trauma exam 1
12. When using medications on burn patients what are the issues you need to keep in mind? What if they are older or younger patients? - Keep in mind that burn victims require higher doses of medication. - Older patients are susceptible to pulmonary edema. Caution for fluid overload. - Pediatrics require more fluids, caution for fluid overload.
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2. You arrive on the scene of an assault. Your patient is a 66 yom who is found sitting on the couch in his living room. The pt. states that he was just watching TV when 2 men busted in his house wearing masks. During your physical assessment you find several lacerations of various depths. The pt. tells you that during the altercation one assailant had a knife and kept slashing at him. - Why are some injuries more open than others? Think about tension. The amount of force used when stabbing the pt. - Since these are considered open wounds, what are some of the tissues you would need to think about during care? Direct pressure, control bleeding, proper bandaging, focus on ABCs
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Patients who are rendered unresponsive by radiation or who manifest with vomiting within 10 minutes of exposure will not survive. Those who manifest vomiting in less than an hour have severe exposure and have a 30%-80% survival rate. Many people with moderate exposure will vomit within 1-2 hours and have a 95%-100% survival rate
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Patients with more than 20% of the body is burned will need fluid resuscitation.
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Patients with the following injuries should be transferred to a burn specialty center, also called a burn unit: partial thickness burns of more than 10% of the body surface area, burns that involve the face, hands, feet, genitalia, perineum, or major joints, full thickness burns in any age group, electrical burns, chemical burns, inhalation burns.
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Scalp injuries tend to bleed profusely owing to their rich blood supply
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Sodium metals produce considerable heat when mixed with water and may explode. Cover this type of burn with oil, which will help stop the reaction by preventing the sodium from coming into contact with the atmosphere
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The difference between velocity and speed is that velocity is also defined by moving in a specific direction
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The ear is the organ system most sensitive to blast injuries.
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The final phase of an MVA is the result of additional impacts that the vehicle may receive, such as when it is hit by a second vehicle, or is deflected into another vehicle, tree, or other object.
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The first phase of an MVA is deceleration of the vehicle, occurs when the vehicle strikes another object and is brought to an abrupt stop.
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The fourth phase of an MVA is the result of secondary collisions, which occur when a vehicle occupant is hit by objects moving within the auto such as loose objects, packages, animals or other passengers
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The human limit to deceleration is about 30 g
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The kidneys will be permanently damaged after 45 minutes of inadequate perfusion. Which is the same for most other vital organs. Skeletal muscles cannot tolerate more than 2 hours of inadequate perfusion
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• Compare and contrast the types of injuries that might come from a restrained vs. and unrestrained passenger in an MVC. For example, what damage could the seatbelt do? What happens if you get thrown from the vehicle? How high is your suspicion for injuries on this type of call? -seat belts are highly effective because they stop the motion of any automobile occupant who is traveling at the same speed as the vehicle, until stopped. -the seatbelt, although capable of delivering some injury at high speeds, will prevent the serious to fatal injuries of being unrestrained in the car and being ejected from the car. Specific injuries associated with seat belt use include cervical fractures due to flexion stresses and neck sprains due to deceleration and hyperextension. Most serious injuries occur because the patient did not use the seat belt correctly. If the occupant does not use the shoulder strap, sever the upper body injuries, including spinal injuries and decapitation, can occur. If the seat belt is placed above the pelvic bone, abdominal injuries and lumbar spine injuries result. -one out of 13 victims of ejection sustains major and permanent cervical spine damage. Occupants who have been ejected or partially ejected may have struck the interior of the car many times before ejection.
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• What are the differences in how we treat multi-system trauma vs. a singular type of trauma? In other words, what should be going through our mind when dealing with multi-system trauma? - A singular type of trauma differs from multi-system trauma, because a singular type trauma focuses on one area of the body, compared to multi-system trauma which involves several body systems. Examples are the head and spine, chest and abdomen, or chest and multiple extremities. - The body can compensate fairly well to an isolated injury, but it has a much harder time dealing with multiple injuries that involve several major body areas. - Prioritize the treatment of the injuries, and transport multisystem trauma patients without delay. - With multi-system trauma, the most important thing to focus on is life threats; airway and bleeding. If patient is bleeding find the bleeding and stop the bleeding. If the patients is in respiratory distress, or not breathing at all, assist respirations, or breath for the patient. If patient has airway obstruction, remove obstruction. Suspect shock, if blood pressure is low, give fluid bolus, treat for shock, give high flow o2, cover with blanket. Go back to basics if needed.
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is often referred to the fight or flight, or freeze mode and is your body's normal response to stress
The sympathetic nervous system
Revised trauma score
is a scoring system used for patients with head injury.
Kinetic energy
the energy associated with bodies in motion, expressed mathematically as half the mass times the square of the velocity
Mechanical energy .
the energy that results from motion or that is stored in an object
Barometric energy
the energy that results from sudden changes in pressure as may occur in a diving accident or sudden decompression in an airplane
Blast front
the leading edge of the shock wave
Deceleration
the negative acceleration or slowing down.
