Test 9: Trauma

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Newborn Reflexes

Moro Rooting Grasp Babinski

Convection

Movement of air or water across skin

Do you wait for CXR for tension pneumo?

NO

What can hip joint dislocations lead to?

Necrosis of femoral head within 4-6 hours r/t vessel entrapment

Therapeutic Intervention unique to clavicular fracture

Neurologic and pulse check (d/t possibility of decreased pulses and motor weakness)

Triage Categories for Mascal

-Immediate-Require immediate lifesaving intervention w/in minutes or up to two hours -Delayed-Likely require surgery, but can wait without danger to life, limb, or eyesight. Require sustaining tx like blood, stabilization of fractures, pain control, antibiotics, gastric decompression. -Minimal/Minor-Walking wounded -Expectant-Survival unlikely, overwhelm current medical resources and compromise tx of salvageable pts.

Primary Blast Injury

-Injuries caused by the impact of over-pressurization waves with body surfaces -Affect gas and fluid-filled structures

Medium Velocity Penetrating Injury

-Injury primarily the result of laceration and crushing of tissue -Hollow/gas filled organs fare better than solid organs

Needle Decompression

-Insert 14 or 16-gauge catheter at the 2nd intercostal, midclavicular -4th or 5th anterior-axillary -Emergency tx only

Two possible complications from puncture wounds

-Joints -septic arthritis -Cartilage, bone, periosteum-osteomyelitis

Rhabdomyolysis Findings

-Limb weakness, Myalgia, Edema -Myoglobinuria-AKI -Acidosis & ↑ K+ (very concerning > 6 mmol/L) -Shock

Low Titer O WB (LTOWB)

-Low anti-A and anti-B titers: <256 may vary by facility -Universal blood product for resuscitation

Le Fort I Fracture

-Maxilla moves separately from upper face: -Slight swelling of the maxillary area -Mobility of upper teeth & hard palate: Malocclusion -Upper jaw pain, dental numbness -Lip laceration or tooth fracture

Chylothorax

-Milky fluid containing lymph and fat -Trauma, surgery, infection, disruption on lymph transport

Acute laryngotracheobronchitis or Croup

-Most frequent cause of upper airway obstruction in children -Viral infection causing edema & inflammation of the trachea & larynx

Moderate Hypothermia

-No shivering reflex, mild LOC change (confusion/sleepiness) -Decreased pulse, a-fib, bradycardia, decreased CO, hypoventilation, hyperreflexia, paradoxical undressing

Orbital Compartment Syndrome

-Often caused by retrobulbar hemorrhage S/Sx: -Decrease or loss of vision -Rock hard eyelids -Proptosis -Relative afferent pupillary defect -Tx: Lateral Canthotomy

Criteria for Chest Tube Removal

-One day after cessation of air leak -Drainage of less than 50-100 mL fluid per day -Obliteration of empyema cavity -Serosanguinous drainage around insertion site -Tube partially migrated out with holes visible -Patient stable, symptoms resolved or improved

Fetal Circulation

-Oxygenation occurs in the placenta, not lungs -Foramen Ovale-flapped orifice between the atria -Allow R-L shunt for fetal circulation -Ductus Arteriosus-communication between pulmonary artery and aorta (becomes a ligament for these structures after birth) -Pressure changes at birth close these pathways

Diagnostics for pulmonary contusion

-Patchy, ground glass opacities (mild) -Large consolidations (severe) -CXR: May not be evident until 24 hrs -CT chest: more sensitive

Common female genitalia injuries

-Pelvic fractures -Vulva -IPV screening

Rewarming Shock

-Periphery warmed before the core -Lactic acid shunted to the heart

Diagnostics for Bladder

-Plain films -Retrograde cystogram -US (FAST)

Primary vs. Secondary Spontaneous Pneumo

-Primary: Bleb rupture Unknown cause, typically in young healthy males Smoking -Secondary: Underlying respiratory disease Emphysema Cystic fibrosis TB Cancer PNA

Mascal Triage

-Primary: On scene or at hospital -Secondary: Prior to or during transport and/or uppon arrival to hospital

Traumatic Pneumo Causes

-Procedure related: iatrogenic -Barotrauma -Blunt injury Penetrating: Rib, Bullet, Knife

Presentation of Pyloric Stenosis

-Projectile vomiting -Continued hungry behavior, poor weight gain, no indication of pain, few stools -Left to right visible peristaltic waves on the abdomen -Abdominal mass, signs of dehydration

ACLS Modification for Hypothermia

-Pulse checks may take 60 seconds -Consider use of a Doppler ultrasound -Defibrillation may be ineffective below 86°F (28°C) -Limit defibrillation to 3 shocks until 86°F (28°C) Resuscitation continues until temperature reaches 32-35°C

Damage Control Resuscitation

-Rapid hemorrhage control through early administration of blood products in balanced ratio -Prevention and immediate correction of coagulopathy -Minimization of crystalloid fluids

Transfusion Transmitted Diseases

-Rapid testing for HIV, Hep B and C and malaria -Recipients tested at 3-, 6-and 12-month post-transfusion

What is the ideal timeline for TXA administration? What is the risk if given outside of that window?

