Module 5

Question 1

Acceleration

Answer 1

injuries involve a change in speed of an object. As speed or velocity increases so does the tissue damage.

Question 2

Deceleration

Answer 2

injuries, in contrast, result from the decrease in speed and causes objects or organ strikes with a stationary object.

Question 3

Compression

Answer 3

injuries result from the application of a squeezing or inward force. This may occur as a result of a fall or crushing force. Subsequently,
solid organs rupture,
vascular organs bleed, and
hollow organs spill their contents into the peritoneal cavity

Question 4

The paper bag effect

Answer 4

In a traumatic accident, a person will often instinctively take a deep breath or “gasp” and hold his or her breath. This deep breath fills the lungs with air (paper bag) and closes the glottis (neck of the bag).
On impact, the chest is hit (by the steering wheel, ground, or handle bars), which causes the internal pressures of the lungs to increase.
Hole is created in the lung and pleural covering, creating a pneumothorax.

Question 5

Major organs in chest

Answer 5

Heart
Lungs
Aorta

Question 6

Rib fracture complications

Answer 6

Pain
Inability to take deep breaths -atelectasis
Pneumothorax
Flail chest

Question 7

Flail chest

Answer 7

segment of ribs that moves opposite to the rest

doesn’t allow lung expansion

Question 8

Pneumothorax signs and symptoms

Answer 8

decreased unilateral breath sounds
SOB
Tracheal deviation- trachea will shift towards the opposing side

Question 9

pneumothorax interventions

Answer 9

chest tube

Question 10

Pulmonary contusion

Answer 10

bruised lung
Supportive management
O2

Question 11

Cardiac contusion

Answer 11

Bruise on heart

Heart can’t beat effectively causes decreased cardiac output

Question 12

Traumatic aortic injury- transection

Answer 12

aorta is attached to the spine in some places but not all so with acceleration or deceleration it can tear
Wide mediastenium on chest X-ray
TO THE OR

Question 13

penetrating injuries

Answer 13

stab wounds, impalements, and gunshot wounds

are concentrated in a smaller area, involve less energy, and may have fewer secondary injuries associated with them. (exception is gunshot wounds)

Question 14

Documenting Gun Shot Wounds

Answer 14

distance from the weapon to the victim during the shooting

wounds and their appearances

suspected number of shots

description of gun powder soot and burns, scorching of wound edges, tearing of the skin and location of palpable bullets

blood loss at the scene and amount of fluid the patient has already received

patient condition at the scene

Question 15

Gunshot wounds

Answer 15

As the bullet enters tissue, it creates a sonic wave as well as a cavity. The tissue then recoils leaving a permanent wound track or cavity. As the bullet passes through tissue, it creates both temporary and crush injuries, stretching the tissues in its path.

the closer the range of the gun shot, the more potential damage the person may suffer.

Question 16

Gunshot and Stab Wound Disclosure Act in BC

Answer 16

it is mandatory to report any confirmed cases or suspicious cases involving gunshots or stabbings to the police

Question 17

What information must be reported to police?

Answer 17

1. The injured person’s name, if known;
2. The fact that the person is being treated, or has been treated; and
3. The name and location of the health care facility or where an emergency medical assistant treated the individual.

Question 18

Penetrating chest trauma

Answer 18

Pneumothorax
Hemothorax
cardiac tamponade
pericardial/cardiac wound 
Tracheal/esophagus trauma

Question 19

how do we prep for trauma

Answer 19

allocates roles to the team

Question 20

damage control resuscitation

Answer 20

Management begins with damage control resuscitation to minimize blood loss and maximize tissue perfusion and oxygenation to optimize outcome.