Negative wave pulse
the phase of an explosion in which pressure from the blast is less than atmospheric pressure
Law of conservation of energy
the principle that energy can be neither created nor destroyed; it can only change form.
Brisance
the shattering effect of a shock wave and its ability to cause disruption of tissues and structures
Biomechanics
the study of the physiology and mechanics of a living organism using the tools of mechanical engineering
Kinetics
the study of the relationship among speed, mass, vector direction, and physical injury
Pathway expansion
the tissue displacement that occurs as a result of low displacement shock waves that travel at the speed of sound in tissue.
Multisystem trauma
trauma caused by generalized mechanisms which affect numerous body systems
The ------- center in the medulla oblongata helps to regulate blood pressure
vasomotor
- Application of cold compress will help reduce pain and diminish blood flow to an open wound
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1. You arrive to find a 24 year old male who was pinned under his car when the bricks he was using to hold the car up after he took the tires and wheels off gave away. He is still AAOx4 and tells you he thinks he has been stuck there for at least 4 hours before someone found him. - What types of injuries would you expect to find? Compartment syndrome, crush injuries, broken bones, internal bleeding, open fractures. - How are you going to treat this patient? Large bore IV, high flow o2, monitor, sodium bicarb, focus on ABCs. Tourniquet the affected area if possible to reduce the flow of rhabdomylosis(toxins released in the blood from necrosis ) - What are you worried about when extricating this patient? Rhabdomylosis, cardiac arrest, internal bleeding, renal failure.
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10. You respond to an MVC in a thunder and lightning storm. As you arrive on scene you find a sedan that has hit an electrical pole. There is a bystander that is lying on the ground near the car and a passenger sitting in the driver seat of the car afraid to get out. - What is your first concern? How would you deal with it? Scene safety for me and my partner is first priority. Call additional resources( electric company, fire department) - What are your concerns with the bystander? With the driver of the car? MVA or Auto ped, question if the pt. was ejected from the car. Was the patient electrocuted from the electric pole? Concerns of the driver would be any injury concerning a front end collision, up and over injuries.
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11. You are called out to three mile island Nuclear plant for several patients that is complaining of ams and burns all over differing parts of the body. - Once the area is deemed safe how do you determine which patients take priority? Set up a triage for MCI. Consider radiation burns from radiation.
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13. You arrive on scene of a 12 year old boy who climbed to the top of a high voltage electrical tower. At the top of the tower the boy was hit by an arc between the two of the wires and fell to the ground. - What are your major concerns with this patient? The electrocution? The fall? Check to see if the patient is alive. Multisystem trauma, multiple fractures, internal bleeding, organ damage, airway. Cardiac arrest. C-spine precautions, begin CPR if indicated. Attach cardiac monitor. - What will you use your secondary assessment for and when will you do this assessment? look for entrance and exit wounds. Treat life threats. - Where and how will you transport this patient? If patient is alive transport to the closest burn center. If the burn center is to far away call for air medical to fly the patient to burn center.
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3. You are called to a possible domestic violence issue. You arrive to find a 15 yof. During your assessment of the pt. you find several discolorations of her skin. Some are black and blue and others are bluish and swollen. She does complain of tenderness over the affected areas. - Whar are those areas of different colors? What does that mean? Black and blue are contusions Bluish and swollen are hematomas. Suspect internal bleeding -what are your concerns in a scene like this? Scene safety
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4. You arrived at an industrial site where a 34 yof was working with a table saw. While cutting a piece of wood she was distracted by a co-worker and cut off her left index finger. How would you treat this patient, package the finger and where would you transport her? - Clean with sterile water, control bleeding, bandage the finger, IV, O2. - Place finger in sterile moist gauze and place it in a cool container, with ice. Do not put the amputated finger directly on the ice.
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5. In treating soft tissue injuries there are several complications to consider in the pre-hospital environment. Describe those and how you would deal with them for the following: Closed wounds- ice pressure, elevate and splint Open wounds- direct pressure, irrigate with sterile water, control bleeding, bandage, elevate, treat for shock.
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6. There are 3 basic descriptions of burns based on the depth of the burn. What are they called, how do we differentiate between them and does your treatment change based on the depth of the burn? - Superficial burns, partial thickness burns, full thickness burns. - Superficial burns involve the epidermis only, the skin will be red and swollen and when touched the color will blanch and return. Blisters are not usually present. Pt. usually will complain of pain. Within the first hour after injury, immerse the burned area in cool water, or apply cold pack to the burn. Towels soaked in cold water may be applied to burns to the face and trunk. Cover with a dry sheet or blanket over wet dressing to prevent hear loss. Provide pain management. - Partial thickness burns involve the epidermis and varying degrees of the dermis. Categorized into moderate partial thickness and deep partial thickness burns. With moderate partial thickness the skin is red when touched, the color will blanch and return usually presents with blisters or moisture. Also hair follicles stay intact. With deep partial thickness burns the depth of the burn goes into the dermis damaging hair follicles, sweat and sebatious glands. Usually difficult to determine in the field. Pt. usually complains of pain. Similar to superficial burn treatment, burned extremities should be elevated to minimize edema, large bore IV with LR or NS depending on the agencies protocol. Pain management. - Full thickness burns involve the destruction of both layers of the skin, including the basement membrane of the dermis that produces new skin cells. Skin may appear white, waxy, brown and leathery or charred. No cap refill will be present. Usually no pain in the burn bc the sensory nerves are destroyed. Usually the pt. will have pain surrounding the burn bc it usually has mixed depth surrounding the burn. Similar to the treatment of the other classes of the burns, establish IV, pain meds, fluids LR or Ns, check with your burn center on their view on wet dressings or analgesia. Try to transport to the closest burn center, consider air medical if the burn center is to far away.
