Trauma

Question 1

Unintentional Injury

Leading cause of death for people ages 1-44
Leading causes of unintentional fatalities:

Answer 1

Motor vehicle traffic (MVA, pedestrian, bicyclists)
Poisoning
Falls

Question 2

Triad of death: a lethal cascade

predictor of poor outcome with severe blood loss in the middle

Answer 2

Coagulopathy: excessive fluid dilution, metabolic events, hyperthermia, DIC

Acidosis: build-up of lactic acidosis, build up of Co2 from poor lung functioning, slow breathing

Hypothermia: wet clothing, IV fluids=shivering, decreased tissue perfusion, decreases removal of lactic acid.

Question 3

Emergency room nurse

Prompt recognition of patients requiring immediate intervention => ___

_______: roles and responsibilities for trauma patient on admission to ER

PPE

Stressful environment

Answer 3

triage -
Triage-takes a lot of experience to triage appropriately

Team assembling-
“Code Trauma”: have specific responsibilities/role

Question 4

Triage “to sort”

Process of sorting or quickly determining victim acuity

Categorizes patients so that ___________ based on illness severity and resource utilization

Emergency Severity Index (ESI): Five levels of triage (1-5)

Answer 4

most critical are treated first

ESI-1 & ESI-2 most critical
ESI-3, ESI-4, ESI-5 patients are stable

Question 5

How sick, how soon need to be seen?
With the ESI, patients are assigned to triage levels based on both their acuity and their anticipated resource needs.
ESI-1 any threats to life (_____)
ESI-2 high risk situation
ESI-3,4,5(nL vs) depends on # of resources(ECG, labs, radiology studies, IV fluids)

Answer 5

cardiac arrest

Question 6

Primary Survey

Answer 6

A: airway
B: breathing
C: circulation
D: disability
E: exposure and environmental control

When a trauma patient first comes in. Trauma resuscitation requires immediate treatment, these five things to prevent death. Trauma viewed as multisystem disease. Identify and treat life-threatening conditions first. Primary (ABCDE) & secondary (FGHI) survey for all trauma patients

Question 7

Secondary Survey

Answer 7

F: full set of vital signs & family
G: give comfort measures
H: head to toe assessment & history
I: Inspection of posterior surfaces

Question 8

A
Airway with simultaneous cervical spine stabilization and/or immobilization

Open airway
Always assume injury to cervical spine
Stabilize/immobilize cervical spine
Remove or sx foreign bodies
Insert airway or prepare for intubation

Nearly all trauma deaths that occur immediately, due to _____ .

S/Sx of compromised airway:
Suspect cervical spine trauma in any patient with ______________________; open airway with modified _________

Answer 8

airway obstruction

face, head, or neck trauma and/or significant upper chest injuries

jaw thrust maneuver

Question 9

Breathing

Assess adequacy of _____
Look, listen, and feel parameters

All trauma patients should receive ______ during initial evaluation/may need BVM

If we must intubate, it is preferred rapid sequence intubation:

If unable to intubate due to injury or edema or a failed intubation: emergency _______ or _______, which is a lifesaving measure.

Answer 9

ventilation

high-flow oxygen (NRB)

induce unresponsiveness followed by neuromuscular blockade to cause muscular relaxation(sedate and paralyze).

cricothyrotomy or a tracheostomy

Question 10

End tidal CO2 monitoring

Increased use of end tidal CO2 monitoring (______) in trauma patients-why?

Answer 10

capnography

More accurate than pulse ox.

Question 11

Circulation

Check central pulse (quality)
Blood pressure, HR, skin color, oxygen saturation, cap refill
If absent pulse, start CPR
STOP THE BLEED!
Determine source of blood loss

Hemorrhage is cause of early post-injury deaths; can occur in several areas:, pelvis, femur, liver, spleen, kidney, head, chest (organs that are vascular or areas that can hold a lot of blood)

Check carotid and brachial

2 large bore IVs (14, 16g)
Type and cross match
Administer fluid/blood products
Aggressive fluid resuscitation: LR or NS

Can give ______ while waiting on type and cross
Type and cross typically takes 45 min.

