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1

Components of the primary survey

  1. Airway with cervical spine precautions
  2. Breathing
  3. Circulation
  4. Disability
  5. Exposure
  6. Monitors (pulse oximetry, BP, ECG)
  7. Resuscitation (2 large bore IV’s, 2L warmed crystalloid, 100% O2 via non-rebreather)
  8. Investigations (trauma blood work)

(A.B.C.D.E.M.R.I.)

2

Glasgow coma scale 

Eye opening

4 – spontaneous

3 – to speech

2 – to pain

1 – none

Best motor

6 – obeys commands

5 – localizes pain

4 – withdraws to pain

3 – abnormal withdrawal (decorticate)

2 – abnormal extension (decerebrate)

1 – none

Verbal

5 – oriented

4 – confused conversation

3 – inappropriate words

2 – incomprehensible sounds

1 – none

3

Classification of shock

Hypovolemic

Cardiogenic

  • Myocardial infarction
  • Mechanical defects

Obstructive

  • Cardiac tamponade
  • Massive pulmonary embolus
  • Tension pneumothorax

Distributive

  • Septic
  • Anaphylactic

4

Keys to determining types of shock

  1. Hypovolemic: decreased CVP (all others increased or normal)
  2. Cardiac tamponade: increased pulmonary wedge pressure
  3. Septic/anaphylactic: decreased systemic vascular resistance and increased SvO2

5

Signs of hemorrhage

  1. Altered level of consciousness
  2. Tachycardia
  3. Tachypnea
  4. Skin pallor
  5. Decreased capillary refill
  6. Cool skin
  7. Decreased urine output

(Proximal → distal)

6

Classification of hemorrhagic shock (4 x 3)

Class I: up to 15% blood volume

  • HR < 100
  • Normal BP
  • U/O > 30 ml/hr

Class II: 15-30% blood volume

  • HR > 100
  • Decreased BP
  • U/O 20-30 ml/hr

Class III: 30-40% blood volume

  • HR > 120
  • Decreased BP
  • U/O 5-15 ml/hr

Class IV: > 40% blood volume

  • HR > 140
  • Decreased BP
  • Negligible U/O

7

Types of possible blood transfusions (3)

  1. O-negative
  2. Type-specific
  3. Cross-matched

(Fastest → slowest)

8

Types of responses to fluid resuscitation (3)

Rapid

10-20% EBL

Vitals return and stay normal

Transient

20-40% EBL

Recurrent tachycardia and hypotension

Type-specific blood

Non-responders

> 40% EBL

Vitals never normalize

Crystalloid and immediate type O blood

9

Hemodynamic goals of shock resuscitation (3)

  1. MAP > 60-65 mmHg
  2. PWP 12-18 mmHg
  3. CI > 2.1 L/min/m2 (Cardiogenic/obstructive) or > 3-3.5 L/min/m2 (septic/hemorrhagic)
  4. U/O > 0.5 ml/kg/h

10

Oxygen delivery goals of shock resuscitation (4)

  1. Hb > 100
  2. SaO2 > 92%
  3. SvO2 > 60%
  4. Lactate < 2.5 mEq/L

11

Side effects of massive transfusion (5)

  1. ARDS
  2. Coagulopathy
  3. Electrolyte abnormalities
  4. Hypothermia
  5. Immunosuppression

(A.C.E.H.I.)

12

Consequences of hypothermia (3)

  1. Acid-base disturbances
  2. Coagulation abnormalities
  3. Ventricular fibrillation

13

Initiators of coagulopathy in trauma (6)

  1. Tissue trauma
  2. Shock
  3. Hemodilution
  4. Hypothermia
  5. Acidemia
  6. Inflammation

14

Factors affecting physiologic response to trauma (9)

External

  1. Type of force (blunt vs. penetrating)
  2. Kinetic energy applied
  3. Temperature exposure
  4. Chemical/gas exposure

Internal

  1. Pre-existing medical disease
  2. Diabetes
  3. Rheumatoid disease
  4. Medications
  5. Illicit drug use/EtOH

15

Definition of systemic inflammatory response syndrome (≥ 2 of 4)

  1. Heart rate > 90 bpm
  2. WBC count < 4 or > 10
  3. Respiratory rate > 20 with PaCO2 < 32 mmHg
  4. Temperature < 36° C or > 38° C

16

Definition of acute respiratory distress syndrome (6)

