Trauma, Emergencies, Disasters Flashcards

Question

Emergency Severity Index Scale Level 4

Answer 1

Non-urgent Patient requires one resource. - Labs - EKG, X-ray, CT Scan, US, IV Fluids - IV, IM, or Nebulized Medications - Specialty Consultation - Simple Procedure (=1) - Complex Procedure (=2) Stable Vital Signs Example: Healthy patient with a sore throat and fever, simple lacerations, simple fractures/sprains

Answer 2

Non-urgent Patient requires no resources. Example: Healthy patient with poison ivy rash, medication refills, wound checks

Answer 3

- Example: UAB, Huntsville Hospital, USA Health, Children’s of Alabama - Provides comprehensive trauma care. - Serves as a regional resource center to provide leadership in education, outreach and systems planning. - Admits at least 1200 trauma patients annually - Attending surgeon with 24-hour in-house availability who can respond within 15 minutes - Conducts trauma research

Answer 4

- Example: Baptist South, Southeast Health, Piedmont Midtown - Provides comprehensive trauma care as a supplement to a Level I center. - Attending surgeon with 24-hour in-house availability.

Answer 5

Example: East Alabama, DCH, Flowers Hospital - Provides immediate emergency care and stabilization of a patient before transfer to a higher level of care. - Attending surgeon with a maximum response time of 30 minutes. - Serves a community that does not have immediate access to a Level I or II center

Answer 6

Example: Wellstar West Georgia - Provides advanced trauma life support before transfer to a higher-level trauma center. - Has primary goal of resuscitation/ stabilization of the patient and arrangement of immediate transfer to a higher level of care

Answer 7

Involves interventions to prevent the event. - Driving safety classes, speed limits, campaigns against drunk driving, fall prevention intervention, drug awareness programs

Answer 8

Strategies to minimize the impact of the traumatic event. - Seat belt use, helmets, anti-bullying hotlines

Answer 9

Interventions to maximize patient outcomes after a traumatic event. - Emergency response systems, medical care, rehabilitation

Answer 10

Most common mechanism of injury - MVCs, assaults with blunt objects, falls, sport-related injuries, pedestrian injuries Injury may be caused by several energy forces. - MVC injury often results from acceleration-deceleration forces. Severity of injury depends on the duration of the energy exposure, the body organ involved, and the underlying structures. - Heart, spleen, and liver are less resilient because of their high-density tissue and decreased ability to release energy without resultant tissue damage.

Answer 11

Results from impalement of the body by foreign objects More easily diagnosed and treated than blunt injuries because of the obvious signs. Damage caused by penetrating mechanisms depends on several variables. - Point of impact - Velocity and speed of impact - Proximity

Answer 12

A combination of blunt and penetrating trauma Blast Injury Classification - Primary: Direct blast effects – direct tissue damage from the high pressure of the blast. - Secondary: Debris and projectiles propelled by explosion – tissue damage caused by objects impaling the body. - Tertiary: Individual thrown by the blast wind – tissue damage results from blunt trauma. - Quaternary: injuries occur as a result of chemical, thermal and biological exposure – tissue damage from burns, inhalation, etc.

Answer 13

Complete Blood Count (CBC) - H/H for bleeding Complete Metabolic Panel (CMP) - Electrolytes - LFTs for liver injury - BUN for CT/contrast PT/PTT/INR - Coagulation Arterial blood Gas (ABG) - Respiratory status Serum Lactate - If elevated, there is a perfusion issue Urinalysis - Blood - Drugs Toxicology and Ethanol Level - Alcohol levels Type and Screen/Cross - Screen: blood type - Cross: preparing blood for pt Creatinine Kinase (CK) - Looks at muscle and tissue breakdown - Elevated CK = rhabdomyolysis Pregnancy Troponin

Answer 14

Chest - Confirm support device placement - Identify immediate life-threatening injuries Pelvis - Quick diagnosis of severe fractures which may be a cause of hemorrhage Extremities with suspected injury - Identify fractures and/or foreign bodies in extremities with suspected injury

Answer 15

Head and/or Face - Evaluate for skull and facial fractures. - Evaluate for swelling and bleeding in the brain. Spine - Evaluate for fractures and alignment Abdomen/Pelvis - High reliability in identifying solid-organ injuries and pelvic fractures. - Reveals free air in the abdomen (indicates injury to hollow organ). - Shows free fluid (a sign that can identify the extent of organ injury) - Shows extravasation of contrast (indicative of vascular injury)

Answer 16

* Focused Assessment with Sonography for Trauma Rapid study (bedside ultrasound) for identifying intraperitoneal fluid. - A negative FAST does not rule out injury and warrants a follow-up CT scan. - Serial FAST exams can identify increasing abdominal fluid collections from hemorrhage. - Positive FAST exams in hemodynamically unstable patients indicate the need for emergent operative management.