Answer 11

0- or LR

Question 12

Circulation (fluids)

What would failure to respond to fluids possibly indicate? rapid surgical intervention is required (hypovolemic shock)

Answer 12

Warm Lactated Ringer’s solution
Isotonic
The components of LR are the closest to our blood crystalloids
Not usually used as a maintenance fluid because of added electrolytes such as Na+ and K+

Question 13

Disability:

_____ is common in the early stages of shock, fight or flight response. As shock progresses their _______.

_____ about an event suggests an altered loc

______- indicative of brain injury- ominous sign

Answer 13

Brief neuro exam
Determine patient’s level of consciousness:
A –Alert
V – Responsive to voice
P – Responsive to pain
U – Unresponsive
or
Glasgow coma scale
PERRL
posturing

Agitation
LOC decreases

Amnesia

Posturing

Glasgow comma scale scoring can be impaired by drugs and alcohol

Question 14

Exposure

Patient completely disrobed in preparation for secondary survey

Exposure to:

-
-

Answer 14

cold ambient temperatures, large volumes of room temperature IV fluids, cold blood products, and wet clothing  hypothermia

-Heated blankets, overhead warmers, warmed fluids, warmed room, and Bair hugger
-Maintain privacy
-Preservation of evidence

Question 15

Hypothermia: core temp _____ or less. Hypothermia is the easiest to treat of the trauma triad.

Answer 15

35 C or 95 F

Question 16

Secondary survey

F

G

Finished primary
Labs you would anticipate:?
Blood at meatus-what would you suspect?
Facial fractures - NGT with US guidance

NGT tube- contraindicated with _________

Answer 16

Full set VS, focused adjuncts, facilitate family presence: continuous ECG,O2 sat, end-tidal CO2 monitoring; urinary catheter/NGT if indicated; tetanus; labs, X-rays; designate team member to support family

Give comfort measures: assess and reassess pain/anxiety

orbital or brain injuries

Question 17

H and I

History andHead-to-toe AssessmentInspection

Obtain details of:

Head to toe assessment

AMPLE:

Log roll and inspect back for:

What did happen? ________ is important when obtaining history can help predict the types and combinations of injuries ie. If a fall, how high? if MVA, driver? Seatbelt? Airbag deployed?

May need to remove anterior portion of c-collar to see if any ____ or ____

Answer 17

incident/illness, mechanism and pattern of injury, length of time since incident, injuries suspected, treatment provided and pt’s response, LOC

allergies, meds, past health hx, last meal, events/environment preceding injury or illness

deformity, bleeding, lacerations, and bruises

Mechanism of injury

tracheal deviation or JVD

Question 18

Diphtheria, Tetanus & PertussisVaccinations

DTaP (given to children under age __)
Tdap (_________)
Td (once every ____ after one Tdap)
TIG

When would you give TIG (tetanus immunoglobulin)?

_____, ____ - signs of tetanus

DTaP vs. Tdap – different _____ of vaccine

DTaP- given before (D comes before T)

Answer 18

7
one dose age 11-64 years
ten years

Given to someone showing signs of tetanus. They will still need vaccine sat some point

Lockjaw, spastic muscles

concentrations

Question 19

Tetanus, diphtheria, and acellular pertussis(Tdap)

Only for individuals older than ___ years of age

Now routinely given around _____ years of age

Healthcare professionals should all have this vaccine

Pregnant women should get one dose of Tdap during every pregnancy (CDC, 2022)* “whooping cough”

Td is a derivative of Tdap…but without the ____

Td boosters should be given every ____

*CDC recommends all women receive a Tdap vaccine during the 27th through 36th week ofeachpregnancy, preferably during the earlier part of this time period. Why?

Given with ___, ___, & ____

Answer 19

7
11 or 12

pertussis.

10 years

burns, trauma, pregnancy

Question 20

Trauma Signs

Answer 20

Battle’s: post-auricular ecchymosis, behind the ear, over the mastoid bone- basilar skull fx

Raccoon eyes- orbital fractures

Gray turners- internal bleeding retroperitoneal

Cullen’s- umbilicus

Liver laceration

Question 21

Chest trauma types:
1. Penetrating
2. Blunt
-
-
-

Sternal fx usually by steering wheel, can cause pulmonary contusion. Increases mortality 50%, present like ____________

Answer 21

Sternal and rib fractures
Pulmonary contusion (mortality rate >50%)
Flail chest

ARDS presentation. Hypoxemia refractory to oxygen.