The three pillars of management:
permissive hypotension,
hemostatic resuscitation
damage control surgery

Question 21

ATMIST

Pt handover form EHS

Answer 21

Age
Time of injury
Mechanism of injury
Injuries sustained
Signs and symptoms
Treatment given so far

Question 22

Prep for trauma

Answer 22

Assemble team
assign roles
brief team
Get equipment and drugs ready

Question 23

Horizontal assessment

Answer 23

Components of the ABCD paradigm and initial investigations (such as chest and pelvic X-Ray, and blood tests) are carried out by several people at the same time, coordinated by the trauma team leader. This allows the team to have the required clinical information quickly

Question 24

Labs needed in a trauma panel

Answer 24

CBC
VBG
Group and screen/crossmatch
Urea & Electrolytes 
INR/PTT

Question 25

TIC TRAUMA INDUCED COAGULOPATHY

Answer 25

TIC is characterized by endothelial dysfunction, dysfibrinogenemia, platelet dysfunction and an imbalance of pro- and anticoagulant factors with systemic anticoagulation. This process is exacerbated by hypothermia, acidemia, and resuscitation with hypocoagulable fluids,

Question 26

DAMAGE CONTROL RESUSCITATION (DCR)

Answer 26

Avoidance or strict limitation of crystalloid use. Target resuscitation to low normal blood pressure to limit hemorrhage and prevent rebleeding from recently clotted sites. massive transfusion protocol Early hemorrhage control

Question 27

Ratio of blood product administration

Answer 27

1:1:1 PRBC Platlets (4 units per bag) FFP

Question 28

RISKS AND COMPLICATIONS ASSOCIATED WITH LARGE VOLUME RESUSCITATION WITH BLOOD PRODUCTS

Answer 28

``` Hypothermia Impaired hemostasis- dilution of clotting factors Hypocalcemia and citrate toxicity Hyperkalemia Volume overload/over transfusion Alloimmunization Risk of transfusion reaction ```

Question 29

Who do we try save first in trauma involving pregnancy

Answer 29

The mother

Question 30

Cardiac changes in pregnancy

Answer 30

``` Increasing heart rate Increased cardiac output 40% increase in blood volume (causes us to miss it until its late) Pregnancy can exacerbate bleeding Lower MAP in 1st and 2nd +++CAN MINIC SHOCK+++ ```

Question 31

Respiratory changes in pregnancy

Answer 31

40% increase in minute ventilation (higher RR) | Decreased vital capacity (less room in thorax for lungs)

Question 32

Respiratory changes in pregnancy

Answer 32

40% increase in minute ventilation (higher RR) -Normal hypercapnia less reserve for acidosis Decreased vital capacity (less room in thorax for lungs) Harder to intubate/Bag High risk for aspiration Increased O2 consumption Decrease oxygen reserve

Question 33

Gastroinestinal physiologic changes

Answer 33

Reduced sphincter response and Gi motility so they are at a high risk for aspiration Increased acid production Put NG in to decompress

Question 34

List 8 unique considerations in the management of the pregnant trauma patient

Answer 34

- Pregnancy alterations in BP and HR can mimic shock - The gravid uterus syndrome - Blood volume increases can mask hypovolemic shock - Pregnancy can exacerbate traumatic bleeding - Reduced FRC – tube quickly - Increased 02 consumption needs - reduced sphincter response and GI motility (increased aspiration risk) - increased acid production (consider early gastric decompression)

Question 35

Fetal distress is detected with:

Answer 35

1. Non-stress testing - Abnormal baseline HR (> 120-160) - Assess for Late decelerations 2. Fetal movement assessment (subjective)

Question 36

placental abruption pathophysiology,

Answer 36

Blunt trauma leading to abruption results in 60% of fetal losses Placental (inelastic) separation/shearing (abruption) form the uterus (elastic uterus) Can occur with NO visible abdominal trauma Can lead to uterine contractions which further inhibit blood flow

Question 37

placental abruption clinical findings

Answer 37

- painful, vaginal bleeding - abd cramps - uterine tenderness - Frequent uterine contractions - Maternal shock - change in fetal HR * ***fetal distress*** (most sensitive indicator of abruption )

