TCAR

How many falls annually in US

7 million

What is the most *frequent* mechanism of injury

Falls

What are classifications of Blunt trauma (70% of MOIs)

*MVC *Auto-Pedestrian *Falls *Struck by or against an object

How fast does an airbag inflate?

Inflation velocity - 170-200 mph

How does posterior cord syndrome present?

Loss of dorsal column functions including proprioception/vibration

If vertebrae are stacked, what keeps them from falling over?

Muscles and ligaments

What is the MOI for Brown-Sequard Syndrome?

Penetrating trauma or disc herniation/hyperextension

Which ribs are most frequently broken?

Ribs 4-9

What clinical findings suggest hepatic injury?

Right flank bruising, RUQ Pain/tenderness/ Abdominal distension/rigidity

How do you manipulate the stroke volume Preload

With crystalloids, blood products to increase Decrease with diurectics and dialysis

Hypothermia and Alkalosis make ____ oxygen available to the tissue

less

How do you measure diffusion

pulse ox

How do I know if my patient's diffusion status is adequate?

If the PaO2 is less than expected for a given FiO2, oxygen diffusion is impaired. 21% FiO2 = 105 PaO2 40% (x5) = 200 60% (x5) = 300 100 (x5) = 500

How do you manipulate the stroke volume Contractility (pump)

Increase the reverse myocardial hypoxia, give dobutamine, provide ventricular assistance Decrease obstructions with cardiac tamponade, tension pneumothorax, and pulmonary embolus

How do you manipulate the stroke volume afterload

Increase with vasoconsctrictors and decrease with vasodilators

What is considered too much output from a chest tube?

Initially 1000-1500 mL 150-200 / hour for 2-4 hours

What clinical findings suggest a splenic injury?

Left flank bruising, LUQ pain/tenderness, abdominal distension/rigidity, and signs of blood loss (Tachy/Hypotension/low hgb/Kehr's Sign)

What abdominal organ is most commonly injured in blunt trauma?

Liver or the spleen because they are minimally elastic and highly vascular

What are potential etiologies of tissue oxygen utilization

Low oxygen delivery, high metabolic demands, capillary occlusion, cellular dysfunction

Which vertebral segment is most commonly injured?

Lumbar (sometimes missed)

What are the leading causes of death from trauma?

Massive head trauma, high spinal cord injury, aortic rupture

Fever and Acidosis make ____ oxygen available to the tissue

More

What is the most common cause of *serious* traumatic injuries in the US?

Motorized vehicles

What clinical findings suggest cardiac tamponade?

Muffled heart sounds, tachy, hypotension, narrowed pulse pressure, dyspnea/tachypnea, JVD, Low voltage ECG waveform

Best parameter for serially monitoring patient's diffusion status

P:F Ratio

WHAT DELAYED CLINICAL FINDING IS CHARACTERISTIC OF AN ANTERIOR FOSSA FRACTURE?

Periorbital bruising

What assessment findings suggest tension pneumothorax?

Pleuritic chest pain, resp distress, tachy

What's the initial intervention for pneumothorax?

Pop the bubble - needle or finger decompression followed by a chest tube insertion

What are potential etiologies of diffusion

Pulmonary edema, atelectatsis, pneumonia, ARDS, fat emboli

How do I know if my patient's ventilation status is adequate?

Quantitative/objective respiratory assessment with the PACO2 (35-45) and the ETCO2 and clinical respiratory assessment

Kehr's sign

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

How do you measure ventilation

Respiratory rate, rhythm, and depth

How are pancreatic injuries identified?

Serial amylase, serial lipase, CT, burning epigastric pain (delayed)

How do you measure tissue oxygen utilization

SvO2, serum lactate, arterial pH, base deficit

What is the physiological criteria for a trauma patient?

Systolic blood pressure less than 90, Respiratory rate less than 10 or greater than 29, GCS 14

What are potential etiologies of cardio output

Tachy/brady/volume loss or overload/cardiac tamponade/tension pneumothorax, cardiac dysfunction, vasodilation, vasoconstriction

What causes a subdural hematoma?

