Lecture 2: Trauma Flashcards
(167 cards)
1
Q
- What is primary and secondary survey?
- Geriatric trauma (brain shrinks from 25yo) lesser trauma to head can cause what?
- Trauma in pregnancy, what is important?
A
Primary survey (resuscitation – done only in primary survey)
* ABCDE
Secondary survey (Specific injuries from head to toe)
* Begins after acute resuscitation
Geriatric trauma (brain shrinks from 25yo) lesser trauma to head can cause hemorrhage
Trauma in pregnancy (40% of volume gone = tachycardia – maybe too late)
ABCDE – airway, breathing, circulation, disability, exposure.
2
Q
Management of the trauma patient
Time distribution of Death from trauma: First Peak
* What is the timing?
* Where is the injury?
* Most do what?
A
- Death within minutes (usually due to aorta damage)
- Brain injury, injury to great vessels
- Most die before reaching hospital
3
Q
Management of the trauma patient
Time distribution of Death from trauma: Second Peak
* What is the timing?
* Where is the injury?
* What should we do the patients?
A
- Usually occurs during the ‘golden hour’
- Intracranial hematoma, major thoracic or abdominal injury
- “Primary focus of Advanced Trauma Life
4
Q
Time distribution of Death from trauma: Third Peak
* What is the timing?
* Where is the injury?
* What should we do the patients?
A
- Days to weeks
- Multiple organ failure and sepsis
- Proper care during golden hour reduces mortality
5
Q
ATLS “Summary”
* What is primary survey?
* What is resuscitation?
* What is secondary survey?
A
6
Q
What is the Primary Survey’s “ABCDE”
A
7
Q
Primary Survey First
* What do you need to do before moving onto secondary survery?
A
IDENTIFY and TREAT (life threatening injuries) before going on to secondary survey
8
Q
Primary survey includes:
* What is the HIGHEST priority?
* Clear what?
* What is the preferred txt for airway?
* What if needed?
* What about spine fxs?
A
9
Q
Airway and cervical spine
* What should you need with O2?
* Assume what? What do you apply?
* How do you figure out patency of airway?
* How do you reposition airway?
A
- If not able to speak but still ok – airway is compromised (air isn’t going thru the vocal cords).
- Fractured trachea in peds – hit the handle bars of a bike – GET C-Spine 3 views or CT (better)
- Most deaths come from head injury.
10
Q
What is the single most important prehospital priority?
A
AIRWAY CONTROL
11
Q
Breathing:
* Assess for what? (2) What are the different characteristics? (4)
A
12
Q
Breathing:
* Treat what? What are the different tyeps (3)?
* What is the o2 levels?
A
Treat life threatening ventilatory problems
* Tension pneumothorax (do chest tube)
* Open pneumothorax (sucking chest wound)
* Flail Chest
Oxygen 10-12L/min to deliver an FIO2>.85/.90%
If loose blood – less Hgb so pulse OX is less too. .85% is satisfactory.
13
Q
What is an open pneumothorax?
A
14
Q
How do you temporary fix open pneumothorax?
A
15
Q
What is flial chest? What is common and what imaging should you get done?
A
More than 3 ribs are broken in 2 places
Soft tissue + vascular injuries are common
* Do not only x-ray, do CTa
16
Q
Circulation and hemorrhage control
* Control what?
* Assess what?
* What do you need to relieve?
* What do you monitor?
A
- Control Bleeding
- Assess pulse, capillary filling and neck veins
- Relieve pericardial tamponade
- Cardiac Monitor (include fetal monitor)
17
Q
Circulation and hemorrhage control
* What about IVs?
A
2 large bore proximal IV’s (NEED TWO, usually one is central line)
* 1-2 L NS/LR
* If Negative response to NS IV bolus use blood (LOTS OF BLOOD LOSS: GIVE FLUIDs+BLOOD)
* AVOID PRESSORS until after fluids
18
Q
Circulation and hemorrhage control
* How do you monitor urine?
A
Monitor urine output (1cc/kg/hr)
* See how fluid replacement is going
19
Q
Tension pneumothorax will cause what? What should you do and not do?
