Ch 20 Trauma and Surgical Management

Hypothermia

Caused by a combination of accelerated heat loss and decreased heat production and is associated with poor outcomes - especially older adults are more susceptible after severe injury, excessive blood loss, alcohol use and massive fluid resuscitation - prolonged is associated with the development of myocardial dysfunction, coagulopathies, reduced perfusion, bradycardia and atrial/ventricular fibrillation and decreased metabolic rate

Overresuscitation

Causes life-threatening complications such as abdominal compartment syndrome and ARDS

Endotracheal intubation

Definitive nonsurgical airway management technique, allows for complete control of the airway - may be required for a pt who presents with apnea, a GCS score of 8 or less, or an inability to protect the airway

Temporal variation

Describes the pattern and timing of the trauma

Pulmonary contusion

Develops when capillary blood leaks into the lung parenchyma, resulting in inflammation and edema - degree of respiratory distress develops gradually, with worsening severity of oxygenation and ventilation as the edema progresses - often difficult to detect because the initial chest radiographic study may be normal; infiltrates and hypoxemia may not be present until hours or day - one of the most common causes of death after chest trauma, predisposes pt to pneumonia, acute lung injury, and ARDS - worsening dyspnea, ineffective cough, hypoxia, bloody secretions, chest wall abrasions and ecchymosis - administer fluids cautiously - provide adequate pain relief with IV narcotics to optimize lung expansion and respiratory effort and to prevent complications including atelectasis and pneumonia

Suspect a cervical spine injury

In any pt with multi system trauma until radiographic or CT studies determine otherwise - until cleared, manually stabilize the cervical spine by holding the head and neck in alignment, or immobilize the cervical spine with a cervical collar when establishing the pt airwa

Diagnostic tests in trauma

Include CT, radiography and FAST or E-FAST - FAST: ultrasound assessment that provides a rapid, noninvasive means of diagnosing accumulation of blood or free fluid in the peritoneal cavity or pericardial sac - E-FAST: extends the ultrasound examination to evaluate possible injuries in the chest, looking for hemothorax and pneumothorax

Thoracic injuries

Include injuries to heart, great vessels and lungs - FAST and EFAST typically first line diagnostic used with the emergent evaluation, providing essential information for the immediate management of the trauma pt

Intraosseous access complications

Include pain on instillation of fluids, extravasation of fluids, and compartment syndrome

Second peak of death

Labeled as early death, occurs within minutes to several hours after injuries - death results from injuries such as hemopneumothorax, ruptured spleen, liver laceration, pelvic fracture, or other multiple injuries associated with significant blood loss - "golden hour": first hour, focuses on rapid assessment, resuscitation, and treatment of life-threatening injuries

First peak of death

Labeled as immediate death, occurs within seconds to minutes from the time of injury - pt is declared dead at the scene or shortly after arrival in an emergency department - death caused by severe injuries such as apnea from severe brain damage, high spinal cord injury or massive hemorrhage - only trauma prevention will decrease these deaths

Third peak of death

Labeled as late death, occurs several days to weeks after the initial injury and is most often the result of sepsis, acute respiratory distress syndrome, increased intracranial pressure, and multiple organ dysfunction syndrome

Assess for neurologic disabilities by evaluating the pt

Level of consciousness, pupillary size and reaction, and spontaneous and reflective spinal movement - management priorities focus on the primary injury from the traumatic event and secondary injuries that occur as a result of cerebral hypoperfusion, increased ICP and/or cerebral edema

Crush injuries

May produce local soft tissue trauma or extensive damage distant from the site of injury - life threatening: pelvis or lower extremities or a prolonged entrapment - prolonged compression produces ischemia and anoxia of the affected muscle tissue - third spacing, localized edema and increased compartment pressures cause sedentary ischemia

Blunt trauma

Most common mechanism of injury - most often occurs from MVCs, but also occurs with motorcycle crashes, assaults with blunt objects, falls from heights, sports-related activities, and pedestrians struck by a motor vehicle - may be caused by accelerating, decelerating, shearing, crushing and compressing forces

Primary survey

Most crucial assessment tool in trauma care - rapid 1-2 minute evaluation designed to identify life-threatening injuries accurately, establish priorities, and provide simultaneous therapeutic interventions - systematic assessment including: airway with cervical spine immobilization, breathing and ventilation, circulation with hemorrhage control, disability or neurologic status, exposure with environmental considerations, full set of vital signs and family presence, and get resuscitation adjuncts - life-threatening conditions are identified and management is instituted simultaneously

