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90 Cards in this Set
- Front
- Back
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Leading cause of death between the ages of 1 - 44
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trauma
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4 components of INITIAL ASSESSMENT AND MANAGEMENT
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Primary survey - rapid exam (30 secs - decide if life is threatened)
Resuscitation - in conjunction with the primary survey Secondary survey - detailed exam Definitive care and treatment |
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ABCDE of primary survey
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A - airway with “in-line” cervical spine control
B - breathing and ventilation C - circulation with hemorrhage control D - disability, neurologic status E - exposure, environmental control |
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c-spine immobilization during A of ABCDE?
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Yes- Must maintain c-spine immobilization during this time with rigid collar
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% of patients with major head injuries or blunt injury above the clavicles have c-spine injuries
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10 - 20
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Intubate? to protect airway if necessary
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Yes - it's better to over do it.
Intubate to protect airway if necessary |
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Life threatening probs to diagnose during B of ABCDE
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Tension pneumothorax
Flail chest Pulmonary contusion Massive hemothorax |
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All hypotension is secondary to_________ until proven otherwise
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hypovolemia
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Bleeding - always control by WHAT
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direct pressure
Never with tourniquets or clamps |
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Rapid neurologic assessment
A - V - P - U - |
Rapid neurologic assessment
A - alert V - responds to vocal stimuli P - responds to painful stimuli U - unresponsive |
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When is Glascow Coma scale done?
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done in the more detailed secondary survey
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Completely undress the patient for thorough examination
Immediately cover with warm blankets Hypothermia occurs rapidly in the shock state Hypothermia leads to__________ |
coagulopathy
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All patients receive supplemental oxygen
WHEN? |
primary survey ("resuscitation")
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Components of resuscitation
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All patients receive supplemental oxygen
Initial vital signs obtained Pulse-ox and EKG leads placed 2 large-bore I.V.’S (16 gauge minimum) Initial blood draw Maintain airway Chest decompression if needed Foley, OGT/NGT |
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Components of secondary survey
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Complete head-to-toe exam with complete neurologic evaluation
Special procedures, x-rays, and lab studies are obtained and completed at this time “Tubes and fingers in every orifice.” Includes history |
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ALL INITIAL EFFORTS ARE PEFORMED TO PREVENT____ FROM DEVELOPING
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SHOCK
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1st step in treating shock is to “_______”.
2nd step in treating shock is to “________”. |
1st step in treating shock is to “recognize its presence”.
2nd step in treating shock is to “identify the probable cause”. |
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types of shock
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Hypovolemic
Cardiogenic Neurogenic Septic |
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the most common cause of shock in the injured patient
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Hemorrhage
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Cardiac Output =
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Heart Rate x Stroke Volume
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Factors that Stroke Vol depends on
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Preload
Myocardial Contractility Afterload |
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Stroke Volume : What parrameter can you control to change it?
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End-Diastolic Volume (preload)
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Preload – volume of venous return to the heart
Determined By: |
1. Venous Capacitance
a. Reservoir System b. 70 % of total blood volume is in venous circuit 2. Volume Status – volume of blood returned to the heart a. Determines myocardial muscle fiber length after ventricular filling at end-diastole b. Contractility of the myocardium is the pump that drives the system 3. Difference between mean venous systemic pressure and right atrial pressure (determines venous flow) |
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earliest measurable circulatory sign of shock
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Tachycardia
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Does endogenous catecholamine release increase organ perfusion?
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no
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Inadequately perfused and oxygenated cells shift from aerobic to anaerobic metabolism
- resulting in WHAT |
formation of Lactic Acid
- development of metabolic acidosis |
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Hemorrhagic Shock:
What is goal? |
Incr preload, or restore adequate circulating blood volume
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The most sensitive indicator of adequate resuscitation
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URINE OUTPUT
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Assure adequate renal blood flow
Adult > ___ ml/kg/hr Child > _ ml/kg/hr Infant > _ ml/kg/hr |
Assure adequate renal blood flow
Adult > 0.5 ml/kg/hr Child > 1 ml/kg/hr Infant > 2 ml/kg/hr |
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For hypovolemia, WHAT DRUGS ARE CONTRAINDICATED !!!!
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VASOPRESSORS ARE CONTRAINDICATED !!!!
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Profound Shock ?
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hemodynamic collapse with inadequate perfusion of the skin, kidneys, and CNS
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To recogniz e shock,
Don’t rely on ‘d BP alone Look at ? |
Look at Pulse Rate, Resp. Rate, Skin Circulation, and Pulse Pressure (the difference between systolic and diastolic pressure)
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ORDER OF FINDINGS in shock
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1. Tachycardia
2. Vasoconstriction 2. Decr ‘d Cardiac Output 2. Narrow Pulse Pressure (significant loss) 3. Decr ‘d Mean Arterial Pressure 3. Decr ‘d Blood Flow |
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Cool and________ is shock until proven otherwise!