A
Tension pneumothorax will cause restricted preload (JVD) and afterload – don’t do epi or other stuff. DO NS and whole blood (want clotting factors) or PRBCs (if no trauma).
20
Q
- Pulse changes first when?
- BP cahnges when?
- Pregnant?
A
- Pulse changes first at 750cc loss.
- BP changes at 1.5L of loss.
- Pregnants are 40% loss.
21
Q
Venous Access
* Where is a peripheral acess? How much? What should you do to the arm?
* Do not use vein if what?
A
22
Q
Venous Access
* _ veins
* venous cutdown-
* What are the interosseous routes (Adults vs children)?
A
Central Veins
Venous cutdown – saphenous (medial malleolus)
INTEROSSEOUS route Adults vs Children
* Tibia- Adults and Children
* Clavicle- Adults
* Sternum- Adults
*
23
Q
IO techique?
A
- IO – adult is many sites – sternum, PSIS.
- Kids – best place is tibia. Stay away from joint
24
Q
Circulation
* Circulation is stabilized by what?
* Wht do you do if IV attempts are unsuccessful?
A
Circulation is stabilized by vascular access, IV fluids and drugs
If IV attempts are unsuccessful:
* Deliver meds through ETT (2x the IV dose) – squirt them into ET tube
* Atropine, epinephrine, lidocaine, naloxone (narcan)(LEAN)
Narcan – cant give IM – do it by ET tube
25
What is the tamponade tx?
* Want patient to be at 45 degree up reclining.
* From xiphoid process at 45 degree angle towards heart. Back up if get lots of reb blood.
26
Disability
* Assess mental status how?
Assess Mental status (AVPU) -qualitative
* A-alert (4)
* V-responds to voice (3)
* P- responds to pain (2)
* U – unresponsive (1)
* cannot have 0
27
Exposure:
* Fully do what to patient?
* What should you avoid (2)
* Components of lethal triad?
28
# KNOW
Fill in for the Glasgow coma scale
## Footnote
* QUANTITATIVE SCALE
* Lowest score is 3
* Under 9=airway
29
Primary Survey
* What labs need to be done?
* What is mandatory?
Labs
* Type and Cross, CBC, electrolytes, (Glc), toxicology, ABG and Hcg (females)
Imaging( mandatory )
## Footnote
Electrolytes – look for HCO3 and K mainly.
30
Primary Survey
* What are different imaging?
Depends on injury, but in trauma:
* CXR (upright if possible)
* C-spine( 3 view )
* Lateral, AP, Odontoid
* CT is better
* Pelvis
* CT Brain/Chest/Abdomen
## Footnote
Trauma to face – still do open mouth for odontoid shot if no CT is available. Deal with complications later. Never do NG tube or endotracheal tube thru the nose in facial trauma. Oral is ok.
31
Secondary Survey
* _ medical hx
* Complete what?
* What else should be done?
* Assess/re-assess what?
* What do you give if indicated?
## Footnote
Reassess the vital signs. Do IV ABX and tetanus (more than 10 years if clean, more than 5 years if dirty) if indicated
32
What is AMPLE
33
Hypovolemic Shock: Classification
* What is happening in class one?
34
Hypovolemic Shock: Classification
* What is class two?
35
Hypovolemic Shock: Classification
* What is class three?
36
Hypovolemic Shock: Classification
* What is class 4?
37
Cannot begin secondary survey until what? (3)
* Primary survey is completed (ABCDEs)
* Resuscitation is initiated
* Patient’s ABC’s (VS) are re-assessed
38
What are the components of common IV solutions (cations)?
39
What are the different components of common IV solutions? (anions)
What does lactate convert into?
* 0.9% NS: over 2L can cause acute kidney injury+metabolic acidosis
* Lactated ringer's: Has bicard unlike NS, which is used for acidosis patients
## Footnote
Give 30 cc per kg for Fluids
40
Secondary Survey
* What are all the different chest traumas?
* Simple pneumothorax
* Hemothorax
* Pulmonary contusion
* Myocardial contusion
* Aortic disruption
* Traumatic diaphragmatic hernia (bowel sounds in chest)
* Esophageal disruption
41
Chest:
* What do you need to assess again?
