``` Blood loss: up to 750ml, up to 15% Pulse rate: 30ml/hr Cognition: slightly anxious Fluid replacement: crystalloid ```

Trauma Flashcards by Jaclyn Goble

Triage: mechanism of injury that makes something a “major trauma”

Falls >20 ft (adult)
Falls 2x height of child
High risk auto: intrusion, ejection, death of occupant, vehicle data high risk
Auto-bike: thrown, run-over, >20mph
Motorcycle: >20mph

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Triage: clinical info that makes something a “major trauma”

Penetration injury to head/neck/torso/proximal extremities
≥2 long bone fx
Amputations, crushed, mangled extremity
Burns + multi-trauma
Paralysis
GSC ≤13
SBP <90
RR <10 or >29 or vent support needed

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What is the 1st, 2nd, and 3rd peak in the trimodal death distribution?

1st: immediate
2nd: minutes - hours
3rd: days - weeks

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What are the causes of death in the 1st peak of the trimodal death distribution?

High C spine
Brain injury
Great vessel injury

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How do we treat pt. the 1st peak of the trimodal death distribution?

Prevention!

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What are the causes of death in the 2nd peak of the trimodal death distribution?

Intracranial injury
Pelvic fx
Abd & lung injuries

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How do we treat pt. the 2nd peak of the trimodal death distribution?

Good pre-hospital and ATLS care

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What are the causes of death in the 3rd peak of the trimodal death distribution?

Sepsis

- MSOF

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How do we treat pt. the 3rd peak of the trimodal death distribution?

Good ATLS & inpt. care

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Injuries are the #__ reason for death in persons <45 and #__ leading cause of death overall

1; #3

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Injuries: ___ are minor, ___ are moderate

1/2; 1/3

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Trauma related mortality is __%

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What 3 types of injuries have the highest case fatality rate?

Suffocation
Drowning/submersion
Firearms

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3 leading causes of trauma injury

Falls (esp children <7, elderly >75)
MVC (esp adolescents, young adults)
Firearm (12-22yo)

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Most likely cause of shock in trauma pt.

Hemorrhage

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Class I hemorrhage:

Blood loss: up to 750ml, up to 15%
Pulse rate: <100
BP: normal 
PP: normal or increased
RR: 14-20 
UO: >30ml/hr
Cognition: slightly anxious
Fluid replacement: crystalloid

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Class II hemorrhage:

Blood loss: 750-1000ml, 15-30%
Pulse rate: >100
BP: normal 
PP: decreased
RR: 20-30
UO: 20-30ml/hr
Cognition: mildly anxious
Fluid replacement: crystalloid

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Class III hemorrhage:

Blood loss: 1500-2000ml, 30-40%
Pulse rate: >120
BP: decreased
PP: decreased
RR: 30-40
UO: 5-15
Cognition: anxious, confused
Fluid replacement: crystalloid + blood

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Class IV hemorrhage:

Blood loss: >2000ml, >40%
Pulse rate: >140
BP: decreased
PP: decreased
RR: >35
UO: negligible
Cognition: confused, lethargic 
Fluid replacement: crystalloid + blood

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Hemorrhage general trends as it increases in severity (Class I-IV)

Blood loss (ml, %): ↑
