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54 Cards in this Set
- Front
- Back
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Why would a patients neurological symptoms get worse when they get to the ER
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1. Ischemia or progression of spinal cord edema
2. Failure to provide adequate immobilization |
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Where do 50% of all spinal injuries result from
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MVC
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Which region of the spinal cord is mostly injuried
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Cervical
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What are 4 ways to classify Spinal Injuries
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1. Fracture
2. Dislocation 3. Spinal Cord Injury Without Radiographic Abnormalities (SCIWORA) 4. Penetrating injury |
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What is a primary cord injury
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1. Damage is immediate and irreversible. The injury is directly to the nerve tissue itself (i.e. cut cord)
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What is secondary cord injury
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Results from the body's response to an injury (i.e. hypoxia, shock inflammation) We have impact on this one
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Which MOI should you consider to have spinal trauma
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1. Fall greater than 10 feet/3meters (1 story/5 stairs)
2. Getting hit by a car 3. Car accident 4. Diving accident |
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What are the symptoms of spinal trauma
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1. Neck/back pain
2. Paralysis 3. Sensory dysfunction (numbness/tingling) 4. Loss of bladder control 5. Perineal (saddle) anesthesia (numbness in groin region) |
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When is spinal assessment performed
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It is part of the secondary survey BUT cervical spinal precaution should be part of the primary survey (Airway & C spine, Breathing, Circulation)
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What are some exam findings that suggest spinal trauma
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1. Pain on movement or palpation
2. Obvious deformity 3. Loss of sensation 4. Loss of rectal tone/incontinence/Priaprism 5. Weak/flaccid muscle 6 Spinal shock |
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What is spinal shock
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Autonomic nervous system malfunction
Low BP Normal/low HR Warm, pink skin Diagnosis of exclusion (treat as hemorrhagic shock until proven otherwise) |
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What are the Canadian C-Spine Rules
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If the following 3 criteria are met imagining is not necessary
1. No high risk factor (>64, dangerous MOI, high speed vehicle crash) 2. A low risk factor present (simple rear end, ambulatory at any time) 3. Able to rotate the neck actively (45degrees) |
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What is the Nexus Criteria
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If following 5 criteria are met no risk of cervical spine fracture and no X ray is needed
1. No posterior midline tenderness 2. No neurological deficit 3. Normal level of consciousness 4. No intoxication 5. No painful distracting injury |
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Which radiologic investigations would you use
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Lateral neck x ray alone (75% of injuries seen)
AP and odontoid view (add 10-15% more sensitivity) CT is more sensitive but can miss ligament injuries |
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What do you look for in the x-ray
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1. 4 lines of alignment (anterior vertebral line, posterior vertebral line, spinolaminal line, interspinous line)
2. Shape of vertebral bodies 3. Soft tissue swelling (< 7 mm in front of C2; < 22mm in front of C6) 4. Predental space (distance between anterior aspect of dens and posterior aspect of C1)(< 3 mm) |
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What do you look for in the odontoid view x-ray
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1. Fracture of odontoid
2. Widening of C1 relative to C2 3. Asymmetry of the space on each side of odontoid and C1 |
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Why do thoracic injuries have lower incidence
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More restricted movement and has additional support from ribs
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What are the 3 categories thoracic spinal fractures are classified
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1. Anterior wedge compression
2. Burst injury 3. Chance fractures (T12-L1) |
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Why are there less neurologic deficits with lumbar spine injuries
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Increased space around cord/cauda equina
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How do you treat a spinal cord injury
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1. Immbolize for transport (use C spine and backboard but remove board as soon as you get into ER)
2. Hydration: limit IV because you don't want to cause swelling or cord, determine if neurogenic or hypovolemic shock and put in catheter 3. Do not give steroids |
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What is prolonged immobilization bad
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Can lead to ulcers
Once removed from spine board roll the persons legs every 2 hours |
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What should you consider for a pregnant patient
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Uterus can push on inferior vena cava therefore 20-30 degree tilt to the left (> 20 weeks pregnant)
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What is low volume shock
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Hemorrhagic or other fluid loss (absolute hypovolemia)
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What is high space shock
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Neurogenic shock (relative hypovolemia)
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What are the 2 types of mechanical shock
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1. Obstructive (cardiac tamponade, tension pneumothorax)
2.Pump Failure (Heart contusion) |
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Describe the progression of shock
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It is on a continumum
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What are the symptoms of shock caused by