Injuries to the stomach and small and large bowel

Most frequently the consequence of penetrating trauma from gunshot wounds - suspected based on the mechanism of injury, and surgical intervention is usually required - complications: infection and difficultly maintaining nutrition

Four major mechanisms of injury accounting for most of all injury deaths include

Poisoning, motor vehicle traffic, firearms and falls

Oral tracheal intubation

Requires careful manipulation of the neck and therefore is contraindicated in pt with suspected spinal or neck injuries - disadvantages: incorrect tube placement in the esophagus or right mainstream bronchus, vocal cord trauma, and injury to the intramural structors - if not feasible, a laryngeal mask airway may be used

Complications associated with multi system injuries such as

Respiratory impairment, infection, AKI, high nutritional demands and MODS

Penetrating trauma

Results from impalement of the body by foreign objects - important considerations: length and width of the object and the presence of vital organs in the area of the wound - monitor closely for subsequent complications such as organ damage, hemorrhage, and infection

Underesuscitation

Results in worsening tissue ischemia, shock, and death

Triage

Sorting the pt to determine which patients need specialized care for actual or potential injuries - decisions based on abnormal findings in the pt's physiologic function, the mechanism of injury, the severity of injury, the anatomic area of injury, or evidence of risk factors such as age and preexisting disease

Disaster

Sudden event in which local EMS, hospitals, and community resources are overwhelmed by the demands placed on them - classified by the number of victims involved or the extent of resources required to provide assistance - effective field triage is vital in determining how pt are transported to local hospitals and trauma centers

Rhabdomyolysis

Syndrome of muscle damage and cellular destruction that results in release of myoglobin which compromises renal blood flow - causes: crush injuries, compartment syndrome, burns, and injuries form being struck by lightening - marker: myoglobinuria, causes urine to be dark tea color; causes acute tubular necrosis, electrolyte and acid base imbalance and AKI

Cricothyrotomy

Used when it is difficult to intubate the trauma pt - conditions that may require this include maxillofacial trauma, laryngeal fractures, upper airway burns, airway edema and severe oropharyngeal hemorrhage

Nasotracheal intubation

Used when the urgency of the resuscitation procedure does not allow time to obtain preliminary radiographs of the cervical spine; contraindicated if there are any signs of mid-face, frontal sinus, basilar skull or cribriform plate fractures - disadvantages: possible epistaxis or injury to the nasal turbinates and an increased risk for ventilator associated events such as infection

VTE

Usually results from a DVT in the lower extremities - enhanced in the presence of Virchow's triad: vessel damage, venous stasis and hypercoagulability - encourage ambulation, evaluate overall hydration, ensure pneumatic compression or sequential compression devices are used properly

Active internal strategies

Warmed gases to respiratory tract, warmed IV fluids, body cavity irrigation, continuous arteriovenous rewarming, cardiopulmonary bypass

Transient responders

Improve in response to the initial fluid bolus but begin to show deterioration in perfusion when fluids are slowed to maintenance rates - indicates ongoing blood loss or inadequate resuscitation -f pt continues to respond in this manner, pt is probably bleeding and requires rapid surgical intervention

Minor trauma

Refers to a single-system injury that does not pose a threat to life or climb and can be appropriately treated in a basic emergency facility

Mechanism of injury

Refers to how a traumatic event occurred, the injuring agent, and information about the type and amount of energy exchanged during the event - knowledge of this assists the trauma team in early identification and management of injuries that may not be apparent on initial assessment - guides the assessment and interventions to minimize the change of missing injuries that are more subtle

Tertiary prevention

Refers to interventions to maximize patient outcomes after a traumatic event through emergency response systems, medical care, and rehabilitation

Major trauma

Refers to serious multiple system injuries that require immediate intervention to prevent disability, loss of limb, or death

Passive external strategies

Removal of wet clothing, warm room, decreased airflow over pt, blankets, head coverings

When spontaneous breathing is present but ineffective, consider the presence of a life-threatening condition if any of the following are present

- altered mental status - central cyanosis - asymmetric expansion of the chest wall - use of accessory muscles or abdominal muscles - paradoxic movement of the chest wall during inspiration and expiration - diminished or absent breath sounds - tracheal shift from midline position - decreasing oxygen saturation via pulse oximetry - distended jugular veins

Monitor pt response to initial fluid administration by

- assessing urine output; goal: 0.5 mL/kg/hr - LOC - HR - BP - pulse pressure - laboratory indices (serum lactate, base deficit) - also monitor for electrolyte imbalances, dilution coagulopathies and consequences of excessive third-spacing of IV fluids