Prevent pneumonia with IS or flutter valve

Question 22

Flail Chest

Fracture of several consecutive ribs in _____ separate places causing ____
causes,
signs and symptoms,
treatment

Answer 22

two or more
unstable segment

Causes: severe blunt injury – crushing roll-over injury due to a flipped ATV, MVA or a fall might cause it.

S&S:
Paradoxical breathing-the opposite of what it should be. (lung deflates when it should inflate)

Rapid, shallow respirations and tachycardia

Treatment:
Supportive therapy is key while the ribs heal
Rarely need surgery (external device), supportive therapy-taping, splinting.
If major injury, may be intubated

Question 23

Thoracic Injuries

______: air enters the pleural space causing a total or partial collapse of the lung
-Loss of _______
-Signs and symptoms depend on ___
Types:
–
-
-

Hemothorax: may require ______

Treatment?

Answer 23

Pneumothorax:

negative pressure

size

Types:
-Simple or spontaneous
-Traumatic
-Tension

autotransfusion

Insert CT into pleural space: to drain fluid, blood or air; re-establish the negative pressure, and re-expand the lungs

Sometimes lung issues such as asthma can precipitate the pneumothorax

Question 24

Spontaneous pneumothorax:

Primary:
Secondary:

Risk factors:

Treatment:

Answer 24

Rupture of small blebs

Primary: healthy young individuals
Secondary: as a result of lung disease

VATS procedure: video-assisted thoracic surgery – if it won’t stay inflated with chest tube

Tall and thin adolescent males are typically at greatest risk

Rupture of small blebs, leads to loss of negative pressure, lung collapses.

Question 25

Traumatic pneumothorax

Answer 25

Closed- can occur during invasive thoracic procedures (“drop a lung”) like CVC insertion Open pneumothorax- “sucking chest wound” (mediastinal shift) Causes? Open (flap may act as one-way valve) occurs with a penetrating wound.

Question 26

Tension pneumothorax Progressive build-up of air within the ______ and cannot escape - - - - - We want to prevent a tension pneumothorax because:

Answer 26

pleural space Increased intrathoracic pressure compression of lung on affected side mediastinum shifts to unaffected side decreased venous return  decreased cardiac output (trapped air causes pressure on the heart and lungs)

Question 27

Tension pneumo s/sx

Answer 27

Sudden pleuritic pain Air hunger, decreased pulse ox Marked tachycardia, delayed cap refill Tracheal deviation Decreased or absent breath sounds on affected side Neck vein distention Cyanosis Profuse diaphoresis

Question 28

Tension pneumo Remember tension pneumothorax is one of your “t’s “ in causes of ____ Medical emergency! Possible: Not getting blood returning to the heart…what are we gonna do

Answer 28

PEA circulatory collapse w/ hypotension and traumatic arrest

Question 29

Tension pneumo treatment

Answer 29

Act fast! Prepare patient for needle decompression followed by chest tube insertion to water seal drainage First action, second action: needle decompression (angiocath inserted to release air, everything goes back into normal place); follow with CT insertion and connect to pleurovac drainage system

Question 30

Cardiac Tamponade Causes Tx Also another one of your “t’s “ in causes of ____!

Answer 30

blunt or penetrating trauma (hemorrhage) diagnostic cardiac procedures pericardial effusions from metastasis Pericardiocentesis using echocardiography – immediate relief PEA

Question 31

Cardiac Tamponade-Beck’s Triad

Answer 31

JVD Muffled of distant heart sounds low blood pressure

Question 32

Abdominal trauma Etiology

Answer 32

1. Blunt compression & shearing injuries may not be obvious - no open wound Blunt: MVA usually; assoc with: low rib fx, femur fx, pelvic fx, thoracic injuries Abdominal trauma can cause massive life-threatening blood loss into abdominal cavity. 2. Penetrating 0pen wound

Question 33

Abdominal trauma Clinical Manifestations: MUST lift your patient’s gown to accurately assess abdomen! Assess for referred pain which may indicate : What is hematemesis/hematuria?

