PST2102 EXAM ESSENTIALS

Newton's 4 Laws

1. a body at rest will remain at rest, and a body in motion will remain in motion unless acted on by an outside force 2. that energy is neither created or destroyed, but changes form 3. the force that an object exerts on another object is equal to the mass of the object multiplied by its acceleration 4. kinetic energy (Ek) is the energy associated with motion, and reflects the connection between weight (mass) and speed (velocity)

treatment goals for shock

1. stop the bleeding 2. oxygen therapy 3. replace fluids

indigenous patients are ? likely to be injured or die of injury. remote areas are ?

2x more likely more likely for trauma injuries

what % of trauma in Australia is blunt

95%

CPP

= MAP - ICP CPP should be 70-80mmHg ICP should be less than 15mmHg

Epidural/extradural haematoma

Caused by low velocity blows to head, violent altercations, deceleration injuries

Severe Haemorrhage

Distention, tenderness, tenseness, pelvic tenderness or bony crepitation

Types of Falls

Don Juan Syndrome Hands Outstretched Headfirst

7. Myocardial contusion

Most common cardiac injury o Blunt anterior chest injury Same as myocardial infarction o Chest pain o Arrhythmia o Cariogenic shock (RARE) o Treat the same as cardiac tamponade

Diffuse Axonal Injury

Mostly from blunt trauma Acceleration or deceleration forces = shearing of neuronal structures

11. Esophageal injury

Penetrating trauma Difficult to assess in prehospital field Can be lethal if left unrecognized

Compression injury

Results from an organ or structure (or part of) being directly squeezed between other organs or structures.

12. Pulmonary contusion

Results from direct injury to the lung which causes haemorrhage and oedema without pulmonary laceration o Bleeding into alveolar space will impede gas exchange o Marked hypoxemia

most common causes of trauma in Australia

Road trauma = most common cause of major trauma (52%), falls (31%), violence (6%)

Outline the principles of standardising trauma management

Scene Assessment 1. Recognition of Multiple Casualty Incident 2. Evaluation of individual patients 3. Conditions that may result in the loss of life and 4. Conditions that may result in the loss of limb, and 5. All other conditions that do not threaten life or limb

Subarachnoid haemorrhage

Symptoms: • Thunderclap headache • Unequal pupils • Seizures

5. Massive haemothorax

Symptoms: • Anxiety and confusion • Neck veins • Flat = hypovolaemia • Distended = mediastinal compression • Breath sounds decreased • Shock Treatment: Load and go -> treat for shock -> fluid admin (titrate to radial pulse 90 - 100 mmHg) consider chest tube to drain blood

shock

a physiologic state characterized by a systemic reduction in tissue perfusion, resulting in decreased oxygen delivery to tissues of the body

difference between absolute and relative hypovolemic shock

absolute: loss of blood, plasma(from burns) or other fluids relative: pooling of blood/internal bleeding

high velocity

missiles that compress and accelerate tissue away from the bullet = leaves cavity

low velocity

missiles that localise injury to small radius with little disruptive effect

MAP

mean arterial pressure pressure needed for adequate tissue perfusion 85-95 diastolic pressure + 1/3 pulse pressure pulse pressure: SBP - DBP

2. Open pneumothorax

"sucking chest wound" Air enters pleural space = ventilation impaired = hypoxia Signs and symptoms are dependent on size of defect

Deadly Dozen of thoracic trauma

1. Airway obstruction 2. Open pneumothorax 3. Flail chest 4. Tension pneumothorax 5. Massive hemothorax 6. Cardiac tamponade 7. Myocardial contusion 8. Traumatic aortic rupture 9. Tracheal or bronchial tree injury 10. Diaphragmatic tears 11. Esophageal injury 12. Pulmonary contusions

9 Laws of Trauma

1. Any anomaly in your trauma patient is due to trauma, no matter how unlike it may seem. 2. Your trauma patient is bleeding to death until you prove otherwise 3. The only place an unstable trauma can go is to a major trauma centre 4. Even awake, alert and stable patients die. It hurts much more when they do. 5. A previously health child who is in arrest or nearly so, is a victim of child abuse until proven otherwise 6. Always complete basic vital sign assessment including exposure yourself 7. Your patient is at their healthiest as you take them into the emergency department 8. Journal of Neurotrauma 9. Question everything!

