TEM Flashcards
1
Q
What should you be thinking about enroute to the call?
A
- Major trauma centre
- Helicopter availability
- Landing sites
- CCP availability
- High Acuity Response Unit
- Speed zone of accident
- Weather
2
Q
What does the mnemonic ETHANE stand for?
A
Exact location
Type of incident
Hazards on scene
Access/egress
Number of patients
Emergency services required
3
Q
What is the primary survey order in trauma?
A
D – Danger
R – Response – AVPU
A – Airway – suction, OP/NP if not patent
B – Breathing – Y/N
C – Circulation – Y/N, Control bleeding
D – Disability – Pupils, GCS
E – Expose (if unconscious cut clothes off)
4
Q
What takes priority over airway and breathing interventions in trauma?
A
life-threatening bleeding
5
Q
What order are the secondary surveys done in trauma?
A
Head to toe
life threats
CVS
SAMPLE
Neuro
Respiratory
Pain
6
Q
What gross abnormalities are you looking for in a H2T?
A
- Angulated limbs
- Unequal chest movement
- Flail chest
- Rigid or bruised abdomen
7
Q
What are the four major life threat areas and why?
A
chest
abdomen
pelvis
femur
they bleed out internally
8
Q
When will a tension pneumothorax be apparent in the assessments?
A
when assessing life threats
9
Q
What criteria ascertain if you stay and play or load and go?
A
- Isolated (eg compound fracture) or multisystem trauma (chest and abdomen)
- Time (choking, cardiac arrest) or transport criticality (internal bleeding, closed head injury)
- Downstream thinking
10
Q
With a time critical injury do you stay and play or load and go?
A
stay and play
11
Q
With a transport critical injury do you stay and play or load and go?
A
load and go
12
Q
What does downstream thinking take into account?
A
what does the patient need and can we do it
13
Q
What are the Nexus Criteria components?
A
- no ALOC
- no focal neurological deficit
- no midline tenderness
- no intoxication
- no distracting injury
14
Q
What are the methods of vehicle extrication?
A
self extrication
combi carrier
15
Q
What are the options for self extrication from a car?
A
- Pt step out of their car themselves? (Pts can self manage their spines better than rescuers)
- Rescuers apply a c-spine collar and ask the patient to self extricate
16
Q
What are the options for combi carrier extrication from a car for patients unable to self extricate?
A
- Board inserted under patient’s backside, they are rotated while providing MILS and slid out onto the stretcher
- Extricate via rear windscreen
17
Q
What should you avoid doing when a pt is entrapped?
A
impeding the fire department
18
Q
How many of the Nexus criteria does a Pt need to meet to clear them from needing cervical spine imaging
A
all
19
Q
What is the normal intracranial pressure (ICP)?
A
5 - 15 mmHg
20
Q
What contents does intracranial pressure (ICP) include?
A
brain and contents in the skull
21
Q
What is the normal Cerebral perfusion pressure (CPP)?
A
50 - 70 mmHg
22
Q
What is cerebral perfusion pressure (CPP)?
A
Pressure required to perfuse brain
23
Q
How do you calculate mean arterial pressure (MAP)?
A
Diastolic BP + 1/3 pulse pressure
24
Q
How do you calculate cerebral perfusion pressure (CPP)?
A
CPP = MAP – ICP
25
What is the MAP range for CPP?
50 - 150 mmHg
26
What is autoregulation?
the brain maintaining the same cerebral perfusion pressure (CPP)
27
Is autoregulation lost in traumatic brain injury?
yes
28
What is the goal MAP for head injury Pts?
90 mmHg
29
How do you calculate pulse pressure (PP)?
PP = SBP - DBP
30
What is Cushing Reflex?
a physiological nervous system response to acute elevations of intracranial pressure (ICP)
31
What are the components of cushings triad?
hypertension
bradycardia
increased ventilations
32
What is cerebral herniation syndrome?
Displacement of any part of the brain within the skull due to raised ICP
33
What are the 6 types of cerebral herniation syndrome?
subfalcine (cingulate)
central (tentorial)
transcalvarial (external)
uncal (transtentorial)
upward
tonsillar (downward cerebellar)
34
What is the Monroe Kellie Doctrine
Skull is a closed vault – Can only fit a certain amount in there
If the amount of blood increases, something else has to go
35
What are the percentages of brain tissue, CSF and blood within the skull?
brain tissue 80%
CSF 10%
blood 10%
36
What is the Mass Effect?
Brain swelling causes CSF into spinal column followed by herniation
37
In a brain herniation, what do constricted pupils indicate?
posterior herniation
38
In a brain herniation, what do dilated pupils indicate?
both optic nerves getting squashed
39
In a brain herniation, what does unequal pupils indicate?
only one optic nerve is being squashed
40
What are is are the 2 severe signs of TBI?
decorticate (flexion) - arms flexed and legs extended
decerebrate (extension) - arms and legs extended
41
What is the GCS score when you should suspect severe brain injury?
GCS <9
42
What is a primary head injury?
Initial traumatic insult to the brain
43
What is a secondary head injury?
The cascade of events following primary injury that can worsen the injury
44
What are the 2 primary goals in head injury/TBI management?
Avoid hypoxia & hyperoxia
Avoid hypotension
45
What do hypoxia, hyperoxia and hypotension do in a traumatic brain injury (TBI)?
* dramatically increase mortality
* Hypoxia increases brain damage
* Hyperoxia increases oxygen free radical production further damaging injured cells
* Hypotension stops brain auto-regulating CPP so maintain blood pressure and MAP to ensure brain perfusion
46
What is the traumatic brain injury (TBI) management for Pts with a GCS 15?
Consider:
bleeding control
C spine support
oxygen
IV access
analgesia
IV fluids
47
What is the traumatic brain injury (TBI) management for Pts with a GCS <15?
maintain airway, oxygen, BP and then transport
oxygen
IV access
IV fluids - MAP around 90 (SBP 100 - 120 mmHg)
Consider:
basic airway adjuncts
c spine support
semi recumbent position at 30 degrees if isolated head injury
analgesia
antiemetic
CCP backup
midazolam/ketamine - CCP only
hypertonic saline 7.5 % - HARU
transport
pre-notify as appropriate
48
What is the scalp injury management?
explore to determine severity (see skull OK, see yellow CSF or brain matter - transport quickly)
pad and bandage
transport
49
What are the four types of skull fractures?
depressed
impaled object
linear nondisplaced
open
50
What are the 2 bruising signs of a basilar skull fracture?
battle's sign
raccoon eyes
51
What are the 4 types of traumatic brain injury (TBI)?
Bleeding
Contusion
Concussion
Diffuse axonal injury
52
What are the 4 types of bleeding traumatic brain injury (TBI)?
Epidural - Between skull and dura
Subdural - Between dura and arachnoid
Subarachnoid - Between the arachnoid and pia mater
Intracerebral - Directly into brain tissue
53
What are some of the secondary brain injuries?
* Brain herniation and death results from untreated cerebral haemorrhage
* Breach of blood-brain barrier causes severe meningitis
* Hypoventilation results in hypercarbia, increasing ICP
* Raised ICP reduces cerebral perfusion pressure (CPP), causing anoxia injury
* Subarachnoid haemorrhage causes vasospasm, causing large area of ischaemia
54
How does traumatic brain injury (TBI) bleeding cause problems?
* Blood irritates brain tissue causing pain and symptoms such as neck stiffness
* Monroe-Kellie Doctrine – Mass effect –intracranial pressure – reduced brain perfusion
55
What is the epidural haematoma aetiology?
* rupture of middle meningeal artery causing rapid rise in ICP as haematoma accumulates within the extradural space
56
What are the epidural haematoma signs and symptoms?
(above the dura mater)
Initial loss of consciousness followed by ‘lucid interval’ of coherence
Progressive deterioration over minutes to hours
Signs of raised ICP:
ALOC or LOC
severe headache
Ipsilateral fixed & dilated pupil
Contralateral paralysis
vomiting
57
What is the subdural haematoma aetiology?
(between dura mater and arachnoid mater)
* Bleeding into the subdural space from bridging veins
* Very slow progression due to venous origin and compensation
* traumatic or spontaneous
* Severe cases associated with catastrophic TBI
58
What are the subdural haematoma signs and symptoms?
(between dura mater and arachnoid mater)
Possible initial LOC followed by lucid intervals
conscious state may fluctuate
Headache
Focal neurological deficits relate to underlying brain region
59
Who are at higher risk of subdural haematoma?
elderly
people on anticoagulants
PMHx alcohol abuse
60
What is the subarachnoid haemorrage aetiology?
Arterial bleed into the subarachnoid space
trauma or spontaneous
61
What are the subarachnoid haemorrage signs and symptoms?
sudden onset of ‘thunderclap’ headache
Meningeal irritation
Photophobia
visual impairment
Focal neurological deficits, increasing severity
nausea and vomiting
+/- mild hypertension and/or mild hyperthermia
62
What are the two types of intracerebral haemorrhage (CVA)?
arterial
venous
63
What are the intracerebral haemorrhage (CVA) signs and symptoms?