42
What is this?
Don’t see BV on Right side.
43
Secondary Survey: abdominal trauma
* Assessment can be difficult why?
* When is exam not helpful?
* What are the different dx tests (4)?
## Footnote
* Do DPL and FAST for unstable patients.
* CT only if the patient is stable.
44
45
What is DP:?
* Now not used as much due to FAST US exam.
* DPL in pregnant patient – go to umbilicus and put 1L of NS and then drain it – if blood go to OR.
* In nonpregnant – use different location, not umbilicus.
46
Abdomen
* Presence of what?
* Palpation?
* Look for what?
* What about mental? What can change that?
* Presence of bowel sounds?
* Rigid to palpation?
* Obvious bruises or penetrating injury?
* Does the patient have AMS?
* Ethanol?
* Drugs?
47
What are the different signs?
48
Abdominal Trauma: Pattern of injury - involvement
* What organ is most commonly affected from penetrating trauma? What are examples?
* What organ is most commonly affected from blunt trauma? What are examples?
49
What are the different velocity of gun
50
Abdominal trauma:
* Stability of the patient dictates what?
* Classic teaching was that penetrating injuries were what?
* DPL can screen for what?
* What is FAST?
51
Laporotomy
* What is the stardard?
* Indications are what?
* The stability of the patient will determine what? Explain
* What will a stable patient get?
52
What should you pay attention to if this was your patient?
Pay attention to carotid arteries due to seat belt trauma – do an US or CT.
53
Pelvic Trauma:
* Check what?
* Associate what? Give exampes?
Pelvic trauma
* Check stability
* palpate/push A-P/Lateral-Medial
* Associate GU injuries
* Blood at penile meatus
* High riding prostate on rectal exam
54
* What are the different primary head injuries?
* What are the different secondary brain injuries?
Primary brain injury:
* Subdural Hematoma( venous origin ) – higher chance of survival.
* Epidural Hematoma( artery origin )
Secondary brain injury
* Hypoxia
* Hypotension
* Elevated intracranial pressure(MOST FREQUENT CAUSE OF DEATH
55
Head injury severity
* What are the different GCS levels?
* Severe ..GCS <9 i.e 8 or below (MUST INTUBATE)
* Moderate GCS 9-13
* Minor GCS 14-15
56
Pelvic Fractures
* Can die from what?
* Splinting will help prevent what?
* Pelvic fractures are invariably associated with what?
* Can die from blood loss (from superior epigastric artery) from pelvic and femur fractures (>1-2 Liters)
* Splinting will help prevent blood loss – external fixators hold it and making it bleed less.
* Pelvic fractures are invariably associated with bladder injuries
| Pelvic fracture – very likely to have bladder rupture.
57
What is this?
58
Genitalia:
* What suggests urethral disruption?
* What can you not do?
Male – is there blood at the urethral meatus? This
suggests urethral disruption.
* This patient will not be able to have a foley catheter and will need a retrograde cystourethrogram.
## Footnote
Put syringe w/o needle and put contrast fluid in and look for damage location.
59
Female Genitalia
* What do you need to exam?
* What do you need to look for a patient if they are pregnant?
* What do you need to look out for?
60
Rectal exam
* What are the different questions should you ask?
## Footnote
Under slide: The bulbocavernosus reflex is useful in testing for spinal shock and gaining information about the state of spinal cord injuries (SCI). The test involves monitoring [anal sphincter] contraction in response to squeezing the (head) glans penis or tugging on an indwelling Foley catheter[1]. The reflex is spinal mediated and involves S1-S3. The absence of the reflex without sacral spinal cord trauma indicates spinal shock. Typically this is one of the first reflexes to return after spinal shock. Lack of motor and sensory function after the reflex has returned indicates complete SCI.
61
Secondary Survey: Head injury (TBI)
* Leading cause of what?
* Assume what?
* What is the hallmark of brain injury?
* Leading cause of death in trauma
* Assume a cervical spine injury (do the CT C-Spine simultaneously)
* Change in LOC is the hallmark of brain injury
## Footnote
* Level of consciousness.
* Don’t get XR of skull, just get a CT – much better.
62
What are different questions you need to ask about head?
