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trauma and trauma systems > Trauma Final > Flashcards

Trauma Final Flashcards

1
Q

femur fracture

A

-only facture we apply traction to

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2
Q

Primary Blast

A
  • damage is caused by pressure wave generated by explosion
  • close proximity to the origin of the pressure wave carries a high risk of injury or death
  • can rupture membranes and affect organs
  • Tympanic membrane is the most sensitive
  • we are most concerned about lungs
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3
Q

Secondary Blast

A
  • result from being struck by flying debris
  • a blast wind occurs
  • flying debris may cause blunt and penetration injuries
  • most common
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4
Q

Tertiary Blast

A
  • occur when a person is hurled against stationary, rigid objects
  • ground shock
  • amputations, broken bones, penetrations
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5
Q

Quaternary Blast

A
  • occur from the miscellaneous events that occur during an explosion
  • may include:
  • burns
  • respiratory injury
  • crush injury
  • entrapment
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6
Q

Quinary Blast

A
  • caused by biologic, chemical, or radioactive contaminants added to an explosive
  • associated with dirty bombs
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7
Q

Shock

A
  • Not producing energy normally (aerobic) -> less perfusion (anaerobic)
  • patent airway, functioning lungs, adequate circulation and perfusion = aerobic metabolism
  • obstructed airway, impaired lung function (hypoxia), impaired circulation (hypoperfusion) = anaerobic metabolism
  • lactic acid build up -> acidic
  • secondary to hypoperfusion
  • delivery of oxygen is inadequate to meet metabolic demands
  • decreased energy production
  • cellular and organ death
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8
Q

Triangle of Death

A
  • acidosis- what little ATP is being produced is used to shiver -> lactic acid production increases
  • hypothermia
  • coagulopathy- cold impairs blood clotting
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9
Q

Hypovolemic Shock

A
  • Hemorrhagic:
  • most common cause of hypoperfusion after trauma
  • Treat with fluids
  • Pulse increases
  • BP decreases
  • Decreased pulse pressure
  • Increase ventilation rate
  • Decrease urine output
  • Decreased LOC
  • Dehydration
  • loss of plasma (burns)
  • nausea, vomiting, diarrhea
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10
Q

Distributive Shock

A
  • Neurogenic:
  • lack of tone
  • associated with spinal cord injury
  • interruption of the sympathetic nervous system resulting in vasodilation
  • patient has normal blood volume but vascular container has enlarged -> thus decreasing blood pressure
  • warm, dry skin temp
  • pink skin color
  • BP drops
  • lucid
  • normal capillary refill
  • Septic
  • Anaphylactic
  • psychogenic
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11
Q

Cardiogenic Shock

A
  • pump failure
  • pericardial tamponade- fluid between pericardial sac and heart muscle -> cant expand
  • tension pneumothorax- pressure does not allow blood to come back to heart
  • results from external compression of the heart
  • less blood is ejected with each contraction
  • cool, clammy skin temp
  • pale, cyanotic skin color
  • BP drops
  • consciousness is altered
  • capillary refill is slowed
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12
Q

XABCDE

A
  • X- Xanguation
  • A- Airway
  • B- Breathing
  • C- Circulation
  • D- Disability
  • E- Exposure
  • primary assessment
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13
Q

I PASS O2

A
  • I- inspection
  • P- palpation
  • A- auscultation - 4 places- aortic, pulmonic, tricuspid, and mitral valves
  • S- seal holes
  • S- stabilize flail segments- two or more ribs broken in two or more places
  • O- oxygen/ventilation
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14
Q

Breathing Assessment

A
  • look, listen, feel for 5-10 sec
  • assess rate in value of breaths per minute
  • ventilate the patient if they are not breathing
  • ensure a patient airway and compliance with ventilation
  • ensure oxygen delivered is 85% or greater
  • make sure you are having mechanical compliance -> chest rise
  • depth is just as important
  • if the patients is breathing you must think about the quality/efficacy of that patients efforts
  • 12-20 is normal
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15
Q

Epidural

A

under normal circumstance it does not exist, middle meningeal arteries follow grooves in the temporal bone here

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16
Q

DCAP- BTLS

A
  • D- deformities
  • C- contusion
  • A- abrasions
  • P- punctures
  • B- burns
  • T- tenderness- pain only when you touch it
  • L- lacerations
  • S- Swelling
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17
Q

Dura Mater

A
  • Made of rough fibrous tissue

- forms Tentorium: divides cerebrum and cerebellum

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18
Q

Subdural space

A
  • Space that is spanned with Veins
  • Low pressure
  • may take a while to show symptoms
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19
Q

Arachnoid Space

A

Covering over the brains vasculature

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20
Q

Subarachnoid Space

A

Gap in which brains vasculature runs

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21
Q

Pia Mater

A

Thin covering Directly over the brain.

