Trauma

Question 1

what is the prognosis of the majority of trauma patients?

Answer 1

*Immediate Within Minutes (50%)– trauma due to widespread brain damage and/or rupture of heart or great vessels
* Within Hours (30%)– “The Golden Hour” – An injured person has about 60 minutes in which traumatic care can improve survival rate.
* Within Days (20%)– Sepsis and multi-organ failure

Question 2

when do the majority of trauma deaths occur?

Answer 2

at the scene or within 1st hr

Question 3

Levels of Trauma

Answer 3

• Level 1 – Provides total care for every aspect of injury; research leader
• Level 2 – Provides definitive care for a wide range of traumatic complexities (pts needing Cardiac Sx, hemodialysis and microvascular Sx are stabilized in level 2 and then passed to level 1)
• Level 3 – Provides initial stabilization and treatment; care of uncomplicated patients
• Level 4 – Provides initial stabilization; transfers all trauma patients for definitive care

Question 4

Parkview and Lutheran handle level ___ trauma

Answer 4

2

Question 5

Should primary and secondary surverys be conducted before or after the pt reaches the hospital?

Answer 5

After they get IN the hospital

Question 6

What is the Primary Survey?

Answer 6

ABCDE
Airway
Breathing
Circulation
Disability
Exposure/Environment

2 goals: Identify life threatening injury quickly, provide stabilization when identified.

Question 7

ABCDE

Airway

Answer 7

talking = patent airway
Unconscious -> Intubation (GCS<8)
Conscious + CANT talk -> check airway (FB rmvl, suction, identify frx)
Assess face/neck injuries
C-spine collar immobilization

Swelling (hematoma/edema) -> compress airway.
Bleeding, nasopharygngeal blood -> aspiration
Crepitus = direct laryngeal or tracheal injury
Burns -> airway edema
Inhalation injury -> hypoxia

Question 8

youre thinking about intubating but arent sure, wdyd?

Answer 8

INTUBATE

Question 9

ABCDE

are airway or chest/pulm (breathing) traumatic injuries MC?

Answer 9

Chest/pulm (breathing) injuries are more common

Question 10

ABCDE

Breathing

Answer 10

1. listen to breath sounds
2. assess resp effort (rate, muscle use)
3. assess O2 Sat
4. r/o tension pneumo, flail chest, open pneumotheroax, hemothorax
5. give O2 (SpO2 >95%)
6. Stabile -> CXR

Question 11

ABCDE - Breathing

Indications for Mechanical Ventilation
RR >___ or <____
O2 <____% despite supp O2

Answer 11

• Respiratory Rate >35 or <6
• Oxygen desaturation to <90% despite supplemental O2
• Cardiopulmonary arrest

Question 12

Why can’t you give Succhinycholine to a pt who has crush injuries and burns?

Answer 12

Natural Hyperkalemia after trauma + Succhinycholine induced Hyperkalemia = cardiac arrest

Question 13

How to do rapid sequence intubation (RSI)

Answer 13

Induction agent (eg. Ketamine or Etomidate) followed by a paralytic agent (eg. Rocuronium or Succinylcholine).
OOA: 1 min

Question 14

What is this? Trmnt?
tracheal deviation, uneven chest, absent breath sounds, hemodynamic compromise.

Answer 14

Tension Pneumothorax
Immediately perform needle decompression in 2nd intercostal space along midclavicular line. Followed by tube thoracostomy

Question 15

Trmnt for flail chest

Answer 15

Often associated with underlying pulmonary contusion.
Trmnt: supportive +/- mechanical ventilation

Question 16

Trmnt for open pneumo due to stab wound

Answer 16

Rapid equilibration of atmospheric and intrathoracic pressure
for impaired oxygenation and ventilation

Question 17

Trmnt for hemothorax

Answer 17

LARGE tube thoracostomy and replacement of blood products

Question 18

you start to do a needle decompression and blood is coming out. wdyd?