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7. Your pt. came running out of a garage on fire and during your assessment you notice 2nd and 3rd degree burns to both legs, 1st degree burns to both hands and 2nd degree burn that goes all the way around the chest. Based on this assessment, what do you consider the most troubling burns and why? What will your treatment be for this pt.? - The main concern would be the burns around the chest, could cause airway compromise, distress, edema to the chest. - Remove the clothing, maintain ABCs IV O2 monitor, fluid resuscitation, dry sterile dressing, pain management, cover with a blanket to prevent heat loss. Consider RSI
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8. You and your partner arrive at the local auto parts store where you find a 35 yom who fancies himself as a car mechanic. He goes to the store to purchase a new battery for his car and decides to replace it in the parking lot. As he goes to take the battery out of his car he hits something with the wrench and the battery explodes. Battery acid blows in his face and covers his hands as he tries to protect himself. - How do we go about stopping the burning process for this patient? Remove clothing, copious irrigation. - How do we determine the amount of damage from the chemical burns? Visually assess your pt. from head to toe. - Would this be worse if this was a drain cleaner? Drain cleaner is an alkaline and would be worse than battery acid.
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9. You are called to a farm where you find a 42 yom who was working with dry lime. He fell and was covered with the powdery substance and is complaining of burning in his eyes and on his skin. - What is your first step in treating this patient? BSI, remove patient from the source, remove clothing, flush eyes, use morgan lens, depending on protocol administer lidocain in the eyes to relieve pain. Brush the lime off the skin. Flush skin with water after brushing off chemical, provide high flow O2.
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A Coma Score of 13 or higher correlates with a mild brain injury, 9 to 12 is a moderate injury and 8 or less a severe brain injury. and 3 the patient is dead.
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A higher priority should be given to patients taking warfarin(Coumadin) or other anticoagulants. Other medications that can lead to continued bleeding, include aspirin, ticlopidine(ticlid) and clopidogrel bislulfate(Plavix
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A shock wave that might cause minimal injury in the open can cause devastating trauma if the patient is standing beside a wall or similar solid object.
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Acceleration is the rate of change in velocity; speeding up
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According to the centers for disease control and prevention, trauma has emerged as the primary cause of death and disability in people between the ages 1 and 44 years
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Air embolism to the cerebrovascular system can produce disturbances in vision, changes in behavior, changes in the state of consciousness, and variety of other neurologic signs.
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Alkalinizing the blood and urine with sodium bicarbonate helps prevent kidney failure, treats hyperkalemia, and reverses metabolic acidosis in crush syndrome
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An air splint will not control arterial bleeding.
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Angle of impact is the angle at which an object hits another; this characterizes the force vectors involved and has a bearing on patterns of energy dissipation.
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Be cautious as well with IV fluids, which may be poorly tolerated in patients with lung injury and result in pulmonary edema
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Blast fragments and gasses move shorter distances in water.
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Blood enters the right atrium via the superior and inferior vena cavae and the coronary sinus, which consists of veins that collect blood returning from the walls of the heart.
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Bradycardia and hypotension are common after an intense pressure wave from an explosion. This is a vagal nerve mediated form of cardiogenic shock without compensatory vasoconstriction.
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Cat bites are especially dangerous due to pasteurella multocida, a small gram-negative bacterium that can cause a host of dangerous clinical conditions in humans, including epiglottitis, endocarditis, and brain abcesses
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Common dosage of morphine is 0.05 mg/kg IV every 5 mins. To a max dose of 10 mg.
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Compartment syndrome presents with the 6 Ps: pain, paresthesia, paresis, pressure, passive stretch pain, and pulslelessness
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Compartment syndrome that persists for more than 8 hours carries a serious risk for death of local tissues
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During each second of a fall, the velocity or speed of the falling object increases by 9.8 m/sec squared.( Approximately 32 feet per second squared)
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Fluoride dust can be inhaled in an industrial setting or at the scenes of fires or explosions where fluorides are stored. HF acid aggressively binds with calcium ions and may require the administration of IV calcium.
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Freshly oxygenated blood returns to the left atrium through the pulmonary veins. Blood then flows through the mitral valve into the left ventricle, which pumps the oxygenated blood through the aortic valve, into the aorta and then to the entire body.