63
Concussion:
* What is it?
* What can their be a brief loss of ? What is never lose tho?
Immediate and brief loss of consciousness(<5 minutes)
Brief amnesia (ante-grade/retrograde) after a blow to the head
* Never loss of patient demographic information like how old they are/family (malingering/hysteria)
## Footnote
If 10-20 min + - its not a concussion – it’s a brain contusion.
64
CONCUSSION CT guide
* Children below the age of 18 use what?
* Adults use what?
* Both address what?
65
What is the PECARN for 2 years and under?
66
What is the PECARN for 2 years and older?
67
What is the canadian CT head rule
68
Brain Injury
* What is the leading cause of death in children over one?
* What are the different caues of head trauma?
69
Brain Injury-Primary
* Occurs when? What are the damage types (2)?
* No txt for what?
* What is vital?
70
Brain Injury: Secondary
* Occurs when?
* Affects what?
* What are the causes?
* Leads to what?
71
Concussion
* Can lead to what?
* Most recover within what?
* Can lead to long term cognitive deficits
* Most recover within hours or days
* 90% recover in 6-8 weeks
72
Concussion:
* What is it?
It is a brain injury
* Complex pathophysiologic process
* Neurometabolic dysfunction rather than structural injury
73
Concussion
* All are what?
* Can occue without what?
* Can occur in what?
* What can help prevent further injury or death?
* All are serious
* Can occur without LOC
* Can occur in any sport
* Recognition and proper management when they first occur can help prevent further injury or death
74
Concussion
* What are the sx that are reported by coach??
75
Concussion
* What are the sx that are reported by athlete?
76
Concussion
* What are the sx that are reported by families?
77
What are the red flags of concussion? What do you need to do?
Do imaging
78
Head Injury
* Whar should you use?
* Never do what?
79
Post Concussive Syndrome
* Common sequela of what?
* Complex sx include what?
* Often described in the setting of what?
* Common sequela of TBI
* Complex symptoms include headache, dizziness, neuropsychiatric symptoms, and cognitive impairment
* PCS is most often described in the setting of mild TBI, but it may also occur after moderate and severe TBI, and similar symptoms are described after whiplash injuries as well
80
Post Concussive Syndrome
* What does not have to occur?
* Recurrent concussions can progress to what?
* Loss of consciousness does not have to occur for PCS to develop.
* Recurrent concussions can progress to 2nd impact syndrome.
81
# Specific Injuries All Ages
Head injury
* What image should you do?
x-rays rarely used—do CT HEAD/C-Spine
* Do head and neck – both will screen for all problems.
82
Acute brain injury
* What is primary?
* What is secondary?
* What are goals?
* What is essential to obtaining this goal?
* Primary (at the time of the injury, a direct result of the traumatic force)
* Secondary (cascades that extend the original damage to cells that are not initially irreversibly injured)
* Goals are to prevent this ischemia and hypoxia
* Early recognition of hypoxemia, hypotension and anemia are essential to obtaining this goal
83
Basilar Skull Fracture
* What is it?
* Commonly associated with what?
* A basilar skull fracture (or basal skull fracture) is a fracture of the base of the skull, typically involving the temporal bone, occipital bone, sphenoid bone, and/or ethmoid bone
* Commonly associated with a torn dura leading to CSF leakage from the ear or nose
84
What are the signs of basilar skull fx?
* CSF otorrhea or rhinorrhea
* Mastoid ecchymosis (battle sign)
* Periorbital ecchymosis (raccoon eyes)
* Hemotympanum
| IMAGE IF THESE SX
85
What is the halo sign?
Clear fluid coming out of ears or nose – get a sample and put into glucometer or just on a sheet/towel– it will be 2/3rds of normal
* CSF in blood
86
What is this?
Battle sign-> Worry about basilar skill fracture
87
What is this?
Racoon eyes
* basilar skull fx
88
What is this?
Hemotympanum
* basilar skull fx
89
Four major brain herniation syndromes:
* What is the most common?
* What is the txt?
## Footnote
* Temporal bone Fx – middle meningeal artery is damaged.
* Brain can only hold750/1500cc. Then see CN changes like unopposed pupil dilation.
