Week 11: Multiple trauma

Question 1

trauma epidemiology

Answer 1

• Leading cause of death in the first 4 decades
• 150,000 deaths annually in the US
• Permanent disability 3 times the mortality rate
• Trauma related dollar costs exceed $400 billion annually

Question 2

Trimodal death distribution

Answer 2

• First peak instantly (brain, heart, large vessel injury)
• Second peak minutes to hours
• Third peak days to weeks (sepsis, MSOF)

Question 3

ATLS focuses on the second peak…..Deaths from:

Answer 3

• TBI, Epidurals, Subdurals, IPH…
• Basilar skull fractures, orbital fractures, NEO complex injury…
• Penetrating neck injuries…
• Spinal cord syndromes…
• Cardiac tamponade, tension pneumothorax, massive hemothorax, esophageal injury, diaphragmatic herniation, flail chest, sucking chest wounds, pulmonary contusion, tracheobronchial injuries, penetrating heart injury, aortic arch injuries …
• Liver laceration, splenic ruptures, pancreatico-duodenal injuries, retroperitoneal injuries
• Bladder rupture, renal contusion, renal laceration, urethral injury…
• Pelvic fractures, femur fractures, humerus fractures…

Question 4

tension pneumo thorax

Answer 4

lung completely collapses. That lung presses against the good lung and the heart

Question 5

Concepts of ATLS

Answer 5

• Treat the greatest threat to life first
• The lack of a definitive diagnosis should never impede the application of an indicated treatment
• A detailed history is not essential to begin the evaluation
• “ABCDE” approach

Question 6

flail chest

Answer 6

multiple ribs by each other that are compromised and the lung doesn’t expand correctly. Pt. has paradoxical chest movement

Question 7

The trauma system includes:

Answer 7

• EMS: goal to stabilize and get them to the hospital
• emergency Physicians/NP’s/Nurses
• trauma surgery team
• *Best is Trauma Center level 1*: all the time have a special group of people who are trained to help

Question 8

Trauma roles

Answer 8

• Trauma captain: person running the show, either physician or APNP who specializes in trauma
• Interventionalists
• Nurses
• Recorder

Question 9

prepping for trauma pt. to arrive

Answer 9

• warm the room to 99 degrees
• have foleys, ngs, intubation, iv supplies, EKG 12 lead, call ct and have them on standby, get portable xray ready, pharmacy on standby, bloodbank, lab

Question 10

nurses roles in trauma

Answer 10

• nurse on the left: ABCDE assessment, 12 lead ekg, vital signs, foley insertion (unless trauma to genital area, or bladder is ruptured)
• nurse on the right: IV access, start admin of fluids, blood draws, assessment of the extremities and the trunk (determine if chest tube is needed: decreased breath sounds one or both sides, tracheal deviation, crepitus or subq emphysema, hypoxia)

Question 11

primary survey

Answer 11

Patients are assessed and treatment priorities established based on their injuries, vital signs, and injury mechanisms
ABCDEs of trauma care
A Airway and c-spine protection
B Breathing and ventilation
C Circulation with hemorrhage control
D Disability/Neurologic status
E Exposure/Environmental control

Question 12

How do we evaluate survey

Answer 12

Airway should be assessed for patency

• Is the patient able to communicate verbally?
• Inspect for any foreign bodies
• Examine for stridor, hoarseness, gurgling, pooled secrecretions or blood

Assume c-spine injury in patients with multisystem trauma

• C-spine clearance is both clinical and radiographic
• C-collar should remain in place until patient can cooperate with clinical exam

pg 214 (maxillary traumas)

Question 13

maxiallry trauma worst ones

Answer 13

Lefort injuries (1-3) 2&3 are the worst. Sputum will be blood tinged, facial swelling, CSF through the nose, tachypnea/tachycardia

Question 14

airway interventions

Answer 14

• Supplemental oxygen
• Suction (can increase swelling and secretions, though)
• Chin lift/jaw thrust (bridge to intubation)
• Oral/nasal airways (if you think there is trauma in that area)

Definitive airways

• RSI (rapid sequence intubation) for agitated patients with c-spine immobilization
• ETI for comatose patients (GCS<8)

Question 15

once et tube is in place do what?

Answer 15

• ascultate and look for co2 (yellow yes)
• get an xray

Question 16

What can we look for clinically to assess a patient’s ‘breathing’ status?