Tearing of "bridging" veins produces venous oozing

Which of the 4 heart chambers is most frequently affected by cardiac trauma?

The right ventricle because it is the most anterior

How many deaths per year in US because of trauma

278,000

How many burn and fire injuries annually

290,000

How many deaths per year from fire/burn

3,500

Speed of gravity

32 ft/sec/sec or 9.8 meters/sec/sec

How many MVC deaths in the US per year

42,000

How many fatal falls in US per year

43,000

How many firearm deaths in US per year

45,000

How many deaths per year worldwide because of trauma

5.8 million

Home much volume loss is associated with a femur fracture?

500-2000 mL

What is the intervention for a thoracic aortic tear?

Aortic graft placement, TEVAR

WHAT DELAYED CLINICAL FINDINGS ARE CHARACTERISTIC OF ANTERIOR AND MIDDLE FOSSA FRACTURES

Battle's sign

Which of the thoracic great vessels is most commonly injured in the trauma patient?

Blunt trauma - the descending aorta (isthmus) at the site of the ligamentum arteriosum (80-90% of the time)

WHAT CLINICAL FINDING IS ASSOCIATED WITH ETHMOID BONE FRACTURE?

CSF rhinorrhea

Cardiac tamponade causes a problem at what point on the tissue oxygenation cascade?

Cardiac Output due to limited ventricular filling (decreased preload) and poor ventricular ejection (decreased stroke volume)

Which vertebral segment do we worry about most?

Cervical

What patients are at particular risk for airbag injuries?

Children, short drivers, pregnant women

In the patient with chest trauma, what simple bedside test can be done to screen for thoracic aortic injury?

Compare bilateral upper extremity SBP measurements

What classic chest radiograph finding suggests a thoracic aortic injury?

Widened mediastinum

What is considered a Level V trauma center?

*Physicians available on-call *Trauma-trained nurse immediately available *Transfer agreements in place * Initial Evaluation, stabilization, and basic diagnostic capabilities *May not be open 24 hours but must have a protocol for trauma response

What is a *Primary* Injury Prevention Intervention?

*Pre-event Interventions that prevent injuring events (divided highways to prevent head-on collisions, distracted driving prevention, gun locks, balance training)

What is considered Level III Trauma center

*Resources for emergency resuscitation, surgery, and ICU * General surgeon promptly available * Neurosurgery not mandatory * Transfer agreements with Level 1 and level 2 trauma centers

WHAT'S THE MOST COMMON SITE OF AN EPIDURAL HEMATOMA (EDH)

*Under the temporal bone, at the site of the middle meningeal artery. Fracture causes the artery to tear and blood accumulates above the dura. There is no natural epidural space and the dura mater is dissected away by arterial pressure

How does anterior cord syndrome present?

- complete motor paralysis below the level of injury - loss of pain and temperature at and below the level of injury - loss of light touch at and below the level of injury *Proprioception/Vibration preserved

What are the four reasons a patient's tissue oxygenation is inadequate?

1. Too little oxygen delivered to the cells due to low oxygen saturation, low hgb levels, or low cardiac output (HR or SV) 2. Oxygen demand is too high from a hypermetabolic state due to fever, healing wounds or burns, fighting sepsis, or patient activity demands such as agitation, seizures, or shivering 3. Capillary occlusion and oxygen not making it the last millimeter through the capillary to the cell due to poor perfusion from a pump failure or hypovolemia or due to vasoconstriction/inflammation 4. The cells cannot use the delivered oxygen and it just recirculates (Due to toxins, sepsis, or cell death)

What is considered Level II Trauma center

* Comprehensive trauma care * 24-hour availability of all essential personnel and specialties including neurosurgery

MOI Criteria for a Trauma patient

* Falls greater than 20 feet or 6 meters * Auto vs. Pedestrian or bicycle and pt was thrown or hit by a vehicle traveling greater than 20 mph *MVC greater than 20 mph *High risk MVC (passenger space intrusion of greater than 12 inches, ejection from a moving vehicle, death of someone in the same passenger compartment, tele data consistent with high risk for injury

What is considered a Level 1 Trauma center

* Full range of specialists/equipment 24 hours a day * Aggressive program of research * Trauma residency * Leader in trauma education/injury prevention * Referral resource for nearby regions

What is considered Level IV trauma center?