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From the right atrium blood passes through the tricuspid valve into the right ventricle. The right ventricle then pumps the blood through the pulmonic valve into the pulmonary artery and then into the lungs
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Given the severity of tetanus, you should ask injured patients about the last time they received a tetanus booster.
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Hemorrhaging from the nose(epistaxis) or ears following a head injury may indicate a skull fracture. In such a case you should not attempt to stop the blood flow. Doing so could couse increasing intracranial pressure and possible causing permanent damage.
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If an avulsed piece of tissue is present, attempt to replace the pedicle to its normal anatomic location as closely as possible.
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If blood is flowing from the ear canal, do not attempt to control it directly, CSF may be leaking, and halting the blood flow may increase pressure within the skull.
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If more blood returns to the heart, the stretched heart pumps harder rather than allowing the blood to back up into the veins.
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In an electrocution injury forget about the cervical spine, especially in a worker who has fallen from a utility pole
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In an underwater explosion, a shock wave travels greater velocity than in open air, thereby making it possible to receive injuries at 3 times the distance that would normally be required to receive such injuries.
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In geriatric burns may also have poor glycogen stores, so their bgl levels should be checked for hypoglycemia. Cardiac monitoring should of course be implemented. Although fluid resuscitation is important, pulmonary edema is more likely to develop in geriatric patients. Routinely assess lung sounds.
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In pediatric burns, children may require more fluid per kg than adults, also because of poor glycogen stores, children may require dextrose containing solutions earlier than adults. Blood glucose monitoring should be routinely performed in seriously burned children.
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Late signs of hypoperfusion suggesting internal hemorrhage include tachycardia, weakness, fainting, or dizziness at rest, thirst, nausea and vomiting, cold, moist(clammy) skin, shallow rapid breathing, dull eyes, slightly dilated pupils that are slow to respond to light, cap refill of more than 2 seconds in infants and children, weak, rapid(thready) pulse, decreasing blood pressure, altered level of consciousness
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Most hydrocarbons are more effectively removed with a soap and water solution than water alone. This type of chemical can cause sleepiness and even a coma.
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Neurologic injuries and head trauma are the most common causes of death from blast injuries.
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Noncardiogenic pulmonary edema can develop after an explosion. A massive pulmonary contusion can lead to microhemmorrhage within the lungs, further compromising ventilation, and respiration
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Pale or ashen skin points to inadequate perfusion. Cool moist skin is an early indicator of shock.
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The 2 most common causes of deaths from electrical injury are asphyxia and cardiac arrest.
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The GCS is scored between 3 and 15, 3 being the worst, and 15 the best. It is composed of three parameters : Best Eye Response, Best Verbal Response, Best Motor Response
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The abdomen has 2 large blood carrying vessels called the abdominal aorta and the inferior vena cava
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The adult male bodies contain approximately 70 ml of blood per kg of body weight. - Adult female bodies contain approximately 65 ml/kg of blood. - The body cannot tolerate an acute blood loss of more than 20% of this total blood volume. Thus if the typical adult loses more than 1L of blood, significant changes in vital signs will occur, including increasing heart and respiratory rates and decreasing blood pressure.
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The brain and spinal cord cannot go for more than 4-6 minutes without perfusion, or the nerve cells will be permanently damaged
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The organs and organ systems with a high incidence of exsanguination from penetrating injuries include the heart, thoracic vascular system, abdominal vascular system(such as abdominal aorta, superior mesenteric artery) venous system( such as inferior vena cava or portal vein), and liver.
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The organs generally affected by primary blast effects are the lungs, eardrums, and other compressible organs. The pressure wave damages air filled cavities.
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The second phase of an MVA is deceleration of the occupant, which starts during sudden braking and continues during the impact of the crash.
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The superior vena cava and the inferior vena cava return deoxygenated blood from the body to the right atrium, blood from the upper part of the body returns to the heart through the superior vena cava, blood from the lower part of the body returns through the inferior vena cava.
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The sympathetic nervous system include faster and stronger heart contractions, faster and deeper respirations along with bronchodilation, shunting of blood to vital areas in the core of the body and away from the skin, and the slowing and cessation of digestive functions.
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The third phase of an MVA is deceleration of internal organs, involves the bodys supporting structures (skull, sternum, ribs, spine, and pelvis) and movable organs( brain, heart, liver, spleen, and intestine) that continue their forward momentum until stopped by anatomic restraints.
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Underwater explosions result in the most severe abdominal injuries.
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Varicose veins on the leg can produce copious bleeding
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While body armor may limit or prevent shrapnel from entering the body, it also catches more energy from the shock wave, possibly resulting in the victim being thrown backward, thus increasing potential spine and spinal cord injury
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damaged cells produces swelling(edema) - mast cells release histamine as part of the bodys response in early stages of inflammation. Histamine causes dilation of blood vessels, increasing blood flow to the injured area and resulting in a reddened, warm area immediately around the site. - Inflammation leads to the removal of foreign material, damaged cellular parts, and invading microorganisms from the wound site.
