PHTLS - Toni Review
Hypoxia
(deficient tissue oxygenation) can be cause by: *The inability of the air to reach the capillaries usually because the alveoli are filled with fluid or debris *Decreased blood flow to the alveoli *Decreased blood flow to the tissue cells
Prehospital Treatment of shock with the goal of preventing anaerobic metabolism
*Maintaining an adequate airway and ventilation, thus providing adequate oxygen to the RBC's *Judicious use of supplemental oxygen as part of ventilating the patient *Maintaining adequate circulation, thus perfusing tissue cells with oxygenated blood--Stopping loss of additional blood to maintain as many RBC's as possible to carry oxygen
Signs of hemothorax are?
1. Diminished or absent lung sounds 2. Hemodynamic compromise 3. Flat neck veins 4. Dull to chest percussion (3L of blood in each plural cavity, JVD is not a reliable source)
Factors to assess on-scene after a vehicle crash
1. Direction of the impact 2. external damage to the vehicle 3. Internal damage
3 phases of the oxygenation process
1. External respiration 2. Oxygen Delivery 3. Internal (cellular) Respiration
Important facts of an epidural bleed are what?
1. Fast bleeds (medial meningeal artery) 2. Usually die in about 1 hr 3. Lucid intervals (knockd out, wake up & act normal, knock back out)
3 Categories of Shock
1. Hypovolemic 2. Vasogenic 3. Cardiogenic
In order for an informed consent to be valid, patients:
1. Must have decision-making capacity 2. Must have the ability to communicate their understanding of their diagnosis, prognosis, and treatment options 3. Must be able to give consent or refusal voluntarily 4. Must actually give a refusal or consent to treatment
Public Health Approach--4 step process
1. Surveillance 2. Risk Factor Identification 3. Intervention Evaluation 4. Implementation
Four phases in the process of caring for patients with acute injuries
1. The Prehospital Phase 2. The initial (resuscitative) phase in the hospital 3. The stabilization and definitive care phase 4. The long-term resolution and rehabilitation to return the patient to a functional status
Three impacts that occur in most vehicular crashes:
1. The impact of the two objects 2. The impact of the occupants into the vehicle 3.The impact of the vital organs inside the occupants
Informed Consent is overridden when:
1. The patient lack decision-making capacity due to unconsciousness or significant cognitive impairment and there is no surrogate available 2. The condition is life or health threatening and the patient may suffer irreversible damage in the absence of treatment 3. A reasonable person would consent to the treatment, in which case a health care provider may proceed with treatment in the absence of an autonomous consent from the patient or surrogate
Three collisions that happen
1. The vehicle of the crash hitting an object, moving or stationary 2. the potential patient hitting the inside of the vehicle, crashing into an object, or being struck by energy in an explosion 3. The internal organs interacting with the walls of a compartment of the body or being torn loose from their supporting structures
Uncontrolled release of energy can produce these three outcomes:
1. When the difficulty of the task suddenly exceeds the individual's performance ability 2. When the individual's performance level falls below the demands of the task 3. When both factors change simultaneously
Fourth degree burns?
1. affect down to the bone and muscle
Third degree burns?
1. affect down to the dermis 2. waxy and leathery looking
Second degree burns?
1. affect the epidermis 2. blisters
What are the 3 phases of a Crash?
1. car into tree 2. person into steering wheel 3. organs into body
What are signs of Cushings Tirad?
1. hypertension 2. bradycardia 3. Ab. Normal Respirations 4. +1 (ALOC, Blown Pupils ect.) = brain steam herniation
Platinum 10 mins are used for what?
1. identify life-threats 2. perform key interventions 3. rapid extrication were indicated 4. timely transport to an appropriate facility 5. early notification to the receiving facility
Abdominal evisceration key points are what?
1. moist sterile dressing 2. occlusive dressing 3. keep PT warm 4. keep PT still
What is crush syndrome?
1. release of pressure from compartment syndrome 2. lactic acid rushes into the body
What are important facts about subdural bleeds?
1. slower bleeds (bridging veins) 2. doesnt usually experience lucid intervals
Distributive Shock key factors are what?
1.vasodilation below the injury site 2. warm skin below the injury site 3. Bradycardia & Hypotension 4. Priapism (Difference between this and hemorrhagic shock is the bradycardia due to parasympathetic system)
Normal ventilatory rates Adults=
10 BPM
A fractured femur can result in___________________mL of hemorrhage.
1000 TO 2000
How warm should you warm your fluids to if possible?
102 degrees
Number of thoracic vertebrae
12
Important aspects of falls?
15 feet or 3x their height & the surface they land on = (severity of fall) Body part they land on = (type of injury)
Number of pounds the human head averages
16-22 pounds
usual age groups for head and spinal injuries
16-35 year old mostly males
After falling from the third story at a construction site, a 27-year-old male is found in contrast with unequal pupils and a regular respirations. Which of the following is most appropriate rate of ventilations?
20 BPM
Normal ventilatory rates Children=
20 BPM
Your patient is a 32 year old female who was thrown from a horse and struck her head on the ground. She was not wearing a helmet. She does not respond verbally or open her eyes to painful stimuli, but responds to painful stimuli with decerebrate posturing. Her right pupil is dilated and does not react to light. Her respirations are 6 per minute and irregular, pulse 56, blood pressure 188/98. You should ventilate the patient at a rate of?
20 BPM.
your patient is a 20yr old male who struck his head on a teammates knee while diving to catch a football. He was not wearing a helmet. He demonstrates decerebrate posturing and has a GCS score of 4. His heart rate is 58, blood pressure 180/102 and his left pupil is dilated. What is the best ventilation rate to use when managing this patient?
20 breaths per minute
Skeletal Injuries Percentage of falls from a height greater than 15 feet involve an associated lumbar spine fracture
20%
estimated spinal injuries per year
20,000
fluid replacement regimen
20ml/kg titrate to 80mm hg with uncompressible bleed and 90mmhg with compressible bleed
After falling out of a second-story window, a 7-year-old male is found unconscious with unequal pupils and irregular respirations. Which of the following is the most appropriate rate of ventilations?
25 BPM
Normal ventilatory rates Infants=
25BPM
ventilation rate for ICP
25bpm or 1 breath every 4-5 seconds
Ratio for loss blood replacement
3 litres of electrolyte solution replacement for each liter of blood lost
What percentage of blood volume loss in an adult patient is associated with findings of tachycardia (>120/beats/minute), tachypnea (30-40 Breaths/min), and hypotension (systolic BP <90mmHg)?
30 TO 40
petco2 should be what during icp
30-35mm hg
Potential Blood loss from a single femoral fracture
30-40%
Closed head injury capography range is what?
35 or less
Normal capography value?
35-45
What is the ratio of fluids given to blood lost during trauma?
3:1 (3 liters of fluid per 1 liter of blood)
Space between the spinal cord and the spinal canal wall
3mm
Number of coccygeal vertebrae
4
The most common fractured ribs are ribs:
4 THROUGH 8.
estimated head injuries per year
4 million
Number of lumbar vertebrae
5
Number of cervical vertebrae
7
the target blood pressure for a trauma patient with suspected intraabdominal hemorrhage is what?