ALOC
Stroke symptoms
Headache
vomiting
plus others depending on region/degree
64
What is a concussion?
brain hits inside of skull - no structural injury to brain
65
What are the concussion signs and symptoms?
LOC or confusion followed by return to normal
Retrograde short-term amnesia - May repeat questions over and over
dizziness
headache
ringing in ears
nausea
66
What is a cerebral contusion?
Bruising of brain tissue (from hitting inside skull)
Swelling may be rapid and severe
67
What are the cerebral contusion signs and symptoms?
Prolonged unconsciousness
Profound confusion or amnesia
Focal neurological signs
68
What is diffuse axonal injury?
shearing of the axons
generally seen in vehicle rollovers - significant cause of morbity and mortality
69
What is the diffuse axonal injury aetiology?
Extreme acceleration/decelation causes shearing forces within the brain that stretches and tears the axons of neurons
70
What are the minor/mild diffuse axonal injury signs and symptoms?
Unconsciousness or confusion followed by return to normal
Retrograde short-term amnesia - May repeat questions over and over
Dizziness
headache
ringing in ears
nausea
71
What are the severe diffuse axonal injury signs and symptoms?
unconscious
DAI determined with GCS <8 for >8hrs
Seizures in acute and sub-acute stages
72
What are the common causes of facial trauma?
assaults
falls
motor vehicle accidents
73
What is a Le Forte I fracture?
fracture under cheek bones
Pain, numb upper teeth, mobile upper teeth
74
What is a Le Forte II fracture?
fracture from bridge of nose across both cheeks
Pain, numb upper lip and nose, midface mobility
75
What is a Le Forte III fracture?
fracture across face through eye sockets
Pain, difficulty breathing, marked facial deformity and swelling
76
How are orbit fractures caused?
Direct impact to the hard structures surrounding the eye can transmit the force to the weaker thinner bones at the rear and base of the eye socket
77
What is the orbit fracture treatment?
icepacks
have the patient avoid nose blowing, vomiting, etc as it can lead to air trapping under the eye
78
What is the treatment for eye trauma to the surface of the eye?
irrigate continuously with saline or water
79
What is the treatment for eye trauma penetration?
cover the eye without applying pressure to the eyeball or the embedded object (Styrofoam cup)
position in semi recumbent
anti-emetic
80
What is the treatment for eye trauma extrusion?
support with a saline soaked dressing and tape it in place
81
What is the epistaxis treatment?
advise patient to lean forward to allow for drainage out
pinch the sides of the nose until bleeding stops
82
What is the jaw fracture treatment?
icepacks
pain relief
soft collar may help splint the jaw
83
What is the jaw fracture signs and symptoms?
pain
swelling
reduced jaw mobility
84
What is tooth avulsion?
whole tooth has been knocked out
85
What is tooth avulsion treatment?
If <1 hours the empty socket and tooth should be cleaned in saline then tooth re-implanted.
The patient will have to hold it in place with a pad for several hours to allow the reattachment to take place.
If re-implantation cannot occur transport the tooth in milk, saline, or in the patient’s mouth.
86
How do you manage the airway in a facial trauma Pt?
if conscious - sit up and lean forward to clear airway
if unconscious - lateral positioning to allow for passive drainage
preferred is rapid sequence intubation - consdier when performing interventions that delay transport
87
What is hyperextension of the neck?
excessive posterior movement of the head or neck
88
What is hyperflexion of the neck?
excessive anterior movement of the head or neck
89
What is compression of the neck?
weight of head or pelvis driven into the stationary neck or torso
90
What is rotation of the neck?
excessive rotation of the torso, head and neck moving one side of the spinal column against the other
91
What is lateral stress of the neck?
direct lateral force on the spinal column typically shearing one level of cord from the other
92
What is distraction of the neck?
excessive stretching of the column and cord
93
In vertebral vs spinal cord injuries, what will vertebral fractures will present with?
pain
94
In vertebral vs spinal cord injuries, what will spinal cord injuries present with?
neurological signs of loss of:
* sensation/altered sensation
* motor function/weakness
95
What does a complete spinal cord injury result in?
No motor function or sensation below the point of injury (paraplegic or quadriplegic)
96
What does an incomplete spinal cord injury result in?
Some function remains below the injury
97
What are the three types of incomplete spinal cord injury?
central cord syndrome
anterior cord syndrome
brown-sequard's syndrome
98
What part of the spinal cord is damaged in central cord syndrome?
the centre of the cord is damaged, typically by hyperextension
99
What does central cord syndrome result in?
Usually the arms lose more function than the lower body
100
What part of the spinal cord is damaged in anterior cord syndrome?
The anterior section of the spinal cord
usually caused by a blood clot but can be traumatic, occluding blood supply to the anterior section of the spinal cord
101
What does anterior cord syndrome result in?
the ability to feel sensation and proprioception is preserved
102
What part of the spinal cord is damaged in brown-sequard's syndrome?
The cord is split in half along its length for a variable distance, typically
caused by penetrating trauma
103
What does brown-sequard's syndrome result in?
preserved motor function on one side of the body and preserved sensory function on the other side
104
What does compression or burst spinal fracture present with?
pain and muscle spasm at site
+/- neurological involvement
105
What is the pathophysiology of neurogenic shock?
vagus nerve runs through C3 and spared from injury in severe spinal cord damage allowing parasympathetic innervation only below level of injury causing large scale vasodilation with associated shock
106
What are the neurogenic shock signs and symptoms?
Hypotensive
+/- Bradycardia
warm and dry (as opposed to cool/clammy in hypovolemic shock)
decreased body temp over time
107
What is the neurogenic shock management?
Consider:
Cervical pain:
* soft collar
* supine or semi-recumbent positioning
Thoracic, lumbar or sacral pain:
* soft collar (even if no cervical pain)
* supine positioning
* +/- immobilisation to a longboard (depend on Pts behaviour)
Neurological signs:
* soft collar
* supine positioning
* immobilisation on a longboard
108
How do you maintain the neutral head position in infants?
infants have big heads – raise their shoulders a
little to keep their cervical spine straight
109
How do you maintain the neutral head position in older children?
Older children are just right
110
How do you maintain the neutral head position in adults?
Adults have small heads – raise their heads a little to keep their cervical spine straight
111
What documentation requirements are there in spinal injuries where there is a loss of sensation or motor function?
document this carefully to enable identification of improvement or worsening especially at what
level the loss occurs (e.g cant feel pinky but can feel rest of hand) as this correlates to the affected
dermatomes
112
What are the 2 types of thoracic trauma mechanisms of injury?
blunt
penetrating
113
What are the 2 types of blunt thoracic trauma?
Direct compression
* Fracture of solid organs
* Blowout of hollow organs
Deceleration forces
* Tearing of organs and blood vessels
114
What can cause penetrating trauma to the thorax?
edged weapons
gun shot wounds
115
What is an open pneumothorax?
hole through chest and lung/sucking chest wound
116
What happens in an open pneumothorax/sucking chest wound?
Air enters pleural space
Ventilation impaired (no gas exchange)
Hypoxia results
117
What is the treatment for an open pneumothorax/sucking chest wound?
Close chest wall defect
Load-and-go
118
What can an open pneumothorax/sucking chest wound develop into?
tension pneumothorax
119
What are the signs and symptoms of a tension pneumothorax?
Anxiety
Jugular distension
Tracheal deviation (rare)
Dyspnea
Tachypnea
Breath sounds diminished
Hyper-resonance if percussed
Shock with hypotension
120
What is the location for the needle thoracostomy (chest decompression)?
2nd intercostal space mid-clavicular line
121
Do you load and go or stay and play for a tension pneumothorax?
load and go
122
What are the signs and symptoms of massive haemothorax?
Anxiety and confusion
Neck veins
- Flat: hypovolemia
- Distended: mediastinal compression
decreased breath sounds
Hyporesonance on percussion
Shock
123
What is the Tx for a massive haemothorax?
Load-and-go–
Treat for shock
- Fluid administration (Titrate to peripheral pulse (80-90 mmHg)
Monitor for tension hemopneumothorax
124
What is a flail chest?
rib fracture that separates whole section of ribs - broken section will pull in when breathe in and blow out when breathe out
125
What is the Tx for a flail chest?
Assist ventilation (IPPV if unconscious)
Load-and-go
Stabilize flail segment (with big pad)
Monitor for:
- Pulmonary contusion
- Haemothorax
- Pneumothorax
126
What is a cardiac tamponade?
Blood in the pericardial sac (it can't stretch)
127
What are the components of Beck's triad?