90
Brain Contusion
* May occur where?
* What type of injury could happen?
* What can be delayed?
91
Brain pathology: subarachnoid hemorrhage
* Results from what?
* What will be in the blood?
* What are the causes?
* Subarachnoid hemorrhage results from diruption of subarachnoid vessels
* The patient will have blood in the CSF
* Aneurysm/A-V malformation or Direct Trauma
92
What is this?
Subarachnoid hemorrhage
93
Epidural hematoma:
* Results fromm what?
* Causes?
* What is the classic presentation?
* What occurs quickly?
## Footnote
<5min = concussion
94
What is this?
Epidural hematoma
95
Subdural hematoma:
* Bleeding occurs where?
* usually results from what type of bleed?
* What are the types?
* Common in who?
## Footnote
Alcoholics have smaller atrophied brain – easier to cause bleeding with trauma.
96
What is this?
subdural hematoma
97
Maxillofacial Trauma
* Consider what first?
* What should NOT happen?
* What do you need to test?
* What do you need to ask (2)?
## Footnote
Tell them not to bite. Cranial facial disassociation – pull hard palate and push on the forehead to see which fracture it is. See which parts of bones will come forward as you pull.
98
Le Fort I, II, III – each higher number is worse
* What are they?
I: Maxilla fracture (floating palate
II: Maxilla, orbital rim and nasal bones (floating maxilla)
III: II+ zygomatic arch fracture (floating face)
* is a craniofacial dysjunction and the patient has a dish-face appearance
## Footnote
You will note facial bone movement with exam
99
What are these?
100
Secondary survey
* What patients should be suspected of having spinal injury?
* What are the types with occurance percentage? (4)
101
Secondary survey: extremities
* Not usually what?
* What are the types (4)
## Footnote
Compartment syndrome: get CK levels, push on tissue to see if it is hard, 5 ps
102
Spinal cord injury
* Seen with what?
* What is the difference between complete and incomplete?
103
What are the three main spinal cord pathways and what fibers are carried?
* Dorsal Column Pathway : ipsilateral position and vibration
* Spinothalamic pathway: contralateral pain and temperature
* Corticospinal pathway: movement/ipsilateral mostly, minimally contralateral
104
* Motor (corticospinal) same side
* Post column – proprioception
* Spinothalamic – pain, temp opposite side.
105
Spinal Cord Syndromes:
* What is anterior and central cord?
* Anterior cord: paralysis below the lesion, loss of pain and temperature, preservation of proprioception and vibratory function
* Central cord: Quadriparesis greater in the upper extremities than in lower; Greater loss of pain and temperature in upper ext.
106
Spinal Cord Syndromes:
* What is brown sequard and cauda equina
* Brown Sequard: ipsilateral weakness, loss of proprioception and vibratory; Contra-lateral loss of pain and temperature
* Cauda Equina: motor and sensory loss in legs, sciatica, bowel/bladder dysfunction and “saddle” anesthesia
* Retention is more common than loss of bladder
107
108
What is spinal shock?
: areflexia, loss of sensation, flaccid paralysis below the level of the lesion, flaccid bladder, loss of rectal tone
109
Spinal shock
* patient has no what? When does it resolve?
* Cannot assess what?
* What is unlikely to improve? What may return of function?
* These patients have no reflexes. This generally resolves after 24-48 hours.
* Cannot assess whether lesions are complete until spinal shock has resolved.
* Complete lesions are unlikely to improve.
* Incomplete cord lesions – patient may have some return of function !!!
110
What is neurogenic shock?
Neurogenic shock – upper thoracic or cervical interruption of sympathetic pathways. Will not have Tachy, only bradycardia. BP will be low. DON’T give them fluid
111
Neck
* Maintain what?
* Remove what?
* Examine/palpate for what?
* Maintain inline mobilization of the neck
* Remove the collar
* Examine/Palpate for deformities, penetrating injuries, crepitus, tenderness (especially over larynx)
## Footnote
If pain on palpation of neck or loss of reflexes etc – keep c-collar on.
112
What are the unstable cervical spine fractures?