Complications of musculoskeletal injury that may occur after a crush injury

- compartment syndrome - rhabdomyolysis - hyperkalemia - VTE - pulmonary embolism - fat embolism

Traumatic soft tissue injuries

- contusions, abrasions, lacerations, puncture wounds, crush injuries, amputations, or avulsion injuries - predisposes pt to secondary complications such as localized and systemic infection, hypoproteinemia and hypothermia

Artificial airways

- if a pt is unable to open their mouth, does not follow commands, or is unresponsive, use a jaw-thrust maneuver to open and assess the airway - clear the airway with gentle suction with a tonsillar tip catheter - nasopharyngeal and oropharyngeal airways are the simplest artificial airway adjuncts used in pt with spontaneous respirations and adequate ventilatory effort - do not insert an oropharyngeal airway in a conscious pt because it may induce gagging, vomiting, and aspiration; nasopharyngeal better tolerated

Specific adjuncts are crucial to assess and manage elements in the primary assessment

- laboratory studies: lactate and base deficit reflect the effectiveness of cellular perfusion, the adequacy of ventilation, and the success of fluid resuscitation - metabolic acidosis occurs secondary to a shift from aerobic to anaerobic metabolism and the production of lactic acid - increases in lactate level and base deficit are accompanied by a decrease in tissue perfusion with increased morbidity and mortality - insertion of NG or OG tube provides a route to compress the stomach, preventing emesis and aspiration, and allows optimal inflation of the lungs - capnography monitoring - pain management and psychologic support

Blunt trauma effect to organs

- lungs tolerate energy transference and often experience little damage due to their elasticity - organs such as the heart, spleen, and liver are less resilient because of their high-density tissue and decreased ability to release energy without resultant tissue damage; often present with fragmentation or rupture - severity of injury is contingent on the duration of energy exposure, the body part involved, and the underlying structure

Causes of ineffective airway patency

- obstruction, structural impairments, and an inability to protect the airway associated with a change in level of alertness - tongue is most common cause - other causes: foreign debris and anatomic obstructions due to maxillofacial fractures

Initial pt assessment

- priorities: based on pt clinical presentation, physical assessment, history of the traumatic event (mechanism of injury), and knowledge of any preexisting disease - evaluation of airway latency, ventilation, hemorrhage control, and stabilization of fractures

Kidney injuries

- pt may present with costovertebral tenderness, microscopic or gross hematuria, bruising or ecchymosis over the 11th and 12th ribs, hemorrhage and shock - diagnostic: FAST, CT, angiography, IV pyelography and cystoscopy - minor: bed rest, hydration and monitoring of kidney function - complications: refractory hypertension, hemorrhage, fistula formation and infection

Prehospital care and transport

- rapid assessment in the field, treatment of life-threatening problems: careful attention given to the airway with cervical spine immobilizations, breathing, and circulations - establishing an airway, providing ventilation, applying pressure to control hemorrhage, immobilizing the complete spine, and stabilizing fractures - ultimate goal: get the pt to the right level of hospital care in the shortest span of time to optimize pt outcomes - large caliber IV or IO access and fluids to restore blood volume and maintain systemic arterial blood pressure, depends on mechanism of injury - large volume resuscitation avoided because over resuscitation can precipitate hyperchloremic metabolic acidosis and inflammatory organ injury

Fat embolism syndrome

Accompanies traumatic injury to the long bones and pelvis that results in multiple skeletal fractures - develops between 24-48 hr after injury - hallmark: begin with the development of a low grade fever followed by new onset tachycardia, dyspnea, increased respiratory rate and effort, hypoxemia, sudden thrombocytopenia and a petechial rash - late signs: ECG changes, Liguria, and changes in LOC progressing to coma - treatment: directed toward preservation of pulmonary function and maintenance of cardiovascular stability

Open pneumothorax

Associated with penetrating chest trauma that allows air to pass in and out of the pleural space - respiratory distress, hypoxia, hemodynamic instability, and subcutaneous emphysema - management: 3 sided nonporous dressing, fourth side left open to allow for exhalation

Cardiac contusion

Blunt trauma is the most frequent cause - force of event bruises the heart muscle and can compromise effective heart functioning and cause dysrhythmias - monitor for 48-72 hr - if significant trauma, obtain a 12-lead ECG and serum levels of cardiac isoenzymes and troponin to rule out ischemia or infarction; inotropic medications may be needed