(Seen in cardiac tamponade)
Hypotension
JVD (backing up as heart not filling properly and back pressure into vena cava)
Heart sounds muffled (fluid dulls sound)
128
What are the signs and symptoms of a cardiac tamponade?
jugular vein distention
decreased or muffled heart sounds
hypotension
tachycardia
narrow pulse pressure
electrical alternans
low voltage QRS complex
129
What is the Tx for a cardiac tamponade?
Load-and-go
Treat for shock
Fluid administration titrated to peripheral pulse (80–90 mmHg)
Prepare for resuscitation
Monitor for:
- Hemothorax
- Pneumothorax
130
What is a myocardial contusion?
bruising on heart (can't contract properly)
131
What causes a myocardial contusion?
blunt anterior chest injury
132
What is the most common cardiac injury?
myocardial contusion
133
What are the signs and symptoms of a myocardial contusion?
Chest pain
Dysrhythmias (often shows as STEMI pattern)
Cardiogenic shock (rare)
134
What is the Tx for a myocardial contusion?
Fluid administration titrated for peripheral pulse (80–90 mmHg)
Prepare for resuscitation
Monitor for Haemothorax and Pneumothorax
135
What is the Tx for a traumatic aortic rupture?
load and go - nothing we can do - 80% die immediately
titrate fluids to maintain radial pulse
scene size up and Hx extremely important (pt may not exhibit obvious signs of chest trauma)
136
What is a Tracheal or bronchial tree injury?
injury to upper part of chest to below vocal cords
137
What are the signs and symptoms of a tracheal or bronchial tree injury?
hoarseness of voice or aphonia
haemoptysis
subcutaneous emphysema (chest, face, neck)
dysphagia
stridor
respiratory failure
138
What is the Tx for a tracheal or bronchial tree injury?
oxygenation
CCP for intubation if unconscious (cuffed ET tube pst site of injury)
monitor for pneumotharax and haemothorax
139
What causes a diaphragmatic tear?
Severe blow to abdomen
140
What is a diaphragmatic tear?
Herniation of abdominal organs into chest cavity (liver, stomach, pancreas)
141
What are the signs and symptoms of a diaphragmatic tear?
More common on left
Breath sounds diminished
Bowel sounds auscultated in chest (rare)
Abdomen appears scaphoid
142
What is a pulmonary contusion?
bruising on lungs causing blood and transidate to leak from microvascular bruising
143
What is the most common cause of pulmonary contusion?
blunt trauma
144
What is the treatment for a pulmonary contusion?
Oxygen/CPAP
145
What is the treatment for impaled objects in the chest?
Do not remove
Stabilize the object (circular bandage/padding taped around)
Monitor for:
- Tension pneumothorax
- Hemothorax
- Cardiac tamponade
Rapid transport
146
Why don't we remove the impaled object from the chest?
removing causes bleeding, sucking chest wound and cardiac tamponade
147
What is traumatic asphyxia?
severe compression of the chest causes all blood to be shunted into upper body, rupturing capilliaries
148
What are the signs and symptoms of traumatic asphyxia?
Cyanosis above crush
Swelling of head, neck, lips and tongue
Conjunctival hemorrhage
149
What causes a sternal fracture?
Significant blunt trauma to anterior chest
150
What are the signs and symptoms of a sternal fracture?
Signs of fracture on palpation
Myocardial contusion presumed (shock, circulatory failure, collapse)
151
What is the Tx for a simple rib fracture?
aggressive pain relief
encourage to take full breath
Monitor for Pneumothorax & Haemothorax
152
What is the priority in all chest injuries?
oxygen and airway
153
What should you pay attention to when evaluting abdominal trauma?
scene
mechanism of injury
154
What are the major causes of preventable death associated with trauma?
haemorrhage
infection
155
What happens to solid organs in trauma?
split and fracture and bleed intensely
156
What are the solid abdominal organs?
kidneys
liver
pancreas
spleen
157
What happens to hollow organs in trauma?
can rupture and spill contents (food, faeces) into the perineum
158
What are the hollow organs in the abdomen?
duodenum
small intestine
large intestine
bladder
159
What is the perineum?
big fibrous sac that encapsulates most of the abdomen
160
What are the major abdominal injuries in the thoracic region?
life threatening harmorrhage to liver and spleen
161
What are the major abdominal injuries in the true abdomen region?
Infection, peritonitis, shock: intestines
Severe haemorrhage with signs
162
What are the major abdominal injuries in the retroperitoneal (outside perineum) abdomen region?
Severe haemorrhage hidden: major vessels
163
What are the concerns with blunt and penetrating abdominal trauma?
* Intra-abdominal bleed with hemorrhagic shock
* Sepsis and/or peritonitis
164
What are you looking and feeling for in an abdominal assessment?
Abrasions
Contusions
Deformities
Distension
Evisceration
Punctures
Tenderness
165
How do you palpate the abdomen
pressing and rolling fingers over all of the quadrants
166
What is the pain sign for a splenic injury?
Referred left posterior shoulder pain
167
What is the pain sign for a liver injury?
Referred right posterior shoulder pain
168
What are the signs and symptoms of abdominal trauma?
* Splenic injury - Referred left posterior shoulder pain
* Liver injury - Referred right posterior shoulder pain
* Severe hemorrhage (bruising around flanks)
* Distention, tenderness, tenseness
* Pelvic tenderness or bony crepitation or bruising around flanks
169
What is the mechanism for a blunt abdominal injury?
direct compression of abdomen
deceleration forces
170
What injuries can a direct compression of the abdomen cause?
Fracture of solid organs (spleen/liver)
Blowout of hollow organs (intestines)
171
What injuries can deceleration forces to the abdomen cause?
tearing of organs and blood vessels
172
What accompanying injuries should you look for when assessing blunt abdominal injuries?
head, chest, extremity
liver and spleen
173
What evidence of injury/signs are there in blunt abdominal trauma injury?
* Often no or minimal external evidence
* Often no pain or overshadowed distracting injuries
* Pain or tenderness
* Seat-belt sign
* Significant blood volume concealed in regions
174
What can cause a penetrating abdominal injury?
* Direct trauma to organ and vasculature
* Projectile and fragments
* Energy transmitted from mass and velocity (cavitation from bullets)
175
If a person is shot in the chest or abdomen, what do you need to assume?
that the other is involved as well (eg chest involved in abdomen injury and abdoment involved in chest injury)
176
Is the size of a penetrating wound an indicator of internal damage?
No, velocity is more important than caliber
177
What is the Young-Burgess classification?
Classification used to identify type of pelvic fractures
178
What are the 3 types of Young-Burgess classifications of pelvic ring fractures?
anterior posterior compression (APC)
lateral compression (LC)
vertical shear (VS)
179
What are APC II and III fractures referred to as?
open book fractures
180
What are the complications of pelvic fractures?
life-threatening haemorrhage
nerve damage
urethral damage
181
What do you need to know about life-threatening haemorrhage in pelvic fractures?
* Blood loss from pelvis itself and/or local vasculature; venous in 90% of cases
* Retroperitoneal space can accommodate your entire blood volume
* High likelihood of associated intra-abdominal bleeding due to kinematics
* Must assume potential or actual haemodynamic instability
182
What do you need to know about nerve damage in pelvic fractures?
* Nerve bundles through the pelvic ring run close to vasculature
* Damage can result in bowel, bladder, and sexual dysfunction
183
What do you need to know about urethral damage in pelvic fractures?
Incidence of 5-25% of pelvic fractures; most common in children & elderly
High-velocity pelvic fractures with destabilisation sits directly inside pelvis
184
What sign can indicate urethral or bladder damage in pelvic injuries?
PV bleed or bleeding from genitals in a person with an abdominal injury
185
Do we still 'spring the pelvis'?
No
186
Why don't we spring the pelvis?
due to the likelihood of clot disruption and further damage
187
How do we identify a pelvic injury if we can't 'spring' the pelvis?
on mechanism of injury and patient presentation without significant palpation by the paramedic
188
What is the prehospital management for penetrating wounds?
direct pressure
189
Why do we limit fluid administration and allow permissive hypotension in Pt's with a pelvic #?
increased BP increases bleeding and dilutes clotting factors
190
Why do we maintain normothermia in a Pt with a pelvic fracture?
to limit coagulopathy
191
How do we treat evisceration?
* Do not push viscera back into abdomen
* Gently rinse with sterile water cover with moistened gauze and cling wrap
* Apply non-adherent material to prevent drying
192
How do we treat an impaled object?
* Do not remove as will cause an uncontrollable hemorrhage
* Gently stabilize object
* Avoid movement
193
When is extremity trauma life-threatening?
When exsanguinating haemorrhage is occuring
194
What are the 2 potential dangers from extremity trauma?
* haemorrhagic shock (reduced tissue perfusion, resulting in the inadequate delivery of oxygen and nutrients)
* neurovascular compromise
195
What is a sprain?
stretching or tearing of ligaments of a joint becauseof a sudden twist
196
What are the signs and symptoms of a sprain?
pain
swelling
197
Can sprains be differentiated from a fracture?