Answer 17

EKG - Evaluate for dysrhythmias and signs of cardiac injury. Diagnostic Peritoneal Lavage - An invasive emergency procedure used to detect hemoperitoneum and help determine the need for laparotomy following abdominal trauma. - A catheter is inserted into the peritoneal cavity, followed by aspiration of intraperitoneal contents. If gross blood is not noted, warmed isotonic crystalloids are instilled, then drained for evaluation. Angiography and Embolization - Provided by interventional radiologists who deploy a catheter to identify the site of active bleeding of vessels. - Embolization places micro-coils, absorbable gelatin, or small occlusion balloons in the vessel to stop hemorrhage.

Answer 18

- Within the cranial vault, a pressure wave is generated at the point of impact (coup injury). - As the pressure wave travels across the cranial contents, injury may occur on the opposite side of the impact (contrecoup injury) - Injury may occur without a direct blow to the head

Answer 19

- Usually caused by blunt trauma - Capillaries within the brain tissue are damaged, resulting in hemorrhage, infarction, necrosis, and edema. - Maximum effects of contusion and edema formation usually peak at 18-36 hours after injury.

Answer 20

Hematomas occurring deep within the brain tissue. May create a mass effect, increased ICP, and result in neurologic deterioration.

Answer 21

- A collection of blood that forms between the dura mater and the skull - Frequently associated with fractures of the temporal or parietal bone that lacerate the middle meningeal artery. - Often require immediate surgical intervention. - “Classic Presentation”: transient LOC followed by a lucid period, then rapid deterioration in neurologic status.

Answer 22

A collection of blood that forms immediately beneath the dura mater Usually caused by tearing of the bridging veins and associated direct injury to the underlying brain tissue.

Answer 23

Shifting of brain tissue with displacement into another compartment as a result of bleeding or edema Shift compresses, tears, or shears the vasculature, decreasing perfusion.

Answer 24

- Also called a mild traumatic brain injury (mTBI) - Caused by blunt injury. - Change in neuro status for a very brief period with/without TBI symptoms that last for several hours or days. - Most concussion have NO findings on CT**

Answer 25

Linear Skull Fracture - A non-displaced fracture that goes through the entire thickness of the skull Depressed Skull Fracture - Pieces of fractured bone extend below the surface of the skull and may cause dura mater laceration and brain tissue injury. Basilar Skull Fracture - Fracture of any of the five bones in the base of the skull Symptoms of a Basilar Skull Fracture - Periorbital ecchymosis (racoon eyes) - Mastoid ecchymosis (Battle sign) - Bleeding behind the tympanic membrane (hemotympanum) - CSF in rhinorrhea or otorrhea

Answer 26

- Le Fort I: transverse maxillary bone fracture that occurs above the level of the teeth and results in separation of the teeth from the maxilla. - Le Fort II: pyramidal maxillary bone fracture involving the mid-face area. - Le Fort III: fracture causing complete craniofacial separation involving the maxilla, zygoma, orbits and bones of the cranial base. **Nothing up the nose**

Answer 27

- Usually, the result of a direct blow. - Complication: entrapment of the inferior rectus or inferior oblique muscle - Ensure that the patient has extraocular eye movement! - Don’t let patient blow their nose!