* Initial evaluation, stabilization, diagnostic capabilities * Trauma-trained nurse immediately available * Physicians are available on-call * Transfer agreements in place *Open 24 hours

What is the anatomical criteria for a trauma patient?

* Penetrating injuries to the head/neck/torso/proximal extremities * Open/Depressed skull fracture *Unstable chest wall *Paralysis *Amputation above the wrist/ankle *Crushed/degloved/mangled extremities *2 or more obvious femur or humerus fractures *Pelvic fractures

What is the significance of posterior rib fractures?

* Unusual direction of injury, short/stubby ribs, good muscle protection * A lot of force was involved * Often associated with t-spine injuries

What is a *tertiary* Injury prevention Intervention?

*After the event Interventions that optimize outcomes after an injury event (trauma center/nursing education/evidence-based protocols)

WHAT OTHER CLINICAL FINDINGS ARE CHARACTERISTIC OF ANTERIOR AND MIDDLE FOSSA FRACTURES

*Cerebral spinal fluid (CSF) otorrhea * Hemotympanium (ruptured tympanic membrane) * Cranial nerve dysfunction

What is a *secondary* Injury Prevention Intervention

*During the event Interventions that reduce injury severity once a traumatic incident occurs (Helmets, car seats, air bags)

What are the pathological effects of a tension pneumothorax?

*No lung function on the injured side *Reduced function on the uninjured side *Cardiac and great vessel compression * Reduced preload / Compromised cardiac filling *Reduced Cardiac output / Compromised cardiac emptying * Increased afterload/ aortic compression

Fractures of which thoracic bones are associated with significant force?

1,2 ribs, post ribs, sternum, scapula, t2-t10 vertebral bodies

What causes poor oxygen diffusion?

1. A problem with the alveoli (ARDS/COPD/Fibrosis/Pneumonia/Pulmonary Edema) 2. A problem with the pulmonary circulation (PE, Fat emboli, Hypoperfusion) 3. Pulmonary Contusions that affect both the alveoli and the capillaries

What are the 4 collisions of where force can go?

1. The Vehicle 2. The Occupants 3. The Internal Organs 4. Secondary Impacts

What are the pieces of the kinematic puzzle?

1. The nature and amount of force 2. Various patient characteristics 3. Characteristics of the wound agent 4. Tissue characteristics

Fat emboli cause a problem at what point of the tissue oxygenation cascade?

Diffusion

Pulmonary contusion causes a problem at what point on the tissue oxygenation cascade

Diffusion due to bruising and alveolar edema impairing gas exchange

What causes anterior cord syndrome?

Extreme hyperflexion or compression (Axial Loading)

What are typical airbag injuries?

Face and upper body abrasions or burns, ocular injuries, hand and forearm injuries

How are bowel injuries assessed?

Fever, leukocytosis, peritoneal signs, rebound tenderness, radiographic studies, free air in the belly, during open lap sx

What is the leading cause of fatal injuries in the US

Firearms

How are most rib fractures managed?

Good nursing/RT care - analgesia and pulmonary hygiene

Intra-abdominal hemorrhage causes problems at what point on the tissue oxygenation cascade?

Hemoglobin availability at first, then cardiac output, then ventilation

What's the most life threatening complication of a femur fracture?

Hemorrhage

What clinical finding is characteristic of Posterior fossa fracture?

Herniation and death

What is the MOI for central cord syndrome?

Hyperextension

What are potential etiologies of ventilation

Hypoventilation from medications, rib fractures, AMS, airway occlusion, spinal cord injury

IN TERMS OF PATIENT MANAGEMENT, WHAT'S THE BIG PROBLEM WITH AN INTRAPARENCHYMAL HEMORRHAGE

Unlike epidural or subdural bleeds, intraparenchymal hemorrhage is not easily evacuated

Hemothorax is a problem where on the tissue oxygenation cascade?

Ventilation and hemoglobin availability