80-90 mmHg
For neurological injured PT's the systolic blood pressure is best if maintained at or above
90 mmHg
a 20 yr old female was ejected from her vehicle during a high speed roll-over motor vehicle collision. She has significant bleeding from a large laceration. Your initial assessment reveals a GCS score of 7, systolic bp of 70 and pupils that are equal but respond sluggishly to light. After establishing two large bore IV lines, you should titrate the infusion rate to achieve a target bp of at least
90 mmHg
What is the % for SP02?
95%
Which of the following patients should be treated first in a blast-related multiple patients situation?
A 30-year-old female with altered level of consciousness and decreased capillary refill
Which of the following findings is not expected in assessment of a pregnant patient?
A DECREASED BLOOD PRESSURE IN THE THIRD TRIMESTER.
Which of the following is indicated for the prehospital management of a circumferential second degree burn extending from the wrist to the elbow in a 70 Kg patient?
A DRY STERILE DRESSING ANALGESIA
Which of the following mechanisms is most likely to result in cardiac tamponade?
A PATIENT IS STRUCK IN THE LEFT ANTERIOR CHEST BY A NAIL EJECTED FROM A NAIL GUN.
Your patient is an injured construction worker bleeding profusely from a large laceration to the left thigh. He is confused and has pale, moist skin. Direct pressure applied to the wound by a first responder has failed to control the bleeding. The next step in controlling bleeding is to apply:
A TOURNIQUET TO THE LACERATION.
Autonomy
A competent adult patient's right to direct his or her own health care free from interference or undue influence
Injury
A harmful event that arises from the release of specific forms of physical energy or barriers to the normal flow of energy
White Blood Cells
A nearly colorless blood cell in the circulation responsible for responding to invading microorganisma
Which of the following best describes shock?
A state of inadequate energy production/ low perfusion
A 24-year-old male is found motionless on the side of the road after being struck by a vehicle. As the prehospital providers approach the patient, they notice he is lying in a puddle of blood and breathing is absent. Which action should be taken first?
A. Airway and cervical spine management.
At what point does the prehospital provider's assessment begin?
A. Before arriving at the scene
Prehospital providers are treating an unconscious patient with irregular respirations who was ejected from a motor vehicle. No obvious external injuries are noted during the initial assessment. Vital signs are P 54 breaths per minute, SpO₂ 94%, and BP 182/112 mm Hg. These findings are most consistent with which of the following injuries?
A. Closed head injury
A 28-year-old female presents with dyspnea and chest pain after falling from a three-story rooftop. She is coughing up copious amounts of blood, has decreased lung sounds on the left, and has a faint radial pulse. What is the prehospital provider's initial objective?
A. Controlling her airway
What is the best method for confirming proper placement of an endotracheal tube in a patient that has a palpable pulse?
A. End-tidal CO₂ monitoring
During the physical examination of a trauma patient, the prehospital provider pushes down on the sides of the pelvis and discovers crepitus. How should the prehospital provider proceed?
A. Immediately stop any further pelvic assessment.
Which of the following best defines shock?
A. Inadequate energy production at the cellular level
A 39-year-old male presents with chest pain and increasing dyspnea after being stabbed in the right anterior chest just above the nipple. His pulse is 112 beats per minute, respirations 28 breaths per minute, and blood pressure 88/64 mm Hg. There are absent lung sounds on the right side with palpable subcutaneous emphysema. What is the most appropriate treatment?
A. Needle decompression
Prehospital care providers approach a 29-year-old male who fell 30 feet (3 meters). Gurgling respirations are heard, cyanosis is displayed, and he has spurting blood from his right wrist. How should the provider manage this patient?
A. Provide cervical spine precautions, suction the airway, and control bleeding.
Prehospital providers are assessing an 82-year-old male who fell out of bed two weeks ago. He has had increasing difficulty speaking, irritability, weakness, and a drastic change in his ability to walk. He is most likely experiencing which of the following?
A. Subdural hematoma
pediactrics head injury first sign
AMS
first clue of TBI
AMS, motor or sensory deficit, loss of coordination and reflexes
An electrical burn caused by superheated air near the source of electricity is an
ARC burn.
What is the most important physical finding a patient with a suspected traumatic brain injury?
Abnormal levels of consciousness
Subdural Hematoma
Account for 30% of TBI-Generally results from venous blood from bridging viens that are torn during a violent blow to the head.
Secondary Prevention
Actions taken to prevent the progression of an acute injury once it has occurred (Example: avoiding the occurrence of hypoxia or hypotension after a traumatic brain injury)
What are the leading causes of death in adults & children?
Adults - MVC Children - Falls
Conditions that should mandate spinal immobilization
Altered LOC Spinal Pain or tenderness Neurologic deficit or complaint Anatomic deformity of the spine
Epidural Hematoma Signs
Altered LOC, dilated and sluggish non reactive pupil on the side of herniation, hemiparesis or hemiplegia on opposite side of injury.
Pulmonary Volume Terminology Dead Space
Amount of air brought into the lungs that does not have the opportunity to exchange oxygen and carbon dioxide
Pulmonary Volume Terminology Tidal Volume (Vo)
Amount of air that is inhaled then exhaled druing a normal breath (.4-.5 litres)
Nonmaleficence
An ethical principle that obligates the medical provider to not take actions that may harm the patient or place the patient in harm's way
Beneficence
An ethical term that means "to do good"; requires prehospital care providers to act in a manner that maximizes the benefits and minimizes the risks to the patient
When energy produced by cells occurs during the state of inadequate oxygenation, it is referred to as which of the following conditions?
Anaerobic metabolism
Prehospital providers respond we 16-year-old male who punched a glass window and sustained a large laceration to his arm that is bleeding heavily. He is restless, diaphoretic and was a weak, 30 pulse. What is the most appropriate action?
Apply direct pressure
The meninge that lays in the middle between the dura and pia matter
Arachnoid membrane-loosely covers the brain and its blood vessels
Level 2 Trauma Center
Area Trauma Center, Most common trauma emergencies with surgical capabilities 24/7, (can handle most common types of trauma) Ex.... St. Francis
Name of the 1st cervical vertebrae
Atlas
Two receiving chambers of the heart
Atria
Name of the 2nd cervical vertebrae
Axis
When ventilating the average adult patient, how much air should be delivered into the lungs during each ventilation?
B. 500 mL
A construction worker fell from a three-story building, landing on his head and upper torso. Upon assessment, prehospital providers discover a large amount of blood coming from one ear canal. Which of the following is the most appropriate action?
B. Allow the blood to collect in a loosely applied dressing.
A 19-year-old male was stabbed in the abdomen several times with a knife and presents with abnormal vital signs. After application of high-flow oxygen and a bolus of IV crystalloid, vital signs are within normal limits. He is now likely in which stage of shock?
B. Compensated
Prehospital providers are treating an adult female who spilled a small cup of hot coffee and sustained partial-thickness burns to the front of her abdomen and right leg. The patient ran cool water over her burns to help relieve the pain. Which of the following interventions is the most appropriate next step?
B. Cover burned area with dry sterile dressings.
Prehospital providers respond to a male patient lying supine on the ground with a single gunshot wound to the left temple. The patient is apneic and pulseless. What is the most appropriate action?
B. Declare the patient dead.
A 17-year-old female was found unresponsive on the ground after falling from a second-floor balcony. The patient is pale, cool, and clammy. Which of the following is the most appropriate initial action?