-Reduces mortality if given within 3 hours of injury -Given greater than 3 hours post-injury = increased risk of mortality

Ocular Triage

-Remove contact lenses -Irrigate if chemical exposure -Immobilizing or protecting an object protruding from globe -Consider bilateral patching -Measure visual acuity -Assess pupillary size, response and accommodation -NO pressure should be applied if globe not intact *Monitor for orbital compartment syndrome

Sternal Fracture MOI and common location of injury

-Requires significant force applied to the chest (steering wheel impact, CPR) -Most common site of fracture is at the angle of Louis (sternal angle)

ETT diameter in Peds

-Size in mm = (age in years/4)+4 -Or the size of the child's pinky finger

What do you have at the bedside for Mandible Fracture Management

-Suction -Airway: OG Tube -Wire Cutters

Aortic Dissection MOI

-Sudden horizontal acceleration or deceleration injuries -High speed MVCs -Falls from great height -Pedestrian hit by car -Caused by Shearing forces, compression of the aorta against vertebral column

Abrasions

-Superficial & partial= painful, Erythema, punctate bleeding -Full= Painless, Damaged nerves, White, No bleeding

Acute Aorta S/Sx

-Systolic murmur over precordium -BP discrepancy in UE -Decreased or absent pulses in LE -LE Paralyis

Factors that affect temperature regulation in infants

-Term infants-sufficient brown fat to produce heat -Decreased ability to conserve heat from convection & conduction: -Small body size -Increased BSA -Unable to shiver -Less SQ fat-less insulation -Sweat glands do not function until 1 month

Types of Viscoelastic Testing

-Thrombelastography (TEG) -Rotational Thromboelastometry (ROTEM)

Hemothorax

-Trachea is midline ->1.5L intrathoracic blood loss -Often arrive in arrest-require thoracotomy -Left massive hemothorax more common than right d/t aortic rupture -Bleeding only stops when pleural cavity pressure is > bleeding vessel. -Caution with chest tube b/c will remove the tamponade on the vessel

What is the leading cause of death in pediatric PTs

-Traumatic injuries -80% Blunt trauma -Most common mechanism is MVC

REBOA

-Truncal internal hemorrhage (non-compressible) -resuscitative endovascular balloon occlusion of the aorta

Shaft of Femure Fracture

-Typical MOIs: Stress fracture, multi-system trauma, chronic disease -Blood loss, swollen thigh, limited ROM, pain radiating to groin -Traction split

Globe Rupture

-Unusually deep or shallow anterior chamber -Decreased vision -Vitreous leak from eye -Teardrop pupil -Ocular pain -Obvious impalement -No Eye drops -Tetanus shot

Head of Femur Fractures

-Usually osteoporotic elderly or falls on hip -Muscle spasms, shortening, external rotation of affected leg

Transudative Pleural Effusion

-Watery fluid diffuses out of capillaries beneath the pleura -Systemic disease

Most to Least Preferred Blood Product Resuscitation given w/in 30 minutes of injury

-Whole Blood -Plasma: RBCs: Platelets in 1:1:1 ratio -Plasma and RBCs in 1:1 ratio -Plasma or RBCs alone -Crystalloid (LR or PlasmaLyte)

Subconjunctival Hemorrhage

-bleeding from small blood vessels between the conjunctiva and the sclera -Usually d/t straining ex. vomiting, coughing, sneezing -Avoid NSAIDs or ASA

Hyphema

-blood in the anterior chamber of the eye -Increased IOP -rigid eye shield to affected eye -Avoid NSAIDs

Lidocaine w/ Epi

-causes vasoconstriction -avoid in avulsions, grossly contaminated wounds, tentative blood supply -↑ rate of infection & ischemia when injected into ear, nose, digits, or penis

Non-Synovial Joints

-completely or slightly immovable ex. joints of the skull or where the ribs meet the sternum

Cartilage

-dense connective tissue -Ex. Ribs, nasal septum, ear, larynx, trachea, bronchi, between vertebrae & on articulating surfaces (e.g. shoulder joint) -Limited vascular supply

Anterior Epistaxis Tx

-direct pressure -Topical vasoconstriction: oxymetazoline -Cautery: silver nitrate -Direct pressure: nasal tampons, rapid rhino, gauze packing

Posterior Epistaxis Tx

-direct pressure is ineffective -Balloon catheter -Surgical ligation or embolization

S/Sx of diaphragm injury

-respiratory distress, -dyspnea -decreased bowel sounds -bowel sounds in thorax -paradoxical movement of abdomen

acromioclavicular joint

-the joint where the acromion and the clavicle meet -Can be injured by direct force to top of shoulder -will be unable to raise arm or adduct across chest

Toddler is defined as

1-3 years Slowed growth Weight gain ≤ 5 lbs/year

Newton's First, Second and Third Law

1. A body at rest remains at rest 2. Mass x Acceleration 3. Equal and Opposite Reaction

Tetanus is given every?