No
198
How do you treat a sprain?
splinted as though it is a fracture
199
What is a strain?
stretching or tearing of a muscle or musculotendinous unit
200
How do you treat a strain?
splinted for comfort
201
Can you differentiate between a strain and a fracture?
Usually (not always)
202
What are the two types of fracture?
open (compound)
closed (simple
203
What are the features of an open fracture?
Communication to outside
Danger of contamination
Blood loss outside body
204
What are the features of a simple (closed) fracture?
No communication to outside
No danger of contamination
Blood loss inside body
205
How to you treat hand and foot injuries?
Manage haemorrhage
irrigate and cover
bandage carefully
206
What type of splint should be considered for hand injuries?
vacuum
cardboard
207
In a foot injury, what can you consider in regards to splinting?
pillows
pads
splinting against opposite limb
208
What is a colles fracture?
distal fracture of the radius
209
How much blood can you lose in a closed femur fracture?
1.5 litres
210
What is the treatment for a closed femur fracture?
CT6 or slishman's splint
analgesia
211
What is the treatment for an open femur fracture?
analgesia
rinse with 1-2L of saline
CT6 or slishman's traction splint
212
What is the management for dislocations?
* Splint in position found (Bind it as you find it)
* Shoulder dislocations may be most comfortable hanging freely or resting on a pillow. (Applying a sling can increase the rotation of the shoulder joint and increase pain.)
* If there is neurovascular compromise transport code 1 (loss of pulse/numbness)
213
What is the most common type of shoulder dislocation at 90% of dislocations?
anterior dislocation
214
What 2 nerves can be pinched if the shoulder is relocated incorrectly?
radial nerve
axillary nerve
215
What type of patella dislocation can paramedics reduce?
lateral patella dislocation
216
What is the procedure for a lateral patella dislocation?
* Provide analgesia (typically methoxyflurane)
* Apply firm medial pressure to the lateral aspect of the patella while extending the knee slowly
217
Is a knee dislocation an orthopaedic emergency?
yes, transport code 1
218
Why is a knee dislocation an othopedic emergency?
Significant vasculature surrounding the knee joint can lead to significant bleeding and limb loss if not corrected surgically
219
What is the treatment for an open fracture?
* Reassurance
* analgesia
* consider backup for procedural sedation
* Remove gross contamination where possible
* irrigate with 1-2L normal saline unless major haemorrhage
* Cover with sterile dressings
* Consider haemostatic agent for significant haemorrhage/tourniquet if uncontrollable arterial bleed
* throrough HTT
220
What should be considered when assessing a femur fracture patient?
kinematics
thorough head to toe
221
Where do hip fractures occur?
anywhere from proximal femoral head to first 5cm of femoral shaft
222
What is the most common type of hip fracture?
NOF
223
What is the presentation for a NOF?
external rotation
abduction of joint (away from body)
shortening
224
What is the presentation for interotrochanter hip fracture?
shortening
swelling
225
What is the presentation for subtrochanter hip fracture?
internal rotation
flexed knee
226
What sign provides a high index of suspicion for a hip fracture?
Hip pain upon rotation of extended leg
227
What should you not assume with a hip fracture?
haemodynamic stability
isolated injury
228
What is the treatment for a hip fracture?
analegesia
providing stabilisation and support for the affected leg (tie legs together using triangular bandages)
229
How are hip dislocations classified?
by the direction of dislocation, i.e. anterior or posterior
230
What causes posterior dislocation of the hip?
direct force applied to flexed hip (eg head on car accident)
231
What causes anterior dislocation of the hip?
forced external rotation of the abducted hip (eg car T boned)
232
What can force the femoral head to dislocate medially in a central dislocation?
enough pelvic damage
233
What are hip dislocations most commonly associated with?
acetabular fractures
234
What type of forces in a hip dislocation can result in vascular compromise that is an emergency requiring reduction?
shearing forces
235
What is the presentation of a hip dislocation?
Leg is typically shortened, and;
* Rotated internally in posterior dislocation
* Rotated externally in anterior dislocation
236
What is the percentage of patients that have other concoitant musculoskeletal and/or internal injuries in hip dislocations due to the forces involved?
40%
237
What is the management of a suspected hip fracture?
* Inspect for pelvic and hip tenderness, distal neurovascular function
* Look for leg shortening, rotation, bruising and swelling, movement loss
* Consider haemodynamic stability and reassess frequently
* Adequate pain relief and consider fentanyl over morphine if hypotensive
* attempt to return leg to anatomical position and splint legs together with triangular bandages to prevent rotating again
* Do not apply traction splint or pelvic binder
238
What is the management of a suspected hip dislocation?
* Inspect for pelvic and hip tenderness, distal neurovascular function
* Look for leg shortening, rotation, bruising and swelling, movement loss
* Consider haemodynamic stability and reassess frequently
* Adequate pain relief and consider fentanyl over morphine if hypotensive
* do not move the leg
* Do not apply traction splint or pelvic binder
239
What is the treatment for amputations?
* Control any exsanguinating haemorrhage
* Irrigate stump, cover with damp sterile dressing
* Bandage firmly with even pressure across the area
* Do your best to find the amputated part
* Cover the amputated part with a saline moistened dressing and place into an airtight bag
* Place airtight bag containing body part within 1:3 ice and water mix
* Consider receiving facility
240
Why should you find the amputated body part?
Even if irreparably damaged it can be used for skin & vascular grafts when resecting the stump & managing other injuries
241
What is the treatment for an impaled object?
Do not remove unless airway is obstructed
Apply very bulky padding
Transport object in place
No unnecessary movement as motion is magnified in tissues
242
What causes compartment syndrome?
crush injuries that have been in place for a long time
243
What is compartment syndrome?
the external crushing of compartments within muscle fascia, increasing pressure that then decreases blood flow and prevents nutrients and oxygen from reaching nerve and muscle cells
244
What can cause compartment syndrome?
* casts dressing or splints
* Increased compartment content from vascular injury or swelling
* tight dressing, crushing object, or circumfrential burns
245
What is crush syndrome?
follows compartment syndrome
release of potassium and myoglobin from damaged cells that is released into the bloodstream once the entrapment is released
246
What does potassium in crush syndrome cause?
cardiac dysrhythmias
247
What ECG changes are seen in crush syndrome from the potassium?
no P waves
wide QRS
peaked T waves
248
What does the release of myoglobin from damaged striated muscle cells (rhabdomyoloysis) do?
enters plasma and filtered by glomerulus and if pH is low, clog up the kidneys, reducing their function
249
How do you treat the crush syndrome (rhabdomyolysis)?
Fluids – 10-20ml/kg of saline - to increase urine output allowing kidneys to flush the toxins and reduce the impact of myoglobin on the nephrons
CCP backup – calcium gluconate and sodium bicarbonate for hyperkalaemia and acidosis
250
What 2 mechanisms cause acidosis (low pH)?
* Blood loss causing anaerobic metabolism and a resultant lactic acid buildup and clearance issue
* acid components from injured muscle cells
251
Why get CCP backup for hyperkalaemia?
They can administer:
salbutamol
sodium bicarbonate
calcium gluconate
252
What is the management for crush injuries?
standard cares
253
What type of transport are fluid injection injuries?
Code 1
254
What causes fluid injection injuries?
Injection of high pressure fluid such as hydraulic oil or paint
255
How does high pressure fluid cause internal injuries?
Fluid disperses internally along tissue plains causing damage and swelling
256
What is the presentation of fluid injection injuries?
Often benign presentation
pinpoint wound and minimal pain
progresses over several hours to severe pain
257
What is there a high risk of with fluid injection injuries?
amputation if not surgically treated
258
Should distal pulses be affected in splinting simple fractures?
no
259
In what position should limbs be splinted in most simple fractures?
in its current position
260
When should you consider manipulating a simple limb fracture?
if limb is threatened
261
When is traction contraindicated in femoral fractures?
in fracture / dislocation of knee or ankle
262
What should you check before and after splinting?
pulse & perfusion (leave pulse points visible in vacuum splints)
263
What is the go to analgesia for trauma?
morphine (unless very hypotensive)
264
What 2 effects does morphine have?
Analgesic and anxiolytic effects
265
In what patients should fentanyl be used in trauma?
hypovolaemic/hypotensive patients
266
What are non-pharmacological pain management options in splinting?
RICE, positioning for comfort (pillows = gold), warmth, reassurance
Splinting alone will significantly reduce pain
267
Why is a burn considered trauma?
due to the acute and rapid nature of the injury
268
What is a burn?
damage to the skin and underlying tissues caused by heat, cold, electricity, chemicals, friction, or radiation
269
In burn pathophysiology, what happens in the Zone of Coagulation?
Cell death occurs immediately, this area isn on-salvageable
270
In burn pathophysiology, what happens in the Zone of Stasis?