B. Ensure a patent airway.
Upon arrival to a motor vehicle collision, prehospital providers locate a male patient lying on the ground with an obvious left femur fracture. Which of the following is the most appropriate first step?
B. Initiate cervical spine precautions.
Prehospital providers are on the scene of a rollover motor vehicle crash (MVC) involving a 26-year-old male. The patient moans to painful stimuli, exhibits unequal chest rise, and has decreased lung sounds on the left side. Of the following, what is the highest treatment priority?
B. Opening and maintaining an airway
A patient with unexplainable signs of shock is likely experiencing hemorrhage from which of the following?
B. Pelvic fracture
While monitoring a patient with a flail chest segment, which of the following is the earliest sign of deterioration?
B. Respiratory rate increase
Which of the following groups of findings represents Cushing's phenomenon?
BRADYCARDIA ABNORMAL RESPIRATORY PATTERN ELEVATED BLOOD PRESSURE
Hypertension medications that may prevent compensatory tachycardia to maintain BP
Beta Adrenergic blocking agents and calcium channel blockers
Pulmonary Contusion
Blunt force can tear lung tissue resulting in bleeding into the alveoli
What is newtons 1st law?
Body at rest will remain at rest and a body in motion will remain in motion until acted upon by an outside force
Injury Triangle 4 parts
Bottom: Episodes of injury medically attended 3rd: Emergency department visits 2nd: Hospital discharges Top: Deaths
Which of the following organs are most sensitive to hypotension?
Brain
what is the most sensitive organs with decreasd levels of o2
Brain, heart, lungs
Prehospital providers discover CSF fluid draining from a patient's nose and ears. This finding is most commonly associated with which type of skull fracture?
C. Basilar.
Which of the following medication classes could mask the signs of internal bleeding in an elderly patient?
C. Beta blockers
Prehospital providers respond to a 30-year-old male who fell through a sliding glass door. The patient has suffered multiple lacerations to the upper extremities that are bleeding heavily. He is restless, diaphoretic, and with a weak, thready pulse. What is the most appropriate intervention?
C. Direct pressure
Prehospital providers respond to an 18-year-old female who lost consciousness after striking her head during a motor vehicle collision. The patient is alert and oriented and complaining of headache and nausea. During the secondary survey, the patient becomes confused and difficult to arouse. What type of injury should be suspected?
C. Epidural hematoma
Which assessment technique should be performed during the primary survey?
C. Exposure of the patient
Prehospital providers are assessing a patient who has been kicked in the ribs by a mule. Instability of the involved ribs is noted. The patient is breathing rapidly and will not take deep breaths. Which of the following is the most likely injury?
C. Flail chest
A 24-year-old male presents with an altered mental status after shoveling rock on a hot summer's day. He is confused, has dry skin, and his behavior is confused and erratic. He will not allow the provider to touch him and is shivering. Which condition is the patient likely suffering?
C. Heat stroke .
What is the most common type of shock experienced by trauma patients?
C. Hypovolemic
A full-term pregnant patient is being spinally immobilized after a motor vehicle collision. After placing her in the ambulance, vital signs reveal a blood pressure of 88/64 mm Hg. What is the most appropriate next step?
C. Immobilize the patient on the backboard and tilt the backboard to the left side.
What changes in vital signs suggest increasing intracranial pressure?
C. Increased blood pressure, decreased pulse rate
What is the most important physical finding in a pediatric patient with a potential traumatic brain injury?
C. Increased respiratory rate
Prehospital providers have arrived on scene of a 23-year-old male patient with a single gunshot wound to the left midaxillary line even with the nipple. The wound is bleeding slightly. What is the first step in patient care that should take place?
C. Open and assess the airway.
Prehospital providers are on the scene of a multiple-casualty incident. Upon assessment of a patient's airway, the provider does not hear any sounds. What is the appropriate next step?
C. Position the airway.
Prehospital providers are treating a victim of a motor vehicle collision who has obvious bilateral midshaft femur fractures, a right humerus fracture, and left wrist deformity. What is the most appropriate on-scene treatment for this patient?
C. Provide immobilization on a backboard.
After being tackled, a football player has lost sensation from the umbilicus down. What area of the spine should prehospital providers suspect is injured?
C. T10
What is a potent vasodilator?
C02
When the application of kinetic energy to the body from either a blunt or penetrating mechanism displaces tissue, this is known as
CAVITATION
PASG is contraindicated in patients with
CHEST TRAUMA.
A chemical solution with a pH of 4.0 is considered an ACID and causes damage to the tissues via
COAGULATION NECROSIS.
What is autoregulation?
CPP increases due to ICP increase
CPP- is normally below ? mmHg
CPP is normally 15 mmHg or below
Which of the following is an example of the tertiary phase blast injury?
CRUSHING INJURY DUE TO STRUCTURAL COLLAPSE.
Hypocentilation
Can result from: *Obstruction of airflow through the upper and lower airways *Decreased expansion of the lungs as a result of direct injury to the chest wall or lung *Loss of ventilatory drive, usually because of decreased neurologic function, most often after a traumatic brain injury
What is the best method for confirming proper placement of an endotracheal tube in a trauma patient that has a palpable pulse?
Capnography
Cause and Symptoms Brown Sequard syndrome
Caused by penetrating injury and involves hemi-transection of the cord. Symptoms include complete cord damage and loss of function of the affected side with loss of pain, temp and sensation on the opposite side of the injury
Vessels that lay on top of the Pia Mater
Cerebral Blood Vessels
Inadvertent hyperventilation of a patient with suspected traumatic brain injury may lead to which complication?
Cerebral vasoconstriction
Care of the trauma patient in the field is an involving science and should be evidence-based. As lifelong learners, we must be prepared to adapt our practices based on research. This is because research may lead to which of the following?
Change in our current practices
Auto vs. Ped facts?
Child - Freeze & stand there, get drug under car, multi-system trauma Adult - turn & run, extremity trauma
Level 3 Trauma Center
Community Trauma Center, Specialized ED and some surgical capability (the speciality staff is on call and has 30 mins to get to hospital)
Skeletal Injuries Compression
Compression fractures that produce wedge compression or total flattening of the body of the vertebra
You're call to treat a patient who was knocked unconscious when he slipped and fell on a wet floor striking his head. it is now several hours later he is awake but confused, does not recall the incident, and is vomiting with a headache. which of the following injuries is most likely?
Concussion
EMS response and adult barista who spilled a cup of hot coffee and sustained partial thickness burns to the abdomen and right leg. The patient ran cool water over the branch which of the following interventions is most appropriate next up?
Cover burn area with dry sterile dressing's
What is broken in a basilar skull fx?
Cribriform plate (look for blood/fluid from nose and/or ears w/o direct injury to nose or ears)
Septic Shock
Cytokines released because of an infection can cause damage to blood vessel walls and cause vasodilation
Which of the following patients should be considered the highest priority for treatment and transport?
D. A 74-year-old pedestrian who was struck by a vehicle, has a pulse rate of 92, and takes a beta blocker on a regular basis
A 33-year-old male was involved in a house fire and the primary survey reveals stridor, bradypnea, and soot around the nose/mouth. Multiple attempts at airway management have been unsuccessful. Which destination is most appropriate for this patient?
D. Community hospital (10 min away)
Which of the following motor responses is indicative of the most severe traumatic brain injury?