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Catecholamines
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What is compensated shock
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Trying to maintain BP but narrowing pulse because of vasodilation
Weak and light headed Pallor Tachycardia, diaphoresis, tachypnea Urinary output decreased |
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What is decompensated shock
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Loss of catecholamine response causing a drop in BP
Tissue hypoxia leads to acidosis Compensated shock suddenly crashes |
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What is the progression of decompensated shock
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1. Hypotension
2. Altered mental status 3. Organ failure and cardiac arrest |
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How do you manage shock
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1. Maintain airway
2. Maintain oxygenation and ventilation 3. Control bleeding 4. Always assume hemorrhagic until proven otherwise 5. Maintain circulation (aggressive replacement of intravascular volume) |
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How do you manage an external hemorrhage that can be controlled
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1. Control bleed with pressure
2. Supine position 3. 100% O2 4. IV access and fluid bolus 5. Ongoing assessment |
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How do you manage a hemorrhage that can not be controlled
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1. DONT try clamping bleeding vessels
2. Use tourniquets 3. Put BP cuff on until its higher than systolic BP |
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How do you manage an internal hemorrhage
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1. Supine
2. 100% O2 3. IV fluids 4. Reassess and monitor 5. Cross and Type of blood |
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For treating hemorrhagic shock how are the way to get access to the vasculature
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1. Peripheral access (2 14-18 G IV)
2. Introsseous 3. Central access (hard to do in ER) |
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What are the types of crystalloids do you use
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1. Normal saline = what most people use
2. Lactate Ringer = has some bicarb in it 3. Hypertonic saline = draws fluid into intravascular space |
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What is the optimal fluid to give
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1. Crystalloid is the initial fluid for all trauma (1 L)
2. Blood (pRBC) O negative is universal donor Cross matched is the most compatible |
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Why is fluid requirement is 3x the blood loss
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Due to redistribution of fluid in body compartments (IVF, ECF, ICF)
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What would you do for fluid resuscitation
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1. Crystalloid 1 liter bolus
If inadequate after 1 litre call from pRBC Give 2nd litre of NS and consider starting blood (Kids 20 ml/kg bolus) |
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What are the 3 responses to fluids
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1. Rapid responder = blood loss fully replaced and no further loss suspected
2. Transient responder = blood loss replaced but may have ongoing occult blood loss (need CT or U/S) 3. Non-responder = massive and probable ongoing blood loss |
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How much does pRBC raise Hct
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3%
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When is pRBC needed for transfusion
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1. MOI (penetrating wound)
2. Cluster of injuries 3. Physiology (low BP, extreme tachycardia) |
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How do you know if you have an adequate response to fluid therapy
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1. Increase in BP and decrease in HR
MAP (1/3 systolic + 2/3 diastolic) = 80-90 (head injury) (65 for young and healthy) 2. End organ perfusion 3. Hgb 70-90 or Hct > 20% |
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What is permissive hypotension
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Over agressive fluid resuscitation can increase bleeding by diluting clotting factors and clot dislodgment by raised BP
Applicable to penetrating toro trauma where there is direct access to OR |
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What is a massive transfusion
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> 10 units pRBC in 24 hours
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How can you predict a massive transfusion
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Penetrating mechanism
SBP < 90 HR > 120 Positive FAST 2 factors 40% 3 factors 50% 4 factors 100% |
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What can massive transfusion cause
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Hyperkalemia
Hypocalcemia Hypothermia Coagulopathy Immunosuppression |
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How do you address coagulopathy in massive transfusion
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1 unit pRBC: 1 unit Fresh Frozen Plasma: 1 unit platelets
Some suggest FFP when INR > 1.5 and Plts when < 50 |
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What is Tranexamic Acid
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Antifibrynolytic
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How is tranexamic acid given and when is it most effective
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1 gm IV initially then 1 gm in 8 hours
Most effective if given within 3 hours and if SBP < 75 |
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What is obstructive mechanical shock
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Obstructs blood flow to or through heart (slows venous return, decreases CO)
Cardiac tamponade Tension Pneumothorax MI contusion |
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What is high space shock
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Blood going to periphery when it shouldn't (spinal, neurogenic, distributive shock)
Found after spinal cord injury Systemic vasodilation (vasculature space now too large for circulating volume) |
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What would you see on the exam of a high space shock
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1. Decreased BP
2. HR normal or slow 3. Skin warm and pink |
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How do you treat high space shock
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1. Supine
2. 100% O2 3. IV fluids 4. Monitor central venous pressure 5. Vasopressors |