Answer 16

*Airway patency alone does not ensure adequate ventilation

*Inspect, palpate, and auscultate

• Deviated trachea, crepitus, flail chest, sucking chest wound, absence of breath sounds, decreased, or diminished, in and out wheezing (or lost all together)

*CXR to evaluate lung fields

Question 17

Answer 17

flail chest, 2 or more ribs broken in a row, pain, most likely intubate and manage the pain. Now movement toward surgical intervention to stabilize the ribs

Question 18

Answer 18

subcutaneous emphysema: been some type of trama that has allowed air to get into subq tissue, like pneumo. Would need a chest tube

Question 19

breathing interventions

Answer 19

• Ventilate with 100% oxygen
• Needle decompression if tension pneumothorax suspected: only if severe, then insert chest tube after
• Chest tubes for pneumothorax / hemothorax
• Occlusive dressing to sucking chest wound
• If intubated, evaluate ETT position

Question 20

type of chest tube?

Answer 20

• more lateral, at 5th intercostal space: for fluid (draining blood)
• for pneumo, it’s the 2nd intercostal space, anterior

Question 21

what’s going on, what do we need to do?

Answer 21

• lung field on right is wiped out
• heart is being pushed over
• trachea is deviated
• TENSION PNEUMOTHORAX
• Needle decompression needed with this as well as subsequent chest tube placement
• You will find trachae deviated away from pneumothorax, tachypnea, tachycardia, cardiac output decreased, narrowed pulse pressure, crepitus

Question 22

which way will the trachae deviate with a pneumothorax

Answer 22

away from the pneumothorax

Question 23

circulation

Answer 23

*Hemorrhagic shock should be assumed in any hypotensive trauma patient
*Rapid assessment of hemodynamic status

• Level of consciousness
• Skin color
• Pulses in four extremities
• Blood pressure and pulse pressure

Question 24

if you can’t get a bp manually, what do you do?

Answer 24

palpatory pressure. Inflate the cuff until you get radial pulse return

Question 25

inraosseus injection

Answer 25

* when you can't get IV access, go through the bone. * flat size of tibial bone * aspirate for bone marrow to confirm placement * secure site * reassess for infiltration for swelling or oozing * can infuse up to 125 cc's an hour

Question 26

circulation interventions

Answer 26

_\*Cardiac monitor \*Apply pressure to sites of external hemorrhage \*Establish IV access_ * 2 large bore IVs (at least 18 guage for potential of giving blood) * Central lines if indicated _\*Cardiac tamponade decompression if indicated_ _\*Volume resuscitation_ * Have blood ready if needed * Level One infusers available (put volume into machine which compresses it to push it in very fast, like a PRBc's in 2 minutes for the whole bag. Also warms the fluid). * Foley catheter to monitor resuscitation

Question 27

classes of blood loss (pg 223)

Answer 27

* class 1: mild blood loss. May not even be symptomatic less than 15 * class 2: 15-30% blood loss, systolic not greatly affected, drip in MAP * class 3: 30-40% blood loss. See a drop 20mmhg in BP. Tachy above 120 * class 4: more than 40% blood loss. Significant tachycardia, significant drops, MAP less than 60

Question 28

fluid resuscitation

Answer 28

* 2 liters isotonic solution first * followed by as need the 2:1:1 ratio (2 prbs, 1 ffp, 1 platelets) * pediatrics: based on weight 20ml/kg x 2 of isotonic solution. Need at lease 2 liters of this before you think about blood.

Question 29

disability

Answer 29

_Abbreviated neurological exam_ * Level of consciousness * Pupil size and reactivity * Motor function * GCS: Utilized to determine severity of injury. Guide for urgency of head CT and ICP monitoring * AVPU scale: looking at their level of conciousness. **_A_**: alert, responding to verbal stimuli. **_V:_** they're responding to verbal stimuli (not alert) **_P:**_ Only respond to painful stimuli _**U:_** no response to even painful stimuli

Question 30

disability interventions

Answer 30

_Spinal cord injury_ * High dose steroids if within 8 hours _ICP monitor- Neurosurgical consultation_ _Elevated ICP_ * Head of bed elevated * Mannitol * Hyperventilation * Emergent decompression

Question 31

exposure

Answer 31

* Complete disrobing of patient * Logroll to inspect back * Rectal temperature * Warm blankets/external warming device to prevent hypothermia

Question 32

Answer 32

* giving large volume fluids * a line in place * intubation * cspine immobilized

Question 33

28 yo M involved in a high speed motorcycle accident. He was not wearing a helmet. He is groaning and utters, “my belly”, “uggghhh.” HR 134 BP 87/42 RR 32 SaO2 89% on 100% facemask Brief initial exam: pt is drowsy but arousable to voice, has large hematoma over L parietal scalp, airway is patent, decreased breath sounds over R chest, diffuse abdominal tenderness, obvious deformity to L ankle What are the management priorities at this time? What are this patient’s possible injuries? What are the interventions that need to happen now?