D. Decerebrate posturing
A tension pneumothorax is differentiated from a simple pneumothorax by which sign?
D. Hemodynamic compromise/hypotension
A 55-year-old male is found unconscious at the bottom of a 14-step, concrete staircase. Assessment reveals snoring respirations, bradypnea, facial swelling, and unequal pupils. What action should the prehospital provider implement first?
D. Jaw thrust maneuver
A temporal bone fracture of the skull will commonly tear which artery?
D. Middle meningeal
Prehospital providers are on scene with a 32-year-old male with a gunshot wound just above his left nipple. The patient is anxious, tachypneic, and has a weak, thready pulse. Lung sounds are absent on the injured side. Which of the following interventions is most appropriate?
D. Needle decompression of injured side
Prehospital providers arrive on a scene and find a pediatric patient immobilized on a long backboard. Upon assessment they note that the patient's head is in a flexed position. Which of the following is the most appropriate action?
D. Place padding under the torso
A 34-year-old male was lying supine on the ground when a large amount of steel rod fell onto his chest. The patient is complaining of shortness of breath and respiratory discomfort and has a bluish skin discoloration from the site of injury upward. What injury should be suspected?
D. Traumatic asphyxia
In which situation should the prehospital provider consider terminating cardiopulmonary resuscitation?
D. Witnessed arrest with 15 minutes of unsuccessful resuscitative efforts
A hemothorax is differentiated from a tension pneumothorax by:
DULL PERCUSSION ON THE AFFECTED SIDE.
Prehospital the writers respond to a male patient lying on the ground after being struck by a high-speed motor vehicle. The patient is apneic and pulseless. What is the most appropriate action?
Declare the patient dead....(This was the actual answer on the test...)
Warning signs of possible ICP
Decline in GCS sluggish or non reactive pupils Hemiplegia or hemiparesis Cushings phenomenon
Distributive Shock
Decrease in preload+decrease in cardiac output...uncontrolled vasodialation causes reduced resistance causing a decrease in the diastolic blood pressure
Hypoxemia
Decreased oxygen level in the blood can result from decreased diffusion of oxygen across the alveolar-capillary membrane
The Fick Principle
Description of the components necessary for oxygenation of the body cells: 1. On-loading of oxygen to RBC's in the lung
Tertiary Prevention
Directed at minimizing death and the long-term disability of an injury after it has occurred.
Outer most meninges
Dura mater- composed of tough fibrous tissue
Which of the following types of traumatic brain injury is most likely to be associated with hemorrhage from the middle meningeal artery?
EPIDURAL HEMATOMA
3 E's of Injury Prevention
Education, Enforcement, and Engeneering
Radiation Energy
Electromagnetic wave that travels in rays and has no physical mass to it. (Example: sunburn)
Thermal Energy
Energy associated with increased temperature and heat
What is law of conservation?
Energy cannot be created or destroyed, but can change forms. Car breaks = friction = heat = fire
Chemical Energy
Energy that results from the interaction of a chemical with exposed human tissue
EMS response for a patient who has sustained a blunt injury to the head. She had a period of consciousness followed by a brief period of consciousness and then became unresponsive just as EMS arrived. Based solely on this information, what is the most likely injury?
Epidural hematoma
Which injury is most likely to be sustained by the driver in a lateral impact collision to the left side of the vehicle with no side impact airbags (assuming the driver sits on the left)?
FRACTURED LEFT CLAVICLE.
What is the most common cause of death from trauma patients over 75 years of age?
Falls
How do you treat a sucking/open chest wound?
First action is to cover it Make occlusive dressing Diameter of sucking chest wound is about 2/3 size trachea
In addition to oxygen what is required to maintain the metabolic processes of life and energy production?
Glucose
Amount of blood loss that can happen before signs of compensatory mechanisms fail and BP become <90 mmHq
Greater than 30%
The most common type of shock in trauma patients is
HYPOVOLEMIC.
The patient presents with a blunt trauma injury to the chest. On exam, he has absent breath sounds on the one side of his chest and respiratory distress which additional sign would indicate that the patient has a tension pneumothorax?
Hemodynamic compromise
A 38 male sustained a large wound to his right thigh while at work what are the following actions is the most important initial step?
Hemorrhage control
What is the most common type of shock resulting from trauma?
Hemorrhagic
In addition to direct pressure, tourniquets and immobilizing fractures, which of the following is most effective by controlling hemorrhage
Hemostatic agents
Which of the following best guides the decision to provide spinal immobilization?
History and complaint
Three factors simulating the epidemiological triangle in relation to injury
Host (Human) Agent Environment
Hyperventilation and TBI
Hyperventilation can reduced CBF by causing vasoconstriction due to hypocapnia, PaCO2 >35 increases risk of cerebral ischemia
EMS response for patient valve in a motor vehicle versus car collision. The patient is unresponsive with vital signs of BP 82/palpitation, are our 24, pulse 128. What is the most likely type of shock?
Hypovolemic
The most common threat to life among trauma patients is?
INTERNAL HEMORRHAGE
Excessive fluid resuscitation of the trauma patient can result in which of the following?
Increased blood loss
The prehospital assessment of the trauma patient begins of which of the following?
Information provided by the dispatcher
What is most likely source of hemorrhage in a patient with unexplainable signs of shock?
Intra-abdominal injury
Cardiac tamponade is suspected with the findings of muffled heart sounds___________, and___________ known as___________.
JUGULAR VEIN DISTENTION, and HYPOTENSION, known as BECK'S TRIAD.
A 55-year-old male is found unconscious after being assaulted. Assessment reveals snoring respirations, bradypnea, facial swelling, and unequal pupils. What is the most appropriate first step?
Jaw thrust maneuver
The preferred fluid for resuscitation of the patient with significant burns is:
LACTATED RINGER'S SOLUTION.
During pregnancy, signs and symptoms of shock may appear _______ due to an _________ in maternal blood volume.
LATER, INCREASE
Your patient is an 82 year old female who was an unrestrained front seat passenger in a motor vehicle collision. Which of the following is the most reliable indication of shock in this patient?
LEVEL OF CONSCIOUSNESS.
Concerns with up & over injuries?
Laryngeal fx (may hear stridor) Sub-Q Emphysema Diaphragmatic tear
Which of the following signs of shock is not found during the primary survey?
Low blood pressure measurement
Which of the following is the most common cause of spinal injuries?
MOTOR VEHICLE COLLISIONS.
Leading cause of TBI
MVC
Managing Volume Resuscitation Uncontrolled hemorrhage-suspected chest, abdomen, retroperitonium
Maintain a systolic bp 80-90 or MAP 60-65
What is more important minute volume or tidal volume?
Minute volume
A patient who sustained extensive blunt trauma to his trunk has absent lung sounds on the right, marked respiratory distress, tachycardia and hypertension. What is the most appropriate intervention?
Needle decompression
Three responses of initial fluid bolus Minimal or no response
No change in PT after 1-2 liter Bolus
When administering isotonic crystalloid solution, about ___________ will remain in the vascular system after 1 hour.
ONE-THIRD
Thoracic Trauma - Penetrating Injury
Objects of varying size transgress the chest wall, enter the thoracic cavity, and possibly injure the organs within the thorax. When a penetrating wound creates a communication between the chest cavity and the outside world, air tends to rush into the pleural space through the wound during inspiration when the pressure inside the chest I lower than the outside, and because the resistance to airflow through the wound is often less that that through the airways.