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22
Q

Medulla Oblongata

A
  • Acts as a pathway for ascending and descending nerve tracts
  • Regulations of heart rate, blood vessel diameter, breathing, swallowing, vomiting, coughing, sneezing
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23
Q

Brainstem

A

Contains Midbrain, Pons, Medulla

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24
Q

Pons

A
  • Contains ascending and descending nerve tracts
  • Relays information from the cerebrum to cerebellum
  • Houses the sleep center and respiratory center
  • Like medulla helps in the regulation of breathing
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25
Q

Midbrain

A
  • Involved in hearing through audio pathways in the CNS
  • Responsible for visual tracking of moving objects, turning the eyes
  • Coordinates regulation of the automatic functions that require no conscious thought
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26
Q

CPP (cerebral perfusion pressure)

A

MAP - ICP

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27
Q

MAP

A

diastolic + (⅓ pulse pressure)

-minimal is 60 to perfuse organs

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28
Q

Basal Skull Fractures

A
  • may tear dura
  • permit CSF to drain through an external passageway
  • May mediate the rise of ICP
  • Evaluate for target or halo sign -> clear part of the CSF will be on the outside ring of a blood drop coming from the ear
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29
Q

Basal Skull Fracture: Battle Signs

A
  • retroauricular ecchymosis - bruising behind ear

- associated with fracture of auditory canal and lower of skull

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30
Q

Basal Skull Fracture: Raccoon Eyes

A
  • bilateral periorbital ecchymosis

- associated with orbital fractures

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31
Q

direct brain injury categories: focal

A
  • occur at a specific location in brain
  • differentials:
  • cerebral contusion
  • intracranial hemorrhage:
    - >epidural hematoma
    - >subdural hematoma
  • intracerebral hemorrhage
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32
Q

Focal Injury: cerebral contusion

A
  • blunt trauma to local brain tissue
  • capillary bleeding into brain tissue
  • common with blunt head trauma
  • confusion
  • neurologic deficit
  • personality changes
  • vision changes
  • speech changes
  • result from coup-contrecoup injury
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33
Q

Focal Injury: intracranial hemorrhage: epidural hematoma

A
  • bleeding between dura mater and skull
  • blood is where the brain should be -> herniation
  • involves arteries - middle meningeal artery most common
  • rapid bleeding and reduction of oxygen to tissues
  • patients will have lucid interval
  • unconscious goes unconscious again
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34
Q

Focal Injury: Intracranial hemorrhage: subdural hematoma

A
  • bleeding within meninges
  • beneath dura mater
  • above arachnoid
  • slow bleeding- superior sagittal sinus
  • signs progress over several days
  • slow deterioration of mentation
  • blood is displacing the brain
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35
Q

Focal Injury: intracranial hemorrhage

A
  • ruptured blood vessel within the brain
  • presentation similar to to stroke symptoms
  • Signs and symptoms worsen over time
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36
Q

ICP cascade

A

cranial insult -> tissue edema -> increased ICP -> compression of arteries -> decrease cerebral blood flow -> decrease O2 with death of brain cells -> edema around necrotic tissue -> increase ICP with compression of brain stem and respiratory center -> CO2 accumulates -> vasodilation -> increase ICP due to increased blood volume -> death

  • compresses brain tissue
  • herniates brainstem
  • compromises blood supply
  • vomiting
  • Altered mental status
  • Pupillary dilation
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37
Q

Glasgow Coma Scale

A
  • eyes: Spontaneous (4); Responds to Command (3); Responds to Pain (2); Nothing (1)
  • verbal: Spontaneous (5); Disorganized,. Confused (4); Nonsensical (3); Moaning and Groaning (2); Nothing (1)
  • Motor: Spontaneous (6); Localizes Pain (5); Withdrawals from Pain (4); Decorticate (3); Decerebrate (2); Nothing (1)
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38
Q

Cushing Reflex

A
  • increased BP
  • bradycardia
  • erratic respirations
  • these 3 symptoms are really only ever seen together for brain injury
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39
Q

Diffuse Injury

A
  • Due to stretching forces placed on axons
  • Pathology distributed throughout brain
  • Types:
  • Concussion
  • Moderate diffuse axonal injury- classic concussion
  • Severe diffuse axonal injury- brainstem injury, deadly, cushings
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40
Q

Cervical Spine

A

-7
-C1 (atlas):
• Supports head
• Securely affixed to the occiput
• Permits nodding
-C2 (axis)- Odontoid process (dens) -> Projects upward and Provides pivot point so head can rotate
-C7- Prominent spinous process (vertebra prominens)

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41
Q

Spine

A
  • 33 bones in the spine

- Lumbar spine is the strongest and largest

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42
Q

Thoracic Vertebrae

A
  • 12
  • 1st rib articulates with T-1
  • Attaches to transverse process and vertebral body
  • Next nine ribs attach to the inferior and superior portion of adjacent vertebral bodies
  • Limits rib movement and provides increased rigidity
  • Larger and stronger than cervical spine
  • Larger muscles help to ensure that the body stays erect
  • Supports movement of the thoracic cage during respirations
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43
Q

Lumbar Spine

A
  • 5
  • Bear forces of bending and lifting above the pelvis
  • Largest and thickest vertebral bodies and intervertebral disks
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44
Q

Sacral Spine

A
  • 5 fused
  • Form posterior plate of pelvis
  • Help protect urinary and reproductive organs
  • Attach pelvis and lower extremities to axial skeleton
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45
Q

Coccygeal

A
  • 3–5 fused

- Residual elements of a tail

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46
Q

Pedicles

A

Thick, bony structures that connect the vertebral body to the spinous and transverse processes

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47
Q

Laminae

A

Posterior bones of vertebrae that make up foramen

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48
Q

Transverse Process

A

Bilateral projections from vertebrae; muscle attachment and articulation location with ribs