10 years unless wound is grossly contaminated then 5 years

Adolescent age is

12-18 years

What are the factors predicting injury in a frontal crash

18 inches of intrusion or more Starring or shattered windshield Bent steering wheel Dashboard damage

Gold Standard of Triage

2-tiered: Quick-look RN-triage RN

Preschool is defined as

3-5 years old Limbs grow>trunk

Tetralogy of Fallot

4 defects (shunting from R to L) 1. Large ventricular septal defect 2. Overriding aorta 3. Pulmonary stenosis 4. Right ventricular hypertrophy

How long do you have to determine compromised blood supply with avulsions?

48-72 hrs to determine extent

School Age is defined as

6-12 years Increased neuron myelination Weight gain ~ 5.5 lbs/year

Anterior Hypothalamus

Responds to heat by vasodilation

Ureter Diagnostic Exam

Retrograde Pyelography and FAST exam

Urethral Trauma Diagnostic Exam

Retrograde urethralgram

What is the most preventable death?

Uncontrolled Hemorrhage

A diaphragm rupture will cause what chest tube drainage? What will it do to the bowel?

Undigested food/fecal matter drainage, Bowel strangulation

Damage Control Surgery

Life saving control non-compressible surgical hemorrhage(NCTH) Transfer to definitive care

Transposition of Great Arteries

Unoxygenated blood thru systemic circulation Oxygenated blood thru pulmonary circulation

Fluid resuscitation rates in Peds

-Blood-administer 10mL/kg -Blood lost replaced w/ warmed isotonic crystalloid at 20mL/KG and in a ratio of 3:1 bood lost to crystalloid

Superficial Frostbite S/sx

Local tingling, numbness, burning Erythema to white, waxy color, large blisters (based on length of exposure) Stinging, hot sensation after thawing

Ventricular Septal Defect in Pediatrics

Loud, harsh holosystoloic murmur & systolic thrill over L lower sternal border Large VSD: s/s of HF & poor weight gain

calcaneus

MOI: fall w/ landing on heel bone *suspect other spinal and leg injury

Severe Hypothermia

Pulmonary edema, hypotension, oliguria, bradycardia, v-fib/asystole, areflexia -Fixed & dilated pupils, no shivering, coma

Bites acronym: RAT

Rabies, Antibiotics, Tetanus

What type of injuries are the 1st two ribs associated with? How common are they?

Rare, often associated w/ Cardiac, vascular, spine, and thoracic Injuries

Broselows Tape

Red to head and measure to heels

Kehr's sign

Referred pain down the left shoulder; indicative of a ruptured diaphragm or spleen.

What is the most common thoracic injury? What should it make you suspicious of?

Rib Fractures, Suspicious for serious intrathoracic or abdominal injuries

Where do rib fractures typically occur

Ribs 4-10 (usually accompanied by lung injury) Typicall fractured at angle junctures

What side of the diaphragm is more often injured? What is the typical MOI?

Right injury is more common than left and often d/t blunt trauma

Level IV Trauma Center

Rural facility that supplements care within larger trauma system Initial evaluation and assessment of injured patients 24-hour emergency coverage by a physician Transfer agreements with nearest Level I, II or III TCs

Clinical Resuscitation goals

SBP at goal Temperature greater than 95*F UO > 0.5mL/kg/hr Hemoglobin > 8 Hematocrit > 27% Lactate <2.5 mmol/L BD <4

Over Triage

Scarce resources and limited bed availability are not available for a patient who may require immediate attention

Acute Aortic Dissection

Tear in the intimal layer allows blood to enter media layer and the pressure compresses the true lumen

Internal Forces that cause injury include

Tensile, compressive and shearing stress

Immediately Life Threatening Thoracic Injuries

Tension Pneumo Cardiac Tamponade Open Pneumo Hemothorax Flail Chest Myocardial Rupture

Clinical Randomization of Antifibrinolytic in Significant Hemorrhage (CRASH-2)

TXA statistically significant reduction in the relative risk of all-cause mortality

Mild Hypothermia

Tachycardia, tachypnea, & shivering Signs of apathy, ataxia, dysarthria, impaired judgement

Synovial Joints

-2 articulating surfaces covered with cartilage & surrounded by 2-layered synovial membrane sac -Synovial fluid -reduces friction with movement -Joint encapsulated by dense, ligamentous material

Pittsburgh Knee Rules

-Blunt trauma or fall as MOI plus either of the following: -Age < 12 or > 50 years OR -Inability to walk 4 weight-bearing steps at time of exam -If above criteria x-ray met

Neurologic changes with age

-Brain volume and weight decreases -Neurodegeneration --Decrease in neurotransmitters -Blood-brain permeability increases -Decrease in cerebral blood flow -Increased cranial dead space

S/Sx of Open Pneumo

-Bubbling of blood around wound with exhalation -Respiratory distress -Sucking sound with breathing -SQ emphysema -Sucking sound on inspiration -Visible chest wound

Diagnostics for Tracheobronchial Disruption

-CXR: Mediastinal air Pneumothorax Concurrent rib fractures 1-5 -Bronchoscopy: Visualize disruption

