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231 Cards in this Set

  • Front
  • Back
Trauma remains a major cause of death for people ages 1 to __ years of age

44


Ch1 - pg1

First TNCC course was 19_ _

1986


Ch1 - Pg2

Trauma is ___

injury to the living tissue caused by an extrinsic agent


Ch3 - pg9

Unintentional injury remains the ____ leading cause of death across all ages in the U.S. and the leading cause of death for people ages 1 to ___ years.

5th leading cause of death.


44 years of age


Ch3 - pg9

Leading cause of injury related deaths for individuals 65yo and older is ___

Falls


Ch3 - pg9

Leading cause of death for ages 25 to 64 is ___

Poisoning


Ch3 - pg9

Leading cause of death for ages 5 to 24 is

MVCs


Ch3 - pg9

In 2009 nearly ___ of all traffic related deaths involved alcohol.

1/3


Ch3 - pg10

Homicide is one of the top ___ causes of injury related death for individuals 1 to 44yo, the ___ leading cause of death for those 15 to 24yo, and the ____ leading cause for ages 1 to 4 and 25 to 34

5


2nd


3rd


Ch3 - pg10

Primary Injury Prevention
prevention of the Occurrence of the injury
Secondary Injury Prevention
Reduction in the Severity of the injury that has occurred.
Tertiary Injury Prevention
Improvement of outcomes related to the traumatic injury
Kinematics

The study of energy transfer as it applies to identifying actual or potential injuries.


Ch4 - pg25

Biomechanics

The general study of forces and their effects.


Ch4 - pg25

Mechanism of Injury

How external energy forces in the environment are transferred to the body.


Ch4 - pg25

Potential energy =


Kinetic energy =

Potential energy = "at rest" pot of water on the edge of a stove.


Kinetic energy = "in motion", pot of water falling on the floor


Ch4 - pg25



Newtons 1st Law of Motion

A body at rest will remain at rest, and a body in motion with staty in motion.




Pot stays on the stove until the toddler grabs the handle. Once in motion it stays in motion until it strikes the toddler on the head.


Ch4 - pg26

Newtons 2nd Law of Motion

Force = Mass x Acceleration


Force is proportional to Acceleration(the more force is applied to an object the more it accelerates). More force is needed to move a large mass object than a small mass object.




Ch4 - pg26

Newtons 3rd Law of Motion

For every action, there is an equal and opposite reaction.


Ch4 - pg26

Law of Conservationo of Energy


Energy cannot be created nor destroyed, but it can change form.


Energy is transferred from kinetic object to the object being impacted.


Ch4 - pg26


Concomitant (definition)

naturally accompanying or associated


Ch4 - pg26

KE = 1/2MV^2



Kinetic Energy = 1/2 Mass x Velocity^2


KE =1/2(6kg)(2m/s)^2




When Mass is doubled energy is doubled. When Velocity is doubled energy is quadrupled. (high velocity rifles have the capability to transfer more energy to their target)


Ch4 - pg27



Structural Strength : 1of3


Compression Strength

Compression injuries to organs when seatbelt worn high on abdomen, causing compression of small bowel or fracture to the lumbar spine


Ch4 - pg 27

Structural Strenght : 2of3


Tensile Strength

Ability for tissue to resist pulling apart when stretched.


Tendons, ligaments, muscles


Ch4 - pg27



Structural Strength : 3of3


Shear Strength

Tissues ability to resist a force applied parallel to the tissue.


Coup/countrecoup


Ch4 -pg27

Attenuated (definition)
Weakened in force or effect
Deleterious (definition)
Causing harm or damage
____ _____ can result from broad energy impacts across large surface areas and involve energy transfer causing deceleration or acceleration

Blunt Trauma


Ch4 - pg28

A fall is considered significant in the pediatric patient if the fall is from _____ times the childs height.

3 times


Ch4 - pg28

MVC 3 Impacts

1st : Vehicle striking object.


2nd : Occupant collides with interior of vehicle.


3rd : Internal structures collide within the body cavity.


Predicting survivability is based on velocity and stopping distance.


Ch4 - pg29

Frontal Collision


"up and over" path

Head and chest lead the way to the windshield.


Associated with head, neck, chest, and abdominal injuries.


Can occur when no seatbelt is used.


Ch4 - pg29

Frontal Collision


"down and under" path

Associated with lower extremity and pelvic fractues.


Can occur when seatbelt is placed above the pelvis.

Lateral Collision



Associated with shear injuries to the aorta, and other organs, fracture of the side of the clavicle, lateral pelvic and abdominal injuries, and lateral head and neck injury.


Ch4 - pg30

Rotational Collision


(vehicle is struck on one corner, causing vehicle to move around pivot point)

combination of frontal and lateral collision injuries.


Ch4 - pg30

Rear Impact Collision

Result in immediate forward acceleration.


Extension and flexion of the neck as well as frontal impact injuries.


Ch4 - pg30

Motorcycle : low side crash "laying the bike down"

Sliding does not slow the bike down quickly.


Abrasions, shoulder and clavical injuries, and lateral head and lower extremity injuries are common.


Ch4 - pg31

Motorcycle : high side crash (begins to crash to the low side then grabs traction and flips)

Catapults rider.


All injuries with a low side crash as well as those associated with the speed and impact of landing.


Ch4 - pg31

Motorcycle : head on impact

Ejects the rider forward.


Lowe extremities can collide with handle bars, fracturing femur, pelvis.


