Trauma & Triage

Amputation

Less life-threatening 1. Put direct pressure on the bleeding site 2. Elevate extremity 3. Transport amputated part in a cold state: -Wrap amputated part in saline soaked gaze and put in in a bag and then in a bag with crushed ice put the bag with the amputated part wraped in the saline soaked gauze Complete amputations (clean laceration) have less bleeding than partial amputations because of vasoconstrictive reflex Traumatic amputations involve the ripping and tearing of nerves, ligaments and vessels. An xray is done on the amputated part and stump. Results from machine accidents, traumatic avulsion/tearing injury. These are much harder to retransplant bc of tissue damage When caring for an amputation remember ABCDs: 1. Focus on life-threatening injuries 2. Circulation- control bleeding elevate & apply pressure on artery) 3. Vasoconstriction reflex- decreases bleeding

Mechanism of Injury: Blunt trauma

No penetration of the skin Force or speed is significant (related to the degree of injury) Acceleration-deceleration and shearing forces are present External and internal injuries are common A direct impact causes the greatest injury ex: heart compression, aortic tears, an increase in intra-abdominal pressure causing bruising and rupture of organs

Factors contributing to degree of traumatic injury and death

Non-use of restraints Age of injured person: co-morbidity related Position of the person in the vehicle Type of impact/collision (side vs front) Ejection from vehicle and type of vehicle

Diagnostic procedures for suspected abdominal trauma

PURPOSE: TO ASSESS FOR FREE FLUID (BLOOD) IN THE ABDOMINAL CAVITY In the abdomen you can have retroperitoneal or intraperitoneal bleeding: Intraperitoneal Bleeding involves the small and large bowel, stomach, gall bladder and appendix Retroperitoneal bleeding involves bleeding from the aorta or inferior vena cava, kidneys and pancreas. There is no external blood loss with this type of bleed, pt is very hypotensive TREATMENT: SURGERY FOR DEFINITIVE CARE ESP IF UNSTABLE

Mechanism of Injury: Penetrating trauma

Penetration of the skin has occurred The external wound from the penetration is NOT reflective of the amount of internal injury ex: stabbings and GSWs Obvious wounds with variable blood loss, pain and tissue damage

Phases of Trauma Care- Emergency Dept

Rapid assessment GOLDEN HOUR- 1 hr to definitive care (surgery to stop the bleeding) which increases chances of survival Verification of injuries Resuscitation Definitive care- surgery PRIMARY AND SECONDARY ASSESSMENTS ARE USED HERE

Crush injuries

Results from an injured muscle releasing myoglobin and a surplus of K+- myoglobin is irritating to the tissue and skin so the area starts to swell and is painful Compartment syndrome occurs because of this type on injury

Cardiac Tamponade signs & treatment

Signs: BECKS TRIAD (+JVD, muffled heart sounds, hypotension) -+JVD bc of back pressure. Heart can fill bc theres pressure pushing on the ventricles -muffled heart sounds from fluid surrounding the heart -hypotension d/t decreased SV and CO TREATMENT: PERICARDIOCENTESIS

Shearing forces

Tearing of tissue resulting in organ injury ex: Axonal (when head strikes the ground or something strikes the head) or aorta shearing (tension, bending rupture)

Impalements

The object should always be removed in controlled conditions- (OR). It can cause more injuries to the tissue and arteries if it is not removed in the OR Treat all impalement injuries surrounding the eye as potential emergencies -stabilize/support the object -tape in place if possible-prepare for OR -object removed in OR

Crushing injury: overall complications & interventions

With a crushing injury pt can develop rhabdomyolysis and a fat emboli from a long bone fracture (crushing of bone) Sx: of fat emboli: SOB, decreased LOC, petechiae on chest, hypoxia, ARDS like changes Interventions: corticosteroids, supportive care, splint and transfer to lvl 1 trauma center

Intraosseus (IO) access

used if unable to obtain vascular access Common insertion sites: Proximal tibia, humeral, sternum Any fluid or medication that can be given IV can be given IO because the IO uses the bone marrow as a noncollapsible vein and b/c bone marrow is rich in blood vessels

