Em_Trauma_Penney

Front 1

what is the primary survey?
A B C D E F G H I

Back 1

airway
breathing
circulation
debilitation
exposure
foley
gastric tube
HPI
initiate transfer

Front 2

what is Airway?

Back 2

absence of obstruction b/t mouth, oropharynx, larynx, trachea

Front 3

what is Breathing?

Back 3

movement of air to & from lungs, req.s intact airway & diaphragmatic contrxn to create neg. intrathoracic P

Front 4

what is Circulation?

Back 4

CO that provides oxygenated blood to vital organs
PULSES present radial, femoral, carotid

Front 5

what is Debilitation?

Back 5

neurologic compromise, either global depression of consciousness or specific neuro deficits (GCS)

Front 6

what is Exposure?

Back 6

fully exposed so that no injuries are missed

Front 7

what is Foley?

Back 7

seriously injured pt.s should have a Foley catheter placed to monitor urine output & check for hematuria, essential to do a RECTAL EXAM before Foley is placed in male pt.s to ensure NL prostatic position

Front 8

what is Gastric tube?

Back 8

orogastric tube should be placed in all intubated pt.s to decompress stomach, reducing risk of aspiration

Front 9

For HPI in trauma pt., get it from who?

Back 9

pt., EMS, witnesses
this detailed hx should be obtained during the 2ndary survey

Front 10

what are the components of the 2ndary survey in trauma?

Back 10

general
head
ears
eyes
nose
mouth
neck
chest
ABD
pelvis
GU
rectal
extremities
back
neurologic

Front 11

what should the trauma Hx include?

Back 11

mechanism & sites of apparent injury
damage to vehicle including windshield starring, **injuries to other ppl**
passenger compartment intrusion, seat belt use, airbag deployment
any blood loss at the scene, descriptions of weapons used, vital signs recorded at scene
meds, allergies, alcohol use, illicit drugs

**death to an individual correlates with serious injuries

Front 12

in trauma review of hypotensive, tachycardic pt., most immediate goal is what?

Back 12

to ID a source of BLEEDING by both the 2ndary survey & ancillary imaging techniques available in the trauma bay (CXR for hemothorax, aortic injury...FAST exam for intraperitoneal blood, & pelvic XR)

Front 13

what's the advantage of trauma series over CT, MR, or angiography?

Back 13

trauma series can be done IN the ED

(for the unstable pt. who requires rapid stabilization & workup in the bay)

Front 14

primary & 2ndary surveys should guide doc to appropriate interventions & imaging studies, such as what?

Back 14

intubation, chest tube, admin of blood

FAST, trauma series, CT scan

Front 15

what does the 2ndary survey include in order to inspect for bleeding scalp lacerations, to palpate the back, & to perform a rectal exam?

Back 15

a LOG ROLL

Front 16

pneumothorax is a ____ dx
hemothorax is a ______ dx

Back 16

CLINICAL (if you suspect a pneumo, dont need a CXR to confirm!)

radiological

Front 17

supine CXR:
Rt ant. ribs 6-10 fx w/o obvious underlying pneumothorax
mediastinum somewhat widened, diffuse haziness of Rt lung
NEXT STEP??

Back 17

intubate 1st (could be pulmonary contusion)
then, Rt-sided chest tube for hemothorax (a radiological dx)

Front 18

supine CXR: diffuse haziness of whole lung compared with other side bc of pooling of blood posterior to the lung

Back 18

hemothorax

(likely given rib fxs & possible intercostal A laceration)

Front 19

anterior breath sounds are often unchanged in supine pts w/ hemothorax, why?

Back 19

bc lung floats atop blood

Front 20

how does pulmonary contusion present?

Back 20

w/ rib fxs
results in hypoxia
NOT hypotension

Front 21

what is the BECK's triad of pericardial tamponade?

Back 21

hypotension
distended neck Vs
distant heart sounds

**most impt: fluid in pericardial sac on FAST exam

Front 22

DDX of slightly widened mediastinum on supine CXR

Back 22

aortic injury
pericardial tamponade

Front 23

pt with hemothorax.
you drain 1500cc of blood w/ chest tube, pt becomes pale & loses consciousness, loses carotid pulses. what NEXT?

Back 23

intubate
CPR
ED thoracotomy

Front 24

what is thoracotomy?

Back 24

incision into pleural space to dx or tx

indications depend on whether its blunt or penetrating trauma

Front 25

loss of vital signs in the field or ED, pt. has penetrating trauma, what's indicated?

Back 25

ED thoracotomy

Front 26

pt. w/ blunt trauma, in cardiac arrest, what's indicated?

Back 26

not ED thoracotomy...these pt.s less amenable to EDT given wide extent of injury

Front 27

pt. w/ blunt trauma, arrives to ED w/o vital signs, what is futile at this point?