Answer 28

Cause - Backward thrust of the head beyond the anatomic capacity of the cervical vertebral column Effect - Damage to anterior ligaments ranging from stretching to ligament tears. - Bony dislocations Example - Rear-end MVC resulting in whiplash

Answer 29

Cause - Forceful forward flexion of the cervical spine with the head striking an immovable object Effect - Wedge fracture - Facet dislocations - Subluxation - Teardrop, odontoid, or transverse process fractures Example - Head-on MVC with head striking the windshield

Answer 30

Cause - A combination of forceful forward flexion with lateral displacement of the spine Effect - Rupture of the posterior ligament and/or anterior fracture - Dislocation of the vertebral body Example - MVC to front or rear lateral area of the vehicle, resulting in conversion of forward motion to a spinning type motion

Answer 31

Cause - Direct force transmitted along the length of the vertebral column Effect - Burst and laminar fractures - Secondary edema of the spinal cord, resulting in neurologic deficits Example - Diver striking the head on the bottom of the pool or landing on the feet after a long fall

Answer 32

- Force of the traumatic event bruises the heart muscle and can compromise heart functioning, causing dysrhythmias. - Patients who sustain blunt trauma to the anterior chest wall should have an EKG and cardiac enzymes (troponin) evaluated**

Answer 33

A life-threatening condition caused by rapid accumulation of fluid (usually blood) in the pericardial sac. May be caused by blunt or penetrating trauma to the chest. Classic Sign: Beck’s Triad** - Hypotension - Muffled or distant heart sounds - Elevated venous pressure (distended neck veins, JVD) Treatment: Pericardiocentesis

Answer 34

- Occurs when air escapes from the injured lung into the pleural space, altering the negative intra-pleural pressure and resulting in a partial or complete collapse of the lung. - Signs: Respiratory distress, tachypnea, tachycardia, diminished or absent breath sounds on affected side, chest pain - Treatment: Supplemental oxygen and chest tube placement

Answer 35

- Associated with penetrating trauma that allows air to pass in and out of the pleural space. - May progress to a tension pneumothorax if not treated appropriately. - Signs: symptoms of pneumothorax, subcutaneous emphysema, “sucking” chest wound - Treatment: nonporous dressing taped on three sides - Definitive repair: chest tube placement and wound closure

Answer 36

- Rapidly fatal emergency that occurs when an injury to the chest allows air to enter the pleural cavity without a route for escape. - Causes compression of the heart and great vessels - Signs: severe respiratory distress, absence of breath sounds on the affected side, hypotension, distended neck veins and tracheal deviation away from the side of injury - Treatment: IMMEDIATE Needle Decompression followed by chest tube placement - Needle Decompression: A large-bore (14-16 gauge) needle is inserted into the second intercostal space in the midclavicular line of the affected side** - A rush of air and improvement in patient’s condition should be immediately noted.

Answer 37

- A collection of blood in the pleural space from injury to the lung, costal blood vessels, great vessels, or other structures - Signs: anxiety, dyspnea, chest pain, signs of shock, decreased breath sounds on affected side - Treatment: chest tube placement

Answer 38

- Develops when capillary blood leaks into the lung parenchyma, resulting in inflammation and edema. - Commonly seen with other thoracic injuries. - Signs: worsening dyspnea, ineffective cough, hypoxia, chest wall abrasions and chest pain. - Treatment: supplemental oxygen and possibly mechanical ventilation; cautious fluid administration; pain relief to optimize lung expansion and prevent complications

Answer 39

- Most common injury associated with chest trauma. - May lead to significant respiratory dysfunction and may indicate serious injury to organs and structures below the rib cage. - Management depends on the number of ribs fractured, the degree of underlying injury, and the age of the patient. - Pain Management - Education on coughing and deep breathing exercises

Answer 40

- Fractures of 3 or more adjacent ribs in 2 or more places, creating a free-floating segment of the rib cage - Results in paradoxical chest movement (chest contracts inward with inhalation and outward with exhalation) - Impairs the ability of the body to generate effective changes in intrathoracic pressure for ventilation. - Usually requires endotracheal intubation and mechanical ventilation.

Answer 41

- Liver is the organ most commonly injured as a result of trauma. - Should be suspected when right rib fractures are present. - Injury severity is defined by a grading system with a grade I considered minor and grade VI as most severe. - Signs: RUQ tenderness or guarding, ecchymosis of the RUQ, Cullen’s sign, elevated LFTs without history of liver disease - Treatment: May be managed expectantly or operatively, depending on extent of injury and hemodynamic status.