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49
Q

Spinous Process

A

Posterior prominence on vertebrae

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50
Q

Intervertebral Discs

A

Cartilaginous pad between vertebrae that serves as shock absorber

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51
Q

Vertebral Ligaments: Anterior Longitudinal

A
  • Anterior surface of vertebral bodies
  • Provides major stability of the spinal column
  • Resists hyperextension
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52
Q

Vertebral Ligaments: Posterior Longitudinal

A
  • Posterior surface of vertebral bodies in spinal canal

- Prevents hyperflexion

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53
Q

Incomplete Cord Transection: Anterior Cord Syndrome

A

Anterior vascular disruption
Loss of motor function and sensation of pain, light touch, and temperature below injury site
Retain motor, positional, and vibration sensation

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54
Q

Incomplete Cord Transection: Central Cord Syndrome

A
  • Hyperextension of cervical spine
  • Motor weakness affecting upper extremities
  • Bladder dysfunction
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55
Q

Incomplete Cord Transection: Brown Sequard Syndrome

A
  • Penetrating injury that affects one side of the cord
  • Ipsilateral (same side) sensory and motor loss
  • Contralateral pain and temperature sensation loss
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56
Q

Spinal Shock

A
  • Temporary insult to the cord
  • Affects body below the level of injury
  • Hypotension secondary to vasodilation
  • Affected area:
  • Flaccid
  • Without feeling
  • Loss of movement (flaccid paralysis)
  • Frequent loss of bowel and bladder control
  • Priapism
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57
Q

Neurogenic Shock

A
  • AKA Spinal-Vascular Shock
  • Occurs when injury to the spinal cord disrupts the brain’s ability to control the body
  • ANS loses sympathetic control over adrenal medulla
  • Unable to control release of epinephrine and norepinephrine -> Loss of positive inotropic and chronotropic effects
  • Cool, moist, and pale skin above the injury
  • Warm, dry, and flushed skin below the injury
  • Male: priapism
  • Loss of sympathetic tone:
  • Dilation of arteries and veins -> Expands vascular space and results in relative hypotension
  • Reduced cardiac preload
  • Reduction of the strength of contraction -> Frank-Starling reflex
  • Bradycardia
  • Hypotension
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58
Q

Neurogenic Shock

A
  • AKA Spinal-Vascular Shock
  • Occurs when injury to the spinal cord disrupts the brain’s ability to control the body
  • ANS loses sympathetic control over adrenal medulla
  • Unable to control release of epinephrine and norepinephrine -> Loss of positive inotropic and chronotropic effects
  • Cool, moist, and pale skin above the injury
  • Warm, dry, and flushed skin below the injury
  • Male: priapism
  • Loss of sympathetic tone:
  • Dilation of arteries and veins -> Expands vascular space and results in relative hypotension
  • Reduced cardiac preload
  • Reduction of the strength of contraction -> Frank-Starling reflex
  • Bradycardia
  • Hypotension
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59
Q

Autonomic Hyperreflexia Syndrome

A
  • Associated with the body’s resolution of the effects of spinal shock
  • Commonly associated with injuries at or above T-6
  • Sudden hypertension
  • Bradycardia
  • Pounding headache
  • Blurred vision
  • Sweating and flushing of skin above the point of injury
60
Q

Chest Anatomy

A
  • Heart, Great Vessels, Esophagus, Tracheobronchial Tree, & Lungs
  • muscles of respiration: diaphragm, intercostal muscles, Sternocleidomastoid
  • pleura
  • old people have more fractures than kids (more cartilage)
61
Q

Diaphragm

A
  • Primary muscle of respiration
  • Inhalation: Contracts downward
  • Exhalation: Relaxes upward
62
Q

Intercostal Muscles

A
  • Contract to elevate the ribs and increase thoracic diameter
  • Increase depth of respiration
63
Q

sternocleidomastoid

A

Raise upper rib and sternum

64
Q

Crush (compression) Trauma

A
  • Body is compressed between an object and a hard surface

- Direct injury of chest wall and internal structures

65
Q

Deceleration Trauma

A
  • Body in motion strikes a fixed object
  • Blunt trauma to chest wall
  • Internal structures continue in motion- Ligamentum Arteriosum shears aorta
66
Q

Flail Chest

A
  • Segment of the chest that becomes free to move with the pressure changes of respiration
  • 3 or more adjacent rib fracture in two or more places
  • Serious chest wall injury with underlying pulmonary injury
  • Reduces volume of respiration
  • Adds to increased mortality
  • Paradoxical flail segment movement
  • Positive pressure ventilation can restore tidal volume
67
Q

Chest Contusion

A

-Most Common result of blunt injury
-Signs & Symptoms:
• Erythema
• Ecchymosis
• Difficulty Breathing
• Limited breath sounds
• Hypoventilation
– BIGGEST CONCERN = “HURTS TO BREATHE”

68
Q

Rib Fractures

A
  • more than 50% of significant chest trauma cases due to blunt trauma
  • Compressional forces flex and fracture ribs at weakest points
  • Ribs 1-3 requires great force to fracture
  • Possible underlying lung injury
  • Ribs 4-8 are most commonly fractured
  • Ribs 9-12 less likely to be fractured ->Transmit energy of trauma to internal organs
  • If 9-12 fractured, suspect liver and spleen injury
  • Hypoventilation from pain
  • TREATMENT:
  • Consider analgesics for pain and to improve chest excursion -> Valium, Morphine Sulfate, Meperidine
  • No Nitrous Oxide- > May migrate into pleural or mediastinal space and worsen condition
  • if you give too much pain management -> pt looses the drive to breathe
69
Q