Third spacing

Can pose a significant problem during, and within hours after aggressive fluid resuscitation - predisposes pt to additional complications such as abdominal compartment syndrome, ARDS, acute kidney injury and MODS - goal: provide adequate fluid resuscitation to prevent tissue hypoxemia

Impaired gas exchange

Can result from ineffective ventilation, an ability to exchange gases at the alveoli, or both - possible causes: decrease in inspired air, retained secretions, lung collapse or compression, atelectasis, or accumulation of blood in the thoracic cavity - assess any pt who presents with multiple systemic injuries, hemorrhagic shock, chest trauma, and/or CNS trauma for this - have the potential to affect the pt volume status and oxygen-carrying capacity, interfere with the mechanics of ventilation, or interrupt the autonomic control of respirations

Pelvic injuries

Challenging because of the large vascular supply, nervous system pathways, location of urologic structures and articulation of the hip going within the pelvic ring - mortality related to massive bleeding that causes hemodynamic instability and hypovolemic shock - primary interventions: pelvic stabilization and aggressive fluid resuscitation to ensure adequate tissue perfusion

Dissemintated Intravascular Coagulation

Characterized by diffuse activation of coagulation with the formation of microthrombi in small blood vessels and consumption of coagulation factors - systemic inflammation primary trigger - other triggers: traumatic injury, rhabdomyolysis, massive blood transfusion, fat emboli, shock states, sepsis and prolonged hypothermia - treatment: identify and treat trigger - pt presents with unexplained and prolonged bleeding and reduction in clotting factors, including prolonged PT/PTT, decreased fibrinogen and platelets, and elevated fibrin split products

Abdominal injuries

Classic sign is pain - pain cannot be used as an assessment tool if the pt has altered sensorium, drug intoxication or SCI with impaired sensation

Hemothorax

Collection of blood in the pleural space - decreased breath sounds, dullness to percussion on the affected side, hypotension, and respiratory distress - placement of chest tube facilitates removal of blood from the pleural space with resolution of ventilation and gas exchange abnormalities - manage chest tube, closely observe the amount of blood drained from pleural space, and monitor the pt's hemodynamic response

Treatment of rhabdomyolysis

Consists of aggressive fluid resuscitation to flush the myoglobin from renal tubules - titration of IV fluids to achieve a urine output of 100-200, osmotic diuretics may be administered - sodium bicarbonate may be added to IV fluids to protect the renal tubules

Damage control surgery

Emphasizes rapid surgical control of active hemorrhage while minimizing extensive or lengthy interventions fo definitive treatment - definitive surgery deferred for 24-48 hr after resuscitation is complete - pt returned to critical care unit for aggressive rewarming, ongoing resuscitation and attainment of hemodynamic stability

Lactate

End-product of anaerobic metabolism that results from a decrease in tissue perfusion - can be a marker for cellular hypoxia in hypovolemic/hemorrhagic shock - level >4 have been reported as an independent predictor of mortality in trauma pt

Injuries to the head management

Ensure adequate BP to meet cerebral perfusion, provide oxygen and nutrients, maximize ventilation and oxygenation through effective airway management, maintain the head in a midline position to enhance cerebral blood flow, administer sedatives to address agitation and increased iCP, and conduct frequent assessments - goals for BP focus on interventions to maintain a cerebral perfusion pressure greater than 60 - key to neurologic assessments is recognizing subtle changes and notifying the physician for prompt intervention

Secondary prevention

Entails strategies to minimize the impact of the traumatic event - seat belt use, airbags, advances in automobile construction, car seats, helmets, anti bullying hotlines

Minimal or nonresponders

Fail to respond to crystalloid and blood administration in the ED and surgical intervention is needed immediately to control hemorrhage

Management of hypovolemic shock

Focuses on finding and eliminating the cause of bleeding and concomitant support of the pt's circulatory system with IV fluids and blood products - sympathetic compensatory mechanisms in the body respond to states of hypo perfusion through tachycardia, narrowing pulse pressure, tachypnea, and decreased urine output; may not be obvious until pt in later stages

Blast injuries

Forms of blunt and penetrating trauma - primary: generates shock waves that change air pressure and tissue damage results form the pressure waves passing through body, injures gas containing organs - secondary: occur as an increased negative pressure from the shock wave causes debris to impale the body, creating organ and tissue damage - tertiary: results as the body is thrown or propelled by the force of the explosion, resulting in blunt tissue trauma including closed head injuries, fractures and visceral organ injury - quaternary: occur as a result of chemical, thermal and biologic exposure