Abdominal Assessment (8)

1. Deformities 2. Contusions 3. Abrasions 4. Punctures 5. Evisceration 6. Distension 7. Tenderness 8. Tenseness

Motor Vehicle Crashes (first loves rarely reap rewards)

1. Frontal Impact 2. Rear Impact 3. Lateral Impact 4. Rotational Impact 5. Rollover

Phases for Children (WADDELL'S TRIAD)

1. Initial impact occurs on the legs 2. Second impact when bonnet impacts into the child's thorax 3. The third impact occurs when the child is thrown downward

triad of death

1. No oxygen = ATP can only be produced by anaerobic glycolysis = produce lactic acid = acidosis in body 2. Less ATP being produced = less heat made as by product = hypothermia 3. Tissue damage from hypoxic cells = triggers inflammatory response = issues with clotting = coagulopathy (lack of blood clotting)

6. Cardiac tamponade WHAT TRIAD BITCH

Beck's Triad - Distant/muffled heart sounds - Jugular vein distention - Low blood pressure (hypotension) Treatment: rapid transport -> treat for shock -> fluid administration (titrate to peripheral pulse 90 - 100mmHg) -> monitor and treat arrhythmias

types of shock (chod)

Cardiogenic Hypovolemic Obstructive Distributive

Subdural haematoma

Classified as acute, subacute and chronic • Depends on time lapse between injury and development of symptoms With 24 hours = acute 2-10 days = subacute 2 weeks = chronic Iconic symptoms: decorticate or decerebrate posturing, bulging fontanelles

Intracerebral haematoma

Collection of more than 5mls of blood in brain once symptoms appear = patient detiorates rapidly

Trauma to the eye and orbit (5 types)

Eyelid lacerations Corneal abrasions o Results in photophobia Subconjunctival haemorrhage o Bright red sclera o Usually resolves after several weeks o Not life threatening Hyphema o Blood in the iris and cornea o Can only be diagnosed if upright Open globe o Globe of the eye has ruptured o Threat of infection

neurogenic shock

Form of distributive shock Less common than hypovolaemic shock • Injury to the cervical or thoracic spinal cord = loss of sympathetic control = widespread vasodilation = inappropriate matching of the size of the vascular space to the blood volume EFFECTS: • Constriction of the blood vessels will be lost • Vasodilation will occur • Relative hypotension • Bradycardia • Sympathetic tone loss = environmental heat loss

importance of high level cervical injuries

High level cervical injuries may lead to airway obstruction due to local haematoma and swelling Lesions at C5 or higher = diaphragmatic paresis or paralysis because the phrenic nerve arises from C3 to C5.

why do we never hyperventilate patients

Hyperventilation decreases ICP = decreases PaCO2 = chemoreceptors are not stimulated = body's natural respiratory regulation system is impaired

dislocation management

Management Check PMS distal to major joint dislocations No neurovascular compromise • Splint in position found Neurovascular compromise • Apply only gentle traction in effort to straighten • Often best: pad and splint in most comfortable position and rapid safe transport For both: moist combined and splint Methoxy takes 8-10 breathes before it works Obesity = more prone to severe fractures

amputation management

Management 1. Clean the amputated part by gentle rinsing with crystalloid solution; 2. Wrap the part in sterile gauze moistened with crystalloid solution and place it in a plastic bag or container (sealed) 3. Label the bag/container, place it in an outer container filled with crushed ice 4. Do not freeze the part by placing it directly on the ice or by adding another coolant such as dry ice 5. Transport part WITH patient to the appropriate facility

spinal shock

Not a true form of shock Temporary loss of all neurological activity below the level of the cord injury, includes reflexes. Refers to the flaccid areflexia after spinal cord injury, and may last hours to weeks