Tx for Croup

-Cardio-respiratroy monitoring, racemic epi, Corticosteriod (Dexamethasone)

DCR Candidates Criteria

-3 of the following = 70% risk of MT •All 4 = 80% risk of MT •Systolic blood pressure < 100 mm Hg •Heart rates > 100 bpm •Hematocrit < 32% •pH <7.25 -Injury pattern (above-the-knee traumatic amputation especially if pelvic injury is present, multi-amputation, clinically obvious penetrating injury to chest or abdomen) ->2 regions positive on FAST scan -Lactate concentration on admission >2.5 -Admission INR ≥ 1.5 -BD >6 mEq/L

Antivenom (CroFab)

-4-6 hours after bite if hypotension or confusion -CALL the Poison Center -20 -30 minutes to reconstitute -No contraindication based on what snake bit the PT, do not need to identify snake

Le Fort II Fracture

-Along naso-frontal and zygomatico-maxillary sutures -Separates nose and upper palate from the face -Basilar skull fracture w/ CSF leak common Signs: -Telecanthus, subconjunctival hemorrhage, epistaxis -Mobility of the midface -Possible CSF rhinorrhea -Massive facial edema -Malocclusion

Ottawa Ankle Rules

-Any pain in the malleolar zone AND: Tenderness on palpation at posterior tip of lateral malleolus OR Tenderness on palpation at posterior tip of medial malleolus OR -Inability to bear weight (4 steps) at time of injury or exam -If above x-ray

Potential Thoracic life threatening injuries

-Aorta injuries -Blunt cardiac injury -Pulmonary contusion -Tracheobronchial injury -Diaphragm rupture

Cardiovascular Changes in cold related injuries

-Atrial fibrillation, prolonged QTi, death from asystole -Dysrhythmias refractory to defibrillation, medications, and pacing

Associated w/ nasal fractures

-Basilar Skull fracture -CSF leak -Septal hematoma

Injury considerations for Small versus Large bowel

- Small Bowel: Low risk for sepsis - gastric acid may lead to peritonitis - Large Bowel: High bacterial count - risk for sepsis and abscess formation

Compartment syndrome

-0 -8 mmHg normal -20 mmHg capillary blood flow is compromised, "Poop" (pain out of proportion) develops -fasciotomy -> 30 mmHg Ischemia-emergent surgical intervention

Who is more sensitive to hypoxia adults or infants?

-02 consumption in infants = 6-8 ml/kg/min -02 consumption in adults = 3-4 ml/kg/min

When is a volvulus most common in pediatrics? What are the signs and sx?

-1st month of life -Bilious vomiting, severe abdominal pain, visible peristaltic waves -Abdominal distention, bloody stools, hematemesis

Renal System Changes in Cold Related injuries

"Cold diuresis" due to peripheral vasoconstriction Renal hypoperfusion, acute tubular necrosis Myoglobinuria

Pediatric Early Warning System

*Asthma PTs on continuous albuterol will be a 3

Types of Pneumothorax

*closed is non-life threatening but can progress -Lung collapses toward the hilum

S/Sx of Spleen Injury

- Signs of hypovolemic shock - LUQ tenderness - Pain in left shoulder (Kehr's sign) - Muscle rigidity, spasm, or guarding - Elevated WBCs

Presentation of Pertussis Peds PTs

-Child will look ill when coughing & normal when not coughing -Paroxysmal coughing with thick mucous -Long inspiratory effort with "whoop" -Cyanosis with coughing -Vomiting & fatigue after coughing

Emergency Service Index (ESI) Triage

-Clients are assigned to triage levels based on both acuity (consider Danger Zone VS) and their anticipated resource needs -Five level tool used in the ED: >Level 1: Resuscitation >Level 2: Emergent >Level 3: Urgent >Level 4: Less urgent >Level 5: Non-urgent

Hematologic System in Cold related injuries

-Coagulopathies and DIC -Hemoconcentration Increased blood viscosity

Battery ingestion delayed presentation

-Cough, anorexia, N/V, hematemesis, diarrhea, fever Chest, epigastric or abdominal pain Dysphagia, drooling, black flecks in saliva Esophageal perforation: hemorrhagic shock, SQ emphysema with crepitus, tension ptxwith tracheal deviation

Linear Resuscitation

-Crystalloids-RBC's-Plasma Dilutional coagulopathy Abdominal Compartment Syndrome -MODs ->1.5 L crystalloid associated with ↑mortality

Permissive Hypotension

-Current resuscitative goals SBP 90-110mmHg -TBI patients goal 110mmHg -Reduces hemorrhage by minimizing intravascular hydrostatic pressure

CNS changes in cold related injuries

-Decline in LOC, impaired judgment and disorientation -Sluggish pupillary response

Pulmonary Changes with Age

-Decreased PaO2 level-leads to decreased ventilatory response to hypoxia and hypercapnia and increased sensitivity to opiods and benzos

Cardiovascular Changes with age

-Decreased inotropic and chronotropic myocardial response to catecholamine stimulation -Decreased baroreceptor sensitivity (leads to ortho hypotension) and blood vessel compliance (leads to increased PVR and BP)

How is Respiratory Failure defined in pediatrics?