Flail chest

Frequently defined as fracture of two or more adjacent ribs in two or more places, creating a free floating segment of the rib cage - results in paradoxic chest movement, chest contracts inward with inhalation and outward with exhalation - paradoxic chest movement, increased work of breathing, tachypnea, and eventually signs and symptoms of hypoxemia - management: endotracheal intubation and mechanical ventilation with adequate pain control - position pt to enhance ventilation and oxygenation, and provide frequent pulmonary care to prevent pneumonia

Trauma

Frequently referred to as a disease of the young because the majority of injured persons range in age from 16-54 years

Resuscitation phase

From the time of initial injury until the pt is stabilized in the ED or OR - reestablishing an effective circulatory volume and a sable hemodynamic status in the pt

Assessment of compartment syndrome

Guided by the 6 P's - pt complains of increasing throbbing pain disproportionate to the injury not relieved by narcotics - pain localized to the involved compartment and increases with passive muscle stretching; area firm - late signs: paresthesia distal to the compartment, pulselessness and paralysis - irreversible: pallor, paresthesia, paralysis, pulses - elevate limb to heart level to promote venous outflow and prevent further swelling

Electrolyte imbalances from fluid administration include

Hypocalcemia, hypomagnesemia, hyperkalemia, and hypokalemia - may lead to changes in myocardial function, laryngeal spasm, and neuromuscular and CNS hyperirritability

Most common cause of hypotension and impaired cardiac output in the pt after traumatic injury is

Hypovolemic shock from acute blood loss - causes: external (hemorrhage) or internal (hemothorax, hemoperitoneum, solid organ injury, long bone or massive pelvic fractures) - interventions: applying pressure to control the bleeding, replacing circulatory volume with crystalloid and blood products, and determine definitive treatment

Red

Indicates emergent, life-threatening injuries

Green

Indicates non urgent injuries that the pt can self treat

Black

Indicates that the pt is dead or near death

Yellow

Indicates urgent major injuries requiring care within 1 hours

Secondary survey

Initiated after all actual or potential life-threatening injures have been identified and addressed and resuscitative efforts have been initiated - methodic approach to obtain a patient and event history and a head to toe assessment of the pt - radiologic and ultrasound studies: sequence of procedures influenced by the pt's level of consciousness, the stability of the pt's condition, the mechanism of injury, and the identified injuries

Rib fractures

Injury most commonly associated with chest trauma - assess for hemodynamic instability, may indicate the presence of major vessel injury such as aortic disruption or injury to the subclavian artery - injury to the liver, spleen or kidney may accompany ribs 10-12 - management depends on the number of ribs, degree of underlying injury, and age of pt - pneumonia is the primary complication

Postoperative management of critically ill patients

Involves a systematic and thorough assessment and monitoring of respiratory and cardiovascular function, neuromuscular abilities, mental status, temperature, pain, drainage and bleeding, urine output and resuscitation efforts - standard: every 5 minutes x3, every 15 minutes x3, every 30 minutes for 1 hour and then hourly

Primary prevention

Involves interventions to prevent the event - driving safety classes, speed limits, campaigns against driving and driving, fall prevention interventions, and domestic violence prevention campaigns

The goal of the trauma system

Is to match the needs of injured patients to the resources and capabilities of the trauma facility

Cardiac tamponade

Life threatening condition caused by rapid accumulation of fluid (usually blood) in the pericardial sac - as the intrapericardial pressure increases, cardiac output is impaired because of decreased venous return - blood causes increased RAP and distended neck veins - beck's triad: hypotension, muffled or distant heart sounds, elevated blood pressure; may not be present until late in development - should be suspected in any pt with chest and multi system injuries who presents in shock and does not respond to aggressive fluid resuscitation - diagnosed by FAST and pericardiocentesis

Basilar skull fractures

Located at the base of the cranium and potentially involve the 5 bones that form the skull base - diagnosis is based on the presence of cerebrospinal fluid in the nose (rhinorrhea), in the ears (otorrhea) or both; ecchymosis over the mastoid area (battle sign) or hemotypanum (blood in the middle ear) - raccoon eyes or periorbital ecchymoses are present

Spinal cord injury

Major neurologic disability that is assessed early in the emergent phase of traumatic injury - mechanisms of injury that may lead to this include hyperflexion, hyperextension, axial loading, rotation, and penetrating trauma - initial treatment: ABCs, spinal immobilization and prevention of further injury through surgical stabilization of the spine - determine the appropriate level because higher injuries may result in loss of phrenic nerve innervations, compromising the pt ability to breath spontaneously - causes a loss of sympathetic output, resulting in distributive shock with hypotension and bradycardia - vasopressors often required to compensate for the loss of sympathetic innervation and resultant vasodilation