Cerebral contusion

Occurs when a force causes the brain to be displaced against irregular surfaces of the skull = tiny blood vessels in pia matter rupture Coup: brain damaged at site of impact Contra coup: brain damaged at opposite of site/contralateral side

Splenic Injury

Referred left posterior shoulder pain

Liver Injury

Referred right posterior shoulder pain

Shear injury

The result of one organ or structure (or part thereof) changing speed faster than another organ or structure

Evisceration

This includes: • Disembowelment • Removal of other abdominal organs Treatment Do not push viscera back into abdomen Gently cover with moistened gauze / dressing Apply non-adherent material to prevent drying If intestines are allowed to dry, they may become irreversibly damaged • Flexing the legs slightly at the knees can assist in taking pressure off abdominal musculature

Le Fort III

Transverse fracture "craniofacial dysjunction" TBI, injury to tear ducts, CSF from nose

3. Flail chest

Treatment: Assist ventilation -> consider ICP support for intubation -> load and go -> stabilise flail segment

4. Tension pneumothorax

Treatment: Decompress affected side if: • Respiratory distress • Cyanosis • Loss of radial pulse • Decreasing level of consciousness • Load and go Altered conscious state • Incorrect tube placement mimics tension pneumothorax

spinal cord injury? primary vs secondary

an insult to the spinal cord which results in an alteration either temporarily or permanently to the normal motor, sensory or autonomic function of the cord. Primary (occur at the time of impact) Secondary (occur after primary injury due to pathological cascade)

types of thoracic injuries

axial loading hyperflexion extension rotation distraction

quinary blast injuries

bacteria, chemical and radioactive hyper inflammatory states

all major trauma patients require a ? C5 injuries require ? vagus stimulation from the gag reflex can?

canula intubation for mechanical ventilation worsen neurogenic shock

what happens in shock

cells are unable to generate enough ATP for their metabolic requirements = cell death = when cells die, their membranes allow the cell contents to leak into the extracellular space = generate more toxic environment for the adjacent cells = increased cell death

tension pneumothorax skills (2)

chest needle decompression OR finger thoracostomy

muzzle blast

cloudof hot gas and powder from gun

cavitation

creation of temporary cavity as tissues are stretched or compressed

quaternary blast injuries

crush injuries, burns, psychological trauma, hypothermia

velocity

determined by how much energy is behind a weapon e.g low (stab wound), high (gunshot)

signs and symptoms of thoracic trauma

distended neck veins tracheal deviation abnormal breath sounds, shortness of breath hemopytsis (coughing blood) subcutaneous emphysema chest wall contusion, tenderness, cavitation

Le Fort I

downward force blood clots occulde airway also swelling of soft palate

tertiary blast injuries

ejection from blast waves. similar to fall injuries.

how much blood can be lost in a pelvic fracture or a femur fracture

femur: 1000ml - 2000ml each pelvic: 1000ml - may lacerate bladder or large pelvic blood vessels

tranexamic acid

for non compressivle injuries (SBP <90 AND HR >120) 1000mg in 100mls 0.9% salive over 10 mins within 3 hours of injury

Diffused TBI:

injury is spread across the brain e.g concussion, diffse axonal injury

obstructive shock

heart pumps well but the outflow is obstructed cardiac output = increase preload = decrease afterload = decrease

cardiac output

heart rate x stroke volume

every fracture patient needs ?

ice!

cushings triad

increase SBP, decrease PR, decrease RR (opposite to shock)

how does the body naturally counter hypo perfusion

increase in CO2 and acid = relaxes precapillary sphincters = sluggish blood flow acidic waste = triggers hemoglobin to dissociate from O2 at a faster rate = blood carries 4x more O2 than usual

C3, C4, C5

keep the diaphragm alive :) ooo dermatones

hypovolemic shock

loss of blood or fluid, heart pumps well but not enough blood to pump cardiac output = decrease preload = decrease afterload = increase

secondary tbi

occurring as a result of the changes in the brain after injury (treatable and reversible)

focal TBIs

one local part of the brain is injured

kinematics

process of evaluating an event and determining the injuries that could have occured given the forces and motion involved

secondary blast injuries

projection of debris = laceration, burns

Le Fort II

pyramidal fracture blood loss occludes airway

Haemostatic agents

recommended in the pre-hospital setting in anatomic areas where tourniquets cannot be applied and where sustained direct pressure alone is ineffective or impractical