Answer 18

get a large tube
the blood will clot in the small needle diameter

Question 19

ABCDE

Circulation

Answer 19

1. asses color, mental state, cap refill
2. feel peripheral pulses and check vitals on monitor
3. r/o MC places to bleed out -> hemorrhagic shock (chest, abd, retroperitoneum, hip, femur, cranium (small kids)
4. r/o obstructive shock (cardiac tamponade, tension pneumo)
5. direct pressure on external bleeds
6. IV access (2 large bore peripheral IVs 18g or larger, Intraosseous line, or central line)
7. Start with isotonic crystalloid (consider blood transfusion)
8. emergent trmnt based on underlying injury

Peripheral pulses SBP
Carotid >60 mmHg
Femoral >70 mmHg
Radial >80 mmHg
Dorsalis pedis >90 mmHg

Question 20

ABCDE

Circulation FAST Exam
(Which regions do you US to check for ascites?)

Answer 20

• RUQ (Morrison’s pouch) - in b/w liver & kidney
• Subxiphoid
• LUQ
• Suprapubic (pouch of Douglas) - below the bladder

Question 21

ABCDE

Disability

Answer 21

1. Assess Level of consciousness using AVPU (alert, voic, pain, unresponsive), or Glasgow Coma Scale (GCS)
2. Pupillary Fn
3. Four extremity Movement (brain/spinal cord injury)
4. External signs of head/neck trauma
5. If patient is in any way altered -> check blood glucose (Pts with medical illness can have trauma precipitated by the medical problem)
6. Assess for life threatening neurological injury

Penetrating cranial injury
Intracranial hemorrhage (Subdural hematoma, epidural hematoma, traumatic sub-arachnoid hemorrhage, intraparenchymal hemorrhage, or intraventricular bleed)
Diffuse axonal injury
High spinal cord injury

Question 22

Glasgow Coma Scale (GCS)

Answer 22

“4 eyes”
“Jackson 5”
“V6 motor”

Scoring
3 = unresponsive (Dead)
8 = Intubate
15 = Gucci (fully responding)

Question 23

If GCS is <_____ = INTUBATE

Answer 23

8

Question 24

Order a STAT ____ for a low GCS score

Answer 24

Cranial image

doesnt say which study specifically

Question 25

# ABCDE - Disability How to r/o a cervical spine injury

Answer 25

Question 26

# ABCDE Environment/Exposure

Answer 26

* Remove clothing/covering. * Look at the patient’s skin * Avoid ***hypothermia*** (use a warm trauma bay, warm with fluids or blankets, transfuse blood if needed) * Perform a complete head to toe exam (esp axilla, back, back of head, neck) * Cover them up again

Question 27

Primary Survery Points

Answer 27

* Do the Primary survey first * Do it the same way every time * Identify specific life threatening issues and treat simultaneously * Know the differential diagnoses of the ABCDEs * Following the survey, know if you need to transfer * If something changes during exam, return to A, and redo the survey

Question 28

Special Population Considerations: Children Pregnancy Elderly

Answer 28

* **Children**: Different anatomic variables. They will have more anterior airways. They may not have as many fractured bones given flexible nature. * **Pregnancy**: Higher circulating volumes, gravid uterus * **Eldery**: **comorbidities**, may be on blood thinners, have less physiologic reserve.

Question 29

Secondary Survery

Answer 29

**Does not begin until primary survey is finished** **_Use AMPLEM history_** * Allergies * Medication * Past surgical/medical history * Medication * Last meal * Events * Mechanism (blunt, penetrating, burn/inhalation)

Question 30

Secondary Survery Look for what on PE?

Answer 30

Spine (check cervical, thoracic, lumbar spine for **deformities, step-offs, areas of tenderness)** Head and scalp (depressed skull fractures) Maxillofacial C-spine/neck Chest Abdomen **(Bruising/distension, penetration)** Perineum/genitalia Extremities Neurologic ## Footnote Flank discoloration = grey turners (think retroperitoneal bleed)

Question 31

This flank discoloration found during Secondary Survery is a concern for _____

Answer 31

Flank discoloration = grey turners (think retroperitoneal bleed)

Question 32

Following Survey ## Footnote following is a verb in this "PA is to follow or FU"

Answer 32

* **Consider Pan-Scan (CT it ALL -> Head, C-spine, Chest, Abd/Pelvis)** * Obtain specific imaging (spine, extremity) * Stabilize and transfer to definitive care center if needed * Trauma patients must be evaluated continuously * Patients should improve as they go * Sudden decompensation -> go back to A again and do primary survey all over again (double it and give it to the next person) * **Tertiary** survey refers to rounding on the patient