Answer 33

abdominal pain guarding/splinting of abdominal wall hard, distended abdomen (“Rigidity”: hard, distended, “board-like”) decreased or absent bowel sounds contusions, abrasions, or bruising over abdomen scapular pain hematemesis/hematuria signs of hypovolemic shock spleen, liver, or intraperitoneal injury. Blood/fluid irritating in the abdominal cavity and phrenic nerve involved

Question 34

Abdominal trauma Complications

Answer 34

When solid organs injured (liver, spleen) bleeding can be profuse  hypovolemic shock (requires aggressive fluid resuscitation) When hollow organs (bladder, stomach) spill into peritoneal cavity  risk for peritonitis and abdominal compartment syndrome Compartments = can put pressure on diaphragm and lungs causing respiratory compromise

Question 35

Abdominal trauma diagnostic studies

Answer 35

labs urinalysis CT diagnostic peritoneal lavage (DPT) focused assessment with sonography in trauma (FAST) on next slide Labs: T &CM, BMP, CBC, liver fx tests, UA, CT, US DPT-accurate, quick bedside assessment: checking for blood and bowel contents 10-15 min. DPT and FAST can be done at bedside

Question 36

Focused Assessment with Sonography for Trauma Bedside ultrasound - used to rapidly examine all four abdominal quadrants and the pericardium to identify the presence of ______ Used in high risk injury of mechanism Unstable and +FAST = Stable and +FAST =

Answer 36

free fluid, usually blood. goes straight to OR goes to CT for better localization of the problem

Question 37

Management of the patient with intra-abdominal injuries : Impaled objects should never be removed except by skilled provider. Pelvic binder used in suspected: Who would use an oral gastric tube instead of NGT?

Answer 37

Primary survey Document all wounds If viscera are protruding, cover with sterile, moist saline dressing Pelvic binder Hold oral fluids NG to aspirate stomach contents Tetanus and antibiotic prophylaxis Continuous monitoring and reassessment Rapid transport to surgery if indicated pelvic trauma to prevent from further injury. To help stabilize Ab for open wound or a peritonitis

Question 38

Head injury Any injury or trauma to the: ___ & ___ most common cause Factors that predict a poor outcome: Suspect cervical spine injury with: TBI more likely in males

Answer 38

scalp, skull, or brain MVA & falls Factors predicting poor outcome- abnormal neuro check, blood thinners, older age face, head, neck trauma

Question 39

Glasgow Comma Scale GCS scores on arrival to hospital strong predictor the ---- the GCS score, the less chance of survival Minor: Moderate: Severe: Comatose= Totally unresponsive=

Answer 39

lower Minor 13-15 GCS Moderate 9-12 GCS Severe 3-8 GCS comatose = 8 or less totally unresponsive = 3

Question 40

Scalp lacerations Profuse bleeding Tx:

Answer 40

staple or suture closed

Question 41

Skull fractures Can cause _______ Manifestations: Complications: Skull fx frequently occur with head trauma. Type and fx depends on: ___ fracture are assoc. with a tear in the dura, leaking of CSF. May have CSF leak-may have:

Answer 41

CSF leaks (basilar fracture) Battles sign Periorbital ecchymosis (raccoon eyes) Halo sign (csf leak) Intracranial infections, hematoma, Meningeal and brain tissue damage velocity, momentum, site of impact. Basilar May have CSF leak-may have rhinorrhea (clear fluid from nose or pt c/o of postnasal drip) or can have fluid draining from ear. rhinorrhea (clear fluid from nose or pt c/o of postnasal drip) or can have fluid draining from ear.

Question 42

Traumatic brain injury(TBI) includes:

Answer 42

Concussion Diffuse axonal injury Contusion (coup contre coup) Hematoma

Question 43

Concussion: local injury; sports-soccer, boxing, football. Repeated concussions are cumulative effect-autopsies show __________ Concussion syndrome: We do better with post concussion return to game protocol now.

Answer 43

chronic encephalopathy. irritable, difficulty concentrating, reading, math skills.

Question 44

Diffuse axonal injury DAI-poor prognosis. All over brain injury. 90 % in a ______

Answer 44

persistent vegetative state

Question 45

Contusion: minor to severe. Coup contre coup: two injuries, assoc. with closed head injury, ____ common. Increased mortality with ______.