Tourniquets

recommended that in the pre-hospital setting tourniquets remain place once properly applied until definitive care has been reached 5cm above wound/uninjured tissue life or limb scenarios only note time placed no pulse = good placement

afterload

resistance left ventricle must overcome to circulate blood

primary tbi

result of the initial mechanical force

distributive shock

resulting from loss of vasomotor tone in vessels = drop in blood pressure. heart pumps well but ther eis peripheral vasodilation. cardiac output = increase preload = decrease afterload = decrease e.g sepsis shock (infection), neurogenic shock (injury in T5 or above = vasomotor depression = spinal anesthesia), anaphylactic shock (hypersensitivity = overproduction of vasodilators)

cardiogenic shock

resulting from pump failure cardiac output = decrease preload = increase afterload = decrease

10. Diaphragmatic tears

severe blow to abdomen = herniation of abdominal organs more common on left side, abdomen appears scaphoid

primary blast injuries

shock wave damages ear drum, pulmonary haemorrhage, contusion, rupture

homeostasis is? and what variables indicate the body's state of homeostasis

the maintenance of the body's internal environment despite changes in the external environment. PaCO2 RR work of breathing adventisious sounds urine, skin (plasma osmolarity) core temperature hyperkaleamia MAP

preload

volume of blood in ventricles after diastole OR how much blood is returned to the heart OR the degree to which the heart is stretched when it is filled.

Splinting Rules

• Adequately visualize • Distal PMS before and after splinting • Treat neurovascular compromise • Cover open wounds with sterile dressing • Immobilize one joint above and below • Apply on side away from open wound • Pad splint well • Do not attempt to push bone ends under skin

primary spinal cord injuries

• Cord concussion (Temp disruption of function) • Cord contusion (bleeding, bruising to tissues of SC) • Cord compression (swelling and pressure) • Laceration (permanent loss of function) • Cord transection complete/incomplete

concussion

• Diagnosed when a patient shows any transient alteration in neurologic function. • Post-traumatic amnesia is the hallmark sign of concussion. Symptoms • Vacant stare • Disorientation • Slurred or incoherent speech • Memory deficits

blunt abdominal trauma

• Direct compression of the abdomen: o Fracture of solid organs (spleen/liver) o Blowout of hollow organs (intestines) • Deceleration forces: o Tearing of organs and blood vessels Liver and spleen injury is most common

Compartment Syndrome

• Forearm and lower leg most common • Swelling compresses nerves and vessels

Specific Musculoskeletal Injuries

• Fractures • Dislocations • Amputations • Open wounds • Neurovascular injuries • Impaled objects • Compartment syndrome

Specific Eye Injury Management

• Place patient on spine board and elevate head of spine board 40 degrees to decrease intraocular pressure o Elevate head to decrease intraocular pressure • Instruct patient to avoid any activity that might increase intraocular pressure • Analgesics and antiemetics may be indicated for pain relief and nausea

Crush Syndrome (myoglobin, urine, hyperkalaemia)

• Renal failure & death after severe muscle trauma • Arises from crushing type injury to large muscle masses - commonly thigh or calf • Gives coca cola coloured urine from renal failure • Occurs when destruction of muscle releases myoglobin and potassium • Myoglobin serves as an intracellular storage site for oxygen in the muscle cells • When released in excess can cause damage to kidneys = renal failure and death • Myoglobin is what gives muscles their red color Management • Early and aggressive fluid resuscitation with normal saline at a rate of up to 1500ml / hour • Dilutes excess of potassium and myoglobin in blood • Prophylaxis for hyperkalaemia

secondary spinal cord injuries

• Swelling • Ischemia • Movement of bone fragments

direct pressure

• helps to slow down or stop bleeding. • Also reduces the area (size) of the opening of the damaged vessel = reduced blood flow