Remaining injuries depend on subsequent collisions.


Ch4 - pg31

Motorcycle : lateral or angular impacts

May result in initial lower extremity crush injuries followed by shoulder and head when rider tumbles over car.


Ch4 - pg31

Vehicle versus pedestrian injuries

Adults : Crush force to the lower extremity. Adults tend to try to escape resulting in lateral and posterior impacts.


Children : tend to turn toward vehicle, causing anterior impact. Commonly thrown onto hood and slides off hood onto ground. Waddell triad - head, thorax, lower extremity injuries.

Waddells Triad

Children struck by vehicles.




1)Fractured femoral shaft


2)Intra-abdominal or Intra-thoracic injuries.


3)Contralateral head injuries




Ch4 -pg31, internet

Cavitation

Refers to the separation of tissue resulting from a sound and/or hydraulic wave force.


Ch4 - pg32

Yaw

Yaw of a projectile is its ability to wobble up and down.


Produces a waved cavitation pattern


Ch4 - pg32

Tumble
Tumble of a projectile is when it rotates end over end.Causes a larger surface area to come into contact with tissue and transfer more energy to the tissue.

Referring to kinetic energy: when velocity is doubled energy is

Quadrupled


Ch4 - online module

____ organs, such as the ___ are more likely to shear under cavitation forces. Whereas ____ organs such as the ____ can tolerate them more due to their elasticity

Solid


Liver


Air-filled


Lungs


Ch4 - online module

Blast Trauma : Overpressure

victim enveloped on all sides with crush forces


Ch4 - pg33

Blast Trauma : Dynamic pressure
Directional, similar to a gust of wind. Can cary fragments and debris at high velocity.
Primary Blast injuries

Found closest to the detonation. Air filled organs (TM, lungs, stomach and bowel) most susceptible.


Ch4 - pg33

Secondary Blast injuries

Include fragment injuries and generally cause the greatest number of casualties. Puncture wounds, lacerations, impaled objects.


Ch4 - pg33

Tertiary Blast injuries

Impacts with larger objects propelled by the blast wind resulting in blunt trauma. Can also propel the patient into objects causing blunt trauma.


Ch4 - pg33

Quaternary Blast injuries

result of heat, flame, gas and smoke. External and internal burns from inhaled hot gases


Ch4 - pg33

Quinary Blast injuries

Associated with exposure to hazardous materials from NBC components of the blast.


Ch4 - pg33

Which of the following is the best measure of the adequacy of cellular perfusion and helps to predict the outcome of resuscitation?

Base Deficit


TNCC practice test

Treatment for frostbite includes:

Administer Aspirin


TNCC practice test

Normal vital signs in pregnancy Rationale: In pregnancy, the resting heart rate increases by __ to __ beats/minute and a small decrease in systolic blood pressure and a larger decrease in diastolic blood pressure. Normal fetal heart rate is between ___ and ___ beats/minute (pp. 226, 228 ).

Normal vital signs in pregnancy Rationale: In pregnancy, the resting heart rate increases by 10 to 20 beats/minute and a small decrease in systolic blood pressure and a larger decrease in diastolic blood pressure. Normal fetal heart rate is between 120 and 160 beats/minute (pp. 226, 228 ).


TNCC - practice test

Initial Assessment : A to I

A = Airway and alertness with C-spine stabilization


B = Breathing and Ventilation


C = Circulation and control of hemorrhage


D = Disability (neurologic status)


E = Exposure and Environmental control


F = Full set of vitals and family presence


G = Get resuscitation adjuncts (L=Lab studies, M=Monitor cardiac rate rhythm, N=Naso or orogastric tube insertion, O=Oxygenation and ventilation analysis[pulse ox, ETCO2], P=pain assessment and management)


H = History and Head to toe assessment


I = inspect posterior surfaces


Ch5 - pg39

Across the Room Observation

completed as the patient is brought into the room. This can allow for rapid determination of the pt overall physiologic stability and the identification of any uncontrolled external hemorrhage.


Ch5 - pg40

MARCH acronym

M = Massive Hemmorhage - control life threatening bleeding.


A = Airway - establish and maintain a patent airway.


R = Respiration - decompress suspected tension pneumothorax, seal open chest wounds, and support ventilation and oxygenation as required.


C = Circulation - vascualer access, and administer fluids as required to treat shock


H = Head injury/Hypothermia - prevent or treat hypotension and hypoxia to prevent worsening TBI and prevent or treat hyhpothermia.


Ch5 - pg40

MIST acronym

Used during the History


M = MOI


I = Injuries sustained


S = Signs and symptoms (in the field)


T = Treatment (in the field)


Ch5 - pg47

Large volumes of fluid infused lead to ____ coagulopathy which worsens _____ and may cause _____

dilutional


metabolic acidosis


hypothermia


Ch5 - pg45

Lactic Acid is associated with hypoperfusion


Lactic acid level greater than _ to _ mmol/L is associated ith poor outcomes

2 to 4 mmol/L


Ch5 - pg 46

ABG :


A base deficit of less than ___ is associated with poor outcomes

-6


Ch5 - pg47

SAMPLE acronym

Used in patient History.