* Cells are alive but have compromised circulation
* can fully recover or become part of zone of coagulation depending on treatment
271
In burn pathophysiology, what happens in the Zone of Hyperaemia?
Cell damage is minimal and full recovery is expected
272
What type layers of skin are damaged in a 1st degree or superficial burn?
Minor epithelial damage to the epidermis
273
What type layers of skin are damaged in a 2nd degree or partial burn?
Complete damage of epidermis;
may have superficial or deep dermal damage
274
What type layers of skin are damaged in a 3rd degree or full burn?
Destruction of epidermal and dermal layers
275
What type layers of skin are damaged in a 4th degree or full+++ burn?
* Complete destruction of skin layers
* subcutaneous adipose tissues, fascia, muscles, bones, and/or organs burnt
276
What are the clinical features of a superficial (1st degree) burn?
* Red and warm to touch
* Tissue damage to outer epidermal layer
* Intense and painful inflammatory response–
277
How do you manage a superficial (1st degree) burn?
Symptomatic treatment:
paracetamol
ibuprofen
soothing creams
278
What are the clinical features of a partial thickness (2nd degree) burn?
* Entire epidermis into variable depth of dermis
* Can progress to full thickness burn with poor management
279
How do you manage a partial thickness (2nd degree) burn?
* cool burn
* cover with clean, dry dressing
* analgesia
280
What are the clinical features of a full thickness (3rd or 4th degree) burn?
* Often white, dry, leathery regardless of skin tone /race, or;
* Charred appearance in high heat / severe cases
* Area of full-thickness necrosis will be insensitive but surrounding areas very painful
281
What are the hospital treatments for a full thickness (3rd or 4th degree burn)?
* surgery
* may require emergency escharotomy to cut skin and relieve pressure
282
What skin layers does the coagulation zone comprise of in a full thickness (3rd or 4th degree) burn?
all three skin layers
283
What causes superficial (1st degree) burns?
sun or minor flash
284
What causes partial thickness (2nd degree) burns?
hot liquids, flashes or flame
285
What causes full thickness (3rd or 4th degree) burns?
chemicals
electricity
flame
hot metals
286
What is the skin colour in a superficial (1st degree) burn?
red
287
What is the skin colour in a partial thickness (2nd degree) burn?
mottled red
288
What is the skin colour in a full thickness (3rd or 4th degree) burn?
early white and/or charred, translucent and parchment-like
289
What does the skin surface look like in a superficial (1st degree) burn?
dry with no blisters
290
What does the skin surface look like in a partial (2nd degree) burn?
blisters with weeping
291
What does the skin surface look like in a full thickness (3rd or 4th degree) burn?
dry with thrombosed blood vessels
292
What is the sensation of a superficial (1st degree) burn?
painful
293
What is the sensation of a partial thickness (2nd degree) burn?
painful
294
What is the sensation of a full thickness (3rd or 4th degree) burn?
anesthetic with peripheral pain
295
What is the healing time of a partial thickness (2nd degree) burn?
2-4 weeks depending on depth
296
What is the healing time of a full thickness (3rd or 4th degree) burn?
requires skin grafting
297
What is the healing time of a superficial (1st degree) burn?
3-6 days
298
what is the systemic response to a burn?
Burned tissue releases inflammatory mediators in the surrounding circulation
299
What does the systemic response in a burn achieve in small burns?
helps expand the zone of hyperaemia to bring more blood, oxygen, and nutrients to the zone of stasis to assist with healing
300
What can the systemic response in a burn achieve in burns >20% TBSA?
systemic vasodilation causing albumin to move into intracellular spaces and sodium into cells, depleting intravascular space and increasing tissue oedema as cells and extracellular spaces swell
301
What are the 6 types of burns?
airway
chemical
electrical
friction
radiation
thermal
302
What are the 2 types of thermal burns?
hot
cold
303
What are the 2 types of chemical burns?
Acidic (coagulative necrosis)
Alkali (liquefactive necrosis)
304
What can cause thermal - heat burns?
fire, water, oil, steam
305
What is the most common type of burn?
thermal - heat
306
What is the pathophysiology of a thermal - heat burn?
coagulates proteins wihtin tissues causing cell death
307
What type of thermal - heat burn are very common in children and how do they occur?
* scalds
* from pulling a hot drink or pot onto themselves while exploring
308
What is the characteristic burn pattern in a paediatric scald?
V pattern over face and chest
309
What causes thermal - cold burns?
liquid nitrogen or dry ice
310
Are thermal - cold burns deep or shallow?
shallow
311
What is the treatment for a thermal - cold burn?
rewarm affected area in warm water
312
Are thermal - cold burns common or uncommon?
uncommon
313
What is the pathophysiology of a thermal - cold burn?
tissue proteins are coagulated causing cell death
314
How do you treat a chemical - acid burn?
* Brush off powders before commencing irrigation
* Irrigate with water until burning process stops (to remove the agent, not cool the burn)
315
What are the common acids that cause a chemical - acid burn?
* hydrochloric acid (toilet & drain cleaner)
* sulphuric acid (car batteries)
* hydrogen peroxide (bleaching agent)
316
What is the pathophysiology of an acid burn?
tissue proteins are coagulated, causing cell death
317
What is the pathophysiology of a chemical - alkali burn?
* liquefy tissue, leaving the next level down available for more burning
* typically work slower than acid
318
How do you treat a chemical - alkali burn?
Brush off powders before commencing irrigation
Irrigate with water until burning process stops, may take >30 mins for alkali (to remove the agent, not cool the burn)
319
What are the common acids that cause a chemical - alkali burn?
* lime (calcium oxide, used in agriculture)
* sodium hypochlorite (bleaching agent)
* sodium hydroxide (oven cleaner).
320
What causes a friction burn?
rapid abrasion of skin causing direct damage and heat generation
321
What is the treatment for friction burns?
first aid
322
What is the pathophysiology of radiation - sunburn/windburn?
UV radiation from the sun damages the DNA in skin cells, causing an inflammatory response
323
What skin layers can radation - sunburn/windburn damage?
epidermal to dermal
324
Why can large (typically ful body) radiatio - sunburn/windburn cause hospitalisation?
large release of inflammatory mediators can cause systemic effects
325
What is the treatment for radiation - sunburn/windburn?
oral analgesia and topical creams
326
What is radiation - flash burn (welders burn)?
UV damage to the cornea
327
What causes radiation - flash burn (welders burn)?
welding without a mask or looking at the sun
328
What are the clinical features of a radiation - flash burn (welders burn)?
painful bloodshot eyes
329
What is the treatment for radiation - flash burn (welders burn)?
typically self resolves
330
What is the mechanism of electrical burns?
Electrical current passes through body, potentially creating entry & exit wounds
331
Is tissue damage proportional to voltage in electrical burns?
yes
332
What is low voltage in relation to electrical burns?
household 240V
333
What is high voltage in relation to electrical burns?
>1,000V
334
What is fatal voltage in relation to electrical burns?
>70,000V
335
What do low voltage entry and exit wounds look like?
small, deep wounds
336
What do high voltage entry and exit wounds look like?
* extensive damage
* charring
* limb loss
* often massive tissue loss
337
What secondary injuries can electrical burns cause?
* musculoskeletal injuries due to intense musclecontraction
* rhabdomylosis
338
What causes airway burns?
Inhalation of hot gasses:
smoke, steam, fumes, etc
339
What do airway burns predominately affect?
upper airways as heat not transferred to lungs
340
What are the clinical features of airway burns?
* Sooty sputum, swollen lips, tongue, throat, difficulty swallowing
* Stridor, laryngeoedema, progressive obstruction due to swelling, constantly clearing throat
341
Is the onset of airway swelling in airway burns rapid or delayed?
delayed but can progress rapidly once begins
342
What can cause lung injury in airway burns?
steam - due to high heat carrying capacity of water vapour
343
What does a thermal injury to the lungs cause?
damage to lower airways
may cause bronchspasm
results in pulmonary oedema
344
What area is the focus of burns management?
zone of stasis
345
What is the recovery of the zone of stasis dependent on?
* Good first aid
* Prevention of hypothermia
* Good fluid resuscitation
* Elevation of affected limbs
* Prevention of infection
* Covering of the burn
* Analgesia
346
How long should a burn be cooled under running water and how long this effective?
20 minutes
effective up to 3 hours post burn
347
What does first aid for burns consist of?
* Cooling - 20 minutes under running water
* Remove rings, watches, etc. from affected limb – oedema will develop
* Remove loose, non adherent clothing
* Don’t remove adherent or burned-on clothing or substances
348
When should IV access be gained and fluids started in a burns patient?
ASAP
349
What is the formula for PHIFTEEN-B volume guidelines for burns?
15mL/hr x TBSA, rounded to nearest 10%
350
In airway burns, when should you administer fluids?
after the airway is secure due to risk of rapid airway oedema and obstruction
351
If a burns patient has hypovolamia, what should you do?
look for an additional injury
352
What does raising the burned limb achieve?
increased passive drainage and reduced swelling
353
How do you prevent infection and cover a burn?