Answer 42

- Highly vascular organ with minimal elasticity and flexibility that can lacerate under sudden abdominal pressure. - Injury occurs in patients who have trauma to the left side of the body. - Signs: abdominal distention asymmetry, or rigidity; abrasions, wounds in the LUQ; left shoulder pain when lying flat, ecchymosis of the left flank - Treatment: Goal is nonoperative management to preserve the immunologic function of the spleen - Non-operative management: admission; serial abdominal exams, serial Hcg/Hct monitoring, serial FAST exams - Non-Op: Recommended in patients who are hemodynamically stable, less than 55 years of age, and have absent peritoneal signs. - Operative management likely for the following patients: *Age greater than 55 *Hemodynamic instability *Massive transfusion requirements *Presence of other intra-abdominal injuries requiring laparotomy *Severe TBI limiting ability to perform serial exams. - **These patients will have permanent immunologic impairment and are at risk for infection in the first 2 years post-surgery** - Meningococcal, pneumococcal, and influenza vaccines are given within 14 days.

Answer 43

Common with pelvic fractures Signs: blood at the urethral meatus, inability to urinate, suprapubic hematoma, abdominal distension, hematuria, pelvic instability **DO NOT INSERT A FOLEY CATHETER!**

Answer 44

- May cause hemorrhage from lacerated veins, arteries, or the fractures themselves - Blood loss could be massive! - Signs: palpable motion and pain on palpation of the pelvis; hypovolemic shock; shortening or rotation of the leg - May be managed expectantly or operatively - Initial Treatment: Pelvic Binder Placement

Answer 45

*Fracture: disruption in the continuity of a bone - Open: skin is open at the fracture site - Closed: skin at fracture site is intact *Dislocation: ends of two or more bones that make up a joint are forced from their normal position *Amputation: Removal of all or part of a limb *Sprain: stretch or tear to a ligament *Strain: stretch or tear to a tendon or muscle *Subluxation: Partial dislocation of two or more bones that make up a joint *Contusion: area of broken capillaries or venules beneath the skin with extravasation of blood *Avulsion: tissue is torn away or separated *Crush: tissue is compressed between two hard surfaces and damaged *Mangled: injury to three or more systems in a limb (soft tissue, bone, nerve, vascular)

Answer 46

Fractures - Immobilization with a splint or application of traction - If fracture is open, antibiotics (Cefazolin, Ancef) should be administered within 1 hour** Amputations - Elevate the extremity and apply direct pressure over the artery above the bleeding site. - Apply a tourniquet if needed. Soft Tissue Injuries - Wounds cleansed and debrided as indicated. - Antibiotics as directed. - Tetanus toxoid administration

Answer 47

- Occurs when the tissue pressure within a fascia-enclosed muscle compartment experiences increased pressure. - Pressure may be from internal sources (edema, hemorrhage) or external (splints, immobilizers, dressings) - Muscle necrosis can occur within 4-6 hours. - 6 Ps (pain, pressure, pallor, pulses, paresthesia, and paralysis) guide the assessment. - Pain that is disproportionate to the injury and does not respond to opioids is a hallmark sign. Treatment - Elevate affected extremity and remove splint if present. - Surgical fasciotomy

Answer 48

- Characterized by muscle damage and cellular destruction that results in release of myoglobin, which compromises renal blood flow. - Causes: crush injuries, compartment syndrome, burns electrical burns - Myoglobinuria (causes urine to be a dark tea color) is a marker of rhabdomyolysis. - Treatment: aggressive fluid resuscitation to flush the myoglobin from the renal tubules.

Answer 49

May occur as a result of cellular damage. Peaks within the first 12 hours.

Answer 50

Risk depends on the severity of the injury, the type of injury, presence of shock, recent surgeries, vascular injury and immobility. Prevention of VTE is essential!

Answer 51

Potential complication that accompanies traumatic injury to the long bones and pelvis - Long bone injury may release fat globules into torn vessels and the systemic circulation, allowing them to act as emboli. Signs of Fat Embolism Syndrome - Low-grade fever followed by new-onset tachycardia, dyspnea, increased respiratory rate, hypoxemia, sudden thrombocytopenia, and a petechial rash. Prevention is the best treatment! - Early stabilization of extremity fractures Treatment - Supportive care to preserve pulmonary function and maintain cardiovascular stability.