S = Symptoms associated with the injury


A = Allergies and tetanus status


M = Medications currently used (anticoagulants)


P = Past medical history


L = Last oral intake


E = Events and Environmental factors related to the injury


Ch5 - pg48

Contraindication for insertion of Nasogastric tube

Suspected CSF


Ch5 - pg49

Contraindications for insertion of urinary catheter (5)

Blood at the urethral meatus


Perineal ecchymosis


Scrotal ecchymosis


High riding or nonpalpable prostate


Suspected pelvic fracture


Ch5 - pg50



Upper Airway components

Nose, mouth, pharynx, larynx, epiglottis, and trachea


Ch6 - pg55

Lower Airway components

Bronchi and lungs


Ch6 - pg55

Vagal response

Stimulation of vagus nerve (CN X) which serves as primary parasympathetic nerve.


Can be stimulated during intubation.


Stimulation can cause bradycardia, bronchial vasoconstriction, and increased ICP


Ch6 - pg55

SaO2 is

Arterial saturation. the percentage of hemoglobin saturated with oxygen as determined by an ABG


Ch6 - pg59

SpO2 is

pulse oximetry reading of arterial saturation (SaO2) and is measured as a percentage


Ch6 - pg59

PaO2 is

Reflection of tissue oxygenation. The partial pressure of oxygen dissolved in arterial blood and is measured in mm/Hg.


Ch6 - pg59

PaCO2 is

partial pressure of carbon dioxide dissolved in the blood and is measured in millimeters of mm/Hg.


Ch6 - pg59

FiO2 is

The inspired concentration of oxygen measured in a percentage.


Room air is 21%


Ch6 - pg59

Hypoxemia is

oxygen deficiency within arterial blood and is measured by SpO2, SaO2, or PaO2


Ch6 - pg59

Hypoxia is

a deficiency in oxygen perfusion of the tissues. It is not directly measurable but is considered to be present in decreased paO2


Ch6 - pg59

Jaw Thrust in sunspected cervical spine injury

"may be best performed by 2 providers". One maintains cspine, one performs jaw thrust.


Ch6 - pg59

Bag Valve Mask Ventilation rate

10-12 breaths per minute


one breath every 5-6 seconds


Ch6 - pg61

Nasopharyngeal Airway contraindicated in

patients with facial trauma or a suspected basilar skull fracture.


Ch6 - pg62

3 indications for definitive airway management in emergency or trauma

1) Failure to maintain or protect the airway


2) Failure to maintain oxygenation or ventilation


3) a specific anticipated clinical course


Ch6 - pg63

CO2 is the end product of ____ and a reflection of ___ and ____

Ventilation


metabolism and pulmonary function


Ch6 - pg66

DOPE acronym for troubleshooting ventilator or capnography alarms

D = Displaced tube


O = Obstructed or kinked tube


P = Pneumothorax


E = Equipment failure


Ch6 - pg66

Hyperoxia outcomes


Recommended SpO2 and PaO2

1) Hyperoxic patients had two times the inhospital mortality than patients who were normoxic.


2) May decrease hemodynamic stability


Recommended SpO2 between 94% and 98%


Recommended PaO2 between 100 and 200 mm Hg


Ch6 - pg66

7Ps of RSI

Preparation


Preoxygenation - 94%


Pretreatment - medication to mitigate adverse effects associated with endotracheal intubation (lidocaine for ICP)


Paralysis with Induction


Protection and Positioning


Placement with Proof


Post intubation Management - secure tube, CXR.


Ch6 - pg69-71

Shock definition

Inadequate tissue perfusion, resulting from insufficient oxygen delivery, uptake, and utilization to meet the metabolic demands of cells and organs.


Ch7 - pg73

4 Types of Shock

Hypovolemic


Obstructive


Cardiogenic


Distributive


Ch7 - pg73

____ shock from ____ is the leading cause of preventable deaths in trauma patients

Hypovolemic


hemorrhage


Ch7 - pg73

Obstructive Shock definition

hypoperfusion of the tissue due to an obstruction in either the vasculature or the heart.


Ch7 - pg73

Cardiogenic Shock definition

pump failure in the presence of adequate intravascular volume


Heart Failure is an example of chronic.


Ch7 - pg74

Distributive Shock definition

maldistribution of an adequate circulating blood volume with the loss of vascular tone or increased permeability.


Ch7 pg75

Hypovolemic Shock definition

decrease in the amount of circulating blood volume


Ch7 - pg73

Hypovolemic Shock Etiologies

Hemorrhage


Burns


Ch7 - pg74

Cardiogenic Shock Etiologies

Myocardial Infarction - decr cardiac contractility


Dysrhythmias - decr cardiac output


Blunt cardiac trauma - decr contractility and dysrhythmias


Ch7 - pg74

Obstructive Shock Etiologies

Cardiac Tamponade


Tension Pneumothorax


Tension Hemothorax


Ch7 - pg74

Distributive Shock Etiologies

Neurogenic shock


Anaphylactic shock


Septic shock


Ch7 - pg74

Class 1 Hypovolemic Shock

Blood Loss = 750ml


Blood % = 15%


HR = <100


Systolic = normal


Pulse Pressure <Normal or increased


RR = 14-20


Urine output = >30


CNS = slightly anxious


Initial fluid replacement = Crystalloid

Class 2 Hypovolemic Shock

Blood Loss= 750-1500


Blood %= 15-30%


HR= 100-120


Systolic= Normal


Pulse Pressure = decreased


RR= 20-30


Urine output = 20-30


CNS= Mildly anxious


Initial fluid replacement = Crystalloid


Ch7 - pg75

Class 3 Hypovolemic Shock

Blood Loss= 1500-2000


Blood %= 30-40


HR= 120-140


Systolic= Decreased


Pulse Pressure = Decreased


RR= 30-40


Urine output5-15


CNS= anxious, confused


Initial fluid replacement = Crystaloid and blood

Class 4 Hypovolemic Shock

Blood Loss= >2000


Blood %= >40%


HR= >140


Systolic= Decreased


Pulse Pressure = Decreased


RR= >35


Urine output= Negligile


CNS= confused, lethargic


Initial fluid replacement = crystalloid and blood

Pregnant Pt HR increases

10-20 beats per minute, increasing cardiac output.