* patted dry (rubbing will tear the skin)
* clear plastic cling wrap should be applied to the burn
* Circumferential wrapping is fine as long as it is not tight
354
What type of burns can BurnAid dressing be used on?
small burns <10% TBSA
355
What should you consider with regards to analgesia in burn patients?
* among the most painful types of injuries
* early, aggressive analgesia for significant burns
* Place IV early or administer IM fentanyl prior to turning off cool running water as it controls pain but it will spike dramatically when the water is removed
* Poor pain management makes every other aspect of the case extremely challenging due to patient agitation.
* CCP’s can administer several analgesic agents (midazolam, ketamine)
356
What is the management for chemical burns?
* PPE, and provide glasses & mask to Pt if you have them
* Remove patient & yourselves from source
* Remove patient's clothing and place into plastic bags
* Brush chemical from skin if dry in nature
* Flush copiously with water; be careful where it splashes & drains
* Check for any retained matter, repeat flush
* Apply non-adherent dressing even if no obvious wound
* Never apply cling wrap or BurnAid to chemical burns
357
Why are airway burns potentially dangerous?
due to damage and associated oedema of the upper airway
358
What signs indicate airway burns?
singed hair
soot in nose or mouth
hoarse voice
359
How long does it take for oedema and associated airway compromise to develop?
several hours
360
What is the focus and priority of airway burns?
recognition and early transport to a tertiary hospital
361
What causes high voltage burns?
Lightning or electric shock
362
How do high voltage burns cause death?
Current causes immediate cardiac arrest
Tissue between entry and exit wounds is damaged and leaks K+ causing cardiac arrest (get CCP as they can give meds for this)
363
When should a burns patient be taken to a dedicated burns unit?
* Partial thickness burns >20% all ages; or >10% in patients younger than 10 or older than 50
* Full thickness burns >5%
* Burns involving face, eyes, ears, hands, feet, genitalia, buttocks, perineum or overlying a major joint
* All inhalation burns
* All significant electrical burns
* Burns in people with significant co-morbidities (e.g. heart failure)
364
What is multi system trauma?
Trauma involving more than one part of the body
365
What kills in multi-system trauma?
Multisystem trauma life threats:
* Airway compromise
* Tension pneumothorax
* Hypovolaemicshock
* Traumatic Brain Injury
(cardiac tamponade and hamothorax but we cant fix)
366
What are the 2 options for managing the airway in multi trauma?
* Basic management – Simple, proven, often requires lateral positioning, no protection from aspiration or trismus, patient agitation complicates.
* RSI – complex, proven, adds to on scene time, patient remains supine, total airway protection, pt is controlled (HARU or HEMS)
367
What are the 2 options for managing tension
pneumothorax?
* Needle thoracostomy (decompression) –Pneumodart
* Finger thoracostomy (HARU or HEMS)
368
What is a finger thoracostomy?
incision in made in the upper mid axilla, forceps used to dissect through to the pleural space and finger used to sweep the inside of the cavity
creates an open chest wound – requires intubation
369
What can cause hypovolaemic shock?
* external bleeding
* internal bleeding
370
How do you treat external bleeding?
* Pad & bandage
* Tourniquet
* Wound packing with haemostatic dressings
371
How do you treat internal bleeding?
Tranexamic acid (TXA)
372
What are the variables in the coagulopathy of severe trauma (COAST) score?
* entrapment
* systolic blood pressure
* temperature
* major chest injury likey to require intervention
* likely intra-abdominal or pelvic injury
373
How much blood is lost in a fractured rib?
150ml per rib
374
How much blood is lost in a fractured tibula, fibula or humerus?
500ml each
375
How much blood is lost in a fractured femur?
1500ml each
376
How much blood is lost in a fractured pelvis?
entire blood volume
377
Why is early notification of a multi-trauma
that may require MTP essential?
Takes time to prepare blood for massive transfusion protocol
378
What components of blood are required to prepare for massive transfusion protocol?
red blood cells
fresh frozen plasma
platelets
379
What MAP is required in a suspected TBI?
90
380
What is the preferred minimum volume resuscitation goal in all multi-trauma (without a known/suspected TBI)?
MAP 65 or radial pulse
381
What MAP is rquired in the multi-trauma patient with a suspected TBI?
MAP 90
(SBP 100-120)
382
In multi system trauma what specific interventions can paramedics do to improve outcome?
* Early control of airway + maximise oxygenation
* Early control of bleeding – internal (pelvic splint +traction splint) and external (tourniquet, pad andbandage, wound packing)
* Recognition and correction of tension pneumothorax
* Early transport to trauma centre
383
What Damage Control Resuscitation components are to be used in multi-trauma or the severely injured trauma patient?
Minimum volume resuscitation
Managing the lethal triad
384
What are some of the unfavourable side efftects of saline when treating hypovoleamia?
dilutional coagulopathy
hypothermia
385
What is the end goal for minimum volume resuscitation?
Maintain a radial pulse
MAP of 65 - ‘65 kidneys alive’
386
What is the order of organ demise in hypovolaemia?
kidneys
liver
spleen
intestines
heart
lungs
brain
387
What are the components of the lethal triad in trauma (part of damage control resuscitation)?
hypothermia
coagulopathy
acidosis
388
What causes the hypothermia component of the lethal triad in trauma?
Remove clothes
IV access –fluids
Move to air conditioned ambulance
389
What do paramedics need to do to prevent the hypothermia component of the lethal triad when treating trauma patients?
Give minimal fluids
Apply blankets, ideally self warming blankets early
Warm ambulance, in major trauma you should be sweating from the ambient heat in the vehicle
390
What causes the acidosis component of the lethal triad in trauma?
Hypoxia from poor perfusion
leads to anaerobic metabolism
(ATP created from differnt fuel source resulting in lactic acid causing blood to become acidic)
391
What do paramedics need to do to prevent the acidosis component of the lethal triad when treating trauma patients?
Maximise oxygen delivery
Mildly hyperventilate where possible to maintain EtCO2 at 35-45 mmHg
Minimise normal saline (which has a pH of 5.5!)
392
What causes the coagulopathy component of the lethal triad in trauma?
blood's clotting factors depleted or imbalanced in massive bleeding
worsened by dilutional anaemia, acidosis and hypothermia
393
What do paramedics need to do to prevent the coagulopathy component of the lethal triad when treating trauma patients?
* Avoid hypothermia
* Administer fluid according to minimum volume resuscitation principles
* Provide early notification to hospital of incoming trauma so blood products can be prepared
394
What is shock?
circulatory failure resulting in cellular and tissue hypoxia causing cellular death and vital organ dysfunction.
395
What are the types of shock?
Distributive
Obstructive
Cardiogenic
Hypovolaemic
396
What does ‘Shock’ in the public vernacular refer to?
psychological shock as opposed to physiological shock
(they're upset)
397
What determines blood pressure?
cardiac output x peripheral vascular resistance
398
What determines cardiac output?
stroke volume x heart rate
399
What are the signs of shock?
tachycardic
tachypnoeic
mottled peripheries
400
When can you begin treating shock?
When you know what type of shock it is
401
What causes distributive shock?
hypotension (pipes expanding)
sepsis
anaphylaxis
neurogenic shock
402
What causes neurogenic shock?
trauma from injury in spinal cord and body loses sympathetic tone below level of injury
403
What causes obstructive shock?
Hypotension (pipes or pump blocked)
massive PE - pipe
tension pneumothorax - pump
tamponade - pump
404
How does a tension pneumothorax cause obstructive shock?
air trapping in chest moves lungs and squashes heart
405
How does a tamponade cause obstructive shock?
pericardial sac can't expand so crushes heart
406
What causes cardiogenic shock?
hypotension (pump failure)
penetrating injury to heart
myocardial infarction
contusion (bruise stops cells from contracting properly as they are damaged)
407
What causes hypovolaemic shock?
hypotension (pipes empty)
bleeding
dehydration (over longer term)
408
What are the signs and symptoms of 15% blood loss?
(750ml in 70 kg)
minimal or no tachycardiac response
BP changes do not usually occur
409
What are the signs and symptoms of 15-30% blood loss?
(750ml - 1500ml in 70 kg)
tachycardia
hypotension
peripheral hypoperfusion
ALOC
410
What are the signs and symptoms of >40% blood loss?
(>2L in 70 kg)
haemodynamic compensation at liit
decompensation imminent
ALOC
411
When should a major trauma hospital be the primary destination?
if patient i5 60 minutes or less from major trauma hospital
(if urgent interventions are needed eg airway - take to nearest tertiary centre)
412
What do you do if you are more than 60 minutes from a major trauma centre?
notify the communications department that a transfer will be required and transport to the nearest regional centre
413
What vital signs are associated with major trauma?
conscious state
respiratory rate
SPO2
heart rate
systolic BP
414
What are the mechanisms of injury that define major trauma?