Rhabdomyolysis

A crush injury resulting from extensive muscular injury. WIth this you will see a big release of myoglobin in the urine (myoglobinuria) Myoglobin is toxic to the proximal renal tubule of the kidneys-> acute renal failure bc of the release surplus release of myoglobin and K+ rising from muscle damage\ MONITOR: K+ AND CREATINE FOR AKF Signs and symptoms: Pt will develop a burgundy (port wine) color to their urine from the increased myoglbin, K+ and CPK-MM TREATMENT: Increase IV fluids to maintain urine output of at least 100-150 ml/hr. Increasing IV fluids flushes out the kidneys Rhabdomyolysis can occur from: traumatic injury, extensive exercise and laying in the same position for an extended period of time

Deceleration

A decrease in speed of the moving object ex: Victim strikes steering column or impact ground- this impact can cause an aortic injury Found in blunt trauma

Which of the following tests is the mainstay of diagnostic evaluation in a patient with blunt abdominal trauma who is hemodynamically stable?

A. Focused Assessment with Sonography for Trauma (FAST) B. Diagnostic Peritoneal Lavage (DPL) C. Abdominal X-rays D. CT scan of the abdomen ANSWER: CT SCAN OF THE ABDOMEN

In a trauma patient which condition can be caused by hypothermia?

A. Hypervolemia B. Atrial flutter C. Metabolic alkalosis D. Coagulopathy ANSWER: COAGULOPATHY

If a patient with blunt chest and abdominal trauma complains of left shoulder pain, to which organ may be suspected?

A. Liver B. Left Kidney C. Spleen D. Left Lung ANSWER: SPLEEN

If a patient with blunt chest and abdominal trauma complains of right shoulder pain, to which organ may be suspected?

A. Liver B. Left Kidney C. Spleen D. Left lung ANSWER: LIVER-referred pain would come from the liver irritating the diaphragm or bleeding from the liver irritating the diaphragm

For a client with suspected compartment syndrome: which assessment finding in the affected extremity will require an emergency fasciotomy?

A. Paresthesis in the distal extremity B. Inability to auscultate a pulse with the doppler distal to the injury C. The affected extremity is cooler than the unaffected extremity D. Pain medication is not relieving the pain in the injured extremity ANSWER: INABILITY TO AUSCULTATE A PULSE

For a client diagnosed with acute compartment syndrome involving the forearm which is the best way to position the extremity?

A. Position the extremity above heart level B. Position the extremity at heart level C. Position the extremity below heart level ANSWER: POSITION THE EXTREMITY AT HEART LEVEL You don't want to place it above heart level because elevation decreases arterial flow and narrows the arterial-venous pressure gradient You dont want to place it below heart level because it generates too much pressure.

What ventilator setting increases the risk of developing a tension pneumothorax?

A. Pressure support B. Tidal volumes of 6 to 8ml/kg C. PEEP- Positive End Expiratory Pressure D. CPAP- Continuous Positive Airway Pressure ANSWER: PEEP- too high of a presssure can create a tension pneumo

Acceleration

An increase in speed of the moving object ex: Person hit with a bat or car Found in blunt trauma

Mechanisms of injury

Can be blunt or penetrating Used as a triage marker

Thoracic injuries

Causes of: 1. Blunt thoracic injuries: frontal or side impact with MVCs 2. Penetrating thoracic injuries: assaults (firearms or stabbings)

Major abdominal trauma

Consists of blunt and penetrating injuries GOALS OF EARLY SURGICAL TREATMENT: -control hemorrhage -remove dead tissue -lavage the abdominal cavity- removes blood, fecal mattter from peritoneal cavity -control contamination (dirty wounds need broad spectrum antbx) -close the abdomen without tension- (bowel swelling can lead to compartment syndrome-must allow bowel to swell so intra-abdominal hypertension is not created