Answer 33

. Always ABCDE first! * A – airway patent; go to NRB mask, frequent reassessment, don’t forget proper C-spine immobilization. May need intubation * B – tachypnea, decr. BS, hypoxia (? PTX, hemothorax); consider needle decompression , CXR, then chest tube * C- hypotensive, tachycardic (? Tension PTX v. massive hemothorax v. intraabdominal hemorrhage, ? Pelvic fractures); needs large bore IV v. CVL, IVF, blood available. (fluid resucitation) * D – do quick GCS, pupils, motor assessment * E – exposure, blankets

Question 34

secondary survey

Answer 34

F: vital signs & family members G: give comfort comfort to your patient. H: head to toe assessment & history I: insepcting the posterior surfaces * Ample history:Allergies, medications, PMH, last meal, events * Physical exam from head to toe, including rectal exam * Frequent reassessment of vitals * Diagnostic studies at this time simultaneously: X-rays, lab work, CT orders if indicated, FAST exam

Question 35

Answer 35

seatbelt sign (seatbelt injury). Seatbelt can rupture the bladder.

Question 36

diagnostic aids

Answer 36

* _Standard trauma labs_: CBC, K, Cr, PTT, Utox, EtOH, ABG * _Standard trauma radiographs_: CXR, pelvis, lateral C-spine (traditionally) * _CT/FAST scans_ * _Pt must be monitored in radiology_ * _Pt should only go to radiology if stable_

Question 37

Answer 37

* simple pneumothorax * a classic line tells you that there's air there. Means that potential pleural space had become a real space

Question 38

Answer 38

* widened mediastinum, cardiac tampenade. Know there's fluid collecting around the heart. * there's also a chest tube on the right side. lateral and low, so it's probably for blood

Question 39

What is this and what do you worry about?

Answer 39

bilateral pubic ramus fractures and sacroiliac joint disruption. Worry about fatty and blood emobli.

Question 40

abdominal trauma

Answer 40

* Common source of traumatic injury * _Mechanism is important_: Bike accident over the handlebars, MVC with steering wheel trauma * High suspicion with tachycardia, hypotension, and abdominal tenderness * Can be asymptomatic early on * FAST exam can be early screening tool * Look for distension, tenderness, seatbelt marks, penetrating trauma, retroperitoneal ecchymosis * Be suspicious of free fluid without evidence of solid organ injury * \*Treat with rapid fluid hydration and fast exam * Bruising retroperitoneal : liver/kidney, pain in shoulder: spleen

Question 41

Splenic Injury

Answer 41

* Most commonly injured organ in blunt trauma * Often associated with other injuries * Left lower rib pain may be indicative * Often can be managed non-operatively

Question 42

liver injury

Answer 42

* Second most common solid organ injury * Can be difficult to manage surgically * Often associated with other abdominal injuries

Question 43

Answer 43

* diaphragmatic hernia * heart is pushed over because bowel is pushing on it * May only see the nasogastric tube appear to be coiled in the lung. Left \> right due to liver protection of the diaphragm. * more common on the left side

Question 44

hollow viscous injury

Answer 44

* Injury can involve stomach, bowel, or mesentery * Symptoms are a result from a combination of blood loss and peritoneal contamination * Small bowel and colon injuries result most often from penetrating trauma * Deceleration injuries can result in bucket-handle tears of mesentery * Free fluid without solid organ injury is a hollow viscus injury until proven otherwise

Question 45

ct scan in trauma

Answer 45

* Abdominal CT scan visualizes solid organs and vessels well * CT does NOT see hollow viscus, duodenum, diaphram, or omentum well * _Some recent surgery literature advocates whole body scans on all trauma_: Keep in mind that there is an increase in mortality related to cancer from CT scans

Question 46

fast exam

Answer 46

* Focused Abdominal Scanning in Trauma * 4 views: Cardiac, RUQ, LUQ, suprapubic looking at liver, spleen, bladder, heart * Goal: evaluate for free fluid

Question 47

non-accidental trauma

Answer 47

* Key is SUSPICION!!! * Incongruent stories of mechanism * Delay in seeking treatment * Multiple stages of injuries * Pattern Injuries * Multiple hospital visits * Injury mechanism beyond the scope of the age of child (6week old rolled over off the bed) * Bite marks, submersion injury, cigarette burns