
Tx:
> aggressive fluid resuscitation
> watch urine output— 1-2mL/kg/hr
> give Sodium bicarb to alkalize the urine
> Mannitol
> diuretic (Lasix)

Question 30

What is the trauma diamond previously known as the trauma triad?

Answer 30

Hypocalcemia
Hypothermia
Acidosis
Coagulopathy