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• An adult and a child have both been hit by a pickup truck head on. Compare and contrast the injuries you might find and why. ADULT - When the auto strikes an adult body with its bumpers, creates lower extremity injuries, particularly to the knee and leg. These injuries are in the form of various patterns of the tib-fib fractures, often open knee dislocations and tibial plateau fractures. Usually the tibia is fractured on the side of impact; the impact potentially fractures the other leg as well. Knee dislocations are common with severe multiligamentous injury. - A second impact occurs as the adult is thrown on the hood and or grille of the vehicle, resulting in head, pelvis, chest, and coup- contrecoup traumatic brain injuries, lateral compression pelvic fractures are common in theis mechanism and can cause open fractures with bony punctures in viscera in the area of the body, or in the vagina in women. - A third impact occurs when the body strikes the ground or some other object after it has been subjected to a sudden acceleration by the colliding vehicle. PEDIATRIC -pediatric patterns of pedestrian injury are different from patterns in adults. Small children are shorter, so the car bumper is more likely to strike them in the pelvis or torso, causing sever injuries from direct impact. Although they are less likely than adults to fly over the hood of the car, they are more likely to be run over by the vehicle as they are propelled to the ground by the impact. Multiple extremity and pelvic fractures and abdominal and thoracic crush injuries are to be expected. Traumatic brain injury often kills young patients. -the waddell triad refers to the pattern of automobile pedestrian injuries in children and people of short stature: 1. The bumper hits the pelvis and femur instead of the knees and tibias. 2. The chest and abdomen hit the grille or low on the hood of the car(sternal and rib fractures as well as abdominal injuries are likely)3. The head strikes the vehicle and then the ground(skull and facial fractures, facial abrasions, and closed head injury)
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• As you arrive at the entrance of the carnival, you are lead to a ferris wheel where you see a female teenager, supine, contorted and unmoving on the ground beneath the ferris wheel. Looking up at the ferris wheel, what possible mechanisms of injury should you consider, and why? -head trauma -spinal -internal bleeding -external bleeding -shock -hemothorax/pneumothorax I would consider all these injuries due to the fact that the patient has most likely fell from at least 3 times her height. Consider that the patient could have hit her head, and any other part of her body on multiple objects during the fall, and could have laceration, and even puncture wounds. Patient could have internal bleeding from organs that may have ruptured during impact of the fall, consider hemo/pneumo thorax from the fall, broken ribs could have lacerated lungs causing blood and air to enter the pleural space. Most definitely spinal injury, and head injury from impact. Respiratory compromise, from hemo/pneumothorax, and possible vomiting if head injury is present. What kinds of injuries might you find? -head trauma -spinal -internal bleeding -external bleeding -shock -hemothorax/pneumothorax Respiratory compromise
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• Compare and contrast the up and over types of injuries vs. the down and under from an MVC - An up and over type of injury, usually a front end collision, in the up and over, the lead point is the head. In this sequence, rotation occurs around the ankles with the torso moving in the upward and forward direction. The head takes a higher trajectory, impacting the windshield, roof, mirror, or dashboard, causing compression and deceleration injuries in your patient that can include significant head and cervical spine trauma. The anterior part of the neck may strike the steering wheel, causing laryngeal fracture, serious lacerations, and other soft-tissue injury. Ejection is possible if the windshield does not stop the body from projecting through it. Likely causing great vessel damage and death. The spine absorbs energy as it is compressed between the stationary head and the moving torso, which leads to injury. Pneumothorax, abdomen, pelvis, or upper thigh contacts the lower aspect of the steering wheel or dash, and lower leg fractures could be present. Facial injuries, soft tissue neck trauma, fractured sternum, myocardial contusion, pericardial tamponade, pulmonary contusion, hemothorax, rib fractures, flail chest, ruptured aorta, intra-abdominal injuries. - Down and under usually caused by a rear end collision, caused by occupant who slides under the steering column or dash. As the vehicle is decelerating, the occupant continues to travel downward and forward into the dashboard or steering column, led by the knees. The knees hit the dashboard, transmitting the energy of the deceleration up the femurs to the pelvis. With knees locked in the dash and hips in the seat, force vectors go down the tibia and along the femur. If the feet are not locked by folding floor boards or brake pedals, energy along the tibia will be transferred to the lower leg, with no immediate injury. If the feet are locked in place, femur can occur. In some cases the head of the femur will dislocate. If the occupants knees hit the dashboard, look for a fracture-dislocation of the knee or other related injuries. Also look for hip and pelvic fractures. Look for spinal injuries. Rib fractures, pulmonary and cardiovascular injuries.
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• Describe how we know where compensated shock becomes decompensated to irreversible shock. What are the issues for in each level? - Compensated shock becomes decompensated shock when heart rate increases, blood pressure decreases, respiratory rate increases, becomes anxious and confused, skin becomes cool, pale, and moist. Decompensated shock is refractory to any therapy, which becomes irreversible shock when the body has lost more than 2000 ml of blood which is over 40 percent of the bodys blood volume, causing the heart rate to increase, blood pressure to drop even lower, no cap refill, increased respiratory rate, from anxious and confused, to confused and lethargic, cold and cyanotic. Once pt. is in irreversible shock, they usually die.
