Msk - Emergency Med

Front 1

Initial Assessment

Back 1

1. Preparation
2. Triage
3. Primary survey (ABCs)
4. Resuscitation
5. Secondary survey (head-to-toe)
6. Continued post-resuscitation monitoring and re-evaluation
7. Definitive care

Front 2

ABCs of trauma care

Back 2

A. Airway maintenance with cervical spine control
B. Breathing and ventilation
C. Circulation with hemorrhage control
D. Disability: Neurological status
E. Exposure/Environmental Control: Completely undress the patient, but prevent hypothermia

Front 3

Airway with Cervical Spine Control

Back 3

Pitfalls:
Assume this in any patient with multi-system trauma, especially with an altered level of consciousness or a blunt injury above the clavicle.

Pitfalls:
1. Foreign body in the airway
2. Mandibular or maxillofacial fracture
3. Tracheal or laryngeal disruption
4. Cervical spine injury

Front 4

Breathing

Back 4

1. Tension pneumothorax
2. Flail chest wil pulmonary contusion
3. Open pneumothorax
4. Massive hemothorax

Front 5

EVALUATING CIRCULATION

Back 5

• Capillary Refill: takes less than 2 secs for pink color to return when fingernail blanches (normally) - if takes longer, it shows decreased peripheral perfusion (happens also in very cold room)
• Pulse: heart rate and stroke volume (people who are hypovolemic will have increased heart rate) - weak thready pulse - poor perfusion - sign of SHOCK
o Last thing to change when hypovolemic is blood pressure - going into shock, but blood pressure might be normal (it's the last thing to go)

Front 6

BLEEDING:

Back 6

direct pressure best way to control bleeding
 Turnicates can cause ischemia to extremities
 Pelvic fractures and femur fracs bleed a lot!!
 EXTERNAL SEVERE HEMORRHAGE IS IDENTIFIED AND CONTROLLED IN THE PRIMARY SURVEY
 Use of bedside ultrasound too

Front 7

DISABILITY

Back 7

• AVPU - way to do brief neuro exam
• Alert, respond to Voice, respond to Pain, or Unresponsive
• Glasgow Coma Scale - more detailed exam
• Don't fall into pitfall of thing altered level of consciousness is limited to drugs and alcohol - it's a diagnosis of exclusion - if don't find anything else first, then look to this

Front 8

Circulation

Back 8

If need to give blood right away, need to give them O-neg blood
1 patient - 70 units of blood - some people require very large amounts

Front 9

Where is blood kept? Fridge

Back 9

IV fluid - kept at room temp - body temp is 20 deg. Higher
• Potential for hypothermia from IV fluids
• When trauma, bleeding patient gets hypothermic, you're knocking out coagulation factors, platelet function - so ultimately they'll just bleed more

Front 10

Shock = inadquate perfusion to meet needs of body

Back 10

• Compensated Shock - signs of hyperperfusion, but you've got normal bp
• Decompensated Shock - signs plus hypotensive bp

Front 11

Secondary Survey: H&P

Back 11

AMPLE
• A = Allergies
• M = medications currently taking (some meds will make management of trauma more complicated - coumadin or warfarin, or aspirin e.g.)
• P = past illnesses (focus on HTN, diabetes, e.g.)
• L = last meal (could be at risk for aspiration if they have to intubate you)
• E = events (what was the mechanism involved in your trauma )

Front 12

Mech of Injury: Frontal impact
Bent steering wheel
Knee imprint in dashboard
Bull’s eye fracture of windshield (head hit windshield)

Back 12

Suspected Injury Patterns
Cervical spine fracture
Anterior flail chest
Myocardial contusion
Pneumothorax
Transection of aorta (decelerating injury)
Fractured spleen or liver
Posterior fracture/dislocation of hip
and/or knee

Front 13

Mechanisms of Injury
Side impact to automobile

Back 13

Suspected Injury Patterns:
Contralateral neck sprain
Cervical spine fracture
Lateral flail chest
Pneumothorax
Traumatic aortic rupture
Diaphragmatic rupture
Fractured spleen or liver
(depending on side of impact)
Fractured pelvis or acetabulum

Front 14

Mechanisms of Injury:
Rear impact automobile collision

Back 14

Suspected Injury Patterns:
Cervical spine injury

Front 15

Mechanisms of Injury:
Ejection from vehicle

Back 15

Suspected Injury Patterns:
Ejection from the vehicle precludes
meaningful prediction of injury
patterns but places the patient at a
greater risk from virtually all injury
mechanisms.
Mortality is increased significantly.

Front 16

Mechanisms of Injury:
Motor vehicle-pedestrian

Back 16

Suspected Injury Patterns:
Head Injury (rebounds off car)
Thoracic and abdominal injuries
Fractured lower extremities

Front 17

Penetrating Trauma

Back 17

a small bullet can go thru body w/o touching anything, but cause huge lacerations n such due to high kinetic energy--shock wave propogates in all directions (higher mortality rate, compared to knife stab)

Front 18

• Why you always get head CT

Back 18

o Intercranial injury: subdural, epidural, subarrachnoid are most common

Front 19

Neurological - Pain Management

Back 19

Fentanyl - short acting, and doesn't cause as much hypotension as other narcotics might - causes minimal histamine release

Front 20

Neurological

Back 20

• COMPLETE IMMOBILIZATION OF ENTIRE PATIENT IS REQUIRED AT ALL TIMES UNTIL SPINE INJURY EXCLUDED - ESPECIALLY WHEN PATIENT TRANSFERRED

Front 21

Abdomen

Back 21

--CT scan really important for any distension/tenderness/etc
--Ultrasound not as great--can't see retroperitoneal area (bleeding)

Pitfalls:
1. Liver or splenic rupture
2. Hollow viscus and lumbar spine injuries (seat belts, deceleration)

Front 22

B. Resuscitation

Back 22

1. Oxygenation and ventilation
2. Shock management—intravenous lines, Ringer’s lactate
3. The management of life-threatening problems identified in the primary survey is continued.
4. Monitoring
a. Arterial blood gases and ventilatory rate
b. End-tidal carbon dioxide
c. Electro-cardiograph
d. Pulse oximetry
e. Blood pressure

Front 23

C. Secondary Survey—Total Patient Evaluation

Back 23

1. Head and skull
2. Maxillofacial
3. Neck
4. Chest
5. Abdomen
6. Perineum/rectum/vagina
7. Musculoskeletal
8. Complete neurological examination
9. Appropriate roentgenograms, laboratory tests and special studies
10. “Tubes and fingers” in every orifice

Front 24

D. Definitive Care

Back 24

After identifying the patient’s injuries, managing life-threatening problems and obtaining special studies, definitive care begins. Definitive care, associated with the major trauma entities, is described in later chapters.

Front 25

E. Transfer

Back 25

If the patient’s injuries exceed the institution’s immediate treatment capabilities, the process of transferring the patient is initiated as soon as the need is identified. Delay in transferring the patient to a facility with a higher level of care may significantly increase the patient’s risk of mortality. (See Chapter 12, Stabilization and Transfer.)