Sternal Fracture and Dislocation

A
  • Associated with severe blunt anterior trauma
  • Typical Mechanism of Injury
  • Direct Blow
  • Incidence: 5-8%
  • Mortality: 25-45%
  • Myocardial contusion
  • Pericardial tamponade
  • Cardiac rupture
  • Pulmonary contusion
  • Dislocation uncommon but same MOI as fracture- tracheal depression if posterior
70
Q

Simple Pneumothorax

A
  • AKA: Closed Pneumothorax
  • Progresses into Tension Pneumothorax
  • Occurs when lung tissue is disrupted and air leaks into the pleural space
  • Progressive Pathology:
  • Air accumulates in pleural space
  • Alveoli collapse (atelectasis)
  • Reduced oxygen and carbon dioxide exchange
  • ventilation/Perfusion Mismatch -> Increased ventilation but no alveolar perfusion
  • Reduced respiratory efficiency results in HYPOXIA
  • typical Mechanism: “Paper Bag Syndrome”
71
Q

Open Pneumothorax

A

-Free passage of air between atmosphere and pleural space
-Air replaces lung tissue -> shift
-Mediastinum shifts to uninjured side
-Air will be drawn through wound if wound is 2/3 diameter of the trachea or larger
-Signs & Symptoms:
• Penetrating chest trauma
• Sucking chest wound
• Frothy blood at wound site
• Severe Dyspnea
• Hypovolemia

72
Q

Tension Pneumothorax

A
  • Buildup of air under pressure in the thorax.
  • Excessive pressure reduces effectiveness of respiration
  • Air is unable to escape from inside the pleural space
  • Progression of Simple/Open Pneumothorax
  • Dyspnea- Tachypnea at first
  • Hypoxemia
  • Hyperinflation of injured side of chest
  • Hyperresonance of injured side of chest
  • Diminished then absent breath sounds on injured side
  • Cyanosis
  • Diaphoresis
  • AMS
  • JVD
  • Hypotension, Hypovolemia
  • Tracheal Shifting (late sign)
73
Q

Hemothorax

A
  • Accumulation of blood in the pleural space
  • Serious hemorrhage may accumulate 1,500 mL of blood
  • Mortality rate of 75%
  • Each side of thorax may hold up to 3,000 mL
  • Blood loss in thorax causes a decrease in tidal volume
  • Ventilation/Perfusion Mismatch & Shock
  • Typically accompanies pneumothorax- Hemopneumothorax
  • Dyspnea
  • Tachycardia
  • Tachypnea
  • Diaphoresis
  • Hypotension
  • Percussion: Dull over injured side
74
Q

Myocardial Contusion

A
  • Occurs in 76% of patients with severe blunt chest trauma
  • Right Atrium and Ventricle is commonly injured
  • injury may reduce strength of cardiac contractions- > Reduced cardiac output
  • Electrical Disturbances due to irritability of damaged myocardial cells
  • associated with Rib/Sternal fracture
  • Progressive Problems:
  • Hematoma
  • Myocardial necrosis
  • Dysrhythmias
  • CHF & or Cardiogenic shock
  • Bruising of chest wall
  • Tachycardia and/or irregular rhythm
  • Retrosternal pain similar to MI
  • treatment -> pain is not relieved by oxygenation -> May be relieved with rest
75
Q

Pericardial Tamponade

A
  • Restriction to cardiac filling caused by blood or other fluid within the pericardium
  • Occurs in <2% of all serious chest trauma -> Very high mortality
  • Results from tear in the coronary artery or penetration of myocardium
  • Blood seeps into pericardium and is unable to escape
  • 200-300 ml of blood can restrict effectiveness of cardiac contractions
  • Removing as little as 20 ml can provide relief
  • Dyspnea
  • Possible cyanosis
  • *Beck’s Triad:
    1. JVD
    1. Distant heart tones
    1. Hypotension or narrowing pulse pressure* (numbers getting closer together)
  • Weak, thready pulse
  • Shock
  • Kussmaul’s sign- Decrease or absence of JVD during inspiration
  • Pulsus Paradoxus- Drop in SBP > 10 during inspiration due to increase in CO2 during inspiration
  • Electrical Alterans- P, QRS, & T amplitude changes in every other cardiac cycle**
  • PEA
76
Q

Traumatic Rupture of the Diaphragm

A
  • High pressure blunt chest trauma
  • Penetrating trauma
  • Most common in patients with lower chest injury
  • Most often occurs on left side
  • Signs & Symptoms:
  • Herniation of abdominal organs into thorax
  • Compression of lung
  • Displacement of mediastinum
  • Abdomen may appear hollow
  • Bowel sounds may be noted in thorax
  • Similar to tension pneumothorax
  • Dyspnea, Hypotension & JVD
  • Evaluate for other injuries
77
Q

Flail Chest Treatment

A
  • Place patient on side of injury
  • If spinal injury is not suspected
  • expose injury site
  • Dress with bulky bandage against flail segment
  • Stabilizes fracture site
  • High flow O2
  • Consider PPV or ET if decreasing respiratory status
  • No Sandbags/IV Fluid Bag
78
Q