Answer 52

Completed as the patient is brought into the room. - Allows for rapid determination of the patient’s overall stability and identification of any uncontrolled external hemorrhage. - Uncontrolled hemorrhage is the major cause of preventable death after injury. - If uncontrolled hemorrhage is noted during the across-the-room observation, priorities may be re-ordered to ABC.**

Answer 53

May be accomplished using two techniques. - Manual Stabilization: two hands holding the patient’s head and neck in alignment. - Spinal Motion Restriction: A correctly sized, semi-rigid cervical collar securely fastened.

Answer 54

Helps to evaluate patient’s ability to protect their own airway. AVPU Pneumonic** A – Alert V – Responds to Verbal Stimuli P – Responds to Pain U – Unresponsive

Answer 55

If not previously intubated: - Ask the patient to open their mouth. - If unable, perform a jaw-thrust maneuver. - Inspect for the following: *Tongue obstructing the airway *Loose or missing teeth *Foreign objects *Blood, vomitus, or secretions *Edema *Burns or evidence of inhalation injury - Auscultate for the following: *Adventitious airways sounds such as snoring, gurgling, or stridor which may indicate obstructions - Palpate for the following: *Possible occlusive maxillofacial bony deformity *Subcutaneous emphysema If the patient has a definitive airway (is intubated), confirm proper placement: - CO2 Detector (after 5-6 breaths) - Observe for adequate rise and fall of the chest - Auscultate for bilateral breath sounds and absence of gurgling over the epigastrium.

Answer 56

If the airway is patent, efforts are aimed at supporting and maintaining the airway. If airway is not patient: - Suction the airway. -Suction blood, vomitus, or other secretions - Remove foreign body if present. - If suctioning does not relieve the obstruction, insert an airway adjunct. *Nasopharyngeal Airway (NPA) - Can be used in conscious or unconscious patients. - Do not use in patients with evidence of mid-face fractures!** *Oropharyngeal Airway (OPA) - Can only be used in patients without a gag reflex

Answer 57

- Apnea - GCS score of 8 or less - Severe maxillofacial fractures - Evidence of inhalation injury - Laryngeal or tracheal injury or neck hematoma - High risk of aspiration - Compromised or ineffective ventilation - Anticipated deterioration of neurologic status

Answer 58

Inspect for the following: - Spontaneous breathing - Symmetrical rise and fall of the chest, respiratory depth, pattern, and rate. - Contusions, abrasions, or deformities that may indicate underlying injury. - Open pneumothorax - JVD and trachea position - Signs of inhalation injury Auscultate for the following: - Presence, quality, and equality of breath sounds Palpate for the following: - Injury to the bony structures - Subcutaneous emphysema - Soft tissue injury

Answer 59

If breathing is absent: - Provide ventilations using a bag-valve mask. - Prepare for intubation. If breathing is present - Administer O2 @ 10-15L/min via non-rebreather mask. - Assess for effective ventilation. *End-tidal CO2 monitoring *O2 Saturation *If ineffective, intervene as indicated: - Ex: needle decompression for tension pneumothorax - Intubation if needed.

Answer 60

Assessment - Inspect for the following: *Uncontrolled external bleeding *Pale skin color *Signs of internal bleeding (Cullen’s Sign) Auscultate for the following: - Muffled heart sounds Palpate for the following: - Skin temperature and moisture - Presence of carotid and/or femoral pulses - If pulses are absent, begin CPR and place on monitor if not already. - Consider the following causes of PEA: *Penetrating wound to the heart *Pericardial tamponade *Rupture of great vessels *Intra-abdominal hemorrhage

Answer 61

*Control and treat external bleeding. - Apply direct pressure. - Elevate bleeding extremity. - Apply tourniquet if indicated. - Consider a pelvic binder if pelvic fracture suspected. *Insert 2 large bore IV catheters. - Consider IO access if unable to gain venous access quickly. *Administer 0.9% Sodium Chloride *Administer blood products as ordered. - Massive Transfusion - Autotransfusion

Answer 62

*Glasgow Coma Scale** Eyes Opening - Spontaneously: 4 - To speech: 3 - To pain: 2 - No response: 1 Verbal Response - Oriented: 5 - Confused: 4 - Inappropriate words: 3 - Incomprehensible sounds: 2 - No response: 1 Motor Response - Obeys command: 6 - Moved to localized pain: 5 - Flex to withdraw from pain: 4 - Abnormal flexion: 3 - Abnormal extension: 2 - No response: 1 *Assess pupils

Answer 63

- Evaluate need for CT of the head. - Check blood sugar!** - Intubate if indicated

Answer 64

Assessment - Completely undress the patient - Inspect for any uncontrolled bleeding and other obvious injuries. Interventions - Preserve clothing if needed for evidence. - Maintain body temperature. *Cover with warm blankets *Administer warmed IV fluids.