* Jefferson (C1)
* Bit (B/L)
* Off (odontoid)
* A (any combo of fracture dislocation)
* Hangman’s -> C2 (pedicles break)
* Thumb (tear-drop fracture which can be from swimming)
113
# Review
* What is bilateral and unilater facet dislocation?
* What is Clay shoveler's fracture
* What is a wedge fracture?
* What is a burst fracture
114
Clearing the C-spine
* What are the traditional rules?
* What criteria is used?
* What do you need to examine?
* How many views?
115
What is the NEXUS criteria
116
Management of Spinal cord
* Prevent what?
* Alleviate what?
* Establish what?
* What should you give in blunt trauma?
* Prevent secondary injury
* Alleviate any cord compression
* Establish spinal stability
* High doses of methylprednisolone within 8 hours of injury in blunt trauma only
* Hypothermia – not used as much in brain trauma. Used a lot in Cardiac causes.
117
What are the injuries to the extremities?
* Open injuries
* Crepitus
* Tenderness
* Deformity
* Pulses, perfusion
* Expanding hematomas
* Splint all fractures
* No cast application initially (prevent compartment syndrome)
118
What are hard and soft extrmity vascular trauma?
119
Extremities
* What type of injury?
* What should you worry about? What are the signs?
120
Commonly Associated Fractures(Look for them)
* Calcaneal fx---
* Posterior fx/dislocation of the hip----
* Transverse fx of 5th lumbar vertebrae---
* Calcaneal fx---Thoracolumbar fx
* Posterior fx/dislocation of the hip----Femoral fx or severe tibia/fibula fxs
* Transverse fx of 5th lumbar vertebrae---Sacral fx
121
Vascular Injuries Associated with Musculoskeletal Injuries
* Posterior knee dislocation
* 1st and 2nd rib fx’s, sternal fxs, scapula fxs
* Supracondylar humeral fx
* Popliteal vessel disruption
* Thoracic aortic injury
* Brachial artery injury
## Footnote
* XR joint above and below.
* Knee dislocation – get CT angio.
122
Neurological injury due to fractures
* Anterior shoulder dislocation, humeral neck Fx
* Midshaft of humerus
* Supracondular fx of humerus
* Medial epicondylar fracture of humerus
Anterior shoulder dislocation, humeral neck Fx
* Axillary nerve (Deltoid)
Midshaft of humerus
* Radial nerve
Supracondular fx of humerus
* Median nerve
Medial epicondylar fracture of humerus
* Ulnar nerve
123
Neurological injury due to fractures: Lower extremity
* Posterior Hip dislocation
* Pelvic ring fracture
* Fibular head fracture
Posterior Hip dislocation
* Inferior gluteal nerve, sciatic nerve
Pelvic ring fracture
* Obturator nerve
Fibular head fracture
* Common peroneal nerve
124
Principles of Imaging
* What are the issues with contrast?
* anaphylactic reactions
* dysrhythmias
* pulmonary edema
* RENAL failure
## Footnote
Once Cr is above 1.8 – dye wont be approved. If pat is dehydrated – give bolus of fluid first.
125
Principles of Imaging: Contrast reactions
* Patients with asthma are at increased risk of what?
* Worsening of what? Do not if what?
* Patients taking glucophage can develop what? What do you need to do?
Patients with asthma are at increased risk of anaphylaxis
Worsening of renal function (Cr>1.6)
* Do not worry if on dialysis (kidneys are already dead)
Patients taking glucophage can develop a potentially fatal lactic acidosis (rare)
* Withhold for 48 hrs after study
126
Basic Trauma Imaging Concept- CONTRAST
* Head and Cervical Spine –
* Chest/Abdomen –
* Vascular injuries –
* Head and Cervical Spine – NO contrast
* Chest/Abdomen – YES contrast
* Vascular injuries – Always contrast
## Footnote
Note variations in neck imaging that may require contrast
127
Pediatric Trauma
* Children are not what?
* Children compensate until what?
* What is an important vital sign?
* Children are not like “little adults”
* Children compensate until right before they crash and die
* Tachycardia is an important vital sign; They may not ever become hypotensive or may become hypotensive right before they die
128
Pediatric Trauma
* Children become what earlier than adults?