Pulse rate:↑
BP: ↓
PP: ↓
RR: ↑
UO: ↓
Cognition: anxious → confused → lethargic 
Fluid replacement: add blood to crystalloid in class III

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Mechanism of injury: frontal impact of MVC

Suspected injury pattern:

Cervical spine fx
Anterior flail chest
Myocardial contusion
PTX
Traumatic aortic disruption
Lacerated spleen/liver
Posterior fx or dislocation of hip or knee

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Mechanism of injury: side impact

Suspected injury pattern:

Contralateral neck sprain
Cervical spine fx
Lateral flail chest
PTX
Traumatic aortic disruption
Diaphragmatic rupture
Fx spleen/liver/kidney
Pelvis fx

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Mechanism of injury: rear impact

Suspected injury pattern:

Cervical spine injury

- Soft tissue neck injury

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Mechanism of injury: ejection

Suspected injury pattern:

Greater risk for all injury mechanisms

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Mechanism of injury: MVC vs. pedestrian | Suspected injury pattern:

- Head injury - Traumatic aortic disruption - Abd visceral injuries - Fractured LE/pelvis

Who gets a C collar?

EVERYONE in major trauma

__% of unconscious trauma pt. have a serious C-spine injury

10%

What fraction of spine injuries are cervical?

2/3

What cervical vertebrae are most commonly affected?

C2, C5

Presumptive evidence for an unstable c-spine fx

Para or quadriplegia

#1 reason for fetal demise

Maternal shock/death

CV changes during pregnancy that conceal shock

1. CO increases 2. Plasma volume increases 3. Blood loss directs blood away from uterus

Fetus is most vulnerable to radiation in what trimester

1st

When to admit a pregnant pt. after trauma

- Bleeding - Cramping - Amniotic fluid leak - Hypovolemia - Fetal distress concerns

If a fetuses EGA is _____, the mothers is referred to OB care after initial trauma eval (major trauma has been ruled out)

>20 wks

If a fetuses EGA is _____, the mothers remains in the ED for monitoring (major trauma has been ruled out)

<20 wks

In what ways do pediatric airways differ from adult airways?

- Large tongue - Glottis more anterior & superior - Occiput is large, slight flexion is supine (place rolled towel/pad under neck or shoulders to achieve extension)

M/C cause of death in children

MVC

M/C pediatric injury

Falls

If children do not respond to a 40cc/kg fluid bolus, what should they be given

10cc/kg bolus of PRBC's

Children are more susceptible to what two "environmental" conditions

Hypotheramia, hypoglycemia

Factors that make pt. difficult to intubate

- Obesity - Short neck - Large incisors, tongue - Narrow mouth - Limited neck mobility

Mallampati Class I (what's visible)

Soft palate, uvula, fauces, tonsilar pillars

Mallampati Class II (what's visible)

Soft palate, uvula, fauces

Mallampati Class III (what's visible)

Soft palate, base of uvula | *considered difficult to intubate

Mallampati Class IV (what's visible)

Hard palate only | *considered difficult to intubate

Indications for RSI

- GCS <9 w/ gag reflex - Facial trauma - Head injury, stroke - Burn pt. w/ airway involvement - Resp exhaustions (asthma, CHF, COPD w/ hypoxia, & failure of non-invasive support) - Overdose w/ AMS - COVID-19

7 P's of RSI

1. Preparation 2. Pre-oxygen w/ 100% O2 for 4-5min 3. Pre-medicate (etomidate or midazolam) 4. Paralytic (succinylcholine or rocuronium) 5. Pass tube 6. Proof of placement (listen, CXR, EtCO2) 7. Post intubation care (secure tube, ventilate)

Highest risk age for both TBI and SC injury

15-24yo

ETOH present in ~__% of TBI

50%

Primary brain injury vs. secondary brain injury