Compartment Syndrome

-A crushing injury involving the compression of blood vessels and nerves from the swelling of muscle tissue. -Occurs within a fascial compartment that surrounds the muscle - this pressure and compression will stop blood flow distal to the injury causing no pulse and neurovascular injury, bone injury. You will not have blood flow to this area if the pressure with the fascial compartment rises above the capillary perfusing pressure--> muscle death, depression of large arties and decreasing circulation distal to injury Swelling-ischemia-hypoperfusion bc of high pressure-necrosis - life threatening if it involves the pelvis or legs A manometer with a needle measures the pressure in the compartment. It would know if compartment syndrome is present when the pressure inside the compartment rises above 30 mmHg Associated signs: severe pain (out of proportion to the extent of injury), bruising, shiny swollen skin that loses 2 point discrimination, numbness TREATMENT: FASCIOTOMY

Flail chest

-A freely moving segment of rib cage resulting from 3 or more ribs fractured in 2 or more placed - Flail chest moves the opposite way of regular chest movement bc of a negative intrathoracic pressure. It does not move normally with the chest wall resulting in paradoxical movements

Open pneumothorax

-An opening in the chest wall that allows air to escape. It sounds like sucking or bubbling when ppl try to take a breath -Caused by penetrating chest trauma-GSW or stabbing -the lung collapses causing poor air exchange in the side where the open pneumo is -air enters on inspiration and exists on expiration NEVER PUT A DRESSING OVER THIS- CAN CREATE A TENSION PNEUMO

Spleen and Liver Injuries

-Bleeding is common -May be life-threatening -Severity of Injury graded (I-V): hematoma, laceration, vascular injury

Hemothorax

-Blood in the pleural space due to rib fractures, heart or great vessel injuries -the accumulation of blood makes it harder to inflate the lung causing a restrictive lung problem- lung cannot expand all the way S/sx: -SOB -hypotension from blood loss -dullness to percussion in the area where the fluid is tachycardia TREATMENT: CHEST TUBE & POSSIBLE SURGERY

Spleen Injuries

-Kehr's Sign: spleen pain referred to left shoulder -irritation of phrenic nerve causes "referred pain" -Treat by observation or OR

Internal abdominal injuries

-Most common "Missed Injury" -Vulnerable Organs: spleen, liver, bladder, bowel (abdominal), kidneys, aorta (retroperitoneal) -Ongoing assessment needed -MONITOR FOR: decreasing BP & bowel sounds, N/V, distension, peritonitis (abd pain & guarding), serial H/Hs

Rib fractures

-Most common blunt chest injury -Lower rib fractures indicate possible Abdominal organ/vessel injury -RIBS #11-12 are free floating and can result in liver, spleen or diaphragm injury - Ribs #1-2: fracturing these ribs requires major force. If these are broke 2 injuries are indicated: 1. injury to great vessels in neck (check pulses in arms & legs bilaterally) 2. tracheal injury (hoarseness) S/Sx: dyspnea, pain with breathing, bruising, palpate chest wall for deformity and SQ air Assess for chest wall bruising, emphysema that can indicate a pneumo Want to control anxiety and pain so pts can take deeper breaths

Diagnostic Peritoneal Lavage (DPL)

-Rapid test for Intraperitoneal Bleeding -Invasive -Peritoneal catheter inserted into abdomen (right below umbilicus) & warm NS or LR instilled then drained -Drop bag below level of bed -If bag filled with blood, yellow, green, food, particles, stool= Positive DPL & go to OR

Signs, symptoms and treatment interventions for flail chest

-S/sx: dyspnea, pain, possible chest wall bruising, hemoptysis (coughing up streaks of blood) -Collaborative care: -Adequate o2 (100% mask) -Monitor for hypoxemia (ABG, Sp02) -Pain management- intercostal block, epidural or PCA or combo -Mechanical ventilation-- positive ventilation will make flail chest expand causing more pain with every breath- pt has to heavily sedated). It is only used if flail chest leads to decreased ventilation

Later Complications of Trauma

-Thromboembolism (DVT & Pulmonary) -Fat Embolism with Ortho Trauma -Infection, Sepsis, Septic Shock -ARDS -Primary MODS -Compartment Syndrome -Rhabdomyolysis -Renal Failure -Death

Classic signs of intra-abdominal bleeding

-abdominal pain -rigid abdominal muscles -rebound tenderness/guarding -hypoactive BS -Flank or umbilical ecchymosis-will see 24 hrs after injury -CULLENS SIGN: purplish discoloration of the skin around the umbilicus (indicates intraperitoneal bleeding). This can be detected from a + DPL or + FAST ultrasound