Thoracic Trauma Assessment Four components to the phys exam
Observation, palpation, percussion, auscultation
Indication of TBI Hemiplegia
One sided paralysis
Indication of TBI Hemiparesis
One sided weakness
Can you typically remove impaled objects?
Only if it is occluding the airway otherwise No, it maybe stopping the bleeding!!
Management of flail chest includes:
PAIN MANAGEMENT VENTILATORY SUPPORT 100%O2
The greatest threat to life from injury to hollow abdominal organ is
PERITONITIS.
Which of the following findings indicate the need for immobilization when using a selective spinal immobilization protocol?
Pain or tenderness along the spine
Thoracic Trauma - Rib Fractures (Management)
Pain relief - Primary goal in initial management IV access IV narcotic analgesics Monitor Vitals especially Resp. Rate and Depth. Encourage patient to take deep breaths and cough to prevent the collapse of the alveoli (atelectasis) and the potential for pneumonia and other complications.
Thoracic Trauma - Hemothorax
Pathophysiology - Occurs when blood enters the pleural space. Because this space can accommodate a large volume of blood (2500-3000 ml), hemothorax can represent a source of significant blood loss and the loss of this circulating blood volume into the pleural space is a greater physiologic insult to the patient than the collapse of the lung that the hemothorax produces. Assessment: Presentation - some distress, chest pain and SOB are prominent features, generally signs of significant shock (tachycardia, tachypnea, confusion, pallor and hypotension.) Breath sounds on side of injury are diminished or absent (percussion note is DULL). Pneumothorax may be present in conjuction with hemothorax, increasing the likelihood for cardiorespiratory compromise. **Because of loss of circulating blood volume, JVD often are NOT present. Management: Constant observation to detect physiologic deterioration while providing appropriate support. High flow O2 Ventilation support via BVM or ETT if indicated. Hemodynamic status monitored. IV access an appropriate fluid therapy provided with a goal of maintaining adequate perfusion without large volumes (SBP 80-90) Rapid Transport to appropriate facility for surgical intervention.
Thoracic Trauma - Rib Fractures (Assessment)
Patients with simple rib fractures may have few symptoms. Most often they will complain of: Chest Pain and DIB Present with: Labored respirations Chest wall tenderness and crepitus Vital signs Respiratory rate and depth of breathing Pulse Ox Capnography
Which subset of patients compensates for blood loss the longest?
Pediatrics
Concerns with down & under injuries?
Pelvic fx Femur fx Patellar fx
The inner most meninges that is directly in contact with the brain
Pia Mater-
EMS arrived on scene and finds a emergency medical responder to immobilize a pediatric patient onto a long backboard. They know that the patient's head is in a flex position. Which of the following actions is most appropriate?
Place padding under the patients torso
In addition to using appropriately sized equipment, frequently reassessing the patient, employing age-appropriate Imobilization techniques, prehospital providers should do which of the following when managing pediatric patients?
Preserve body heat
Oncotic Pressure
Pressure that determines the amount of fluid within the vascular space
Hypovolemic Shock
Primarily hemorrhagic in the trauma patient related to loss of circulating blood cells and fluid volume with oxygen-carrying capacity. This is the most common cause of shock in the trauma patient
Skeletal Injuries Fractures
Produce small fragments of bone that may lie in the spinal canal near the cord
Which of the following is a golden principle of trauma care?
Provide adequate pain relief
Which best describes the goal of airway management?
Provide for adequate exchange of oxygen and CO2
EMS is treating an unrestrained driver of an automobile involved in a high-speed crash who struck his chest against the steering column. Prehospital providers no paradoxical movement of a portion of the patient's chest wall. The patient's respiratory rate is 16 and oxygen saturation is 94%. What is the most appropriate action?
Provide supplemental oxygen and observe
Cardiogenic Shock outlined
Pump failure
Level 1 Trauma Center
Regional Trauma Center, All types of specialty surgical care 24/7, (Surgical suites, Surgeons, Blood, CT, X-Ray ... all in house), Tertiary - all levels of care Ex... County USC, Cedars, UCLA- Ronald Regan, UCLA- Harbor General
Distributive or Vasogenic Shock
Related to abnormality in vascular tone arising from several different causes, including spinal cord injury and anaphylaxis, etc...
Prehospital providers have treated a sucking chest wound with an occlusive dressing. During transport to the hospital, the patient developed increasing respiratory distress with increased respirations and absent lung sounds are noted on repeat auscultation. What is the most appropriate next intervention?
Remove the occlusive dressing
Active Strategies for Injury Prevention
Require cooperation of the person being protected; manual seat belts and choosing to wear a helmet
Passive Strategies for Injury Prevention
Require little or no action on the part of the individual; sprinkler systems and vehicle air bags
Anaphylactic Shock
Respiratory distress, airway obstruction and vasodilation
Cause and Symptoms Anterior Cord syndrome
Results from bony fragments or pressure on spinal arteries Symptoms-loss of motor function and pain, temperature and light touch PT's will have some light touch sensations such as vibration.
A burn with reddened, glistening base that may have blisters is most characteristic of a
SECOND degree burn.
Which of the following is contraindicated in the management of a pregnant trauma patient in the third trimester?
SUPINE POSITION.
Hypotension due to spinal cord trauma occurs due to interruption of the _______________nervous system pathway.
SYMPATHETIC
A male patient suffered a stab wound to his left flank. He is found to be in stage III shock. During the 25 minute transport to the trauma center, intravenous fluids should be administered at a rate sufficient to maintain a:
SYSTOLIC BP OF 80 TO 90.
When approaching a trauma patient what is the first thing must be made?
Scene safety
You respond for a patient who is sustained a GSW to the right upper thorax he is barely responsive, pale, and diaphoretic which of the following is most appropriate for transport?
Scoop stretcher
Function of the ascending nervee tracts
Sensory impulses from body parts through the cord up to the brain
What is the least sensitive to ischemia?
Skin and bones (can last 4-6 hrs w/o 02)
Subdural Hematoma
Slow to develop may take days. Can be chronic or acute. Pt on coumadin are at high risk of un identified subdural hematomas that may be chronic. Often may be confused with stroke, infection or general decline of PT.
Psychogenic Shock is caused by what?
Stimulation of the vagus nerve that stimulates bradycardia
Endotracheal intubation is a technique that requires which of the following?
Substantial training to maintain proficiency
Which of the following is a preventable cause of secondary brain injury?
Systemic hypoxia
After falling from The high bar, a gymnast has loss of senstation from the nipples down what area of the spine is most likely damage?
T4
Hypotension in hemothorax is associated with:
THE ABILITY OF EACH SIDE OF THE THORAX TO HOLD UP TO 3 LITERS OF BLOOD.
During the assessment of the trauma patient, auscultation of the lung sounds is first performed during:
THE PRIMARY SURVEY.