Open Pneumothorax Treatment

A
  • high flow O2
  • Cover site with sterile occlusive dressing taped on three sides
  • Progressive airway management if indicated
79
Q

Tension Pneumothorax Treatment

A

-Confirmation
-Auscultation & Percussion
-Pleural Decompression
-2nd intercostal space in mid-clavicular line
–TOP OF RIB
-Consider multiple decompression sites if patient remains symptomatic
-Large over the needle catheter: 14ga
-Create a one-way valve: Glove tip or Heimlich valve

80
Q

Hemothorax Management

A
  • High flow O2
  • 2 large bore IV’s
  • Maintain SBP of 90
  • Monitor Breath Sounds to Prevent Fluid Overload
81
Q

Myocardial Contusion Treatment

A
  • Monitor ECG
  • Alert for dysrhythmias
  • IV if antidysrhythmics needed
82
Q

Pericardial Tamponade Treatment

A
  • High flow O2
  • IV therapy
  • Consider pericardiocentesis
83
Q

Abdominal Anatomy

A
  • one of body’s largest cavities
  • Large volumes of blood can be lost before signs and symptoms manifest
  • boundaries:
  • superior- diaphragm
  • inferior- pelvis
  • posterior- vertebral column and posterior and inferior ribs
  • lateral- muscles of the flank
  • anterior- abdominal muscles
  • peritoneal space- organs covered by abdominal (peritoneal) lining
  • retroperitoneal space- organs posterior to the peritoneal lining
  • pelvic space- organs contained within pelvis
84
Q

4 Abdominal Quadrants

A
  • Upper Right- liver, gal bladder, stomach (small part), small and large intestine, head of pancreas, upper part of kidney
  • Upper Left- spleen, stomach, tail of pancreas, tail of liver, small and large intestine, upper part of kidney
  • Lower Right- small and large intestine, lower part of kidney, half of bladder, appendix, female reproductive organs
  • Lower Left- small and large intestine, lower part of kidney, half bladder, female reproductive organs
85
Q

Hollow vs. Solid Organs

A
  • HOLLOW
  • stomach
  • small intestine
  • large intestine
  • gall bladder
  • bladder
  • uterus
  • SOLID
  • liver
  • spleen
  • pancreas
  • kidneys
  • ovaries
86
Q

Blunt Trauma to Abdomen

A
  • produces least visible signs of injury
  • causes:
  • deceleration- contents damaged by change in velocity
  • compression- organs trapped between other structures
  • shear- part of an organ is able to move while another part is fixed (ex. ligamentum teres)
87
Q

Blast Injury to Abdomen

A
  • blunt and penetrating MOIs
  • irregular shaped shrapnel and debris
  • pressure wave- compresses and relaxes air-filled organs and/or contuses or ruptures organs
  • abdominal injury is secondary concern during blast injury
88
Q

Injury to Abdomen Wall

A
  • skin and muscles transmit blunt trauma to internal structures
  • typically only show erythema
  • visible swelling and ecchymosis occur over several hours
  • penetrating trauma may appear minimal externally in comparison to internal trauma
  • muscle may mask the size of the external wound
  • evisceration may be present
  • trauma to thorax, buttocks, flanks, and back may penetrate abdomen
  • lower chest may injure spleen, liver, stomach, or gallbladder
  • diaphragmatic tears: herniation of abdominal contents into thorax
89
Q

Injury to Hollow Organs

A
  • may rupture with compression from blunt forces
  • may tear due to penetrating trauma
  • intestines have a large amount of bacteria- leakage can result in sepsis
  • manifestations of blood loss
  • hematochezia- blood in stool
  • hematemesis- blood in emesis
  • hematuria- blood in urine
  • spillage of contents into:
  • retroperitoneal space
  • peritoneal space
  • pelvic space
90
Q

Injury to Solid Organs

A
  • dense and less strongly held together
  • prone to contusion- bleeding/fracture (rupture)
  • unrestricted hemorrhage if organ capsule is ruptured
  • specific organs:
  • spleen- pain referred to left shoulder
  • pancreas- pain radiated to back
  • kidneys- pain radiated from flank to groin and hematuria
  • liver- pain referred to the right shoulder
91
Q

Injury to Abdominal Vascular Structures

A
  • abdominal aorta and vena cava- prone to direct blunt or penetrating trauma -> may be injured in deceleration injuries
  • blood accumulates beneath diaphragm:
  • irritation of muscular structures
  • produces referred pain in the shoulder region
  • greater volume of blood can be lost
  • presence of blood in abdomen stimulates vagus nerve resulting in slowing of heart rate
  • blood can isolate in ant of the abdominal spaces
92
Q

Injury to Mesentery and Bowel

A
  • provides bowel with circulation, innervation, and attachment
  • disrupts blood vessels supplying the bowel- leads to ischemia, necrosis, or rupture
  • blood loss minimal- peritoneal layers contain hemorrhage
  • tear of mesentery may rupture bowel
  • penetrating trauma to the lateral abdomen likely to injure large bowel
93
Q