Answer 65

- Obtain and trend vital signs at regular intervals. - Facilitate family presence as soon as a member of the trauma team is available to act as a liaison to the family.

Answer 66

LMNOP Pneumonic *L – Obtain Laboratory Studies *M – Monitor Cardiac Rate and Rhythm *N – Nasogastric or Orogastric Tube Consideration - Oral route preferred of mid-face fractures are suspected! *O – Oxygenation and Ventilation Assessment - Consider weaning oxygen if able. - Initiate capnography monitoring, provides instantaneous information about ventilation. *P – Pain Assessment and Management

Answer 67

At this point, portable chest and pelvis x-rays are obtained. You should also begin to consider the need for transfer.

Answer 68

Pre-Hospital Report: MIST Pneumonic *M – Mechanism of Injury *I – Injuries Sustained *S – Signs and Symptoms (in the field) *T – Treatment (in the field) Patient History: SAMPLE Pneumonic *S – Symptoms associated with illness or injury *A – Allergies *M – Medications currently used – especially anticoagulants! *P – Past medical history (including hospitalization and surgeries) *L – Last oral intake and menstrual period if female of childbearing age *E – Events and environmental factors related to injury

Answer 69

General Appearance Head and Face - Soft tissue injuries - Bony deformities Eyes - Gross visual acuity - Pupils - Extraocular movements - Presence of foreign bodies Ears - Look for drainage, such as blood or clear fluid - Ecchymosis behind the ear (Battle sign) - Avulsions and lacerations Nose - Look for drainage, blood or clear. - Assess for deformity. Neck and Cervical Spine - Inspect for for Lacerations, Abrasions/Avulsions, Contusions, Edema/Ecchymosis (LACE) - Assess for penetrating wounds. - Palpate for cervical tenderness, deformities, or step-offs. - Palpate for tracheal deviation, subcutaneous emphysema. Chest - Respiratory assessment - Insepct the anterior and lateral chest wall for signs of injury - Auscultate heart and lung sounds. - Palpate for subcutaneous emphysema and bony crepitus. Abdomen/Flank - Inspect for LACE, evisceration, distension. - Auscultate bowel sounds. - Palpate for rigidity, guarding masses, areas of tenderness. Pelvis/Perineum - Inspect for LACE, blood at the urethral meatus, priapism, scrotal/labial hematoma. - Palpate for pelvic instability. Extremities - Inspect for soft tissue injuries, bony injuries, skin color, signs of complex medical history (ie., dialysis catheters) - Palpate skin temperature, pulses (comparing one side with the other), bony injury (crepitus, deformity, etc), sensation. Evaluate motor function.

Answer 70

*Best practice recommendations are that it is only appropriate to assess the posterior of the patient after a patient has been cleared of spinal injuries, pelvic fracture and other injuries that may be exacerbated by movement* - Log roll the patient with assistance of the trauma team. - Inspect for LACE, penetrating wounds, presence of blood around the rectum. - Palpate for deformity and areas of tenderness along the vertebral column. - Digital Rectal Exam *Evaluate for the presence of rectal tone. *Evaluate for blood in the rectum.

Answer 71

*Serial assessments and trending are essential!! *Upon completion of the secondary survey, prepare for additional diagnostics and interventions, depending on the patient needs and injuries. *Additional Tests and/or Treatments - Additional lab studies - Radiologic imaging - Wound care - Application of splints - Application of skeletal traction - Administration of medications *Tetanus toxoid *Antibiotics *Anticoagulation reversal agents *Pain medication *Anxiolytics - Angiography - Preparation for the OR - Preparation for admission - Psychosocial support

Trauma, Emergencies, Disasters Flashcards

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