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Cool and Tachycardic is shock until proven otherwise!
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most common type of shock
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Hemorrhagic
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types of non-hem shock
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Tension Pneumothorax
Cardiogenic Neurogenic Septic |
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Bullets of cardiogenic shock
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Characterized by myocardial dysfunction
Blunt – cardiac contusion/cardiac tamponade Air Embolus Myocardial Infarction Suspect in blunt trauma with rapid deceleration EKG Monitoring for dysrhythmias, CPK, Isoenzymes, Troponin, ECHO for function |
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Beck’s Triad
cardiac tamponade |
Tachycardia
Muffled heart sounds Engorged neck veins Along with Decr‘d BP resistant to fluids, is prognostic for Cardiac Tamponade |
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Bullets about TENSION PNEUMOTHORAX
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Decr‘d Blood pressure
Decr ‘d Breath sounds Hyperresonant percussion over affected hemithorax Acute respiratory distress Subcutaneous emphysema Tracheal deviation |
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NEUROGENIC bullets
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Isolated intracranial injuries do not cause shock
Spinal Cord Injury – produces hypotension due to loss of sympathetic tone Hypotension without tachycardia or cutaneous vasoconstriction Narrowed pulse pressure not seen Treat initially for hypovolemia |
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Septic shock bullets
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Hypotension
Possible fever Tachycardia Cutaneous vasoconstriction Decr ‘d Urine output Decr ‘d Systolic Blood Pressure Narrow pulse pressure |
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Bullets of hemorrhagic shock
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Most common in the injured patient
Acute loss of circulating blood volume Normal adult blood volume: ~ 7% body wt. Normal child blood volume: ~ 8-9% body wt. Based on ideal body weight |
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Classes of Hemorrhagic shock
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Class I – condition of the individual who has donated blood
Class II – uncomplicated hemorrhage, but crystalloid resuscitation required Class III – complicated, at least crystalloid, possibly blood required Class IV – preterminal, if not aggressively resuscitated, patient will die |
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Hemorrhagic shock bullets again
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Treat prior to fall in Blood Pressure
Learn to recognize early signs Decr ‘d Pulse pressure occurs secondary to Incr ‘d DBP, which occurs secondary to Incr ‘d circulating catecholamines |
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Second leading cause of trauma deaths per year
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Most common injury - chest wall itself
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Treatment of chest wall injury
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85% can be treated successfully with observation and minor intervention and support
85% require tube thoracostomy 10-15% require thoracotomy |
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Most Common ribs fractured
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lateral aspect ribs 3 - 8 (long, thin, poorly protected)
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Least Common ribs fractured
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ribs 1 and 2 (short, broad, relatively thick, and well protected)
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How bad is it if 1st or 2nd rib is broken?
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30% of patients with first or second rib fractures die from associated injuries,
Up to 5% have ruptured aortas |
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2 or more adjacent ribs each fractured in at least 2 places
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Flail Chest
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Causes of Flail Chest
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Usually caused by impact to sternum or lateral side of thorax
Frontal collision with steering wheel impact T-Bone collision with intrusion into the vehicle |
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Most common potentially lethal chest injury seen in the United States
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PULMONARY CONTUSION
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Tx of Pulmonary Contusion
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Close monitoring with supportive oxygen therapy
Fluid restriction if possible Bag-Valve-Mask Ventilation or Intubation |
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Presence of air in the pleural space, separating the parietal and visceral pleura
Causes lung to collapse as air accumulates Can cause pleuritic pain, rapid and shallow breathing, and shortness of breath Decreased or absent breath sounds on affected side |
PNEUMOTHORAX
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Tx of Pneumothorax
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Constant monitoring to detect evidence of tension developing
High-concentration oxygen Positive pressure ventilation only if necessary as this can increase size of pneumothorax |
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Most often as a result of gunshot or knife wounds
Can also occur from impaled objects, motor vehicle collisions, and falls Severity is directly proportional to size of wound Sucking wounds are the worst, with highest incidence of tension pneumothorax developing |
OPEN PNEUMOTHORAX
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Tx of OPEN PNEUMOTHORAX
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Close the hole with three-sided occlusive dressing to allow air to escape, but not enter the chest
Pressure-assisted ventilation Close monitoring Treat possible hypovolemia with fluids |
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Cause of death in tension pneumothorax
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decreased CO
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Air can enter but not leave the pleural space
Increasing pressure within the pleural space further collapses the lung and forces the mediastinum (heart and great vessels) to the opposite side |
TENSION PNEUMOTHORAX
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Signs of tension pneumothorax
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Tracheal Deviation - usually late and intrathoracic
Distended Neck Veins - may be absent secondary to hypovolemia Cyanosis - can be unreliable Decreased Breath Sounds - most reliable Percussion - difficult in a noisy environment |
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Early , progressive, late signs of tension pneumothorax
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Early Signs - unilateral decreased or absent breath sounds, increasing dyspnea and tachypnea
Progressive Signs - increasing dyspnea and tachypnea, subcutaneous emphysema, difficulty ventilating Late Signs - JVD, tracheal deviation, tympany, acute hypoxia, narrowing pulse pressure, shock |
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Tx of Tension Pneumo
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Reduce the pressure in the pleural space
Penetrating - if dressing in place, remove and allow air to escape, replace dressing, repeat prn Closed Tension - needle decompression Assisted ventilation when needed Large-bore I.V. access |
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where do you insert needle for decompression of pneumo
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into the affected pleural space at the second intercostal space in the midclavicular line
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Tx of Hemothorax
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Correct the ventilatory and circulatory problems
Oxygen with ventilatory assistance Treat hypovolemia or shock with appropriate fluids PASG’s - relative contraindication |
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Most common of all the cardiac injuries
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MYOCARDIAL CONTUSION
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most commonly injured part of heart
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Right Ventricle
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MC dysrhythmia?