-Defined as RR<10 and/or irregular respirations. -Slower than normal or absent HR-weak or absent peripheral pulses -hypotension -unresponsiveness, limp muscle tone

What are the difference in terms of tube placement confirmation in Peds

-ETCO2 unreliable under 2kg -Esophageal detector unreliable under 1 year of age

Complications of Spleen Injury

-Early: recurrent bleeding, subphrenic abscess, and pancreatitis -Late: thrombocytosis and overwhelming post-splenectomy sepsis (OPSS) -Splenectomy - Risk for infection

Primary Closure

-Edges can be approximated; wound not infected -Occurs within/around 4 days post-injury -Enhanced by natural wound contracture

Secondary Closure

-Edges can't be closed; contaminated -Allowed to granulate & heal more slowly; wound packing -May require skin grafting if > 1 cm in diameter-but must have good blood flow and no excessive sub Q fat.

Retrobulbar hematoma

-Emergency -IOP >40mmHg behind globe d/t bleeding -Consider lateral canthotomy -Can lead to orbital compartment syndrome

Flail Chest

-Fractures in two or more adjacent ribs in two or more places OR detachment of sternum from costal cartilage. -Decreases the negative pressure of the chest -Associated with significant pleural contusion -Paradoxical movement

Cold Stored Whole Blood

-Good for 21-35 days between 1-6 C -PLT hemostatic function during 1st 2 weeks of storage -Relatively hemostatic product compared to RBCs and plasma alone through shelf-life -additional PLT transfusion of FWB may be needed

Secondary Survey Assessments

-Head -Maxillofacial -C-spine -Chest -Abdomen/Pelvis -Perineum, Rectum, Vagina -Musculoskeletal -Posterior -Neuro

Pulmonary Contusion MOI

-High energy blunt trauma -Blast injuries, fall from heights, MVC's -High index of suspicion if scapular/rib fractures, or a flail chest

Dental Fracture Types

-I -enamel -II -dentin -III -pulp

NSAIDs are contraindicated in...

-Ibuprofen 10mg/kg (DO NOT GIVE TO children < 6 months old) -NO Aspirin to children under 12 years of age

S/Sx of Patent Ductus Arteriosus

-If decreased PVR -continuous, machine-like murmur at LUSB thru systole & diastole -If significant size-bounding pulse, precordial thrill & s/s of pulmonary over-circulation

Chest Drainage Unit and Monitoring

-If sudden increase-hemorrhage or sudden patency of previously obstructed tube -Sudden decrease-occlusion

Irrigate for chemical injury until pH is...

7.0-7.5 w/ Sterile isotonic saline

Massive Transfusion

>10 units within 24 hours

Open vs. Closed Globe Injury

A closed globe injury does not fully penetrate the eye wall (ie, the cornea, limbus, and sclera) whereas an OGI penetrates the full thickness of the eye wall.

Immersion Syndrome

A syndrome resulting from damage to peripheral tissues from prolonged contact between a wet foot and cold temperature

When is calcium is administered to trauma patients receiving blood transfusions?

Administer Ca during or immediately after first unit of blood product; then after every 4 units of blood

Primary Survey

Airway Breathing Circulation (may need to reprioritize to 1st for hemmorhage) Disability Exposure

What type of chemical injury is worse to the eye? alkaline or acidic?

Alkaline, penetrate deeper

Quaternary Blast Injury

All explosion-related injuries or illnesses not attributed to the preceding blast mechanisms Encompasses exacerbations of existing disease processes

Fontanels

Anterior: closes at 9-18 months Posterior: closes by 3 months

Epiglottitis S/Sx

Anxious Fever 103.1°F ( 39.5°C) Sore throat, muffled voice Stridor, respiratory difficulty Neck and chin extended Pallor, tachycardia

Esmolol (or metoprolol for COPD/bronchospasm PTs) is a treatment for what thoracic injury? Why

Aortic dissection, to keep SBP 100-120 and HR <60

What can aspiration lead to in a drowning incident

Aspiration-surfactant wash out-non-cardiogenic pulmonary edema-ARDS

How do you remove a chest tube?

At end-expiration with Valsalva maneuver

Antibiotic for Human, Dog or Cat bites

Augmentin

What defines a Level 1 Trauma Facility

Regional resource hospital central to trauma care system Total care for every aspect of injury from prevention through rehabilitation Maintains resources and personnel for patient care, education and research Leadershipin education, research and system planning within region

Subungal hematoma and Tx

Blood under nail, Tx w/ xray, drill hole through then remove nail

Stomach injuries MOI is often d/t...

Blunt or penetrating trauma

What MOI typically causes GU tract injuries?

Blunt trauma

MOI for Tracheobronchial Disruption

Blunt: Direct anterior neck impact Penetrating: Risk for vascular injury-More likely to cause tracheobronchial disruption *Associated w/ upper rib fractures and pneumo

What chest xray sign indicates a hemothorax?