Cardiac Tamponade

-acute compression of the heart caused by fluid accumulation in the pericardial cavity -increased pressure on the heart causing a decrease in venous return leading to death -can be diagnosed with an echo or fast test Can occur with: Penetrating wounds in the heart:rupture of myocardium, a weak post transmural MI and sudden deceleration injuries causing thoracic and aortic rupture/tear (exsanguination)

Diaphragmatic rupture

-bowel sounds heard in chest -can be caused by a blunt abdominal injury (blunt force of abdomen) -will see tracheal deviation & mediastinal shift, ruptured diaphragm (stomach in thoracic cavity)

Pulmonary Contusion

-bruising and bleeding into lung tissue often occurring with a rub fracture -inflamm process--SIRs/ARDS risk -S/sx: hemoptysis, decreased BS and crackles over affected area TREATMENT: decreased Spo2 requires oxygen and possibly PEEP

Tension pneumothorax s/sx

-dyspnea -increased RR, increased HR -absent breath sounds on side of collapse -low BP from decreased CO due to mediastinal shift--> heart cant fill and empty bc mediastinum has twisted DEFINITIVE TREATMENT: chest tube

GRAY TURNER'S SIGN

-ecchymosis in flank area -associated with retriperitoneal bleeding LOCATED WHEN YOU TURN TOWARDS YOUR FLANK

CULLEN'S SIGN

-ecchymosis in umbilical area -associated with intraperitoneal bleeding LOCATED AROUND UMBILICUS

Trimodal Distribution of trauma deaths

1st peak- 50% of deaths occur within minutes--> refer to onscene deaths, brain deaths, internal bleeding 2nd peak- 30% of deaths occur minutes to hours (1-3 hrs after accident)--> subdural hematomas, pelvic fractures, long bone fractures 3rd peak- 20% of deaths occur 2-4 wrks after accident from sepsis and MODS GOLDEN HOUR: trying to get the person thats traumatically injured to a trauma center within the 1st hour to decrease mortality

Pelvic Fractures

-fractures to the pelvic area include this ring like structure of bones: the ilium, sacrum, coccyx, pubic rami and ligaments (sacro-iliac ligament) -if ring-like structure is not present, a pelvic fracture is indicated S/sx: -retroperitoneal bleeding -peritoneal ecchymosis -lower limb paresis -pain with palpitation of iliac crest -rupture of full bladder Before turning someone the pelvis must be stabilized before hand -a major source of morbidity & mortality in trauma -bleeding: life threatening, intraperitoneal and retroperitoneal Collaborative management: -prevent/control hemorhage & shock -stabilize pelvis-external/internal -bedrest >5 days-risk of DVT & PEs

Early complications from traumatic injuries

-hemorrhage is #1 -----hypovolemic shock -hypothermia----coagulopathy -met/resp acidosis from blood loss-----decreased perfusion -fluid overload----increased ARDS risk -SIRS due to blood loss, tissue injury, contaminated wounds -INFECTION & MODS from sepsis #1 late killer

Blunt Cardiac Injury (BCI)

-known as myocardial contusion or a bruising of the heart. This bruising causes the heart to stunt and not pump well -associated with sternal fractures, seatbelt injury and steering wheel injury Nonspecific s/sx: -chest pain not relieved with NTG -dysrhythmias-ST, Afib, BBB, Heart blocks, PVCs, PACs -Nonspecific ST changes -Cardiac enzyme elevations do not predict complications Anterior chest wall bruising (seatbelt sign) TREATMENT: PREVENT AND TREAT COMPLICATIONS Observation if abnormal ECG or echo (rules out pericardial tamponade)

Tension pneumothorax collaborative care

-oxygen -needle thoracentesis -Heimlich valve-one way flutter valve (allows air out but not back in) -monitor spo2, ABG, RR, depth and BS DEFINITIVE TREATMENT: CHEST TUBE PREVENTION: -apply a nonporous dressing and tape it on 3 sides-this always allows the air out but when the pt takes a breath, in the dressing sucks up against the chest wall (not letting air in)--> preventing air from getting into thoracic cavity