Answer 45

seizures anticoagulant

Question 46

Epidural bleed is a medical emergency, usually ____ bleed. Classic signs: __________, brain compensates at first, but it’s s fixed structure, can only tolerate so much bleeding before they decompensate. Headache, n/v, unresponsive. Need:

Answer 46

arterial Disoriented, then have a lucid interval surgery, craniotomy to evacuate hematoma

Question 47

Subdural bleed is usually a slower bleed, ____ in nature. Acute and chronic. Difficult to distinguish from:

Answer 47

venous a mentally declining older person or someone with Alzheimer’s.

Question 48

Subdural bleed is usually a slower bleed, ____ in nature. Acute and chronic. Difficult to distinguish from:

Answer 48

venous a mentally declining older person or someone with Alzheimer’s.

Question 49

Epidural hematoma-medical emergency b/c it is arterial Either case of hematoma- requires a _____

Answer 49

craniotomy

Question 50

Nursing Management Head injury ABC: -Administer O2 via ______ -Intubate if GCS ___ -Control external bleeding w/ _____ -IV access x 2 large bore -Stabilize cervical spine Goals: Maintain cerebral oxygenation & perfusion Prevent secondary ____ CT and MRI scans Cushings triad: worsening head injury; the body’s response to increased ICP:

Answer 50

non rebreather mask <8 sterile pressure dressing cerebral ischemia cushings triad: Widening pulse pressure (Inc SBP and dec. DBP), bradycardia, irregular resp= brain herniation leading to cardiac and resp arrest.

Question 51

Musculoskeletal Trauma Complications of Crush Injuries: When a person is caught between opposing forces (for example, you’re standing behind a car that backs up on you, trapping your lower extremities)

Answer 51

Hypovolemic shock Paralysis of body part Erythema and blistering Damage to body part Renal dysfunction

Question 52

Fractures Disruption or break in continuity or structure of the bone Some are “pathologic” in nature 2 Types

Answer 52

1. Open (compound) Skin is broken and bone is exposed 2. Closed (simple) Skin has not been ruptured and bone is not exposed

Question 53

Emergency Managementof Fractures

Answer 53

Treat life threatening injuries first Ensure ABCs Control external bleeding with: --Direct pressure --Sterile pressure dressing --Elevation of extremity Check neurovascular status distal to injury --Elevate injury if possible Apply ice packs to affected area X-rays Last tetanus?

Question 54

Traction Skin Traction Short term (____) treatment Nothing ___ the skin Skeletal traction Longer periods…long term pull Pin (Steinmann pin) or wire is inserted into the bone to align and immobilize the part Traction helps prevent or reduce ____, ____, and ____, helps to ___ the fracture (restore a fx bone to its normal anatomical position).____ With skeletal traction: risk for infection at pin site(s) and pulleys must be able to move freely

Answer 54

48-72 hrs penetrates pain and muscle spasms, and immobilization reduce ORIF

Question 55

Complications of fractures

Answer 55

compartment syndrome fat embolism infection venous thromboembolism

Question 56

Complications of fractures Compartment Syndrome -2 basic causes -remember 6 P’s Treatment - - - Compartment syndrome usually involves the leg, but can occur in ___, ___, ___, & ____; Causes: If you can’t feel a pulse? Worried about _____ Tx: if it’s the cast, remove, if no improvement, may need ____, cut through fascia so we can restore circulation, otherwise will lose extremity UO: with muscle damage in crush injuries, myoglobin released can clog tubules in kidney and get ______

Answer 56

Causes: 1.) decreased compartment size (cast too soon, then edema, or drsg, burn around the leg, like a tourniquet) 2.) increased compartment contents(d/t edema, bleeding or both) remember 6 P’s: pain (disproportionate to injury to passive motion, despite pain med administration), increasing pressure in the compartment, paresthesia (numbness, tingling), pallor, paralysis, pulseless (late sign, check cap refill) or diminished pulses -emergency fasciotomy -neurovascular assessments -urine output arm, shoulder, abdomen, and buttock If you can’t feel a pulse? Worried about rhabdomyolysis fasciotomy, acute tubular necrosis (ATN)

Question 57

Complications of fx 2. Fat Embolism Syndrome Symptoms, if present, typically occur 24 to 72 hours after the trauma; Treatment Esp. with long bone fx or pelvic fx or multiple fx. Fat emboli released from the bone marrow at the fracture site into the venous system Petechial=_____ Similar to ARDS presentation