Back 27

ED thoracotomy

Front 28

pt. w/ blunt trauma, loses vital signs IN the ED, has a suspected reversible cause for decompensation, what's indicated?

Back 28

ED thoracotomy

i.e. for pericardial tamponade, massive hemothorax

Front 29

pt. w/ penetrating trauma, bleeding coming from discrete lesion that can be repaired under direct visualization (i.e. laceration to LV), what's indicated?

Back 29

ED thoracotomy

(typically more successful here)

Front 30

what is shock? how does it manifest?

Back 30

inadequate tissue perfusion
manifests clinically: as hemodynamic disturbances & organ dysfxn

Front 31

what is shock at the cellular level?

Back 31

results from insufficient delivery of req'd metabolic substrates, principally O2, to sustain aerobic metabolism

Front 32

in the setting of trauma, what is the MC cause of shock?

Back 32

loss of circulating blood volume from hemorrhage

(others would be: inadequate oxygenation, mechanical vascular obstruction, neurologic dysfxn, cardiac dysfxn)

Front 33

what is the 2nd leading cause of death from trauma?

Back 33

1. traumatic brain injury
2. SHOCK (common, frequently treatable)

Front 34

what is an imbalance in oxygen supply and demand?

Back 34

shock

these pts suffer from critical reduction in O2 available to mitochondria
(ATP still from anaerobic glycolysis but at only 5-10% of NL rate)
anaerobic glycolysis gives pyruvate, thus lactate

Front 35

how does the sympathetic NS physiologically compensate for/respond to acute hemorrhage (to maintain adequate O2 delivery to tissues)?

Back 35

in HR
vasoconstriction
inc ventricular contractility

Front 36

as shock state progresses, vital organ (heart & brain) perfusion can only be maintained at the expense of what?

Back 36

nonvital organs

Front 37

if shock process is not reversed, what can lead to worsening systemic metabolic ACIDosis?

Back 37

progressive lactate production

*along w/ hypoxia, this ultimately causes the loss of peripheral vasoconstriction & CV collapse

Front 38

what is the DDX for shock?

Back 38

cardiac tamponade
tension pneumothorax
pulmonary contusion or hemothorax
MI or contusion (cardiogenic shock)
SC injury (neurogenic shock) RARE
effects of pharm or tox agents
fat or air embolism
hypovolemia

Front 39

pt. with shock sxs, and C1/2 fx...would you think neurogenic shock etiology?

Back 39

NO, this is too rare a cause of shock

Front 40

ATLS manual describes how many classes of hemorrhage to emphasize the early signs of the shock state?

Back 40

4 classes of hemorrhage

Front 41

ATLS classes of hemorrhage: significant drops in BP begin to manifest in which class? before this occurs, how much of pt.s blood volume may already be lost?

Back 41

class III hemorrhage


30%

Front 42

where are the 5 possible locations at which large scale bleeding can occur?

Back 42

external hemorrhage
thoracic cavity
peritoneal cavity
retroperitoneal space (pelvic fx)
M of subQ tissue (long bone fx)

Front 43

what traumas kill pt.s in seconds to minutes? (at the scene)

Back 43

high SC injury (occiput, axial)
cardiac lacerations
aortic tears

Front 44

what traumas kill pt.s in minutes to hours?

Back 44

ruptured spleen
liver laceration
epidural hematoma

Front 45

what traumas kill pt.s in days to weeks?

Back 45

sepsis
multisystem organ failure

Front 46

what are the earliest signs of hemorrhagic shock?

Back 46

tachycardia & vasoconstriction

Front 47

what is the initial tx for hemorrhagic shock?

Back 47

volume resuscitation using warmed crystalloids

Front 48

what is Class I hemorrhagic shock?

Back 48

blood loss 0-15%
0-750cc
HR <100 but still tachycardic
tx w/ crystalloids
no blood products

Front 49

what is Class II hemorrhagic shock?

Back 49

blood loss 15-30%
750-1500cc
tachypnea
tachycardia >100
narrow pulse P
tx w/ crystalloids 1st, then blood products prn

Front 50

what is Class III hemorrhagic shock?

Back 50

blood loss 30-40%
1500-2000cc
tachypnea
tachycardia HR>120
DEC in systolic BP
change in MS
blood products & crystalloids (typed blood if possible)

Front 51

what is Class IV hemorrhagic shock?

Back 51

blood loss >40% (>2L)
tachycardia >140
dec BP
confusion
lethargy
blood warmers, 2L crystalloid & O Rh Neg for women, Rh Neg or Pos for men

Front 52

definition of shock

Back 52

abnormality in circulatory system resulting in inadequate organ perfusion & tissue oxygenation

Front 53

what 4 components must all be working properly to avoid shock?

Back 53

airway
pump (heart)
pipes (As/Vs)
fluid (blood)

Front 54

what is NL adult blood volume?

Back 54

5L

tx of hypovolemic shock must be based on signs & sxs bc blood volume loss is almost impossible to measure in the field

Front 55

what are the 3 types of shock?