Minute volume of ventilation is best represented as
TIDAL VOLUME x ventilatory rate
Skeletal Injuries Overstretching
Tearing of the ligaments and muscles producing instability between the vertebrae
Justice
That which is fair or just; in medicine , usually refers to how medical resources are distributed with regard to health care
Final stage of uncal herniation
The RAS is affected patient lapses into coma
CPP- Cerebral Perfusion Pressure
The amount of pressure it takes to push blood through the cerebral circulation. CPP=Mean Arterial pressure (MAP) - Intercranial pressure (ICP)
Systemic Vascular Resistance
The amount of resistance to the flow of blood through the vessels. It increases as the vessel constricts. Any change in lumen diameter or vessel elasticity can influence the amount of resistance
MAP-Mean Arterial Pressure
The average pressure for the entire cardiac cycle MAP=Diastolic Pressure + 1/3 of the Pulse Pressure
Mean Arterial Pressure
The average pressure in the vascular system estimated by adding one third of the pulse pressure to the diastolic pressure
Autoregulation
The brain changes the cerebral blood vessel resistance (CVR) to compensate for changes in the cerebral pulse pressure (CPP)
What is most sensitive to ischemia?
The brain, heart and lungs (can last about 4-6 mins w/o 02)
PP- Pulse Pressure
The difference between the systolic and diastolic PP= Systolic (SBP) - Distolic (DBP)
Primary Brain injury
The direct trauma or mechanical injury, includes contusions, hemorrhages and lacerations
Mass effect
The effect of a growing mass or tumor
Interstitial Fluid
The extracellular fluid located between the cell wall and the capillary wall
What the 2nd most sensitive to ischemia?
The kidneys, liver & GI tract (can last 45-90 mins w/o 02)
Osmosis
The movement of water across a membrane from an area that is hypotonic to an area that is hypertonic
Which of the following indicates that a trauma patient is having trouble breathing?
The patient breathing is noticeable
Epidural Hematoma 1-brief Loss of consciousness 2-Lucid Interval 3-Rapid decline in level of consciousness
The period of time after a brief loss of consciousness where the PT may be oriented, lethargic or confused followed by a rapid decline of consciousness. Account for 2% of TBI-Arterial blood starts to dissect or peal the dura off of the inner table of the skull creating an epidural space filled with blood. Rapidly developing.
Afterload
The pressure against which the left ventricle must pump out blood with each beat
Intracellular Pressure
The pressure exerted against the inside of the skull by brain tissue, blood, and cerebrospinal fluid
Dermatome
The sensory area on the body for which a nerve root is responsible
Public Health Impact of Injury
The totality of the impact of injury on the health of the public; includes deaths, injury, disability, and financial considerations
Priciplism
The use of the four ethical principles of autonomy, non maleficence,beneficence, and justice, which provide a framework for one to weigh and balance the benefits and burdens of treating a specific patient in order to do what is in the patient's best interest
Preload
The volume and pressure of the blood coming into the heart from the systemic circulatory system (venous return)
Cardiac Output
The volume of blood pumped by the heart
Stroke Volume
The volume of blood pumped out by each contraction of the left ventricle
What is the most common cause of airway obstruction in the unconscious trauma patient?
Tongue
Pulmonary Volume Terminology Minute Volume (Ve)
Total volume of air moved into and out of during a 1 minute interval.
Pulmonary Volume Terminology Total Lung Capacity (TLC)
Total volume the lungs contain when maximally inflated. This volume declines with age from 6 L. in young adults to 4 L. in elderly.
What systolic BP number do you want to see in a trauma and/or traumatic brain injury patient?
Trauma 80-90 TBI 90-100
The most appropriate for airway maneuver for trauma patients as which of the following?
Trauma jaw thrust
Thoracic Trauma - Physiology
Two components of chest physiology that are most likely to be impacted by injury - BREATHING and CIRCULATION Ventilation - mechanical act of drawin in air through the mouth and nose to the trachea and bronchi then to lungs to alveoli. Respiration - delivery of oxygen to the cells.
While caring for a patient who was involved in an altercation, he vomits and his airways totally obstructed with vomitus and blood. What is the maximum amount of time that you can suction his airway?
Until his airways clear
Thoracic Trauma - Rib Fractures (pathophysiology)
Upper ribs are broad, thick and particularly well protected by the shoulder girdle and muscles. Requires great energy to fracture the upper ribs and patient is at risk for significant injuries such as traumatic disruption of the aorta. Rib fractures occur most often to Ribs 4-8 laterally, where they are thin and have less over lying musculature. Broken ends of ribs may tear muscle, lung and blood vessels with possibility of an associated pulmonary contusion. Simple rib fractures are rarely life threatening in adults, may be deadly in the elderly patient. Compression of the lung may rupture the alveoli and lead to pneumothorax. Fracture of the lower ribs may be associated with injuries of the Spleen and Liver and may indicate the potential for intra-abdominal injuries. These injuries may also present with signs of blood loss or shock.
Distributive shock outlined
Vascular space larger than normal Neurogenic Shock (hypotension) Psychogenic "shock" Septic Shock Anaphylactic shock
Hypovolemic shock outlined
Vascular volume smaller than normal vascular size Loss of fluid and electrolytes (dehydration) Loss of blood and fluid (hemorrhagic shock)
Spinal cord injuries can lead to hypotension due to which of the following physiologic changes?
Vasodilation below the level of injury
Psychogenic Shock
Vasovagal - stimulation of the tenth cranial nerve (vagus nerve) produces bradycardia. May also cause vasodilation. Typically occurs in a very brief period.
Two pumping chambers of the heart
Ventricles
Three responses of initial fluid bolus Transient Response
Vital signs improve (pulse slows, BP increases) however PT shows deterioration. PT has typically lost 20-40% of blood volume
IV fluids administered to patients in shock should be _______ in order to ______________ ______________.
WARM, PREVENT HYPOTHERMIA.
Units responding to a motor vehicle accident on the highway should consider which of the following as part of their pre-arrival assessment?
Weather conditions
Principle
What is necessary or patient improvement or survival
what four questions should be addressed when deciding treatment for shock
What is the cause of shock? what is the definitive care for shock? where can the pt best receive definitive care? what interim steps can be taken to support pt and manage condition while pt is being transported?
In trauma care, a Principle is defined as which of the following?
What needs to be done
When should the secondary survey be accomplished?
When the time and situation allow
kinetic energy
a function of an objects mass and velocity
Skeletal Injuries Sublaxation
a partial dislocation of the vertebra from its normal alignment in the spinal column
pericardiocentesis
a procedure that involves insertion of needle into he pericardial space to remove accumulated blood or fluid
no obvious external cause for signs of shock you should suspect
abdominal or chest as location of bleed
If patient is shocky and you suspect a bleed but cant find it, where should you assume it is?
abdominal until proven other wise!! 1. abdominal pain and tenderness are an early sign 2. abdominal distension are late signs
Cerebral Contusions
actual bleeding into the substance of the brain, CC's often take 12-24 hrs to appear on CT scans, only indicator is a depressed GCS of 9-13
subdural space
actual space located beneath the dura mater and between it and the brain
what are considerations for priority of transport
age, confounding factors such as health, age, meds
Primary Prevention
aimed at avoiding the injury before it occurs. This type of prevention activity involves education programs to help minimize risk-taking behaviors and the use of protective equipment
what is the highest priority in critically injured patients
airway
decerebrate posturing
all extrem become flaccid and motor activity is absent
Intentional Injury
an act of interpersonal or self-directed violence
An adult male sustained a deep laceration to his distal thigh. Bright red blood is spurting from the wound. Direct pressure is not controlling the bleeding. What is the most appropriate next step?