Injury to Peritoneum

A
  • delicate and sensitive lining of anterior abdomen
  • PERITONITIS:
  • inflammation of the peritoneum due to:
  • bacterial irritation- due to torn bowel or open wound
  • chemical irritation- caustic nature of digestive enzymes -> urine initiates inflammatory response
  • blood does not induce peritonitis
  • progression:
  • slight tenderness at location of injury
  • rebound tenderness
  • guarding
  • rigid, board like feel
94
Q

Injury to Pelvis

A
  • life threatening hemorrhage
  • serious skeletal injury
  • potential injury to pelvis organs:
  • ureters
  • bladder
  • urethra
  • female genitalia
  • prostate
  • rectum
  • anus
95
Q

Trauma in Pregnancy

A
  • trauma is the number one killer of pregnant females
  • penetrating abdominal trauma accounts for 36% of maternal mortality
  • gunshot wound (GSW) account for 40-70% of penetrating trauma
  • blunt trauma due to improperly worn seatbelts- auto collisions are leading cause of mortality
  • changes dimension of uterus- protects abdominal organs and endangers uterus and fetus
96
Q

Injury During Pregnancy

A
  • increasing size and weight of uterus-compresses inferior vena cava and reduces venous return to heart
  • increasing maternal blood volume protects mother from hypovolemia-> 30-35% of blood loss necessary before signs of shock
  • uterus is thick and muscular distributes forces of trauma uniformly to fetus -> reduces chances of injury
  • risk of uterine and fetal injury increases with the length of gestation- greatest risk during 3rd trimester
  • penetrating trauma may cause fetal and maternal blood mixing
  • blunt trauma complications:
  • uterine rupture
  • aburptio placentae
  • premature rupture of amniotic sac
97
Q

Pregnancy Considerations

A
  • be observant for:
  • signs of shock:
  • PRETREAT- signs may not develop until 30% of blood volume lost
  • body begins shunting blood from GI/GU to primary organs
  • supine hypotensive syndrome
  • premature contractions
  • vaginal hemorrhage- uterine rupture versus abruptio placentae
  • uterus development- abnormal asymmetry
98
Q

Management of Abdominal Injury

A
  • if suspected pelvic injury, DO NOT test pelvis
  • position patient in a position of comfort unless spinal injury -> flex knees or left lateral recumbent
  • general shock care
  • specific injury care- impaled objects or eviscerations
  • impaled objects- secure in place
  • evisceration- Create conditions similar to the inside of the body -> Coat the bowel in saline and cover with a dressing -> Wrap the bowel in plastic to allow the organ to retain heat and avoid becoming necrotic.
  • NEVER force the bowl back in as that can lead to infection.
  • large-bore IV with isotonic solution- consider 2 bolus if pulse does not slow
  • large-bore IV lock for use if patients BP drops below 80 mmHg
  • fluid challenge 20 mL/kg- limit to 3 L
  • titrate to SBP of 80 mmHg
99
Q

Pregnant Patient Management

A
  • left lateral recumbent
  • if on backboard tilt backboard
  • facilitates venous return
  • high flow O2
  • consider PPV by BVM if hypoxia ensues
  • maintain high index of suspicion for intra-abdominal bleeding
  • consider IV and pneumatic anti-shock garment (PASG)
100
Q

Skeletal Tissue and Structure

A
  • give the body its structural form and protect vital organs
  • promote efficient movement despite the forces of gravity
  • store salts and other materials needed for metabolism
  • produce RBCs
  • 206 bones
  • axial skeleton- head, thorax, and spine
  • appendicula skeleton- upper and lower extremities
  • diaphysis
  • epiphysis- end of a long bone
  • metaphysis- between epiphysis and diaphysis -> growth plate
  • medullary canal- contains bone marrow
  • periosteum-fibrous covering of diaphysis
  • cartilage-connective tissue that provides a smooth articulation surface for other bones
101
Q

joint types and structure

A
  • ball and socket joint- hip
  • condyloid joint- fingers
  • gliding joint- wrist, ankle
  • hinge joint- elbow, knee
  • pivot joint- cervical
  • saddle joint- thumb
  • STRUCTURE:
  • tendon
  • bone
  • bursa
  • synovial membrane
  • articular cartilage
  • joint cavity
  • joint capsule
  • bone
102
Q

Muscle Physiology

A
  • striated
  • smooth
  • cardiac
  • 600 muscle groups
  • muscular injury
  • contusion
  • compartment syndrome
  • penetrating injury
  • fatigue
  • muscle cramp muscle spasm
  • strain
103
Q

Joint Injury

A
  • sprain
  • subluxation
  • dislocation
104
Q

Bone Injury

A
  • open fracture- tears through skin
  • closed fracture- within skin
  • hairline fracture- incomplete break -> usually due to repeated pressure
  • impacted fracture- complete break -> bones collide
  • transverse- complete break across
  • greenstick fractures- incomplete fracture -> bend (common for kids)
  • comminuted- shatter
105
Q

Inflammatory and Degenerative Joint Conditions

A
  • bursitis
  • tendonitis
  • arthritis:
    - osteoarthritis- degenerative
    - rheumatoid arthritis- chronic, systemic, progressive, debilitating
    - gout- inflammation of joints produced by accumulation of uric acid crystals
106
Q

Goal of splinting bones vs Goal of splinting joints

A
  • goal of splinting bones is to splint bone and adjacent joints
  • goal of splinting joints is to immobilize joint and adjacent bones.
107
Q