Answer 57

shortness of breath, confusion, and a transient petechial rash Treatment Reduce long bone fractures Intravascular fluid resuscitation with fluids/albumin, may require intubation coagulopathy

Question 58

Complications of fx cont. 3. Infection Open fractures-> 4. Venous Thromboembolism

Answer 58

aggressive surgical debridement + antibiotic therapy + tetanus & diphtheria prophylaxis

Question 59

Environmental Emergencies Management of the Patient With Poisoning Treatment goals: Remove or inactivate the poison before it is absorbed Provide supportive care in maintaining vital organs systems Administer specific antidotes Hasten the elimination of the poison Poison Control Center

Question 60

Poisons ABCs Monitor VS, LOC, ECG, UO Laboratory specimens Determine: Signs and symptoms of poisoning and tissue damage Health history Age and weight

Answer 60

what, when, and how much substance was ingested

Question 61

Management of the Patient with Ingested Poisons Measures to remove the toxin or decrease its absorption - - - - -

Answer 61

Use of emetics* (do not induce vomiting with corrosive agents) Gastric lavage Activated charcoal Administration of specific antagonist as early as possible (i.e what for acetaminophen OD?) Acetylcysteine (NAC) May include diuresis, dialysis

Question 62

Poisons *Emetics (induce vomiting)not used as much anymore. Gastric lavage if done within the ____; activated charcoal to help absorb poison and eliminate it from your body. Corrosive going down, just as corrosive coming up Possible psychiatric consultation if suicidal or self-harm attempt; accidental poison ingestion=>education on prevention & poison proofing instructions, esp. with children

Answer 62

first hour

Question 63

Snake Bite Treatment S/sx of envenomation: May progress without treatment Tetanus, analgesia, possible fluid or vasopressors Possible administration of antivenom (between ____) DO NOT leave patient ____

Answer 63

edema, ecchymosis, hemorrhagic bullae--necrosis, lymph node tenderness, n/v, metallic taste in mouth Lie down, remove constrictive items, clean and cover wound, immobilize the injured body part below the level of the heart; mark the area with pen to monitor progression 4-12 hrs unattended- they can deteriorate very quickly What don’t you do? Suck out venum, turnictae, ice

Question 64

Manifestations & treatment for spider bites Black Widow Bites feel like pinpricks Systemic effects within 30 min: TX: Brown Recluse Bites are painless Systemic effects; within 24 to 72 hours,: TX:

Answer 64

Black widow: abd. rigidity, N/V, HTN, tachy, paresthesia's Severe pain ice, elevation, last tetanus, analgesic, benzos, antivenom if necessary Continuous monitoring! Brown Recluse: fever, chills, N/V, malaise, joint pain, reddish to purple in color site, necrosis clean with soap and water, possible hyperbaric O2 or surgical debridement

Question 65

Tick Bites/Lyme disease Occur in grassy or wooded areas Pathogen (bacterium Borrelia burgdorferi) transmitted by tick can cause: Rocky Mountain Spotted Fever, West Nile virus, Lyme disease Steps to prevent Lyme disease: using insect repellant, remove ticks promptly, avoid tick-infested areas, check for ticks on self and pets

Question 66

Stages of Lyme disease diagnosis

Answer 66

Stage I S/Sx: flulike, bull’s-eye rash (not always) TX: antibiotics (10-21 days) Stage II S/Sx: facial nerve palsy, joint pain, memory loss, poor motor coordination, adenopathy, cardiac issues Stage III S/Sx: arthritis, neuropathy, myalgia and myocarditis Progresses to stage 2 and 3 if not treated; even with treatment, 10-20% of patients experience long-term effects (post treatment lyme disease syndrome) Eliza test Despite treatment, may progress to further stages

Question 67

If chest tube won't stay inflated:

Answer 67

VATS procedure: video-assisted thoracic surgery

Question 68

Compartments =

Answer 68

can put pressure on diaphragm and lungs causing respiratory compromise

Question 69

irritable, difficulty concentrating, reading, math skills.

Answer 69

concussion syndrome

Question 70

Disoriented, then have a lucid interval

Answer 70

Epidural bleed