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• Discuss cavitation differences and their effects from different calibers of weapons. High vs. low velocity, and the damage they could cause. Shotgun- fires round of pellets from about half a dozen to several dozen at a time, depending on the type of load used. At short range, even the smaller shot can cause devastating injuries. The pellets leave the barrel and immediately start dispersing so that the shot density at the time of impact on a target will be determined by the distance travelled. At very close range a shotgun can induce destructive injuries. Entrance and exit wounds can be very large. With shotgun wadding, bits of clothing, skin, and hair driven into the wound that can cause massive contamination, leading to increased infection potential should the patient survive the initial trauma. - Rifles are firearms firing a single projectile at very high velocity through a grooved barrel that imparts a spin to the projectile that stabilizes the projectiles flight for accuracy. Small entrance wound with large exit wound. - Handguns are of 2 types: revolvers and pistols. Low velocity, limited accuracy. There are several causes of shock. What are the different types of shock and how would you treat them? If you are not sure which type of shock you are dealing with, what should you treat first? - If you are unsure of what type of shock you are dealing with, always focus on ABC's. fluid loss is always the main cause of shock. The main treatment of shock is to maintain volume and bloodpressure. Fluid bolus, and high flow o2, along with covering patient with blanket to maintain core temperature. - Anaphylactic shock; treat with epi, diphenhydramine, dopamine and dosed fluid boluses. Supplemental o2 and airway support. - Septic shock; high flow o2, maintain airway, fluid bolus, consider dopamine to maintain perfusion pressures w\o overloading the lungs. IV antibiotics. - Hemorrhagic shock; high flow o2, control bleeding, 2 large bore IV's, fluid bolus, monitor vitals, maintain ABC's rapid transport. Maintain core temperature. - Cardiogenic shock; high flow o2, fluid bolus( caution in pulmonary edema), dopamine, Nor-epinephrine, transport. Treatment for MI if it is suspected(o2, ASA, Nitro, Morphine) Explain the different types of energy and how it can affect your patient. In other words, how does mass and velocity weigh in? - Kinetic energy = Mass/2 x velocity(2). - Velocity is the distance an object travels per unit time. - Acceleration of an object is the rate of change of velocity that an object is subjected to, whether speeding up or slowing down. - Gravity is the downward acceleration that is imparted to any object moving toward the earth caused by the effect of the earth's mass. - Angle of impact; the differences in the sizes of the two vehicles, and the restraint status and protective gear of the occupants will affect the amount of energy dissipation that affects your patients in a crash. - Deceleration is slowing down of slowing to a stop.
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• The ins and outs of it all. How much blood in volume and percentage can a patient lose and what are the effects that we see when they lose blood? Then what are the rules around volume replacement and what are things we should watch out for? - A patient can lose up to 2 liters of blood, about 20 percent. The body holds about 5 liters of blood. The effects of to much blood loss is hemorrhagic shock. Give pt. a fluid bolus of 5ml/kg 250 ml NS.
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• There's been an explosion at the local high school. Several students are suffering from different injuries. What types of injuries would you find for the following: Primary blast injuries -damage to the body caused by the pressure wave generated by the explosion. When an explosion occurs, a pressure wave rapidly develops; this tremendous, concentrated pressure results from air displacement and heat originating from the center of the blast. The organs generally affected by primary blast effects are the lungs, eardrums, and other compressible organs. The pressure wave damages air filled cavities. Burns may also occur. Close proximity to the origin of the pressure wave carries a high risk of injury or death. Secondary blast injuries - Result from being struck by flying debris that has been set in motion by the explosion. Objects are propelled by the force of the blast and strike the victim, causing injury. These objects can travel great distances and can be propelled at tremendous speeds, up to nearly 3000 mph for the conventional military explosives. A blast wind occurs as the shock wave applies force to air molecules. Although less forceful than the pressure wave, the blast wind is longer lasting and can hurt projectiles at high velocities. Projectiles present serious hazards- flying debris may cause blunt and penetrating injuries. Tertiary blast injuries -there may be multiple victims as a result of a tertiary blast. These blast injuries occur when a person is hurled by the force of the explosion against stationary, rigid, objects, such as the ground, or walls. Physical displacement of the body is also referred to as ground shock when the body impacts the ground. The injuries that result are numerous and result from both blunt and penetrating mechanisms. A blast wind also causes patients body to be hurled or thrown, causing further injury. In some cases, wind injuries can amputate limbs.
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• What are the components of blood? When we find blood coming from the mouth or rear end how do we differentiate where the blood is coming from and how to treat? Use terms for the blood we find. - Blood consists of plasma, erythrocytes(red blood cells), leukocytes(white blood cells) Hemoglobin(binds oxygen that is absorbed in the lungs and transports it to the tissues where it is needed.), platelets( clotting) - Blood coming from mouth; hematemesis which is vomiting blood, it may be bright red or dark red, or if the blood has been partially digested it may look like coffee grounds; a sign of upper GI bleed. Hemoptysis; coughed up blood, usually bright red. - Blood coming from the rear end usually indicated Lower GI bleed. Melena; Black, foul smelling, tarry stool that contains digested blood. Hematochezia; the passage of bloody stool, if it contains bright red blood it may indicate hemorrhage near the external opening of the anus. Hemorrhoids in the lower colon usually cause hematochezia. - Treat with supportive care, transport, monitor vitals. if blood pressure is suffering administer fluid bolus 250 ml NS.
