Test 9: Trauma
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