Penetrating Cardiac Injuries

-stabbings, GSWs, impalements -Rt ventricle commonly injured -HIGH MORTALITY RATE D/T TAMPONADE OR EXSANGUINATION

Psychological aspects of trauma

-stress, crisis -grief -response to loss: anger, fear, powerlessness, mistrust, confusion

Abdominal Compartment Syndrome (ACS)

-the abdomen has become a fixed compartment with increased pressure resulting in ischemia and organ dysfunction -occurs from abdominal hypertension--> can be measured thru a foley catheter

Pericardiocentesis

-the puncture of the pericardial sac for the purpose of removing fluid -pt put in semifowlers position to pull the bloodin the apex -apply o2, ecg leads and defib pads BEFORE attempting this procedure -relieves pressure so the heart can fill and empty-physician enters with a long needle below xyphoid area +Pericardiocentesis = aspirating the entire way & getting blood return. An abnormal finding means there's blood in the pericaridal sac

Renal Trauma (Retroperitoneal)

-would see a + Grey Turners sign (ecchymosis of flank area) -Diagnostics: CT scan -from blunt trauma -Suspect bladder/bowel and spine injuries also S/sx: flank ecchymosis (positive grey turners sign), pain, hematuria Minor injury- medical management--> control pain, manage H&H w/ blood transfusions and fluids to maintain hemodynamic stability. observe pt Surgical- repair or remodel

Focused survey/assessment

1. Lab studies- trauma panel PRIORITY: blood typing, screening and cross matching A type and cross match is when they mix the pts blood with potential donors blood to see if theres any agglutination or reaction if no reaction (blood transfusion to the pt) A screen is when your blood is drawn and screened for antibodies and they tell you your blood type 2. Radiographic studies: Xrays of c-spine, chest and pelvis are most common 3. Injury specific diagnostics: CT scan, extremity, abdomen depending on MOI

Adjuncts to secondary survey (gadgets, testing + meds)

1. Radiology Xrays of: C-spine, chest, pelvis Focused Abdominal Sonography in trauma (FAST)- ultrasound for truncal injuries Cat scan imaging, angiography if pt is more stable 2. Foley Catheter- do not insert a foley if the pt has blood at urethral meatus- indicates pelvic fx or bladder rupture (NO FOLEY USED) 3. Pain control 4. Tetanus Status- tetanus prophylaxis 5. Antibiotics for open fractures (dirty wounds)

Phases of Trauma Care- EMS

1st responders at the scene prehospital GOALS: identification of injuries, stabilization, rapid transport No more than 10 min of stabilization on the scene then transport to a trauma center OVERALL GOALS: 1. Stabilize airway 2. Control bleeding 3. C-spine stabilization 4. Rapid transport

Mass Casualty Triage & tags

Disaster triage is used to identify the most severely injured pts with the greatest chance of survival and the least expenditure of resources that can be easily transferred to the hospital or should be transferred quicker to the hospital with the best chance of survival. Victims are placed into 4 categories based on color-coded tags. These are used outside the hospital on the scene in a disaster if there is greater than 25 pts (multiple pts, limited resources): Black- expected to die (dead or dying) Red- seriously injured (immediate transport) Yellow- less seriously injured; significant MOI. delayed transport (1-3 hrs) Green- walking wounded THERE ARE ONLY 3 TREATMENTS DURING TRIAGE: 1. open airway/insert oral airway 2. stop bleeding- apply pressure/ tourniquet 3. Elevate extremities- increases venous return

Rapid estimation of BP

Done without taking a BP- its done with a palpable method called the 60-70-80 rule. Helps estimate SBP with rapid triage Pulse Palpable: Carotid--> 60 mmHg Femoral--> 70 mmHg Radial--> 80 mmHg QUESTION: During the primary surgery, a trauma pt has a non-palpable radial/femoral pulse but the carotid pulse is palpated, what is the estimated SBP? Answer: 60 mmHg QUESTION: What would be the estimated SBP when the radial artery is somewhat palpable? Answer: 80 mmHg QUESTION: What is the minimum systolic bp when the radial pulse is absent but the femoral pulse is palpable? Answer: 70 mmHg