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• What are the signs and symptoms, both early and late, which you might find during your assessment of a patient that is bleeding internally? Differentiate between early and late. - Late signs of internal bleeding are tachycardia, weakness, fainting, or dizziness at rest, thirst, nausea and vomiting, cold, moist(clammy) skin, shallow, rapid breathing, dull eyes, slightly dilated pupils that are slow to respond to light, cap refill of more than 2 seconds in infants and children, weak, rapid(thready) pulse, decreasing blood pressure, altered level of consciousness. - Early signs of internal bleeding are hematoma, hematemesis, hemoptysis, melena, hematuria, hematochezia, pain, tenderness, bruising, guarding, or swelling. Broken ribs, bruises over the lower part of the chest, or may indicate a lacerated spleen or liver. Controlling bleeding is important. What are the various ways to control bleeding of different types and what are the pros and cons of each? - Apply direct pressure over wound with a dry sterile dressing, elevate the injury if no fracture is suspected. - Tourniquets; useful if a patient is hemorrhaging severely from an extremity injury. Not preferred method due to cutting off circulation of extremity. - Hemostatic agents; the military has successfully used hemostatic agents to control sever hemorrhage, especially to areas where a tourniquet cannot be placed. These agents work by causing vasoconstriction in the wound site. They come in powder form as well as impregnated in dressings. Complications with the use of these in the form of powder include the introduction of emboli through open vasculature as well as the introduction of foreign substance in the wound. - Air splints can control the hemorrhage associated with venous bleeding. They also stabilize the fracture itself. An air splint acts like a pressure dressing applied to an entire extremity rather than to a small local area. It would not be appropriate to use on a patient with an arterial hemorrhage bc the splint would not actually control the hemorrhage until the patients systolic bp dropped to the pressure of the splint.
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• You are dispatched to a possible GSW\Stabbing. You arrive to find a 22 year old male sitting on the sidewalk with his back to the brick wall. You notice some blood on his shirt and pants. Through your physical assessment you find puncture wounds in his upper left chest, RUQ of the abdomen, left upper leg and mid-way down the left side of his back. How can you tell what might have made the puncture wounds? What are some things you should suspect from the GSW? How about the stab wounds? - A stab wound may involve a cutting or hacking type force. Can cause fractures and blunt injury to underlying soft tissues and bone and potentially amputation. - A GSW should have and entry and sometimes an exit wound. Skin and subcutaneous tissues are pushed in, cut, or abraded externally as missile fragment pass and heat is transferred to the tissues. At close range tattoo marks from powder burns can occur. At extremely close ranges, burns can occur from muzzle blast. Heavy wound contamination results from negative pressure generated behind the traveling projectile, which sucks surrounding elements such as clothing into the wound, greatly increasing infection potential.
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• You arrive on the scene of an MVC. You see major front end damage, spidering on the windshield and a deformed steering wheel. You also notice bleeding on the back of the drivers head. What injuries might you expect to find and why? -starting with the spidering on the windshield, a head injury and spinal injury would be considered due to the impact of head to the windshield and possible whiplash. -cardiac tamponade, broken ribs, hemo\pneumothorax, Soft tissue neck trauma, larynx and tracheal trauma, fractured sternum, pulmonary contusion, flail chest, ruptured aorta, intra abdominal injuries. due to the blunt force trauma. -hemorrhage from the bleeding on the back of the head, possible hemorrhagic shock depending on how much blood is lost. What could have caused the bleeding on the back of the drivers head? -objects in the back seat most likely came into motion during impact of collision and hit patient in back of the head.
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WBCs and platelets make up less than % of blood volume
1
the scale for eye response in gcs
1.No eye opening. 2.Eye opening to pain. 3.Eye opening to verbal command. 4.Eyes open spontaneously.
scale for motor response in gcs
1.No motor response. 2.Extension to pain. 3.Flexion to pain. 4.Withdrawal from pain. 5.Localising pain. 6.Obeys Commands.
scale for verbal response in gcs
1.No verbal response 2.Incomprehensible sounds. 3.Inappropriate words. 4.Confused 5.Orientated
RBCs make up about % of blood volume
45
Parkland burn formula or the consensus formula is
4ml x weight in kg x percentage of body surface burned
the rule of 9s for an adult
Head- 9% Chest-9% Abdomen-9% Genetalia- 1% Legs- 18% each Arms- 9% each Back- 18%
rule of 9s for a pedi
Head-12% Chest-9% Abdomen-9% Genetalia- 1% Legs-16.5% each Arms-9% each Back-18%
rule of 9s for an infant
Head-18% Chest-9% Abdomen-9% Genetalia-1% Legs-13.5% each Arms-9% each Back-18%
is often referred to rest and digest mode. includes a slowing of the heart rate, slowing of the breathing rate, and an increase in digestive functions.