* Give what as early as possible?
* Most arrests in children are what?
* Children’s heads constitute what?
* They may have intact ribs without fractures but what?
* What is common in children?
129
Pediatric Trauma
* What can cause fatal air bag injuries?
* What is the most commonly injured abdominal organ?
* What is the second most commonly injured abdominal organ?
* Children sustain fatal air bag injuries.
* Spleen is the most commonly injured abdominal organ.
* Liver is the second most commonly injured abdominal organ.
130
how do you get the pediatric BP?
8yo: 80+16= 96; 64
131
Neonatal Resuscitation
* Maintain what?
* Clear what?
* What is the CPR in HR?
* Can obtain what?
* Can monitor blood pressure and ABGs with catheter in what?
## Footnote
* Airway first and then get core temperature higher.
* If <2weeks old – use umbilical stump to enter the vein.
132
Vascular Access Ages
* Scalp Vein:
* Umbilical vein access:
* What else can be used as well
* Scalp Vein (less than 1 year old)
* Umbilical vein access (1-2 weeks after birth)
* IO’s can be used as well
133
What is the fetal circulation?
134
# KNOWWWW
Pediatric Resuscitation
* What is important?
* How much of NS?
* Repeat what?
* How much blood?
* What is used for measure kid?
Always NS or Ringers. Do it every 10mins – 20cc bolus. Give blood once BP is going up.
135
What is the equation for ET tube size?
136
Pediatric Trauma Stabilized
* Transfer where?
* Enlist the help of who?
* All efforts made to stabilize pediatric patient awaiting/before what?
Its against the law to transfer unstable patient.
137
Geriatric Trauma
* Young old age?
* Old old age?
* What is physiologic age?
* Co-morbidities decrease what?
* Young old 65-80 years old
* Old old 80 years of age and older
* Physiologic age: actual functional capacity of the patient’s organ systems in the pre-trauma state
* Co-morbidities decrease that reserve and make it more difficult for them to recover
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Geriatric Pearls
* They have higher incidence of what?
* Greater amounts of what?
* Have a low threshold for what?
* Any patient who falls and who takes blood thinners must have what?
* They have a higher incidence of Subdural Hematoma
* The greater amount of brain atrophy and “dead space” in the skull delays the appearance of symptoms
* Have a low threshold for CT brain
* Any patient who falls and who takes blood thinners must have a CT brain, regardless how well they may look
139
Geriatric Pearls
* They have frequent what?
* Due to pre-existing arthritis, what is difficult
* Get what if you are worried?
* Elderly are more susceptible to what?
* What is unrealiable?
* They have frequent spine injuries
* Due to pre-existing arthritis, their plain films are very difficult to interpret
* Get a CT of the spine if you are worried
* Elderly are more susceptible to hypoxia and respiratory infection following chest trauma
* Abdominal exam is unreliable in elderly patients, just as it is in children
## Footnote
Lose 25-30cc per year of lung volume from 25yo.
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Trauma in Pregnancy
* Initial efforts must be directed to who
* Critical interventions and diagnostic procedures should not be withheld out of concern for what?
* Patient should be in what position?
* ALWAYS monitor what?
141
Pearls in Pregnancy
* Est what?
* What type of exam?
* Fluid in the canal with a pH of 7 suggests what?
* Fetomaternal hemorrhage is a risk and is important if what? Who do we give Rhogam to?
142
Pearls in Pregnancy
* What is okay to give in pregnancy?
* If DPL is needed, use what type of technique?
* Involve who early?
* Fetal what?
* What is helpful?
* When do you do perimortem c section?
143
Leading causes of maternal death: (4)
* Pulmonary embolism
* Hemorrhage (Placenta Abruption)
* Pregnancy-induced hypertension (ICH, Eclampsia)
* Homicide
144
Cardiac Arrest of preg ppl
* Follow same as what?
* Before 22 weeks gestation, focus only on who?
* Avoid what? How do we do that?
145
Postmortem Cesarean Secton
* No cases of live births by perimortem C-section beyond what?
* Delivery of the fetus should occur by what?
* CPR should be what?
* SHOULD BE DONE WHERE?