apply a tourniquet and tighten it until bleeding stops
your patient has a deep laceration to his antecubital fossa with significant bleeding. What is the most appropriate initial action?
apply direct pressure
compensatory mechanisms
are temporary and short term
when does the assessment begin
before arrival at the scene
your patient is a middle aged male who crashed his motorcycle. He is unresponsive. After opening the airway using a modified jaw thrust, you note the patient has respirations at a rate of 6. Auscultation reveals breath sounds are absent on the left side. What is the most appropriate next intervention?
begin ventilation with BVM
event
begins at the time of impact between one moving object and a second object
medication used by trauma patients for pre-existing conditions may cause what?
beta-blockers may prevent tachycardia with blood loss
what best explains the mechanism by which gas exchange is impaired in pulmonary contusion?
blood in the alveoli
hypotension of unknown etiology in a trauma patient should be assumed to result from what?
blood loss
Years of potential life lost (YPLL)
calculated by subtracting age at death from a fixed age of the group under examination... Life expectancy of a particular group
What is anterograde amnesia?
cant remember the accident or post accident
In PHTLS what is the best ET-Tube confirmation in a PT with a pulse?
capography
extrinsic causes of cardiogenic shock
cardiac tamponade and tension pneumothorax
Hypocapnia (low CO2)
causes vasoconstriction
Hypercapnia (high CO2)
causes vasodilation
signs of increased icp
change in loc, unequal pupils, cushings triad
commotio cordis
clinical situation in which an apparently innocuous blow to the anterior chest results in sudden cardiac arrest
pia mater
closely adhered to the brain, again similar to a laminate, and is the final brain covering
patients with beta blockers have no what during trauma
compensatory responses
cardiac tamponade
compression of the heart from an accumulation of fluid in the pericardium surrounding the heart
signs of hypovolemic shock
cool/clammy, pale, cyanotic skin, BP drops, altered LOC, slow cap refill
signs of cardiogenic shock
cool/clammy, pale/cyanotic skin, BP drops, altered LOC, slow cap refill
during the primary survey of a trauma patient, you note that the patient is agitated and confused, and has multiple injuries from an altercation. what is the most appropriate first treatment priority?
correction of possible hypoxia
bleeding from ear you should
cover with a loose dresing
Traumatic asphyxia has a history of
crush or compression patient may be blue or purple
transmural pressure
difference between the pressure within the vessel and the pressure outside the vessel
what is the preferred prehospital wound management for a patient which a 36% body surface area flame burn?
dry sterile dressings
what should you apply on a burn
dry sterile dressings
Indications for a nose fracture
ecchymosis, edema, nasal deformity, swelling, epistaxis
the potential for death or serious injury is greatest in which of the following motor vehicle collisions? -down and under -ejection from vehicle -lateral compression -up and over
ejection from vehicle
Nerves are a good conductor for what type of burns?
electrical burns
what is the preferred adjunct device for verifying placement of an ET tub in a patient with a perfusing rhythm?
end-tidal CO2 monitoring
law of conservation of energy/newton's 2nd law of motion
energy can neither be created nor destroyed but can be changed in form
Mechanical Energy
energy that an object contains when it is in motion
steps in management of shock
ensure oxygenation, I.D. hemorrhage, transport, IV fluids
what is a key finding that differentiates cardiac tamponade from tension pneumothorax?
equal breath sounds
Ataxic breathing
erratic ventilatory efforts that lack any discernible pattern
confirm placement of et tube with
etco2, edd
injury type that mostly affects elderly
falls
decorticate posturing
flexion of the upper extremities with rigidity and extension of the lower extremities.
newtons 3rd law of motion
for every action or force there is an equal and opposite reaction
What is retrograde amnesia?
forgetting what happened before the accident happened
basilar skull fractures
fractures of the floor of the cranium
five types of MVCs
frontal, rear, lateral, rotational, rollover
what best describes shock?
generalized inadequate tissue perfusion
vital signs for decompensated shock
greatly increased pulse, white/cold/waxy skin, decreased BP, altered LOC
What is important info in regards to GSWs?
hand guns & rifles - velocity shotguns - what was the distance
external hemorrhage steps in field management of external hemorrahe
hand-held pressure, compression dressings, wound packing, elastic wrap, tourniquet, hemostatic agent
bilateral femur fractures are most often associated with which type of motorcycle crash?
head-on impact
intrinsic causes of cardiogenic shock
heart muscle damage and valvular disruption
Injury to solid organs = ?
hemmorage
intial body response is
hemodynamic instability then metabolic changes then microvascular changes
the most immediate life threatening condition resulting from injury to solid abdominal organs is what?
hemorrhage
Preference
how the principle is achieved in the time given and by the prehospital care provider available
hyperventilation in patients without a need can produce
hypocapnia and vasoconstriction
What is the most common type of shock?
hypovolemic / hemorrhagic
most common shock with trauma
hypovolemic due to hemorrhage not enough rbc for oxygen carrying
five conditions that can produce an altered LOC or change in behavior
hypoxia, shock w/ impaired cerebral perfusion, TBI, intoxication with alcohol or drugs, metabolic processes such as diabetes, seizures and eclampsia
D
if patient can maintain own airway tag critical if pt cannot tage black for dead
steps of resuscitation in prehospital setting
improve O2 in RBCs through airway management/ventilations, control external/internal hemorrhage, improve circulation, maintain body heat, reach definitive care asap
Function of the descending nerve tracts
impulses from the brain through the cord down to the body
definition of shock
inadequate energy production in cells secondary to poor volume, failing pump or vasodilation reducing available blood flow
What is the most common threat to life?
inadequate tissue perfusion/shock (a early sign is ALOC)
pre-event
includes all of the events that preceded the incident
cushings triad
increased bp, decreased hr, irregular respirations
vital signs for compensated shock
increased pulse, white/cool/moist skin, normal BP, unaltered LOC
early sign of respiratory failure is
increased respiratory rate
Injury to hollow organs = ?
infection/peritonitis)
postevent
information gathered about the crash and pre-event phase is used to assess and manage the patient
Unintentional Injury
injuries that were unintended but could have been avoided. Previously referred to as accidents
flail chest is
instability of rib cage with asymmetrical movement
clothes should come off when
intial primary assessment
airway maneuver for a trauma patient should be
jaw thrust
shock
lack of tissue perfusion at the cellular level that leads to anaerobic metabolism and loss of energy production needed to support life
what is the preferred fluid for resuscitation of hemorrhagic shock in the prehospital setting?
lactated ringers
arachnoid membrane
loosely covers the brain and its blood vessels giving the appearance of cellophane wrap
Managing Volume Resuscitation CNS injuries or TBI
maintaining the systolic BP (SBP) above 90 or MAP 85-90
An 18 yr old female was struck by a car and has sustained an apparent left femur fracture. communication with her is hampered because she only speaks a foreign language. which finding, by itself, does not mandate immobilization of the cervical spine?
mechanism of injury
Three seperate membranes that surround the brain
meninges
Ventral root=
motor
causes of head and spinal injuries in young adults
mvc
burns to the airway with swelling you should go to which hospital
nearest
if pelvis is showing signs of instability you should
not palpate or assess again
primary injury
occurs upon impact
mci if pt is not breathing
open airway
if blood in the airway
open, clear with log roll and suction
essential airway skills include manual clearing of the airway, manual maneuvers, suctioning and what?