* Ejected from a vehicle
* Fall from a height of 3 metres or more
* Explosion
* High impact RTC with incursion into the occupant’s compartment
* Vehicle rollover
* RTC with a fatality in the same vehicle
* Entrapped for longer than 30 minutes
415
What are the patterns of injury that define major trauma?
Injuries to the head, neck, chest, abdomen, pelvis, axilla, or groin that:
- are penetrating
- are sustained from blasts
- involve two or more of those regions
* Limb amputation above the wrist or ankle.
* Suspected spinal cord injuries
* Burns in adults >20%, or in children >10%, or other complicated burn injury including burn injury to the hand, face, genitals, airway, or respiratory tract
* Serious crush injury
* Major open fracture, or open dislocation with vascular compromise
* Fractured pelvis
* Fractures involving two or more of femur, tibia, or humerus
416
When does HEMS not add value?
If road transport time to a major trauma service is less than 30 minutes
417
What are some considerations regarding Helicopter Emergency Medical Service (HEMS)?
* The helicopter will need somewhere to land
* Flat surface away from trees and overhead wires
* A road is often ideal. Police will need to block or diverttraffic to create space
* Do not approach the helicopter until the rotors have stopped turning
418
What are the common causes of preventable early death in trauma?
60% haemorrhage
33% tension pneumothorax
10% cardiac tamponade (we can't treat this one)
7% airway obstruction
419
In traumatic cardiac arrest, what takes priority over all other interventions?
external haemorrhage control
420
Where do you direct your attention after haemorrhage control in a traumatic cardiac arrest?
airway or breathing
(unless there are sufficient people to perform interventions simultaneously)
421
Which type of trauma has better outcomes in traumatic cardiac arrest - blunt or penetrating?
penetrating as damage is more isolated
422
What are the methods of haemorrhage control in trauma?
direct presure
emergency bandage
tourniquet
wound packing
423
What are the most common methods of haemorrhage control in traumatic cardiac arrest?
emergency bandage
tourniquet
424
How many points of access should you aim to get in a trauma patient with low blood volume and why?
multiple points of access as a large volume of fluid is required very quickly
If IO being drilled still look for IV access
425
What is the rapid infusion rate for hypovolaemia in trauma?
20ml/kg normal saline followed by 5-10ml/kg
426
What is the preferred substance for volume replacement in the trauma patient?
Blood is preferred if HARU or the flight team are available
427
What are the initial steps in airway management in traumatic cardiac arrest?
Double or triple airway maneuver
Suction
Basic airway adjuncts (if eneffective and have time igel can be used)
Opening of the airway may be all that is needed
428
What type of airway adjunct will direct trauma to the airway require?
advanced airway
429
When should traumatic cardiac arrest patients have their chests decompressed?
suspected chest trauma who do not respond to airway opening and restoration of blood volume
430
What are the classic signs of cardiac tamponade that may not be present in traumatic cardiac arrest?
Distended jugular vein
Hypotension
Decreased heart sounds
431
What are the ECG signs of cardiac tamponade?
* Electrical Alternans (onsecutive, normally-conducted QRS complexes that alternate in height)
* Low voltage QRS complex
* Tachycardia
432
What causes electrcial alternans?
when the heart swings backwards and forwards within a large fluid-filled pericardium
433
What is the management for cardiac tamponade in the traumatic cardiac arrest?
resuscitative thoracotomy
(clam shell)
434
What is Resuscitative thoracotomy?
Involves cutting through the ribs and sternum to open the chest. Very unlikely for this to occur prehospitally (although it does happen)
435
What are the benefits of a Resuscitative thoracotomy?
* release tension pneumothorax or cardiac tamponade;
* allow direct control of intrathoracic haemorrhage;
* allow cross-clamping the descending aorta (in so doing stopping blood loss below the diaphragm and improving brain and cardiac perfusion); and
* permit open cardiac compression and defibrillation
436
Who can do a resuscitative thoracotomy?
appropriately trained doctor
437
What is the primary survey in a traumatic cardiac arrest?
Danger
External haemorrhage control
Response
Circulation
Airway
Breathing
438
In what order do you treat reversible causes?
prioritised based on the patient presentation
439
What procedures should you do in traumatic cardiac arrest patients when you don't know what the reversible cause is?
it is ok to attempt all options for reversible causes
440
When do you administer adrenaline in the traumatic cardiac arrest?
as normal after all the reversible causes have been addressed
441
When do you do CPR in traumatic cardiac arrest?
only after haemorrhage control, airway control, and IV access with fluids running, and chest decompression
If you have another crew or bystanders, one of them can do CPR
442
What type of rhythm will over 90% of trauatic arrest patients be in?
PEA or asytole
443
What does a narrow complex PEA suggest?
a reversible cause may be present
444
What heart rate in a PEA in traumatic cardiac arrest is an indicator of survival?
>40
445
What is Impact Brain Apnoea?
Rare presentation of head injury where a concussive impact to the brainstem causes apnoea, generally without other significant brain injury
446
What type of treatment does impact brain apnoe require?
ventilation
447
When do you initiate transport in a traumatic cardiac arrest?
when ROSC is achieved on scene
448
When do you initiate transport in a traumatic cardiac arrest prior to ROSC being achieved?
when the hospital is insuch close proximity that there is a realistic chance of a resuscitative thoracotomy being performed within 10 minutes
449
What is the management of traumatic cardiac arrest after ROSC is achieved?
* If bleeding is suspected as the cause of the arrest, aim for a systolic BP of 90 to avoid further bleeding
* If TBI is suspected as the cause aim for a higher systolic BP of 110
450
When do you stop resuscitation in traumatic cardiac arrest?
* Standard 20 minute resuscitation with all the reversible interventions performed.
* If after this time there is no ROSC, resuscitation can cease
451
Inside an upside down car you find a patient still wearing their seatbelt, breathing with a weak, but fast corotid pulse. They do not appear to be entrapped. How are you going to get them out?
Focus on getting her out as quickly as possible with best attempts to maintain C spine support. But as has significant trauma, haemorrhage is priority.
452
Your primary survey of a trauma patient reveals:
D – None
R – Groans to pain (AVPU)
A – No blood but patient snores in supine position
B – Yes, seems fast, around 1 breath every 2 seconds (30 per minute)
C – Weak carotid, no radial, feels fast
D – Sluggish size 5
E – Multiple abrasions, compound L tib/fib fracture. Yellowish fluid seeping from L ear.
What actions will you undertake in the next 5 minutes?
* OPA & oxygen
* Remove clothing
* Auscultate chest – decompress if needed (no breaths sounds on one side)
* Pelvic binder
* Torniquet around L leg – can remove for something better as case continues – emergency bandage
* IV access
* IV fluids to maintain radial pulse/MAP 65 (due to suspected TBI)
* Actively warm
* CCP backup
453
How would you administer fluid in a severely hypotensive patient eg around 60/40 and what is your end point?
500ml saline bolus via rapid infusion to reach MAP 90/SBP 100-120 due to brain injury. Ongoing reassessments and reducing saline infusion if required to maintain MAP 90/SBP 100-120
454
When is a major trauma centre the primary destination over a regional hospital?
if a pt is 60 minutes or less from the major trauma centre
455
When do you transport a major trauma patient to a regional hospital?
when the major trauma centre is more than 60 minutes away
456
How can you differentiate between hip dislocation and hip fracture?
* Hip fractures typically elderly pts from simple falls or a similarly minor mechanism
* Hip dislocations require very significant mechanisms such as car crashes or long falls
457
What is a crush injury?
tissue trauma produced directly from a crushing force
458
What can cause a crush injury?
being crushed by a falling object
crushing pressure of the body on a hard surface (eg elderly person lying on tiles for several days unable to move)
459
What toxins cause damage in crush syndrome?
potassium
myoglobin
lactic acid
460
How does lactic acid occur in compartment syndrome?
byproduct of the hypoxic and hypo perfused tissues switching to anaerobic metabolism
461
What is the primary objective/role of the first crew on scene in a multi casualty incident?
* initiate command and control of incident
* ensure personal safety and safe approach
* initial triage
* site control
462
Who assumes the role of Forward Commander?
most senior officer (of first crew on scent)
463
Who assumes the role of Triage Officer?
Second officer (of first crew on scene)
464
What are the responsibilities of the Forward Commander who is located in the Forward Command Post?
* all ambulance resources (assigning officers to roles as ambulances arrive)
* liaising with other agency commanders in joint management of the incident
* keeps comms updated
465
What are the responsibilities of the Triage Officer who is located in the Casualty Clearing Post?
initial triage
organise the casualty clearing area
oversee SORT
organise priority of transport
keep the commander updated
should be a hands off role (depending on resourcing)
466
What are the steps on arrival to a multi-casualty event?