Ch16 - Online slides.

Increased hormonal levels in pregnancy can cause __ which may ___ __....

vasodilation, which may make the pregnant patient in shock appear warm and dry.


Ch16 - Online slides.



Plasma volume increases ___ to ___ by the ____ week

30-50%


by the 30th week.


Ch16 - Online slides

Abdominal palpation is more or less reliable in a pregnant patient?

Less because the organs are displaced, abdominal wall muscles are stretched, bowel sounds are less audible.


Ch16 - Online slides

Kleihauer Betke (KB) test

can test for fetal RBC in maternal circulation, can be a sign of hemorrhage of fetal blood through the placenta. and RH incompatibility


Ch16 - Online slides

Increased plasma in pregnancy...

by the 30th week can cause dilutional anemia and decrease in Hct 32%-34%


Ch16 - Online slides

_____ and _____ are the leading causes of maternal death in pregnancy

Brain injury and Hemorrhagic shock


Ch16 - Online slides

Estimating pregnancy length by fundal height.


Symphysis


Umbillicus


Costal

Symphysis 12weeks


Umbillicus 20weeks


Costal 36weeks


Ch16 - Online slides

Amniotic fluid Ph is


Urine ph is

Amniotic fluid ph is 7.5, urine Ph is 4.6-6.


So any obvious fluid in the vaginal vault is ph tested.


Ch16 - Online slides

Preterm labor is present in up to ___% of pregnant trauma patients

25%


Ch16 - Online slides

Cardiac Output =

Stroke Volume x HR


Ch7 - pg76

Afterload ...aka

peripheral vascular resistance


So a tension pneumothorax can change intrathoracic pressure causeing increase in afterload and compressing the hear and venae cavae decreasing preload.


Ch7 - pg76

Increased diastolic BP and _____ may be one of the first concrete measurements signaling compensation for shock.

Increased diastolic BP and narrowing pulse pressure.


Ch7 - pg76

Trauma Triad of Death

Caogulopathy


Hypothermia


Metabilic Acidosis


Ch7 - pg79

Stages of Shock


Stage 1 =


Stage 2 =


Stage 3 =

Stage 1 = Compensated


Stage 2 = Decompensated or Progressive


Stage 3 = Irreversible


Ch7 - pg78

Stage 1 Shock

Compensated


Subtle changes in LOC and vital signs.


Anxiety, lethargy, confusion, restlessness.


Systolic BP = usually normal


Diastolic = usually rising with narrowing pulse pressure.


Pulse = bounding or tachycardic


RR = increased


Urinary output = decreased


Ch7 - pg79

Stage 2 Shock

Decompensate or Progressive


LOC = Obtunded or unconscious


SBP = Normal or slightly decreased


DBP = Narrowing pulse pressure


Pulse = >100, weak and thready


RR = rapid and shallow, to correct acidosis


Skin = cool and clammy, cyanotic


Base Excess = -2 to +2


Serum Lactate = 2-4


Ch7 - pg79

Stage 3 Shock

Irreversible Shock


LOC = obtunded, stuporous, or comotose


SBP = marked hypotension


Pulse = bradycardia with possible dysrhythmias


RR = decreased and shallow


Skin = pale, cool, clammy


Severe acidosis


coagulopathies with petechiae, purpura, or bleeding


Ch7 - pg79

Damage Control Resuscitation

Principle that focuses on prevention rather than intervention. 2 Strategies.


1) Hypotensive Resuscitation - Large volumes of crystalloid is associated with increased bleeding and decreased survival. Less fluids to prevent "popping the clot". Goal is not hypotension, but adequate resuscitation without hypertension.


2) Hemostatic Resuscitation - Hemorrhage control. Transfusion of RBC : FFP given in a 1:1 ratio.


Ch7 - pg80

Hypocalcemia with Massive Transfusion of blood

Citrate is a preservative added to blood for transfusion.


Citrate binds to calcium rendering it inactive.


Calcium is a part of the clotting cascade.


3G of Citrate is added to every unit of blood.


A healthy liver can metabolize 3G every 5minutes.


Sooo...If a trauma patient requires more than 1 unit of blood every 5 minutes...prepare for citrate toxicity and Hypocalcemia.


Give Calcium gluconate or calcium chloride.


Ch7 - pg81



Autotransfusion of blood time limit recommendation

within 6hours


Ch7 - pg81

TXA

A synthetic version of amino acid lysine.


Antifibrinolytic that inhibits activation of plasminogen(dissolves clots).


Ch7 - pg81

One unit of PRBCs is estimated to increase HgB by __ and Hct by ___%

1G


3%


Ch7 - pg83

What measurement is the gold standard for dependable and precise blood pressure readings

Mean Arterial Pressure.


Ch7 - pg83

Output of less than ____ per hour for ___ consecutive hours indicates _____

0.5mL/kg per hour for 2 consecutive hours indicates oliguria.