Factors contributing to MVCs

ETOH Driver inattention/distracted driving- cell phone, drowsy driving Speeding Risk taking and aggressive driving

Newtons 2nd Law

Force = Mass x Acceleration The force a person endures in a motor vehicle crash is a function of mass x speed

Initial assessment & Management

GOAL WITHIN THE "GOLDEN HOUR"- 1st hr to definitive care, helps increase chances of survival Assessment & initial management simultaneous 2 Phases: Primary survey/assessment- main focus is ABCDE Secondary survey/assessment Done by EMS and ED EMS will report to the ED the mechanism of injury based on what was found at the scene, suspected injuries sustained and the treatment given at the scene

Primary (PRIORITY) Survey

GOAL: ID AND SIMULTANEOUS TREATMENT OF LIFE-THREATENING INJURIES TO PREVENT DEATH ABCs are the priorities of care- NOT TAKING A FULL SET OF VS A- Airway and c-spine stabilization GOAL: assess for impending airway obstruction Interventions: make sure airway is open and suction out the airway remove any foreign objects, assess for vomitus/bleeding/edema or tongue obstruction, intubation C-spine stabilization interventions: aspen collar decreases the risk of neurogenic shock, and utilizing jaw thrust or chin lift + head lift to open the airway of a pt with a suspected neck injury All unresponsive patients must have c-spine stabi or immobilization B- Breathing GOAL: Assess for respiratory insufficiency related to pulmonary contusion, flail chest or thoracic injury Note RR, quality of RR using accessory muscles, sucking chest wounds w/ breathing, any SUBQ emphysema, any obvious rib bruising or fractures, listening to breath sounds, bilateral breath sounds, JVD or tracheal deviation Interventions: Spo2 readings, thoracentesis, chest tube, nonporous dressing taped on 3 sides for an open pneumothorax C-Circulation GOAL: Assess for shock from multisystem trauma and hemorrhage. Check 60-70-80 rule for SBP estimating, general pulse rate quality, skin, temp and diaphoresis, assess for external bleeding (use direct pressure to control bleeding and tourniquets) then add vasopressors Interventions: insert 2 #14 or #16 gauge IVs or intraosseus access, hemorrhage control, all blood and IV fluids will be warmed and use NS, LR or blood products Utilize IV fluids and PRBCs first if pt is loosing blood D- Disabiliity (NEURO) GOAL: check pupil reaction and responsiveness, check for consciousness AVPU- (alert, voice, pain, unresponsiveness), GCS E- Expose patient Visually inspect for bruising, deformity, and or injury while undressing pt. While doing this, keep pt warm when exposed and palpating any deformity or area that is bruised

Secondary Survey

GOAL: IDENTIFY ALL INJURIES some small injuries like perforations in the bowel will be missed bc they show up after 24 hrs 1. FAHRENHEIT- keep pt warm. A cold temp causes coagulopathy (bloods ability to form clots is impaired) and bleeding Intervention: warm lights, warm IV fluids, bear hugger 2. GET FULL SET OF VS, ADD GADGETS, GCS- Get a full set of VS w/BP cuff, add cardiac monitor, lab studies with typing and cross-matching. AN NG or OG will be added to decompress the stomach, foley if indicated- would not insert a foley if there is bruising in the perineal area and blood at the meatus = pelvic fracture 3. HEAD TO TO EXAM- meds, allergies, past medical history, palpate any bruised or deformed areas. Look for wounds, drainage, basilar skull fracture. Neck JVD indicates cardiac tamponade 4. INSPECT POSTERIOR SURFACES- Log roll pt checking for perineal ecchymosis which can indicate a pelvic fracture. Check for deformities and bruising on the posterior aspects of the pt. Anal wink (anal sphincter tone) is checked by a physician to see if the spine is intact down to S5 when the pt is logrolled. If anal sphincter tone is intact the spine is intact down to the bottom (just above the coccyx) When logrolling make sure to maintain full spinal immobilization using a back board. To logroll 5 people are need: 1 to inspect, 3 to turn pt and 1 person to mobilize head and neck After completing logrolling we must reassess ABCD and VS bc by turning them we may have unknowingly released a clot causing internal injuries and bleeding which can resume if the pt is moved