  1. Acute onset
  2. Arterial hypoxemia unresponsive to oxygen therapy (PaO2/FiO2 < 200 mmHg)
  3. Bilateral infiltrates on CXR
  4. Dyspnea
  5. PWP < 18 mmHg
  6. Tachypnea

17

Etiology of ARDS in trauma patients (8)

Direct injury (4)

  1. Aspiration
  2. Near drowning
  3. Lung contusion
  4. Toxic inhalation

Indirect injury (4)       

  1. Sepsis
  2. Severe non-thoracic trauma
  3. Massive transfusion
  4. Fat embolism syndrome

18

Clinical signs of basal skull fractures (5)

  1. Bleeding from the ears
  2. Retroauricular ecchymosis (Battle’s sign)
  3. CSF otorrhea/rhinorrhea
  4. Cranial nerve VII palsy
  5. Periorbital ecchymosis (“raccoon eyes”)

(B.B.C.C.R.)

19

ER department management of closed head injuries (4)

  1. Maintain normal blood pressure
  2. Avoid hypoxia
  3. Hyperventilation to PCO2 of 25-30 mmHg
  4. Mannitol (1 g/kg of 20% solution)

20

eminently lethal chest injuries (5)

  1. Tension pneumothorax
  2. Open pneumothorax
  3. Massive hemothorax
  4. Flail chest
  5. Cardiac tamponade

21

Life threatening chest injuries (5)

  1. Simple pneumothorax
  2. Hemothorax
  3. Pulmonary contusion
  4. Tracheobronchial injury
  5. Blunt cardiac injury

22

Radiographic findings of an aortic arch injury (9)

  • Widening of the superior mediastinum
  1. Normal = 8 cm wide
  2. Abnormal = 8-10 cm wide
  3. Aortic Dissection = >10 cm
  • Separation of the calcified intima from the outermost portion of the aorta by more than 5 mm (the “calcium sign”)
  • Loss of aortic knob
  • Displacement of trachea or NG tube to the right
  • Downward displacement of the left mainstem bronchus
  • Disparity in the caliber of the ascending and descending aorta
  • Apical capping
  • Pleural effusion (most commonly left sided)
  • Localized bulge in the aorta

23

Clinical findings of an aortic dissection (3)

  1. Pulse deficit
  2. Diastolic murmur of aortic regurgitation
  3. Abnormal EKG

24

Clinical signs of a tension pneumothorax (6)

  1. Respiratory distress
  2. Absent breath sounds
  3. Hyperresonance to percussion
  4. Distended neck veins 
  5. Tracheal deviation away from the injured side
  6. Shock with hypotension 

25

CXR findings of aortic disruption (11)

  1. Widened mediastinum
  2. Obliteration of the aortic knob
  3. Tracheal deviation to the right
  4. Deviation of the NG to the right
  5. Depression of the left mainstem bronchus
  6. Obliteration of space between pulmonary artery and aorta
  7. Widened paratracheal stripe
  8. Widened paraspinal interfaces
  9. Pleural/apical cap
  10. Left-sided hemothorax
  11. 1st/2nd rib/scapula fractures

26

Positive findings of a diagnostic peritoneal lavage (6)

  1. ≥ 100,000 RBC/mm3
  2. ≥ 500 WBC/mm3
  3. Positive gram stain
  4. Amylase concentration > 175 IU
  5. > 5 ml of gross blood on initial aspiration
  6. Enteric contents on initial aspiration

27

Signs of a urethral injury (5)

  1. Inability to void despite a full bladder
  2. Blood at the urethral meatus
  3. High-riding/mobile prostate
  4. Elevated bladder on IVP
  5. Contrast dye extravasation into the perineum

28

Burn classification (3)

  1. First degree – superficial
  2. Second degree – partial thickness skin
  3. Third degree – full-thickness skin loss
  4. Fourth degree – through deep tissues

29

Signs of inhalational injury (4)

  1. Facial burns
  2. Singed face and hair
  3. Carbon in the pharynx
  4. Carbonaceous sputum

30

Markers of adequate resuscitation (5)

  1. Lactic acid < 2.5 mEq/L (#1)
  2. Base deficit < 5
  3. MAP > 60 mmHg
  4. Urine output 0.5-1 ml/kg/hr (adult)
  5. HR < 100 bpm
  6. SvO2>70