Blunted costophrenic angle when upright

Digestive System Cold related injuries

Bowel peristalsis, ileus Hepatic function slowed Insulin ineffective, pancreatic necrosis

Four common pediatric fractures

Bowing, greenstick, buckle fracture and physis fracture

Pulmonary Contusion

Bruising to the lung parenchyma causes ruptures and hemorrhages into pulmonary tissue, alveoli, and small airways.

Deep Frost Bite S/sx (muscles, bones and tendons)

Burning-warmth-numbness Yellow-white Swelling and burning when thawing Blisters (1-7 days) Edema (months) Discoloration, gangrene

How is spleen injury graded?

By severity, I-V: Higher grade = higher level of injury and risk for morbidity/mortality Grade IV indicates marked injury (be familiar with this grade) *Often injured via blunt force trauma

RPMs

Respirations Pulse Mental Status

Bronchiolitis Most common pathogen

Respiratory Syncytial Virus (highly contagious) in lower respiratory track

Type Specific WB (TSWB) or Fresh Whole Blood (FWB)

Collected from donors in deployed setting must be ABO match

Dislocation

Complete disruption of bony articulating surfaces

Maisonneuve fracture

Complication of ankle with concurrent fibula fracture, often compromising ligaments

Crush Injuries

Composite injury involving 2 or more tissue types-causes extensive bleeding into muscle tissue

ENA Standard of Triage

Comprehensive Triage- RN triages every patient and determines priority of care

Level II Trauma Center

Comprehensive trauma care regardless of severity of injury Might be most prevalent facility in community, supplement the activity of Level I TC Can be academic institution or a public or private community facility Responsible for education and system leadership where no Level I TC exists May not have continuous availability of all sub-specialties Not as robust in research and prevention as Level I

Chilblains

Capillary bed damage occurs after exposure to cold, wet conditions (1-5 hours in temps below 15°C/60°F)

Physeal Plate

Cartilaginous layer between the metaphysis and epiphysis Long bones grow from physealplate until reach adult size

Rigid chest wall syndrome aka wooden chest syndrome

Cause respiratory failure and can be due to rapidly pushing Fentanyl in pediatric PTs

High Velocity Penetrating Injury

Cavitation due to energy transfer displacing tissue

S/Sx of Tricuspid Atresia

Central cyanosis Growth failure Exertional dyspnea Tachypnea & hypoxemia May display hypercyanoticspells Split S2

Infraorbital paresthesia

Cheek and upper lip numbness

S/Sx of Sternal Fracture

Chest pain, dyspnea Sternal ecchymosis Bony step-off, crepitus, deformity ECG changes and arrhythmias

Geriatric

Classified as >65yo age

Heat Exhaustion

Core body temperature 38.3°to 40.0°C (101°-104°F)

Hypothermia

Core body temperature < 95°F (35°C) Severe if < 90°F (32.2°C)

Heat Stroke

Core temperature ≥ 104°F (40°C) -Seizures -Coma -Coagulopathies -NOT sweating

S/Sx of Transposition of the Great Arteries

Cyanosis-worsens during first day Metabolic acidosis Hypoxemia Tachypnea, tachycardia May have loud S2

Tricuspid Atresia

Imperforate tricuspid valve (does not pass) Septal defect Hypoplastic or absent RV Enlarged mitral valve & LV Pulmonic stenosis

Expected urine output in peds

Infant: 2 mL/kg/hr Child: 1 mL/kg/hr Adolescent 0.5 mL/kg/hr

External Forces that cause injury include

Deceleration, acceleration and axial loading

Kidney changes with age

Decrease in functioning nephrons, decreased ability to concentrate and conserve H2O, Decreased GFR, Decreased ability to excrete salt, h2O, urea, ammonia and drugs

Musculoskeletal Age Changes

Decrease in lean body mass, thinning of intervertebral cartilage with compression of spinal column, decreased joint mobility

Liver changes with age

Decreased total hepatic blood flow and peristalsis and bowel sounds

How is Respiratory distress defined in pediatrics?

Defined as a RR>60 breaths/min, grunting/forced expiration, head bobbing and tachycardia.

Delirium vs. Dementia vs. Depression

Delirium: Confusion Assessment Method (CAM) Dementia: Mini-Cog Depression: Patient Health Questionnaire 2

Cortical Bone

Dense, long bones

Respiratory System in Cold Related Injuries

Depressed cough reflex, bronchodilation Non-cardiogenic pulmonary edema Increased viscosity of secretions

Primary Treatment for Wounds

Determine age of wound

Asthma Severity Scoring

Dictates POC

Wound Debridement Timeline

Dirt & debris should be removed with in 4-6 hours from extremities & within 8 hours from facial wounds

Management of Frostbite

Do not massage Analgesia Wound care Tetanus vaccine Escharotomy if vascular compromise Amputation @ 60-90 days if necrotic

Meningococcemia

Droplet precautions Antibiotics w/in 30 min

Complications from Crush Injuries

Infection, Compartment Syndrome, & Rhabdomyolysis

Secondary Blast injury

Injuries result from flying debris and bomb fragments

Tertiary Blast Injury

Injuries that result from the individual being thrown by the blast wind

Lower ribs (8-12) are usually associated with injuries to where?