Ch7 - pg84

Neurons receive sensation in 4 ways

1)Discriminative touch - helps identify objects by feel.


2) Proprioception - relates a sensof movement and position of the body within the environment


3) Temperature


4) Nociception - perception of pain and irritation (itch, sting, tingle)


Ch8 - pg91

Nociception involves 4 inter-related processes

Transduction - Transmission - Perception - Modulation


Transduction = mechanical and thermal sensations from injury. Chemical stimulation from inflammatory responses.


Transmission - through the spinothalamic tracts


Perception - pain threshold, pain tolerance, and expression of pain.


Modulation - neuromodulators can slow down or inhibit the pain ie-endorphin.


Ch8 - pg92-93

Pain as defined by International Association for the Study of Pain

an unpleasant sensory and emotional experience associated with actual or potential tissue damage


Ch8 -pg93

Oligoanalgesia (definition)

the concept of undertreatment of pain.


Ch8 - pg94

The most reliable and valid tool for pain assessment is ___

self report


Ch8 - pg95

Response to Sympathetic (acute pain)

Increased SBP, HR, RR, alertness, rapid speech


Cerebral v asodilation


Pupillary dilation


Ch8 - pg96



Response to Parasympathetic (chronic pain)

Decreased, SBP, HR, slowed speach


Syncope


Variable respiratory patterns


Pupillary constriction


Ch8 - pg96

WHO pain steps

Step 1 - non-opiods for mild (1-3). Tylenol, motrin, toradol.


Step 2 - weak opiods for mild to mod (4-6). Codeine, Nalbuphine.


Step 3 - strong opiods for moderate to severe(7-10). Morphine, Fantanyl dilaudid.


Ch8 -pg98

Minimal Sedation (anxiolysis)

cognitive function and coordination may be impaired, but cardiovascular and ventilator functions are unaffected.


Ch8 - pg99

Moderate Sedation
depression of consciousness in which patients can respond purposefully to verbal commands and can independently maintain a patent airway.
Deep Sedation

Depression of consciousness, patients cannot be easily awakened, can respond purposefully to repeated or painful stimuli. Spontaneous ventilation and maintenance of airway patency may require assistance.


Ch8 - pg 99

General Anesthesia

Loss of consciousness. Patients cannot be aroused. Cardiovascular function may be impaired. Airway and ventilator support is required.


Ch8 - pg99

American Society of Anesthesiologists recommends limiting last oral intake of clear liquids to ___ hours and of solid food or milk to ____ before the procedure

Clear liquids to 2hours.


Solid food or milk to 6 hours.


Ch8 - pg99

The scalp consists of 5 layers of tissue, use the acronym SCALP

Skin


Connective tissue


Aponeurosis(galea aponeurotica)


Loose areolar tissue


Pericranium


Ch9 -pg105

Meninges consist of 3 layers of protective coverings. PAD

Pia mater - innermost


Arachnoid membrane


Dura mater - outermost


Ch9 - pg105



____ in the ____ and ___ vetricles of the brain produces CSF


Choroid plexus in the lateral and third ventricles of the brain produces CSF


Ch9 - pg105

associated with normal aging or diseases such as alcoholism.


_____ bleeding may be less evident in patients who have brain atrophy.

Subdural bleeding


Ch9 -pg105

Tentorium cerebelli divides the cranial vault into 2 compartments ____ and ____.


Injury or edema near the tentorium gap may cause compression and shifting of structures and the ____nerve against the tentorium

Supratentorial and infratentorial.


Oculomotor Nerve. The oculomotor nerve CN3 passes through a gap in the tentorium.


Ch9 - pg106

Frontal lobe responsible for (4)

Judgement


Reasoning


Social restraint


Voluntary motor functions


Ch9 - pg106



Parietal lobe responsible for (2)

Spatial orientation


Sensory functions


Ch9 - pg106

Temporal lobe responsible for (3)

Speech


Auditory functions


Memory functions


Ch9 - pg106

Occipital lobe responsible for (1)

vision


Ch9 - pg 106

Blood-brain barrier is __

a filter for the CNS and controls the exchange of oxygen, carbon dioxide and metabolites between the blood and brain.


Ch9 - pg106

Brain uses approximately ___% of the bodys total oxygen supply

20%


Ch9 - pg106

CO2 is a cerebral ____ thus increasing ___ , ____, and ____

CO2 is a cerebral vasodilatory thus increasing cerebral blood volume and perfusion, and ICP


Ch9 - pg107

Acute hypoxia is PaO2 less than _____ and _____ occurs

PaO2 less than 50mm Hg and cerebral vasodilatoion and increased blood flow occurs


Ch9 - pg107

Normal ICP levels

0 - 15 mmHg


Ch9 - pg107

Abnormal ICP is ___

Sustained >20 mm Hg


Ch9 - pg107

Monro-Kellie Doctrine for ICP

As the volume of one component expands (tissue, venous blood, CSF) the volume of one or both of the other componenets must decrease to maintain a constant ICP.


Ch9 - pg107

Cerebral Perfusion Pressure formula


CPP = ___

CPP = MAP - ICP


CPP of 60-100 is normal


ICP of 0 -15 mm Hg is normal


Ch9 - pg107

Cushing Response : symptoms

Widening pulse pressure


reflex bradycardia


diminished respiratory effort


Ch9 - pg 107

Cushing Response : pathophys

Loss of autoregulation(perfusion becomes solely dependent on pressure) can result in cerebral and brainstem ischemia.