146
What are natural disasters? What are catastophic diasters?
* In disasters, there are usually what?
147
What constitutes a disaster? (3)
148
Triage
* What is it?
* In a disaster, the triage priorities are what?
## Footnote
French word, meaning “to sort”
149
Red triage:
* Priority?
* What type of pts?
* Probability of survival ?
* First Priority
* Most emergent
* Life threatening shock / hypoxia
* Probability of survival if given immediate care is high
150
Yellow triage:
* Priority?
* Requires what
* What type of pts?
* Probability of survival ?
* They can likely withstand how long of a delay?
* Second priority
* Requires urgent care
* Not yet in life-threatening situations
* Systemic decline may occur
* Given appropriate care, they will survive
* They can likely withstand a 45-60 minute delay without immediate risk
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Green triage:
* Priority?
* What type of pts?
* They can likely withstand how long of a delay?
* These are what?
* Third priority
* Not urgent
* Localized injuries
* Unlikely to deteriorate for hours, if at all
* These are the “walking wounded”
152
Black:
* What type of pts?
* Survival?
* Dead
* Unresponsive patient who has no spontaneous ventilation or circulation
* Catastrophically injured patients with a poor chance of survival regardless of care often fall into this category
153
Blast Injuries
* What are the causes?
* What can shatter?
* What happens to tissue?
* Look for what?
154
Crush Injuries
* What type of injury?
* What is disrupted?
* What happens to the tissue?
155
Blood
* Best one?
* Nest best option?
* Can use what type of blood (universal donor)
* Use what two type of blood preparations?
* Best: type and cross-matched
* Next best option: type specific
* Can use O Negative
* Can use whole blood or packed RBCs( preferred )
156
With massive transfusions (4-5 Units) of PRBC’s need to give what?
– FFP (clotting factors)
– Platelets
157
158
* Transport of patients to facilities based on what? (2)
* Do not move what to the hospital
159
Bioterrorism
* Need to involve who?
* Limit what? How?
## Footnote
* Biologic agents may not be immediately recognized
160
Organophosphate Poisoning
* What is it used for?
* Inhibits what? how?
* Organophosphates (malathion, parathion) used not only for insecticides but also used as chemical warfare agents
* **Inhibit cholinesterase – acetylcholine accumulates –cholinergic crisis results;** “aging” occurs when organophosphate binding is permanent and enzyme of cholinesterase is permanently destroyed. Takes weeks to re-synthesize more enzyme.
161
Organophosphate Poisoning
* What are the toxic effects from?
* What are the sxs?
WET Toxidrome from ACh Excess
DUMBELS
* D-diarrhea
* U-urination
* M-miosis
* B-bradycardia
* E-emesis
* L-lacrimation
* S-salivation
162
Organophosphate Poisoning
* What is a sign?
* What can you give for txt? (2)
163
Decontamination
* Decrease what?
* Prevent what?
* What do you do need to do with a critically ill, contaminated pt?
164
What is the protective gear?
165
Radiation Injuries
* Decontaminate the patient before what? What are the letal dose?
* If ingested, what do you need to decontaminate?
* If high levels of internal contamination are suspected or in patients with whole-body irradiation, get help from who?
Decontaminate the patient before they enter the ED
* Lethal L/D 50(dose 50%mortality) = 450 RADS ( max 0.5 rems per year for population)
If ingestion occurred, decontaminate the gut
* Induce diarrhea
If high levels of internal contamination are suspected or in patients with whole-body irradiation, get help from experts!!!
* Call radiation therapist – always available!!!
| 1 rem 1=1 rad
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radition injuries:
* Which cells get the most damage?
* Which organs are high and low?
Cells with highest turn-over injured most often
* Brain slow turn-over least injured
* WBC’S (lymphocytes) most injured (at 48 hrs. )
* Decr. WBC’’s = poor prognosis
* GI frequent cell turn-over injured frequently (diarrhea)
167
Futility
* What is it?
* DNR/DNI/CMO: Must have what? May be changed by who? What is in hospital setting?
## Footnote
* DNR applies only out of the hospital. EMS will resuscitate you unless you have original DNR with you (not a copy).
* Living will in hospital setting.