oropharyngeal airway
dura mater
outermost layer composed of tough fibrous tissue and is applied to the inner table or inside, of the skull similar to a laminate
Secondary brain injury
pathologic mechanisms that related to intercranial mass effect, elevated ICP, and herniation, hemotoma, hypoxia and hypotension
most common airway obstruction
patients tongue
when immpobilizing pediatric plations where should you pad, and for adults?
pedi pad under torso adults pad under the head
signs of neurogenic shock
pink, warm, dry skin, BP drops, lucid LOC, normal cap refill
If you increase the stopping distance what happens to the potential for injury?
potential for injury is decreased
epidural space
potential space
intramural pressure
pressure exerted against the inside of the blood vessel walls by the intravascular fluids and blood pressure cycle
what is the most important reason to maintain an open airway in the trauma patient?
prevents hypoxemia and hypercarbia
hypovolemic shock
primarily hemorrhagic in the trauma patient and is related to loss of circulating blood cells with oxygen-carrying capacity and fluid volume
Surveillance
process of collecting data within a community
shock is
progressive
Haddon Matrix
provides a means to depict graphically the events or actions that increase or decrease the odds that an injury will occur. It can also be used to identify prevention strategies
hypoperfusino is due to
pump failure, volume loss, vasodilation
Managing Volume Resuscitation Controlled Hemorrhage large scalp or extremity controlled with a tourniquet, PT falls into class II,III,IV shock
rapid bolus of 1-2 litres
Central neurogenic hyperventilation
rapid deep breaths
D
rapidly developing
Subarachnoid Hemorrhage
rarely causes mass effect and does not require surgery, it does increase the risk of cerebral contusion by 63-73%
Cushings phenomenon
refers to ominous combination of greatly increased arterial blood pressure and the resultant bradycardia (increase BP + decreased HR) that can occur with severely increased ICP.
cardiogenic shock
related to interference with the pump action of the heart
Cardiogenic
related to interference with the pump action of the heart, often occurring after a heart attack
Cheyne strokes ventilation
repeating cycle of slow hallow breaths that become deeper and more rapid and then return to slow
Class II Hemorrhage
represents a loss of 15-30% blood volume. Most adults are capable of compensating, incresed RR, Tachycardia, narrowed pulse pressure,
Class III Hemorrhage
represents a loss of 30-40% blood volume. No longer able to compensate for volume loss, hypotension occurs, HR >120 BPM, RR 30-40, severe anxiety or confusion
Class IV Hemorrhage
represents a loss of more than 40% loss, severe shock, HR >140 BPM, RR >35, confusion lethargy, decresed systolic blood pressure, typically in the range of 60 mm Hg.
Class I Hemorrhage
represents loss of up to 15% blood volume in adults, minimal tachicardia, no measurable changes in BP or pulse pressure, or RR
D
represents loss of up to 15% of blood volume in the adult
Which of the following is the earliest signs of deterioration in a patient with a flail chest?
respiratory rate increase
Electrical Energy
results from the movement of electrons between two points. it is associated with direct injury and thermal injury
uncal herniation
results in malfunction of the third cranial nerve causing a dilated or blown pupil on the side of the herniation
what are the steps in an assessment
scene survey, general impression, intial assessment, priority decision, rapid trauma assessment or focused assessment
Dorsal root=
sensory
Concerns with rotational forces?
shearing forces to heart, liver, kidneys
heat stroke
signs and symptoms of head injury not sweating
which assessment is most beneficial in differentiating hemorrhagic shock from neurogenic shock in the prehospital setting?
skin
D
slow to develop may take days
Level 4 Trauma Center
small community hospitals, (they have to stabilize and transfer) Have ER DR but no surgeon
What is the secondary brain injury?
something we can prevent (ex. hypoxia post primary injury)
You arrive at the scene of a motor vehicle collision in which a vehicle struck a tree. Which is the best indicator of potential injury? -circumference of vehicle -diameter of the tree -mass of the vehicle -speed of the vehicle
speed of the vehicle
newtons 1st law of motion
states that a body at rest will remain at rest, and a body in motion will remain in motion unless acted on by an outside force
secondary injury
swelling and hypoxia
the body initially compensates for blood loss through activation of what?
sympathetic nervous system
Uncal Herniation
temporal lobe epidural hematoma forces pressure on the medial portion of the temporal lobe (uncus) which in turn puts pressure on the 3rd cranial nerve causing dilation or blown pupil on the side of the herniation. May also cause loss of function of the motor track on the same side.
simple vs tension pneumo
tension will produce signs and symptoms of shock and poor perfusion
cerebral perfusion pressure
the amount of pressure it takes to push blood through the cerebral circulation and thus maintain blood flow and oxygen and glucose delivery to the energy-demanding cells of the brain
What are dermatomes?
the bodies sensory boarders T4 - nipple line down T10 - umbilicus down
kinematics
the branch of mechanics that deals with the motion of objects without reference to the forces that cause the motion
The phrenic nerve originates from
the cervical vertebrae c2-c5
Pulse Pressure
the difference between the systolic and diastolic
What is a primary brain injury?
the insult to the brain itself (ex. gsw to head)
Confidentiality
the obligation of the health care providers to not share patient information that is disclosed to them within the patient-provider relationship to anyone other than those the patient has authorized, other medical professionals involved in the patient's care and agencies responsible for processing state and/or federally mandated reporting
Don Juan syndrome
the pattern of injury in falls occurring feet first
What is the most important mechanism for ventilation?
the plural linings staying intact
reticular activating system
the portion of the brain responsible for arousal and alertness, also found in the brain stem
Privacy
the right of patients to control who has access to their personal health information
Osmotherapy
the use of osmotically active agents that may assist in the treatment of intracranial hypertension`
pregnant should be positioned on
their left side
When people have 20 mmHg CO2 in their blood (half of the official norm),
they have about 40% less blood supply to the brain in comparison with normal conditions
periosteum
thick layer of connective tissue that covers the surface of bones, except for the joint surfaces
What is permanent cavitation?
tissue that is destroyed and not coming back
What is the goal of the primary assessment?
to find & correct life threats
what is the most common cause of upper airway obstruction in the trauma patient?
tongue
galea aponeurotica
tough, thick fibrous tissue that provides structural support to the scalp
transport considerations
trauma center, burn center, weather
TBI
traumatic brain injury
sucking chest wound
use occlusive dressing if needing to loosen the dressing if respiratory distress occurs
temporal bone fracture
usually injures the middle meningeal artery causing rapid bleeding
Cause and Symptoms Central cord syndrome
usually occurs with hyperextension Symptoms include weakness or paresthesia (tickling, tingling, burning, pricking, or numbness) in the upper extremities but normal strength in the lower extremities
What happens during the ischemic phase?
vascular sphincters shut closed
What is more important velocity of mass?
velocity
Three responses of initial fluid bolus Rapid Response
vital signs return indicating that PT lost less than 20% PT is best managed at SBP between 80-90, IV fluid should be titrated
tonsillar herniation
when the brain is pushed down toward the foramen magnum and pushes the cerebellum and medulla ahead of it
how long do you wait to terminate a trauma resuscitation
witnessed arrest after 15 minutes of interventions and unsuccessful efforts
for patients with multi system trauma and multiple fractures
you should splint by placing on a backboard