Back 55

hypovolemic
distributive
cardiogenic

Front 56

how is hypovolemic shock caused? its caused by what 4 things?

Back 56

caused when blood or fluid loss exceeds the body's ability to compensate & provide adequate tissue perfusion & oxygenation
1. significant blood loss
2. burns
3. severe dehydration (i.e. cholera)
4. severe vomiting/diarrhea

Front 57

500cc blood loss
1/2 L
Class I

Back 57

NO sxs
subtle inc in HR, resp.s
no advanced tx usually

Front 58

1000cc blood loss
1L
Class II

Back 58

minor MS changes
inc in HR, resp.s
w/ no tx--> death unlikely

Front 59

1500cc blood loss
1.5 L
Class II

Back 59

SEEING SXS
anxious
HR>100
Resps >or =30
weak pulses in arms & legs
w/ no tx--> death unlikely

Front 60

2000cc blood loss
2L
Class III

Back 60

confused, lethargic
HR>120
resps >or =35
weak/no pulses in arms & legs
w/ no immediate tx--> DEATH POSSIBLE
*look for capillary reflex in nailbeds

Front 61

2500cc
2.5L
Class 4

Back 61

unconscious
HR>140
resps>35
no pulses in arms & legs
w/ no immediate tx--> DEATH LIKELY

Front 62

what is Distributive shock? give 3 possible causes

Back 62

when the body loses the ability to control the diameter of the blood vessels (causes dec in BP)
1. neurogenic, spinal injury RARE
2. septic, severe body infxn
3. anaphylaxes, severe allergic rxn
2.

Front 63

what is Cardiogenic shock?

Back 63

caused when heart is damaged & can no longer adequately pump
blood

usually seen in massive heart attacks where large portion of heart M has died (40% died)

Front 64

what are the 4 stages of shock?

Back 64

1. initial injury/early
2. compensatory
3. decompensating
4. irreversible!

Front 65

what is #1 Initial/early shock?

Back 65

when pt. is able to maintain BP w/o intervention

slight anxiety
BP NL or ~ elevated 120/80
HR NL or ~ elevated 100
RR NL or ~ elevated 16-20

Front 66

what is #2 Compensatory shock?

Back 66

inc force of heart contrxn (rapid HR, blood directed to vital organs)

mildly anxious & restless
BP slightly <NL
HR elev.
RR elev.

Front 67

what is #3 Decompensating shock?

Back 67

dec O2 available at cellular level, body can no longer compensate!

changes in MS
BP rapidly falling <90 sys
HR elev. >120
RR elev. >30

Front 68

what is #4 irreversible shock?

Back 68

body loses all abilities to compensate!!
mortality rate>65%
permanent organ damage (energy stores depleted, cell memb compromised, organ death, varies w/ pt health status)

severe AMS or unconscious
BP <70 or undetectable
HR extremely elev., then rapidly falling
RR extremely elev. >40, then rapidly falling

Front 69

what is the 1st sign of shock??

Back 69

anxiety & restlessness!

other signs & sxs:
rapid breathing
rapid HR
AMS
cold skin
weak peripheral pulses
dec or no urine output
sweating
heart rhythm changes
low BP

Front 70

what are the resuscitative measures for a shock pt.?

Back 70

give appropriate interventions as reqd
- hemorrhage control
- correct airway obstruction
- correct pneumothorax

interventions used are dictated by skill levels of practitioner & agency protocols

Front 71

give 5 points for general shock managment

Back 71

1. position the pt. w/ feet/legs elev. (protect Cspine prn)
2. est. adequate oxygenation
3. gain IV access (admin fluids, ot. is NPO)
4. keep pt. warm & calm
5. add appropriate adjuncts to fluid & O2 tx if able to determine type of shock

Front 72

what is the ultimate measure of resuscitation?

Back 72

URINE OUTPUT

Front 73

what is the ultimate fluid replacement?

Back 73

BLOOD

Front 74

initial therapy is almost always what?

Back 74

IV fluids

Front 75

what makes up 50% of all injuries that lead to death?

Back 75

head trauma!

Front 76

what is the max. GCS score?

Back 76

15

GCS is descriptive and prognostic

Front 77

what are the 3 components of the GCS?

Back 77

1. best EYE response
2. best VERBAL response
3. best MOTOR response

Front 78

GCS best EYE response. give 4 categories.

Back 78

1. no eye opening
2. to pain
3. to verbal command
4. open spontaneously

Front 79

GCS best VERBAL response. give 5 categories.

Back 79

1. no verbal response
2. incomprehensible
3. inappropriate
4. confused
5. oriented

Front 80

GCS best MOTOR response.
give 6 categories.

Back 80

1. no motor response
2. extension to pain
3. flexion to pain
4. withdrawal from pain
5. localizing to pain
6. obeys commands