Injuries to the spleen, liver, diaphragm

Sprains

Injury to ligaments that have been stretched or torn by excessive force *Sprained ankles are often associated w/ inversion forces

Signs of worsening Tension Pneumo

JVD Deviated trachea Hyperressonance Distant heart sounds LOC changes

Stellate

Jagged Wound

Patients with C-Spine precautions, how do you open the airway?

Jaw thrust

What is the most commonly injured GU organ?

Kidney

What is the lumbar curve of newborns

Kyphosis

What are resources in ESI Triage

Labs, EKG, radiology, IV fluids, nebulized medications, specialty consultations, simple procedure (1), complex procedure (2+)

Why are car seats rear facing?

Lax ligaments, incompletely calcified vertebrae until the age of 6

PROPPR (Pragmatic, Randomized Optimal Platelet and Plasma Ratios)

Early admin of plasma, platelets and rbcs in a 1:1:1 ratio compared with 1:1:2 ratio did NOT result in significant differences in mortality at 24hrs or at 30 days. More pts in 1:1:1 group achieved hemostasis and fewer experienced death due to exsanguination by 24 hrs

What does Viscoelastic testing enable?

Early identification of Trauma Induced Coagulopathy (hypocoagulable merits immediate response) and guides resuscitation

Treatment for battery ingestion

Early: Child > 1 year old: 10 mL pure honey every 10 min up to 6 doses Delayed presentation-NPO Urgent endoscopic surgical removal ICU care as needed for mediastinitis

Secondary Survey

Events: MOI

Bladder Rupture

Extraperitoneal (typically blunt) v. intraperitoneal (typically penetrating)

Leading cause of trauma for >65 years of age

Falls

Crystalloids alone are the standard of practice. True or false?

False, Large amts of crystalloids or RBCs alone -NO longer standard practice.

Ligaments

Fibrous connective tissue, Stabilizing elastic bands; connect bone to bone

Atrial Septal Defect in Pediatrics

Fixed splitting of S2 crescendo-decrescendo systolic murmur

Exudative Pleural Effusion

Fluid rich in proteins Inflammation, infection or malignancy

Blow-out fracture

Force striking eyeball, bones fracture outwards

Blow-in fracture

Force striking side of face, bones fracture INTO orbit towards eye

Frostbite

Formation of ice crystals in tissue (tissue temp below 0°C/32°F) -direct tissue cellular damage-vasospasm, arterial thrombosis

Bone Changes in Pediatrics

Genu Varum (bowleg)-peaks at 30 months Genu Valgum (knock knee)- peaks at 5-6 years

Kidney Injury Grading

Grade IV indicates marked injury

Liver Injury Grading Scale

Grades I-III are non operative whereas IV-VI are (be familiar with stage IV)

Examples of Skin traction

Hare Splint, Sager Splint, Buck's traction

What are not resources in ESI Triage

History, physical exam, POC testing, Saline lock, oral medications, prescription refill, tele-consult to PCP, wound check, splints

When is emergency surgery indicated for a hemothorax?

If initial drainage > 1.5 L or 1L followed by 200mL/hr for 2-4 hrs

How do you measure compartment pressures?

If you don't have a Stryker Device-insert an 18 gauge needle into the compartment, attach an art line pressure monitor

When would you re-prioritize your C-AB during your across the room primary survey?

If you see hemorrhage

Tendons

Nonelastic fibrous cords; connect muscle to bone

Airways in infant

Obligate nose breathers until 6 months old Put infants/child in sniffing position: use towel behind shoulders

Pyloric Stenosis

Obstruction of the pyloric sphincter caused by sphincter muscle hypertrophy, often a congenital defect

bedside ultrasound

Ocular and/or orbital injuries

Ocular entrapment

Orbital of the eye is stuck due to fracture and patient is unable to look up.

Mass Casualty

Overwhelms immediately available medical capabilities: Personnel Supplies Equipment

Rabies

PREVENTIVE care only, no curative treatment Passive immunity Rabies IG 20 units/kg Active immunity Vaccine: IM on days 0, 3, 7, 14, 28

Rib fracture management considerations

Pain, ineffective ventilation and secretion retention *Can lead to pneumonia in the elderly

Three trajectories to Resuscitation efforts

Responder, Transient Responder, and non-responder

Posterior Hypothalamus

Responds to cold by vasoconstriction

Under-Triage

Patients may be at risk for deterioration while waiting to be seen.

What do straddle injuries usually cause?

Pelvic Fx, External genitalia injury or urethral

Open Pneumothorax

Penetrating chest injury "sucking chest wound"-treated w/ occlusive dressing taped on three sides "flutter valve" UNLESS respiratory distress increases and it progresses to tension pneumo, then remove dressing

Typical MOI for esophagus

Penetrating trauma

Kidney Diagnostics

Plain films and IV pyelogram

Short and long term complications of Tracheobronchial Disruption

Pneumonia-short term Tracheal stenosis-long term

Diagnostic Peritoneal Lavage

Poke hole in belly add fluid, does blood come out? Performed when fast scan isn't possible

Trimodal Pattern of Distribution

Predicts mortality 1st: Seconds to minutes 2nd: Minutes to hours 3rd: Days to weeks

Trauma assessment starts with...