Pelvis Fracture Management

A
  • scoop stretcher
  • pelvic sling device
  • fluid resuscitation
108
Q

Femur Fracture Management

A
  • traction splints- contraindicated in hip/knee injuries
  • high force injury
  • high potential for shock
109
Q

Tibia and Fibula Fracture Management

A
  • frequently open fractures
  • cove bone ends with moist dressing
  • depending on level of fracture, use:
  • rigid splint
  • air splint
  • pillow
110
Q

Clavicle Fracture Management

A
  • most frequently fractured bone in the body
  • transmitted to 1st and 2nd rib
  • alert lung injury
111
Q

Care for Specific Joint Injuries

A
  • hip
  • knee
  • ankle
  • foot
  • shoulder
  • elbow
  • wrist/hand
  • finger
  • be alert for neurological compromise
112
Q

Hip Fracture Management

A
  • common in the elderly
  • may be able to support weight- ability to walk does not rule out fracture
  • leg often externally rotated
  • may refer pain to the knee
  • use other leg for splint
  • use vacuum mattress if available
113
Q

Hip Dislocation Emergency

A
  • orthopedic emergency
  • posterior dislocation most common
  • hip flexed and leg rotated internally
  • severe pain on attempts to straighten
114
Q

Knee Dislocation/Fracture Management

A
  • orthopedic emergency
  • frequently causes vascular injury
  • dislocation associated with 50% rate of amputation of leg
  • obvious dislocation without distal pulse -> apply gentle traction along the long axis of the joint
  • if gentle traction does not restore the pulse -> splint in place
  • prompt transport
115
Q

Foot or Hand Injury Management

A
  • common industrial injury
  • often disabling
  • rarely life threatening
  • splint foot with pillow
  • splint hand in position of function
  • keep hand in position of function for rigid splint
116
Q

Shoulder Injury Management

A
  • AC (acromiom/clavicle) separation- sling and swathe
  • shoulder dislocation- use pillow with sling and swathe
  • fracture- use sling and swathe
117
Q

Elbow Injury Management

A
  • fracture or dislocation may because neurovascular injury
  • splint in position found
  • transport promptly
118
Q

Air Splint

A

-may be hard to reassess circulation

119
Q

Forearm/Wrist Injury Management

A

-use a pillow

120
Q

Soft and Connective Tissue Injury for Extremities

A
  • tendon- muscle to bone
  • ligament- bone to bone
  • muscle
121
Q

Shoulder dislocations vs Hip dislocations

A
  • Should dislocations are typically anterior

- Hip dislocation are typically posterior

122
Q

Skin Structure

A
  • epidermis - dead
  • dermis - nerves, hair
  • subcutaneous
  • underlying structures: fascia, nerves, tendons, ligaments, muscles, organs, protection from infection
  • sensory organ- temperature, touch, pain
  • controls loss and movement of fluids
  • temperature regulation
  • insulation from trauma
  • flexible to accommodate free body movement
123
Q

Emergent Phase (burns phase 1)

A
  • pain response
  • catecholamine release:
  • tachycardia
  • tachypnea
  • mild hypertension
  • mild anxiety
124
Q

Fluid Shift Phase (burns phase 2)

A
  • length 18-24 hours
  • begins after emergent phase- reaches peak in 6-8 hours
  • damaged cells initiate inflammatory response:
  • vasodilation:
  • increased capillary permeability
  • intravascular hypovolemia
  • extravascular edema
  • burns over 30% BSA present with system immune response **
125
Q

hypermetabolic phase (burns stage 3)

A
  • lasts for days to weeks
  • large increase in the body’s need for nutrients as it repairs itself
  • fluid and electrolytes begin to move back into the vasculature
  • influx of fluid within vascular space causes the GFR to increase, leading to diuresis
  • fluid shifts may lead to hypernatremia and hypokalemia
  • cardiac workload and O2 consumption increase
126
Q

Resolution Phase (burn phase 4)

A
  • scar formation

- general rehabilitation and progression to normal function

127
Q

Stages of Burn Pathophysiology

A
  • emergent phase
  • fluid shift phase
  • hypermetabolic phase
  • resolution phase
128
Q

Jacksons Theory of Burns

A
  • zone of coagulation- -area in a burn nearest the heat source that suffers the most damage as evidenced by clotted blood and thrombosed blood vessels -> center of burn
  • zone of stasis- area surrounding zone of coagulation characterized by decreased blood flow -> middle portion
  • zone of hyperemia- peripheral area around burn that has an increased blood flow -> outermost area
129
Q

types of burns

A 
-thermal- heat changes the molecular structure of tissue -> denatures proteins
depends on:
-temperature of agent
-concentration of heat
-duration of contact
-electrical 
-chemical
-radiation
130
Q

electrical burns

A
  • greatest heat occurs at the points of resistance:
  • dry skin = greater resistance
  • wet skin = less resistance
  • tissue of less resistance - blood vessels and nerve
  • tissue of greater resistance - muscle and bone
  • entrance and exit wounds
  • longer the contact, the greater the potential of injury -> increased damage inside body
  • smaller the point of contact, the more concentrated the energy, the greater the injury
  • results in:
  • serious vascular and nervous injury
  • immobilization of muscles
  • flash burns
131
Q