Extensive or complex surgeries during resuscitation phase

May affect pt outcomes due to the lethal triad of coagulopathy, hypothermia, and acidosis

Central venous catheter

May be necessary because of peripheral vasoconstriction or venous collapse - may be beneficial as a resuscitation monitoring tool and for rapid administration of large volumes of fluids

Hyperkalemia

May occur as a result of cellular damage that peaks within the first 12 hours after injury - places pt at risk for life-threatening dysrhythmias - calcium glutinate may be administered - tissue hypo perfusion and acidotic states may exacerbate

Splenic injury

Occurs most often as a result of blunt trauma to the abdomen - pt may present with left upper quadrant tenderness, peritoneal irritation, referred pain to the left shoulder (Kehr's sign), and hypotension or signs of hypovolemic shock - encapsulated hemorrhage shows no signs of bleeding - diagnosed with same test as for liver injuries - preserve splenic tissue because of its role in immune function

Compartment syndrome

Occurs when a fascia-enclosed muscle compartment such as an extremity experiences increased pressure from internal sources (edema or hemorrhage) or external sources (splints, immobilizers and dressings) - results in ischemia and necrosis of the muscle and nerve tissue - degree of damage depends on the pressure and length of time during which perfusion is compromised - muscle necrosis resulting in permanent loss of function and amputation can occur within 4 Horus of ischemia

Pneumothorax

Occurs when air escapes form the injured lung into the pleural space, altering the negative intrapleural pressure and resulting in a partial or complete collapse of the lung - respiratory distress, tachypnea, tachycardia, diminished or absent breath sounds on the injured side, and c chest pain - confirmed with chest radiography or E-FAST - treatment focuses on supplemental oxygen and chest tube placement to evacuate the pleural air and reexpand the lung

Tension pneumothorax

Occurs when an injury to the chest allows air to enter th pleural cavity without a route to escape - evidenced by mediastinal shift and distended neck veins - resulting decreased cardiac output and alterations and gas exchange causes: anxiety, severe respiratory distress, absence of breath sounds on affected side, hypotension, distended neck veins and tracheal deviations - cyanosis is a late sign - diagnosis: clinical presentation - treatment: immediate needle thoracentesis

Liver injuries

Organ most commonly injured by blunt or penetrating trauma, hemorrhage primary cause of death - pt may present with hx of right lower thoracic trauma, fractured lower right ribs, right upper quadrant ecchymosis, right upper quadrant tenderness and hypotension - confirmed with FAST and abdominal CT - grade I-III treated with close monitoring and bed rest for 5 days - grade IV-VI treated with angiographic embolization or surgical management, when there is expansion of the hemorrhage, a large laceration or complete avulsion of the liver from its vascular supply

Goals of prehospital care

Prevent further injury, initiate resuscitation, and provide safe and timely transport

Aortic disruption

Produced by blunt trauma to the chest and frequently results in death at the scene of the event - lethal injury, but early diagnosis can prevent tearing of the innermost layer, exsanguination and death - signs: weak femoral pulses, dysphagia, dyspnea, hoarseness and pain - chest radiography may show.a widened mediastinum, tracheal deviation to the right, depressed left mainstream bronchus, first and second rib fractures and left hemothorax - confirmed by angiography

Active external strategies

Radiant lights, fluid filled warming blankets, convection air blankets

Musculoskeletal injuries

Rarely a priority in emergency management unless they result in significant hemodynamic instability (pelvic fractures or traumatic amputation) - assess limb swelling, ecchymosis, and deformity - six P's: pain, pallor, pulses, paresthesia, pressure and paralysis; describes the neurovascular status of the extremity and critical in assessing circulation - loss of pulses considered late sign of diminished perfusion - presence of increased pain, pallor and paresthesia supersedes loss of pulses and should be reported immediately

Rapid responders

React quickly and remain hemodynamically stable after administration of the initial fluid bolus - fluids are then slowed to maintenance rates

Trauma's lethal triad of death

The combination of hypothermia, hypotension and acidosis

Banked blood products have high levels of citrate, which may induce

Transient hypocalcemia - may lead to ineffective coagulation because calcium is a necessary cofactor in the coagulation cascade - management focuses on improving perfusion to the body tissues, increasing pt body temperature, and administering clotting factors