Preparation Advance planning Triage Pre-hospital report: MOI Triage Mass Casualties

Level III Trauma Center

Prompt assessment, resuscitation, emergency surgery and stabilization and arrange transfer to higher-level Maintains continuous general surgery coverage Transfer agreements and SOPs to plan for care of injured patients Might not be required in areas with adequate Level I and II TCs

Tet spell

Seen w/ Tetralogy of Fallot: sudden onset of dyspnea, cyanosis, restlessness, occurs during crying and exertion

Scapular Fracture

Significant force required-rare injury

Radiation

Skin exposed to the environment

Small to Large liver Injuries

Small: repair Large: Segmental resection Uncontrolled: packing

Consider Air Transportation

Spinal cord injury Amputation 2+ long bone fractures Major pelvic fracture Crush injuryTrunk/head Major burn Age <12 or > 55 Near drowning Unresponsive to verbal stimuli Head injury with lateralizing signs Adult VSSPB < 90 RR <10 or >35 HR <60 or >120

Low Velocity Penetrating Injury

Stab wounds: Path of injury determinant on position of attacker, type of weapon used and gender. Impalements: Falls, MVCs, flying/falling objects

Strains

Stretching or tearing of muscle or tendon as result of excessive force

Presentation for PTs w/ tracheobronchial disruption

Stridor, hoarseness, hemoptysis, signs of respiratory distress, sub-q emphysema

Infant is defined as

birth to 1 year

Exophthalmos

bulging eyes

Autotransfusion

collecting one's own blood from chest tube to replace blood lost

Periosteum

covers bones, provides point for attachment of muscle & blood supply for underlying bone tissue

Hamman's sign

crunching or bubbling sounds in synchrony with heartbeat associated w/ tracheobronchial disruption

What type of stool is characteristic of intussusception?

currant jelly and bloody mucous

Why are opioids given for acute aortic dissectio?

decreased sympathetic tone

What type of precautions are used in Pertussis patients

droplet precautions

Supracondylar or Scaphoidvfracture

fracture of the distal end of the humerus or the carpal bone of wrist (respectively); both MOIs are typically falls on the outstretched hand (FOOSH)

Conduction

Transfer of heat between objects

Retinal Detachment

Trauma or spontaneous tear in retina with vitreous leak between retina and choroid, decreasing blood flow to retina S/sx: flashes of light, loss of vision, floaters

Hypotension is a late sign of shock in infants true or false?

True

Tx for Flail Chest

Turn patient on to injured side: consider splinting with towels, internal splinting is also possible for intubated PT on positive pressure ventilation

Eldon card

a blood typing test that uses a card with areas that are pre-spotted with antibodies

Enophthalmos

a posterior displacement of the eye within the socket

induration

abnormal hard spots

Mottling is...

an early and reliable indicator of shock in infants d/t decreased perfusion

Axial Loading

application of the forces of trauma along the axis of the spine; this often results in compression fractures of the spine.

Trismus

lockjaw, unable to open mouth

Panorex X-ray

low impact injury to mandible, isolated mandibular, dental fractures

Early blood product resuscitation w/in 36 minutes leads to

lowest early and late mortality rates

Nerve bundles on the ribs are...

on the bottom

Orbit Fracture

orbital contents prolapse into the maxillary sinus

Subluxation

partial dislocation of a joint or tooth

Patent Ductus Arteriosus

passageway between the aorta and the pulmonary artery remains open beyond 15 hours to 2 weeks of life

What is the most common cause of death in hospitalized patients that are being treated for drowning

post-hypoxic encephalopathy

Empyema

pus in the pleural cavity d/t infection

Preservation of Amputation for Replantation

replantation may be possible up to 6-12 hrs

3 Layers of Eye

sclera (external fibrous layer), choroid (middle), retina (innermost)

Cancellous Bone

spongy, porous, bone Skull, vertebrae, pelvis, long-bone ends

Seidels Sign

streaming of fluorescein stain away from a corneal abrasion, measured with woods lamp or slit lamp

At what point do cranial sutures fuse?

~ 24 months

How long is reimplation possible for an avulsed tooth?

~2 hours -Store in cold milk, culture media, saliva -If any tooth is unaccounted for, get x-ray

Le Fort III Fractures

•Craniofacial disruption extending through the orbits •Basilar skull fracture with CSF leak common •Presentation -Face appears elongated and deformed when sitting up -When laying flat, face sinks back into the skull (spoon-like) -Mobility and depression of zygomatic bones -Difficulty breathing -CSF in rhinorrhea or otorrhea -Raccoon eyes -Diplopia

Mandible Fracture S/Sx

•Malocclusion, trismus •Edema and ecchymosis of lower face •Pain •Drooling •Lacerations •Blood, bony fragments in mouth •Sublingual hematoma •Lower lip numbness


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