``` 1 = direct insult 2 = cellular damage following 1 ```

What is cerebral autoregulation?

Allows for constant cerebral blood flow across a range of arterial pressure (as long as BBB is maintained)

How does an increase in PCO2 (d/t apnea, respiratory depression following TBI) affect...... - CBF - ICP - CPP

- CBF ↑ - ICP ↑ (also ↑ d/t edema, expanding mass) - CPP ↓

What is the Monroe-Kelli Doctrine

= Total volume of the brain parenchyma, cerebrospinal fluid, and blood remains constant - Least compressible is brain - CSF first to decrease (& venous flow) - Blood may decrease, but maintains adequate perfusion d/t autoregulation * herniation begins after you can't let off anymore CSF or venous blood

How does increased ICP affect BP and HR? What is this phenomena called?

↑ BP, ↓ HR | = Cushing's reflex

How to reduce ICP?

Raise HOB, IV mannitol

Causes of TBI

- Concussion (mTBI) - Epidural, subdural, intra-cranial, SAH hemorrhage - Cerebral contusion - Diffuse axonal injury - Penetrating cranial injury - Skull fx

Adult head CT indications

Head trauma +....... - GCS <15 after 2 hours - GCS<13 - ***Skull fx*** - ***Age >65*** - LOC >5 or anterograde amnesia - Dangerous mech - Recurrent vomiting - ***Alcohol intox*** - Pt. on ***anticoags/antiplts***

Epidural hematoma (mech, presentation, dx, tx)

Mech: direct blow to temporal region Presentation: LOC, return to consciousness, then AMS (lucid interval), dilated + fixed ipsilateral pupil (uncal herniation) Dx: lenticular lesion on CT Tx: emergent craniotomy & clot evac

Subdural hematoma (mech, presentation, dx, tx)

Mech: falls, acceleration, deceleration Presentation: focal deficits, depressed MS Dx: cresent shaped lesion on CT Tx: emergent craniotomy & clot evac if decompensation

Which has poorer prognosis: epidural or subdural?

Subdural

Decorticate positioning represents ________ lesion and pt. demonstrates ______ of the UE

Hemispheric lesion; flexion

Decerebrate positioning represensts ________ lesion and pt. demonstrates ______ of the UE

Brainstem lesion; extension

If a neck injury violates the platysma muscle, what is the next step in mgmt

Consult surgery

Neck injury - zone I

Extends from manubrium of the sternum to the bottom of the cricoid

Neck injury - zone II

Extends from bottom of cricoid through the body of the mandible

Neck injury - zone III

Above the body of the mandible

Management of zone I, III injuries

Testing to r/o injury (CT, angio, esophageal studies)

Management of zone II injuries

Surgical exploration, routine or selective testing

What functions do you lose with..... Central cord lesion Anterior cord lesion Brown Sequard

Central: motor (UE >) Anterior: paralysis, pain & temp Brown Sequard: ipsilateral motor, contralateral pain & temp.

SC injuries above what cervical vertebrae require mechanical ventilation and why?

C4 | Phrenic n. (supplies diaphragm) is innervated by C3-5

Indication for operative thoracotomy w/ a hemothorax

- Initial tube drainage >20 cc/kg or 1500 cc - Continued bleeding > 7 cc/kg/hr for 3-4 hr - Persistent hypotension despite resuscitation - Lack of lung re-expansion

M/C potentially lethal chest injury

Pulmonary contusion

#1 and #2 solid organ injury

``` #1 spleen #2 liver ```

Indications for immediate laparotomy w/ blunt abd trauma

- Hypotensive pt. w/ peritoneal signs - (+) FAST US w/ hypotension - Free air (abd or retroperitoneum)

GSW most often injure

Large & small bowel

Stab wounds most often injure

Liver & small bowel

Indications for immediate laparotomy w/ penetrating abd trauma

- Hemodynamic instability - Any GSW - Peritoneal signs - Evisceration - Signs of fascial penetration (do NOT prob wound)

Mechanism of most GU trauma

Blunt

Indication for CT in penetrating renal trauma

Any hematuria

Indication for CT in blunt renal trauma

- Frank ecchymosis - Gross hematuria - BP <90 - Known abd injury

Indications for surgery/embolization in renal trauma

- Expanding/pulsatile/non-contained hematoma | - Renal avulsion

Tx of renal injury w/ contusion & micro hematuria

D/C, UA in 1 wk

Tx of renal injury w/ gross hematuria or high grade

Admit for ob

M/C GU injury in kids

Renal contusion

When do we use CT in kids w/ GU injury

>50 RBC/HPF

What type of bladder injury is M/C and how is it managed?

Extraperitoneal - place foley

What is the most important part of your exam with penetrating extremity trauma

Assessing arterial injury

"Hard signs" of penetrating extremity trauma

- Absent/diminished pulses - Obvious arterial injury - Expanding hematoma - Bruit/thrill - Distal ischemia

Trauma Flashcards

(89 cards)