Question 38

placental abruption management

Answer 38

Expectantly If mother and fetus are stable: Usually closely monitored in hospital After 32 weeks – OB may elect to do deliver early

Question 39

placental abruption Diagnosis:

Answer 39

Requires the kleihauer-betke test looks for circulating fetal blood in maternal blood fetal stress test

Question 40

placental abruption Complications:

Answer 40

Premature labour Stillbirth There is an exponential rise in fetal mortality with increasing amounts of abruption Abruption can lead to maternal coagulopathy (resulting in DIC)

Question 41

Gravid uterus syndrome

Answer 41

Compression in IVC 15-30% tilt to the left to get them off the IVC Manually displace fetus off IVC

Question 42

Signs of fetal distress (3)

Answer 42

1. Abnormal baseline HR normal 120-160 2. Decreased variability (Normal beat-beat variability and long term variability) 3. Late decelerations Indicate fetal hypoxia

Question 43

List 2 potential uterine injuries

Answer 43

Pre-mature labour / contractions | Uterine rupture

Question 44

Pre-mature labour / contractions

Answer 44

Most common problem is uterine contractions after trauma | myometrial and decidual cells release prostaglandins –> contractions

Question 45

Uterine rupture

Answer 45

Often due to severe MVCs with pelvic fractures penetrating trauma is rarely a cause Diagnosis is difficult and may be confused with liver/spleen injury fetal parts palpable, massive hemoperitoneum and shock –> high mortality

Question 46

alterations to the primary and secondary survey in the pregnant trauma patient.

Answer 46

From the start: mother is always the first priority

Question 47

Maternal resuscitation | Primary survey

Answer 47

“ABCT + UFO” Primary survey- Focus on mother A+B-give 02 early, get a secure airway: do RSI, goal PaC02 is 30 mmHg C-HR and BP are not consistent predictors of well being uterine blood flow may be reduced with no external signs of bleeding or trauma avoid vasopressors T-“not D” Tilt the mother! U-uterus: if uterus above umbilicus: likely >24 weeks FO- Fetal Tones: Modify primary survey to assess uterine size and presence of fetal tones

Question 48

Maternal resuscitation | Fetal evaluation

Answer 48

(1) fetal heart rate (2) fetal movement Signs of fetal distress (3) abnormal baseline HR normal 120-160 decreased variability-normal beat-beat variability and long term variability Late decelerations-indicate fetal hypoxia

Question 49

Maternal resuscitation | Secondary survey

Answer 49

``` Get maternal detailed info ? Weeks pregnant, number of babies, GTPAL Hx. ? uterine tenderness ? contractions ?vaginal bleeding Pelvic exam: ? signs of ferning on uterine fluid? (ruptured membranes) ?cervical dilatation Swabs for G+C ? GBS status Bimanual exam for pelvic bone protrusion ```

Question 50

Peri mortem C-Section

Answer 50

start 4 mins after arrest if no ROSC

Question 51

What should we use to contain clothes of a patient who was assaulted

Answer 51

Paper bag

Question 52

5 meds to consider for pt who have been assaulted

Answer 52

Pregnancy Exposure- Hep B and HIV Pain STI

Question 53

What causes the breakdown of DNA

Answer 53

Plastic Heat Light Moisture

Question 54

When do we assess the fetus in a pregnant trauma

Answer 54

secondary assessment

Question 55

Advantage of perimortem c-section for mother

Answer 55

increased venous return cardiac output can increase by 25-30%

Question 56

A woman’s blood volume increases by ____ during pregnancy

Answer 56

30-50%

Question 57

Minimum requirement for fetal monitoring post trauma

Answer 57

4 hours is the minimum requirement for fetal monitoring post trauma

Question 58

Signs and symptoms of placenta abruption

Answer 58

vaginal bleeding 8 or more contractions per hour in the first four hours of monitoring abdominal pain

Question 59

Discharge of a pregnant woman after a trauma from the hospital

Answer 59

There should be no vaginal bleeding Contractions should have resolved Membranes should be intact