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sinus tachycardia
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MYOCARDIAL CONTUSION MANAGEMENT
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Oxygen
Close monitoring with ECG Treat dysrhythmias per protocol Most common dysrhythmia: Sinus Tachycardia! I.V. fluids |
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most frequent treatable cause
of pericardial tamponade |
stab wounds
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What is paradoxical pulse with pericardial tamponade
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Paradoxical Pulse - SBP drops > 10 - 15 mmHg with inspiration
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Beck’s Triad - classic findings
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(1) JVD - caused by elevated venous pressure
(2) Muffled Heart Tones (3) Shock - progressively worsening |
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pericardial tamponade management
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Rapid, well-monitored transport
I.V. fluids can improve cardiac output by increasing venous transport PASG’s - contraindicated Remove the blood and control the bleeding Pericardiocentesis - removing as little as 10 cc’s may be enough to return spontaneous activity |
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Variety of thoracic vessel injury
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Subclavian Artery - 21%
Descending Thoracic Aorta - 21% Pulmonary Artery - 16% Subclavian Vein - 13% Intrathoracic Vena Cava - 11% Innominate Artery - 9% Pulmonary Veins - 9% |
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Injury to one of the above vessels is found in one______ of patients undergoing thoracotomy for blunt or penetrating trauma
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Injury to one of the above vessels is found in one third of patients undergoing thoracotomy for blunt or penetrating trauma
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Blunt Trauma - most common vessel injuries
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descending thoracic aorta, the innominate artery, the pulmonary veins, and the vena cava
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__% of migratory bullets finally lodge in the pulmonary arteries
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25% of migratory bullets finally lodge in the pulmonary arteries
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__% of vessel injury patients present without any external physical signs of injury
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50% of vessel injury patients present without any external physical signs of injury
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Your chances with aortic rupture
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80 - 90% sustain aortic rupture and complete exsanguination into the left pleural space within the first hour and never reach the hospital
10 - 20% of patients will reach the hospital alive One third of these initial survivors die within 6 hours, another third die in 24 hours, the final third survive 3 days or longer |
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AORTIC RUPTURE MANAGEMENT
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High concentration oxygen
Ventilatory assistance Judicious use of fluids if possible to prevent further tearing of aorta |
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Most reliable marker in radiology of aortic rupture
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loss of aortic knob
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TRAUMATIC ASPHYXIATION ASSESSMENT
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Bluish discoloration only to the face and upper neck (skin is pink below this area)
JVD Swelling or hemorrhage of the conjunctiva Discoloration usually resolves in a few days Treatment - recognize the condition, provide an airway, maintenance, treat associated injuries |
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things in the retroperitoneum
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kidneys, ureters, bladder, reproductive organs, inferior vena cava, abdominal aorta, pancreas, and a portion of the duodenum, colon, and rectum
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Most commonly injured organs are what? in abdomen
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liver and spleen
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Hollow organs spill their contents when injured leading to_______
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peritonitis and sepsis
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Solid organs bleed causing acute____
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shock
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- most common injury (penetrating to abdomen)
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Small Bowel
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Abdomen can hold up to ___ liters of fluid without showing signs of distention
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Abdomen can hold up to 1.5 liters of fluid without showing signs of distention
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Most frequently injured abdominal organ overall
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liver
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What is it?
Uncommon: 3 - 5 % overall incidence Rupture, avulsion, and contusion Not immediately life-threatening Difficult to diagnose without CT scan Treatment - removal |
GALLBLADDER
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Most commonly injured organ following blunt trauma
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spleen
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