The parasympathetic nervous system
Implosion
a bursting inward
Missile fragmentation
a primary mechanism of tissue disruption from certain rifles in which pieces of the projectile break apart, allowing the pieces to create their own separate paths through tissues.
Avulsing
a tearing away of forcible separation
Arterial air embolism
air bubbles in the arterial blood vessels
Blunt trauma
an impact on the body by objects that cause injury without penetrating soft tissues or internal organs and cavities.
Index of suspicion
anticipating the possibility of specific types of injury
Chemotactic factors
are the factors that cause cells to migrate into an area
Cavitation
cavity formation; shock waves that push tissues in front of and lateral to the projectile and may not necessarily increase the wound size or cause permanent injury but can result in cavitation
what burn injuries require transport to a burn center?
face, chest, genetalia, hands or feet
Each ventricle pumps blood out of the?
heart
Hematocrit
is a blood test that measures the portion of red blood cells in whole blood
Contusion .
is a bruise; an injury that causes bleeding beneath the skin but does not break the skin
Joules law.
is a description of the relationship between heat production, current, and resistance
Hematoma
is a localized collection of blood in the soft tissues as a result of injury or a broken blood vessel
Waddell triad
is a pattern of auto ped injury in children and people of short stature in which the bumper hits pelvis and femur, the chest and abdomen hit the grille or low hood, and the head strikes the ground.
Trauma score
is a score that relates to the likelihood of patient survival with the exception of a severe head injury. It is calculated on a scale of 1-16, with 16 being the best possible score. It takes into account of the GCS score, respiratory rate, respiratory expansion, systolic blood pressure and cap refill.
Trauma
is acute physiologic and structural change that occurs in a victim as a result of the rapid dissipation of energy delivered by an external force
Shearing.
is an applied force or pressure exerted against the surface and layers of the skin as tissues slide in opposite but parallel planes
Whiplash.
is an injury to the cervical vertebrae or their supporting ligaments and muscles, usually resulting from sudden acceleration or deceleration
Hematuria
is blood in the urine
Hemoptysis .
is coughing up blood
Spalling
is delaminating or breaking off into chips and pieces
Adipose.
is fat tissue
Zone of hyperemia
is in a thermal burn, the area that is least affected by the burn injury. This is an area of increased blood flow where the body is attempting to repair injured but otherwise viable tissue
Supraglottic .
is located above the glottic opening as in the upper airway structures
Collagen
is protein that gives tensile strength to the connective tissues of the body
Pulmonary blast injuries
is pulmonary trauma resulting from short-range exposure to the detonation of high explosives.
Erythema
is reddening of the skin
Hemostasis
is stopping hemorrhage
Cardiac output.
is the amount of blood pumped by the heart per minute. Calculated by multiplying the stroke volume by the heart rate per minute
Stroke volume.
is the amount of blood that the left ventricle ejects into the aorta per contraction
Potential energy
is the amount of energy stored in an object, the product of mass, gravity and height that is converted into kinetic energy and results in injury such as from a fall.
Desquamation .
is the continuous shedding of the dead cells on the surface of the skin
Volkmann contracture
is the deformity of the hand, fingers, and wrist resulting from damage to forearm muscles; develops from muscle ischemia and is associated with compartment syndrome
Rhabdomylosis
is the destruction of muscle tissue leading to a release of potassium and myoglobin.
Velocity
is the distance an object travels per unit time
Tympanic membrane
is the eardrum; a thin, semitransparent membrane in the middle ear that transmits sound vibrations to the internal ear by means of the auditory ossicles
Hemophilia
is the lacking of one or more of the bloods clotting factors.
Hematochezia
is the passage of stools containing bright red blood.
Melena
is the passing of dark tarry stools.
Permanent cavity.
is the path of crushed tissue produced by a missile traversing part of the body
Zone of stasis
is the peripheral area surrounding the zone of coagulatioin that has decreased the blood flow and inflammation . this area can undergo necrosis within 24-48 hours after the injury, particularly if perfusion is compromised due to burn shock.
Preload
is the precontraction pressure in the heart as the volume of blood builds up
Afterload.
is the pressure in the aorta against which the left ventricle must pump blood, increasing this can decrease cardiac output
Zone of coagulation
is the reddened area surrounding the leathery and sometimes charred tissue that has sustained a full thickness burn
Positive wave pulse
is thephase of the explosion in which there is a pressure front with a pressure higher than atmospheric pressure
Hematemesis
is vomited blood
Newtons first law of motion
states the principle that a body at rest will remain at rest unless acted on by an outside force.
Newtons second law of motion
states the principle that the force than an object can exert is the product of its mass times its acceleration.
Cardiac output
stroke volumexPulse Rate
Gravity
the acceleration of a body by the attraction of the earths gravitational force, normally 32.2 feet per second squared