Chemical Burns

A
  • destroy tissues
  • acid- form a thick, insoluble mass where they contact tissue
  • coagulation necrosis - limits burn damage
  • alkalis- destroy cell membrane through liquefaction necrosis
  • deeper tissue penetration and deeper burns
132
Q

Inhalation Injury: Toxic Inhalation

A
  • synthetic resin combustion
  • cyanide and hydrogen sulfide
  • systemic poisoning
  • more frequent than thermal inhalation burn
  • carbon monoxide- colorless, odorless, tasteless gas, byproduct of incomplete combustion of carbon products, suspect with faulty heating unit
133
Q

Treating Airway Thermal Burn

A
  • supraglottic structures absorb heat and prevent lower airways burns
  • moist mucosa lining the upper airway
  • injury is common from superheated steam
  • symptoms:
  • stridor or “crowing” inspiratory sounds
  • singed facial and nasal hair
  • black sputum or facial burns
  • progressive respiratory obstruction and arrest due to swelling
  • provide high flow O2 by NRB
  • consider intubation if swelling
  • carbon monoxide poisoning- consider hyperbaric oxygen therapy
  • cyanide exposure- hydroxocobalamin
134
Q

Burn Depth

A
  • superficial burn- epidermis, 1st degree, red, painful, dry (no blisters)
  • partial thickness burn- epidermis and dermis, 2nd degree burn, red or white, painful, blisters (wet), ultraviolet keratitis should be suspected in welders
  • full thickness burn- epidermis, dermis, fat, and muscle, 3rd degree, leathery skin, white, dark brown, charred, minimally painful, dry, hard
135
Q

Rule of Nines

A
  • best used for large surface areas
  • expedient tool to measure extent of burn
  • head and neck- 9%
  • upper posterior trunk- 9%
  • lower posterior trunk- 9%
  • upper anterior trunk- 9%
  • lower anterior trunk- 9%
  • each upper extremity- 9%
  • external genitalia- 1%
  • posterior lower extremity- 9%
  • anterior lower extremity- 9%
  • if you had anterior part of arm and chest -> 22.5% burnt
136
Q

Rule of Palms

A
  • irregular or splash burns
  • best used for burns <10% BSA
  • a burn equivalent to the size of the patients hand is equal to 1% body surface area (BSA)
137
Q

Rule of Nine: Infants

A
  • posterior head/neck- 9%
  • anterior head/neck 9%
  • posterior trunk: upper and lower- each 9%
  • arms- 9% each
  • legs- 14% each
138
Q

Minor Burn

A
  • superficial are less than 50% BSA
  • partial thickness less than 15% BSA
  • full thickness less than 2% BSA
139
Q

Minor/Moderate Burn and Severe Burn

A
  • MINOR/MODERATE
  • superficial are less than 50% BSA
  • partial thickness less than 15% BSA
  • full thickness less than 2% BSA
  • SEVERE
  • partial thickness less than 30% BSA
  • full thickness less than 10% BSA
140
Q

Parkland Formula

A
  • 4 mL x weight x % burn
  • 1/2 volume in first 8 hours
  • second 1/2 over last 16 hours
141
Q

Management of Local and Minor Burns

A
  • local cooling
  • partial thickness <1% of BSA
  • full thickness <2% BSA
  • remove clothing
  • cool or cold water immersion
  • consider analgesics:
  • morphine sulfate
  • fentanyl (sublimaze)
142
Q

Management of Moderate to Severe Burns

A
  • dry sterile dressings
  • partial thickness >10% BSA
  • full thickness
  • maintain warmth- prevent hypothermia
  • consider aggressive fluid therapy
  • burns over IV sites- place IV in partial thickness burn site
  • consider analgesics:
  • morphine sulfate
  • fentanyl (sublimaze)
  • caution for fluid overload
  • frequent auscultation of breath sounds
  • consider analgesics for pain:
  • prevent infection
143
Q

Assessment of thermal, electrical, and chemical burns

A
  • entrance and exit wounds
  • remove clothing, jewelry, and leather items
  • treat and visible injuries- thermal burns
  • ECG monitoring- bradycardia, tachycardia, VF or asystole: ACLS protocols
  • treat cardiac and respiratory arrest
  • aggressive airway, ventilation, and circulatory management
  • consider fluid bolus for serious burns- 20 mL/kg
144
Q

phenol: chemical

A
  • industrial cleaner
  • alcohol dissolves phenol
  • irrigate with copious amounts of water
145
Q

dry lime: chemical

A
  • strong corrosive that reacts with water
  • brush off dry substance
  • irrigate with copious amounts of cool water- prevents reaction with patient tissues
146
Q

Sodium: chemical

A
  • unstable metal
  • reacts vigorously with water
  • releases- extreme heat, hydrogen gas, ignition
  • decontaminate- brush off dry chemical
  • cover the wound with oil substance
147
Q

heat loss

A
  • five ways to lose heat- -feet, hands, ears, nose, whole body (hypothermia)
  • conduction- direct transfer of heat from a part of the body to a colder object by direct contact
  • convection- transfer of heat to circulating air when cool air moves across the body
  • evaporation- conversion of any liquid to gas, evaporation of sweat cools the body
  • radiation- transfer of heat by radiant energy; heat loss caused when a person stands in a cold room
  • respiration- loss of body heat during normal breathing; warm air in the lungs is exhaled into the atmosphere and cooler air is inhaled

trauma and trauma systems (18 decks)

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