Collaborative team approach

GOAL: organized, efficient, comprehensive approach All healthcare team associated with the care of a trauma pt must take an accrediated class on trauma based on their scope of practice: Providers--> take advanced trauma life supports (ATLS) for MDs to be certified in trauma RNs, EMTs, EMT-Ps--> take trauma nurse course (TNCC) Course teach a team approach to assess and treat traumatically injured pts

Trauma Systems and Centers: LEVEL 1

GOALS: decrease time to definitive care (surgical interventions) & increase expertise of care Provide a systematic organized approach to trauma care- proven to decrease disability and death 4 levels of trauma center Level 1 requirements (HIGHEST): Regional resource center + lots of staff Neurosurgeon available (in house surgeons) 24/7 & surgical suite open 24/7 for trauma pt Trauma surgeon available 24/7 CP bypass capability Multi-specialties of surgeons available Rehab. research, prevention, outreach programs To be a level 1 trauma center, the hospital has to have a high acuity with at least 1,200 trauma cases a year DECREASE MORTALITY WITH TRAUMA CENTERS

Mass Casualty Triage (S.T.A.R.T.): adult population

GREEN (minor)- move the walking wounded Morgue (black)- no respirations after head tilt Immediate (red)- respirations over 30 (SNS response) Immediate (red)- perfusion- cap refill over 2 seconds or radial pulse weak or absent Immediate (red)- mental status- unable to follow simple commands or confused Delayed 1-3 hrs (yellow)- otherwise

Focused Assessment with Sonography for Trauma (FAST)

Has the ability to quickly assess a person while their in the ED without having to move them at all (helpful for unstable pts) ASSESSES FOR INTRAPERITONEAL BLEEDING NOT RETROPERITONEAL BLEEDING Consists of ultrasound of 4 pouches that can hide blood in them: subhepatic, pelvic, perinephric, pleural Noninvasive & quick, inexpensive To identify retroperitoneal bleeding a CT scan must be used. A CT scan can identify both intra & retroperitoneal bleeding. PT MUST BE STABLE FOR A CT SCAN- cannot be unstable or hypovolemic

MVCs in the elderly

There are multiple age related changes in systems as a person gets older that makes then more susceptible to be in a MVC 1. Neurologic- decreased: reaction time, hearing, cerebral blood flow and brain atrophy. (all contribute to more acceleration injuries) 2. Respiratory- more rib fractures, vital capacities decrease 3. Cardiovascular-decreased C.O., more atherosclerosis and HTN and more potential to be on anticoagulants (PE, Afib) 4. Musculoskeletal- Osteoporotic changes which increase the risk of bone fractures 5. Integumentary- Skin is thinner, less subq fat, less heat production

Adult Revised Trauma Score (RTS)

Used prehospital triage ESTIMATES ACUITY & SEVERITY of pts physiological response to injury The initial score correlated with survival. A low score means poor prognosis Range: 0-12 RTS is based on 3 paremeters: SBP (0-4) RR (0-4) GCS (0-4) PT MUST BE TAKEN TO A TRAUMA CENTER IF RTS IS 11 OR LESS (refer to chart on BS)

Unintentional injuries

accidents, posioning, overdoses

Multiple trauma is associated with...?

hypovolemic shock (loss of blood volume) BIGGEST PROBLEM: coagulopathy driven by hypothermia--> hemorrhage--> hypovolemic shock--> acidosis from hypoperfusion & hypovolemia

Tension pneumothroax

intrapleural pressure exceeds atmospheric pressure, causing shift of the lung which compresses the vena cava and affects cardiac output. the pressure causes a shift in the mediastinum and deviates the trachea -air leaks from the lung into the pleural space and it cant get out of the chest wall but it can come in causing a build of up pressure -tracheal deviation towards unaffected side but chest wall intact -occurs with blunt trauma--> rutprued lung, sudden impact with a closed glottis -IMMEDIATE TREATMENT: Needle decompression 2nd ICS @ MCL -S/sx: loss of breath sounds on affected side, tracheal deviation towards unaffected side, sudden increased HR, SOB

Intentional

suicides, homicides, assaults