* Arrive and identify multi-cas event
* Sitrep 1
* Decide who is forward commander (senior officer)
* Other officer becomes triage officer
* Triage officer opens SMART triage tags and begins to tag patients (SIEVE)
* Scene commander does not touch patients but:
- Provide Sitrep 2, update regularly
- Create casualty clearing area
467
What does a multi-cas SitRep 1 (windscreen) provide/include?
* Confirm arrival
* Confirm location
* Provide snapshot of “what can been seen”
468
What does a multi-cas SitRep 2 (METHANE) provide/include?
**M**ajor incident confirmation
**E**xact location
**T**ype of incident
**H**azards – prevent potential
**A**ccess to incident site
**N**umber of casualties
**E**mergency Services required
469
What are the categories in SIEVE?
Priority (red) - immediate interventions
Delayed (yellow) - will require interventions
Walking wounded (green)
470
What is the purpose of SIEVE?
determine which area of the casualty clearing area to take the patient to
471
What is the purpose of SORT?
determine the order of transport to hospital
(may change with time as score can be updated)
472
What does CBR stand for?
chemical
biological
radiological
473
What are the chemical poisoning agents?
Nerve – Sarin, VX gas
Blister – Mustard gas
Choking – Phosgene, Chlorine
Blood – Cyanide
Riot control – Tear gas, capsicum spray
474
What is the management for chemical poisoning/exposure?
Decontamination by fire department
- extensive irrigation
Airway control
- Oxygen therapy
– Bronchodilators (salbutamol/ipratropium)
Antidote
– Atropine (nerve gas or bradycardia)
– Hydroxocobalamin (cyanide)
475
What are the biological poisoning agents?
Viruses – Influenza, smallpox, ebola
Bacteria – Anthrax, bubonic plague, smallpox
Toxins – Botulism, Ricin
476
What are the effects of nerve (sarin, VX gas) exposure?
parasympathetic overstimulation (SLUDGE/DUMBBELLS)
477
What does SLUDGE stand for?
Salivation
Lacrimation
Urination
Diarrhoea/diaphoresis
Gastrointestinal
Emesis
478
What does DUMBBELLS stand for?
Diarrhoea
Urination
Miosis
Bronchospsm
Bronchorrhea
Emesis
Lacrimation
Lethargy
Salivation
479
What are the effects of Blister chemical exposure?
chemical burns - eyes and airways especially
480
What are the effects of choking (phosgene chlorine) chemical exposure?
airway damage
481
What are the effects of blood (cyanide) chemical exposure?
histotoxic hypoxia leading to multi organ failure
482
What are the effects of riot control (tear gas) chemical exposure?
Irritation of eyes and mucous membranes, not lethal
483
What are the effects of viruses (influenza, smallpox, ebola) biological exposure?
Variable incubation period and symptoms
484
What are the effects of bacteria (anthrax, bubonic plague, smallpox) biological exposure?
Usually fatal if aerosolised as a powder and inhaled
485
What are the effects of toxins (botulism, ricin) biological exposure?
Variable symptoms, usually not fatal with treatment
486
What is the management of biological poisoning/exposure?
If at exposure:
PPE
Decontaminate
If at onset:
PPE
treat symptomatically
487
How does radiological poisoning/exposure occur?
accidental - laboratories, medical devices
intentional - terrorism (nuclear or dirty bomb)
488
What is the management for radiation exposure?
Decontamination
– Fire department - to remove irradiated material attached to person or clothes and bag them
Symptomatic management
– Acute radiation poisoning affects cell division so does not produce immediate effects (hair and mucous membranes affected first)
489
How do you decontaminate the pt?
PPE for yourself
Wet down the victim
Remove wet clothing
Wash with soap and warmwater
Cover in clean clothes /blanket
490
Do you still need to wear PPE when treating a decontaminated patient?
yes
491
What type of PPE is required for CBR cases?
N95 mask
coveralls
eye protection
gloves
492
Where does a pelvis fracture in an APC Type I?
Pubic symphyseal diastasis, <2.5 cm, no significant posterior ring injury (stable)
493
Where does a pelvis fracture in an APC Type II?
Pubic symphyseal diastasis >2.5 cm, tearing of anterior sacral ligaments (rotationally unstable, vertically stable)
494
Where does a pelvis fracture in an APC Type III?
Hemipelvis separation with complete disruption of pubic symphysis and posterior ligament complexes (completely unstable)
495
Where does a pelvis fracture in a LCI?
Posterior compression of sacroiliac (SI) joint without ligament disruption (stable)
496
Where does a pelvis fracture in a LCII?
Posterior SI ligament rupture, sacral crush injury or iliac wing fracture (rotationally unstable, vertically stable)
497
Where does a pelvis fracture in a LCIII?
LC II, with open book (APC) injury to contralateral pelvis (completely unstable)
498
Where does a pelvis fracture in a vertical shear?
* vertical fracture of the pubic rami
* displaced fractures of the anterior rami and posterior columns, including SI dislocation (completely unstable)
499
What are the reversible causes of traumatic cardiac arrest?
Hypoxia
Hypokalaemia/hyperkalaemia
Hypothermia/hyperthermia
Hypovolaemia
Tension pneumothorax
Tamponade
Thrombosis
Toxins
500
What are the regions and points for the rule of nines in adults?
head (front and back) 9%
chest 9%
abdomen 9%
upper back 9%
lower back 9%
left arm 9%
right arm 9%
left leg 18%
right leg 18%
genitals 1%
501
What are the regions and points for the rule of nines in children?
head (front and back) 18%
chest 9%
abdomen 9%
upper back 9%
lower back 9%
left arm 9%
right arm 9%
left leg 14%
right leg 14%
502
What are the regions and points for the rule of nines in infants?
head (front and back) 18%
front torso 18%
back torso 18%
left arm 9%
right arm 9%
left leg 13%
right leg 13%
genitals 1%
503
What are the four abdominal quadrants?
right upper quadrant
left upper quadrant
right lower quadrant
left lower quadrant
504
What organs are in the right upper quadrant?
liver
gallbladder
stomach
duodenum
right kidney
right adrenal gland
pancreas
transverse colon
small intestine
505
What organs are in the left upper quadrant?
liver
stomach
left kidney
left adrenal gland
pancreas
spleen
transverse colon small intestine
506
What organs are in the right lower quadrant?
small intestine
large intestine
cecum
appendix
right ureter
right reproductive organs
507
What organs are in the left lower quadrant?
small intestine
large intestine
left ureter
left reproductive organs
sigmoid colon
508
What is the weight indication for a pneumodart?
50+kgs
509
What is the weight indication for a 14g cannula for chest decompression?
15-50kg (4-14yrs)
510
What is the weight indication for a 16g cannula for chest decompression?
<15kg (less than 4yrs)
511
What is the COAST score for entrapment?
yes - 1
no - 0
512
What is the COAST score for SBP?
>100 - 0
>90-100 - 1
<90 - 2
513
What is the COAST score for temperature?
>35 - 0
32-35 - 1
<32 - 2
514
What is the COAST score for major chest injury likely to require intervention?
yes - 1
no - 0
515
What is the COAST score for likely intra-abdominal or pelvic injury?
yes - 1
no - 0
516
What organs are in the Right hypochondriac region?
liver
gallbladder
right kidney
small intestine
517
What organs are in the right lumbar region?
liver
gallbladder
right colon
518
What organs are in the right iliac region?
appendix
cecum
519
What organs are in the epigastric region?
adrenal glands
spleen
pancreas
stomach
duodenum
liver
520
What organs are in the umbilical region?
duodenum
small intestine
umbilicus
521
What organs are in the hypogastric or pubic region?
urinary bladder
sigmoid colon
female reproductive organs
522
What organs are in the left hypochondriac region?
spleen
pancreas
left kidney
colon
523
What organs are in the left lumbar region?
left kidney
descending colon
524
What organs are in the left iliac region?
descending colon
sigmoid colon
525
When would it be appropriate to initiate early transport for a traumatic cardiac arrest?
When there is a realistic change of a resuscitative thoracotomy being performed within 10 mins from loss of output
526
What is hypovolaemic shock?
shock due to circulatory failure from intravascular volume loss
527
Is distributive shock a pump or pipe issue?
pipe
expansion = hypotension
528
Is obstructive shock a pump or pipe issue?
both
pump blocked = hypotension
pipes blocked = hypotension
529
Is cardiogenic shock a pump or pipe issue?
pump
pump failure = hypotension
530
Is hypovolaemic shock a pump or pipe issue?
pipes
pipes empty (have holes) = hypotension
531
How long do you irrigate the eyes with water or sodium chloride for if exposed to chemicals?
30 mins or longer
532
How long do you irrigate the eyes with water or sodium chloride for if not penetratin or exposed to chemicals?
<15 minutes
533
If you see a non penetrating foreing body when irrigating eyes, how do you remove it?
moist cotton bud