This causes the response of the Cushings triad, in an attempt to increase MAP and CPP.


Widening pulse pressure = increased SBP to get more blood to brain.


Reflex bradycardia


Diminished respiratory effort - to increase CO2 and cause cerebral vasodilation.


Ch9 - pg107



Traumatic Brain Injury happens to ___ people annually. Contributes to ____% of the injury related deaths in the US

1.7million people annually


30.5% of the injury related deaths in the US


Ch9 - pg107

Brain Injury classified as


Primary


Secondary

Primary - result from a direct transfer of energy. Skull and facial fractures, intracranial lesions, epidural or subdural hematomas.


Secondary - caused by complex pathophysiologic changes that include the following. Hypotension, Hypoxemia, Hypercarbia, Cerebral edema, increased ICP, decreased CPP, cerebral ischemia.


Ch9 - pg108

Brain loses its ability to autoregulate when CPP is outside the range of ___ and ____

50 and 160 mmHg


Then Cerebral flood flow becomes directly dependent on MAP for perfusion.


Ch9 - pg108

Early Assessment findings of increased ICP

>20mm Hg


Headache,


Nausea, Vomitting,


Amnesia


Altered LOC


Behavior changes(impaired judgement, restlessness, or drowsiness)


Ch9 - pg109

Late Assessment findings of increased ICP

>20mm Hg


Dilated, nonreactive pupils


Unresponsive


Abnormal posturing


Cushing response(widening pp, bradycardia, decreased respiratory effort)


Ch9 - pg109

When autoregulation fails perfusion of the brain depends on the ____

MAP


Autoregulation fails if CPP is not maintained between 50 -150mm Hg.


Ch9 - pg107

A single episode of ____ can be harmful to patient outcomes, especially in the context of head injuries.

Single episode of Hypotension SBP <90.


In the context of head injuries hypotension has been linked to more than double the mortality as compared to normotensive patients.


Ch9 - pg108

Rigid cervical collars may contribute to an ___ in ICP due to ____

Increase in ICP


Due to interfering with venous flow and pain and discomfort


Ch9 - pg109



Bag Valve Mask standard operation :


a breath every ___ to ___ seconds (___ to ___ ventilations per minute).


Deliver each breath over ___ to ___ seconds with just enough tidal volume for chest rise

a breath every 5 to 6 seconds (10 to 12 ventilations per minute). Deliver each breath over 1 to 2 seconds with just enough tidal volume for chest rise


Ch9 - pg110

Unilaterally fixed and dilated pupil may indicate

Oculomotor nerve compression from increased ICP and herniation syndrome


Ch9 - pg 110

Bilaterally fixed and pinpoint pupils may indicate

an injury at the pons or the effects of opiods


Ch9 - pg110

A moderately dilated pupil with sluggish response may be an early sign of

Herniation syndrome


Ch9 - pg110

Periorbital Eccymosis (raccoon eyes) indicate a ___, more specifically a ____

basilar skull fracture


anterior fossa fracture


raccoon eyes have a positive predictive value of basilar skull fracture of 85%(Wikipedia)


Ch9 - pg113



Mastoid process ecchymosis (battle sign indicates a ____, more specifically a ___

basilar skull fracture


middle fossa fracture


Ch9 - pg113

Hemotympanum indicates a ____, more specifically a ____

basilar skull fracture


middle fossa fracture


Ch9 - pg113

Basilar skull fractures - 3 main signs

Periorbital ecchymosis (raccoon eyes)


Mastoid process ecchymosis (battle sign)


Hemotympanum


Ch9 - pg113

FOUR Score

Ranges from 0-16, and provides greater neurologic detail than the GCS score


Eye response, motor response, brainstem reflexes, respiration


Ch9 - pg110

B2 Transferrin test

Test of fluid from otorrhea or rhinorrhea for CSF.


Considered gold standard for identifying CSF.


Ch9- pg113

Cerebral Contusion : maximum effects of contusion and edema formation usually peak ___ to ___ hours after injury

18 to 36 hours


Ch9 - pg114

Intracerebral Hematoma : what is it, signs and symptoms

Occur deep within the brain tissue.


-Progressive and RAPID DECLINE in LOC


-contralateral hemiparesis, hemiplegia, abnormal posturing


Ch9 - pg114

Epidural Hematoma

Collection of blood between the dura mater and the skull.


90% associated with fractures of the temporal or parietal skull that lacerate the middle meningeal artery.


bleeding accumulates rapidly



-transient LOC followed by a lucid period lasting minutes to hours




-dizziness


-nausea and vomiting


-ipsilateral unilateral fixed and dilated pupil


Ch9-pg114

Acute Subdural Hematoma

Usually following acceleration, deceleration forces.


Symptoms occuring within 72hours


ipsilateral dilated or nonreactive pupil


Ch9 - pg114



Herniation Syndrom

Shifting of the brain tissue with displacement into another compartment as a result.


Supratentorial herniation is the most common in trauma.



  • asymmetric pupillary reactivity
  • unilateral or bilateral pupillary dilation
Ch9 - pg114

Uncal Transtentorial Herniation

uncus of the temporal lobe is displaced unilaterally over the tentorium into the posterior fossa causeing a shift of the mid brain.


Ch9 - pg115

Central or Transtentorial Herniation

the cerebral hemispheres are pushed downward through the tentorial notch directly compressing the brainstem.


Ch9 - pg115

Mild TBI

  • GCS 13-15
  • Brief <30min LOC
  • post traumatic amnesia <24hrs
  • no change on neuroimaging studies
Ch9 - pg115

Moderate TBI

  • GCS 9-12
  • Variety of Sympotms : ALOC, confusion, amnesia, focal neuro deficits.
  • May detereiorate
Ch9 - pg115

Severe TBI

  • GCS of 8 or less
  • Significant alteration in LOC
  • abnormal pupillary response
  • abnormal motor posturing
Ch9 - pg115

Diffuse Axonal Injury

Widespread microscopic damage, primarily to axons. MOI usually rotational or acceleration/deceleration.



  • Increased ICP
  • Abnormal posturing
  • Hypertention (SBP 140-160)
  • Hyperthermia (104F-105F)
  • Excessive sweating
Ch9 - pg116

Linear Skull Fracture

nondisplaced fracture of the cranium



  • HA
  • Surrounding soft tissue injury
  • possible decreased LOC
Ch9 - pg116

Depressed Skull Fracture

Extends below the surface of the skull and may cause dura mater laceration and brain tissue injury.



  • all of linear skull fx symptoms
  • palpable depression of skull over fracture site
  • possible open fracture
Ch9 - pg116

Basilar Skull Fracture

May include any of the 5 bones in the base of the skull



  • Can result in punctures or lacerations to the brain tissue or cranial nerves and CSF leakage
  • Risk of infections such as meningitis, encephalitis, or brain abscess.
  • Occurs concurrently with facial fractures.
Ch9 - pg116

Late Symptoms of Basilar Skull Fractures


  • periorbital ecchymoses (racoon eyes)
  • Mastoid ecchymoses (battle sign)
  • Bleeding behind the tympanic membrane (hemotympanum)
Ch9 - pg116

LeFort 1 is

Transverse maxillary bone fracture that seperates the teeth from the maxilla.


malocclusion


Ch9 - pg117



LeFort 2 is

Fracture of pyramidal maxillary bone involving the mid face area. Apex of the fracture trasverses the bridge of the nose.



  • nasal swelling with obvious fracture of the nasal bones
  • CSF rhinorrhea
Ch9 - pg117

LeFort 3 is

Complete craniofacial seperation involving the maxilla, zygoma, orbits, and bones of the cranial base



  • Mobility and depression of zygomatic bones
  • diplopia
Ch9 - pg 117

Interventions for pt with brain, cranial, or maxillofacial trauma

  • HOB >30degrees
  • Position head midline to facilitate venous drainage
  • Administer mannitol
  • Administer anti convulsant medication (posttraumatic epilepsy occurs in about 15% of patients). Seizures increase ICP and cerebral metabolic rate.
Ch9 - pg118

Eye Movement and Innervation of :


Medial Rectus


Lateral Rectus


Superior Rectus


Inferior Rectus

Medial - toward nose - Occulomotor (CN3)


Lateral - away from nose - Abducent (CN6)


Superior - upward - Oculomotor (CN3)


Inferior - Downward - Oculomotor (CN3)


Ch10 - pg124

Eye Movement and Innervation of :


Superior Oblique


Inferior Oblique

Superior Oblique - medial rotation - Trochlear (CN4)


Inferior Oblique - lateral rotation - Oculomotor (CN3)


Ch10 - pg124

Intraocular Pressure Measurement

If the production of aqueous humor exceeds the outflow (glaucoma and hyphema), IOP is increased. A decrease may be caused by a disruption in the globe.


Normal IOP is 10-20mm Hg


Ch10 - pg 128

Corneal Abrasion

Common.


S+S:



  • photophobia
  • redness of conjunctiva
Tx :


  • topical opthalmic antibiotics
  • if caused by contact lenses treat for pseudomonas
  • NSAIDs
  • follow up with opthamologist in 24hours
Ch10 - pg129

Corneal Laceration

Full thickness injuries to the cornea. Misshapen iris and positive seidel test(slit lamp w fluoracein)


Small lacerations are treated like corneal abrasions


larger lacerations possible surgery



  • pain out of proportion to injury
  • decreased vision
Ch10 - pg129

Intraocular Foreign Body

a true eye emergency, and early intervention is essential.


S+S:


misshapen pupils


Tx :


elevate HOB


immobilize foreign body


limit eye movement by patching oposite eye


perform globe closure asap.


Ch10 - pg130

Blowout Fracture

Fracture of orbital floor that can cause muscle and or nerve entrapment.


Decreased EOM.


Seen in periorbital contusion (black eye)


Ch10 - pg130

Closed Globe Injuries

According to Birmingham Eye Trauma Terminology as if the glove is intact it is a closed globe injury and is classified as a contusion or lamellar laceration


Ch10 - pg 124

Open Globe Injuries

Classified as either lacerations or ruptures.


Ch10 - pg124

Orbital Fracture :


Usually result of ___?


What bones are weakest?


Can cause ___?

Usually a result of a direct blow. Orbital floor and ethmoid bones are the weakest part of the orbit. Can cause entrapment of the inferior rectus and inferior oblique muscle


Ch10 - pg130

Orbital Fracture :


Assessment


Treatment

Assessment :


  • Diplopia with upward gaze
  • Enopthalamos (posterior displacement of the eyeball)
  • decreased EOM

Treatment


  • Oral antibiotics
  • surgical replair if continued diplopia or exopthalamos for 1-2weeks
  • Avoid and increased in ICP (blowing nose, sneezing, or Valsalva maneuver)
Ch10 - pg 131


Hyphema

Collection of blood in the anterior chamber of the eye. Traumatic or spontaneous


GRaded 1-4 based on amount of blood present


Treatment


  • Topical Cyclopegics and opthalamic steroids, opthalamic beta blockers if IOP is elevated.
  • Admission if IOP is >30%
  • Avoid aspirin and NSAIDs

Ch10 - pg131



Retrobulbar Hematoma

2nd to blunt trauma. Hemorrhage behind the globe. Increased IOP compresses the optic nerve and blood vessels. Early recognition is imperative to save vision.


This is a true opthalmic emergency.


Symptoms

  • Decreased vision
  • Reduced eye movment
  • IOP greater than 40mm Hg (normal is 10-20)

Treatment


  • Emergency decompression if IOP greater than 40mmHg

Ch10 - pg131



Globe Rupture

A full thickness injury occurs to the cornea or sclera or both. Considered a genuine emergency. Protect from further injury.


Symptoms


  • Anterior chamber flat
  • Teardrop shaped pupil

Treatment - rigid shield to protect eye.


Ch10 - pg132



Grading Traumatic Hyphema : 1-4

1 : Blood <1/3 of anterior chamber


2 : Blood 1/3-1/2 of anterior chamber


3 : Blood >1/2 and


4 : Blood occupying the entire anterior chamber


Ch10 - pg131

Pericardial Fluid Volume

Approximately 25ml.


Provides lubrication


Ch11 - pg 138

Most often site of aortic injury

Aortic Isthmus


Transition from the mobile aoritic arch to the relatively fixed descending aorta. (behind the heart)


Ch11 - pg138

The sternum and first and second ribs are more resistant to energy forces when they are injured.


So there is an increased risk of injury to ____



Underlying structures.


Ch11 - pg140

If a penetrating thoracic wound is found below the ____ intercostal space, penetration into the abdominal cavity is suspected until proven otherwise

4th


Ch11 - pg140

Pericardial Tamponade

Fluid in the pericardial sac. Inhibits ventricular filling, decreasing preload. Stroke volume is also decreased, which decreases cardiac output. Obstructive shock.


Hypotension


Muffled heart tones


neck vein distention


Tachycardia


Pulsus Paradoxus (decrease of 10mm Hg on inspiration)


Ch11 - pg141

Becks Triad

Actually 4


Symptoms of Pericardial Tamponade


Hypotension


Muffled Heart tones


Tachycardia


Neck vein distention


Ch11 - pg141

Sternal Fracture Associated injury is

Blunt Cardiac injury


Ch11- pg141

First and Second rib fractures associated injury is

Great vessel injuries


Brachial plexus injuries


Head and spinal cord injuries


Ch11 - pg 141

Multiple rib fractures and flail chest associated injuries

Pulmonary contusion


Pneumothorax


Hethorax


Ch11 - pg141



Lower rib fractures (7-12)

Liver (R sided)


Spleen (L sided)


Ch11 - pg141

Emergency Thoracotomy Indications
  1. Pericardial Tamponade necessitating evacuation
  2. Immediate control of massive intrathoracic bleeding
  3. Penetrating trauma with a witnessed cardiac arrest permitting open cardiac massage
  4. Massive hemorrhage in the peritoneal cavity necessitating cross clamping the aorta
Ch11- pg143


Tracheobronchial Injuries causes

Most likely to be caused by penetrating mechanisms.


Direct blows to the neck or clothesline-tye injuries are common mechanisms.


Ch11 - pg143

Blunt Esophageal Injury

Signs :


Air in the mediastinum with possible widening


Left pneumothorax or hemothorax


Subcutaneous Emphysema


Treatment :


Prepare for surgery


Ch11 - pg143

Flail Chest definition

2 or more fractures of 3 or more ribs, creating a free floating segment.


Ch11 - pg144



Massive Hemothorax : more than _____mL of blood

1,500mL


Ch11 - pg146

As little as ___mL of blood in the pericardial sac can cause a pericardial tamponade

50mL


There is normally 25mL of fluid in the sac for lubrication.


Ch11 - pg146

Aortic Disruption

Aortic Isthmus is the most frequently injured site of the Aorta.


Mortality rates of 75%-90%


Unequal extremity pulse strength or blood pressure (significantly greater in the upper extremities)


Ch11 - pg147

Ruptured Diaphragm

Abdominal contents can herniate into the thoracic cavity, compressing the lung, may lead to respiratory compromise.


Penetrating trauma below the 4th intercostal space


Sharp epigastric or chest pain radiating to Left shoulder (kehr sign)


bowel sounds auscultated in lung fields on injured side.


Ch11- pg147

Kehrs Sign

Left shouder pain.


May occur in ruptured diaphragm


May be due to ruptured spleen


Ch11 - pg 147

FOCA acronym for chest tubes

Fluctuation in the water seal chamber


Output


Color of drainage


Air leak, presence


Ch11 - pg148

DOPE troubleshooting for chest tube

Dislodgement


Obstruction


Pneumothorax


Equipment failure


Ch11 - pg148

Chest Tubes :


Notify the physician and anticipate need for surgery

Initial chest tube drainage >500ml


Continuing blood loss of >200ml per hour for 2-4hours


Ch11 - pg148