ATLS
Patients with maxillofacial or head trauma should be presumed to have
A cervical pine injury and cervical spine motion must be restricted
Transfer template
ABC-SBAR Airway, Breathing, Circulation, Situation, Background, Assessment, Recommendation
When should IV antibiotics be given to patients with open fractures?
All patients with an open fracture should receive IV antibiotics
AMPLE hx
Allergies Medications currently used Past illnesses/Pregnancy Last meal Events/Environment related to the injury
Disability treatments that must be established before transfer
Assist respiration in unconscious patients Administer mannitol or hypertonic saline if needed Restrict spinal motion in spine injuries
What's high risk for compartment syndrome?
Ischemia repercussion injury to enclosed muscle Crush injury Tight dressing or cast
Left stab wound
Left diaphragm injury Spleen injury Hemopneumothoax
Stab wounds most commonly injury?
Liver (40%) Small bowel (30%) Diaphragm (20%) Colon (15%)
Rhabdomyolysis can lead to
Metabolic acidosis Hyperkalemia Hypocalcemia Disseminated intravascular coagulation (DIC)
Antiemetics in pregnancy
Metocloperamide Ondansetron
Intracranial mass effect is defined by the
Monro-Kellie Doctrine
Which surgical airway is recommended in children under 12?
Needle cricothyroidotomy
Extremity GSW
Neurovascular injury Fractures Compartment syndrome
In what situation is it not advisable to immediately wash off chemicals with irrigation?
Not until airway has been assessed and secured and when the chemical is a powder (brush off before irrigation)
A 26-year-old male sustained a posterior stab wound. Blood and bubbling are coming from the wound.
Open pneumothorax
Types of definitive airways
Orotracheal tube Nasotracheal tube Surgical airways (cricothyroidotomy and tracheostomy)
Urinary output is sensitive for
Patient's volume status and renal perfusion
Diagnosis of an open fracture is made based on?
Physical exam and x-ray
What would confirm a diaphragmatic injury in a patient?
Presence of NGT
The cause of hypoxia associated with flail chest is
Pulmonary contusion
Injuries most common in the elderly population?
Rib fractures TBI Pelvic fractures
Rapidly expanding hematoma
Significant vascular injury
What's the appropriate treatment for a C6 vertebral body fracture
Spinal immobilization and IVFs, followed by vasopressors if patient remains bradycardic after fluids
What's the most frequently injured abdominal organ in blunt trauma? Followed by?
Spleen (40-55%) Liver (35-45%) Small bowel (5-10%)
What're adjuncts that might be used during intubation?
Suction Manual laryngealmanipulation (BURP) Elastic bougie Anesthetics, analgesics, and neuromuscular blocking agents
Spinal cord injuries can be defined by neurologic level and severity in addition to associated syndromes and morphology. Describe Brown-Sequard syndrome lesion at T5.
T5, penetrating injury to one side (partial)
Neurogenic shock is associated with what level of spinal cord injury and causes systemic hypotension via what mechanism?
T6 and higher, distributive shock from lack of vasomotor tone
In a conscious trauma patient, airway adequacy can quickly be assessed by
Talking to the patient-- A positive verbal response with clear voice indicated patent airways, ventilation, and brain perfusion
Abnormal motion through a joint segment
Tendon or ligament rupture
What's the most common immediately lift-threatening injury in children?
Tension pneumothorax
In a trauma patient with hypotension, what are the two most important causes to consider in order of importance?
Tension pneumothorax Hemorrhage
What's the most significant difference between burns and other injuries?
The consequence of a burn injury are directly linked to the extent of the inflammatory response to the injury
Why are the elderly at a higher risk for TBIs?
The dura is more adherent to the skull More commonly on anticoagulant/antiplatelet medication
Why are rib fractures in older adults a more significant concern than in young patients?
The incidence of PNA and mortality is doubled in older patients
When does muscle necrosis begin?
When there is a lack of arterial blood flow for more than 6 hours
The first maneuver to improve oxygenation after chest injury is:
administer supplemental oxygen
The diagnosis of shock must include:
evidence of inadequate organ perfusion
The following are contraindications for tetanus toxoid administration:
history of neurological reaction or severe hypersensitivity to the product
In managing a patient with a severe traumatic brain injury, the most important initial step is to:
secure the airway
Heat loss can occur at moderated temperatures
59 to 68 F (15-20 C)
What is your first step when a patient condition changes?
ABCDEs
Massive hemothorax
Accumulation of >1500 ml of blood in one side of chest
A previously healthy, 70-kg (154-pound) man suffers an estimated acute blood loss of 2 liters. What applies to this patient?
An ABG would demonstrate a base deficit between -6 and -10 mEq/L.
Laryngeal manipulation for visualization
Backward, upward, and rightward pressure on thyroid cartilage can aid in visualizing vocal cords
Gastric catheter placement can induce vomiting
Be prepared to logroll Ensure suction is immediately available
Why is continual pulse ox monitoring necessary in critically injured patients?
Because changes in oxygenation occur rapidly and are impossible to detect clinically
A 6-month-old infant is brought to the ED after a fall onto a hard floor. She is crying and appropriately interactive. Her eyes are open. She is moving all extremities. There is a laceration on the scalp and the anterior fontanelle is firm and bulging. What is the next appropriate step?
CT of the head
What can conform a suspected laryngeal fracture?
CT scan
Anterior stab wound
Cardiac tamponade Hemothorax Pneumothorax Hemopneumothorax
A geriatric trauma patient may be in shock despite VS that appear normal due to?
Cardiovascular disease
Antibiotics in pregnancy
Ceftriaxone Clindamycin (if PCN allergy)
Circulation treatments that must be established before transfer
Control external bleeding Establish 2 large bore IVs and begin IVF Restore blood volume using crystalloid fluids and blood Insert indwelling catheter to monitor UOP Monitor cardiac rate and rhythm Transport patients late in pregnancy (tilted to the left side) Restrict spinal motion
What's the importance of meticulous record keeping?
Crucial during patient assessment and management because often more than one clinician cares for an individual patient and allows those to evaluate the patient's needs and clinical status
A 70-year-old female falls at home and strikes her head on the bathtub. She is found down by her granddaughter ~6 hours later. GCS is 8: eye opening 2, verbal 2, motor 4. She is intubated for airway protection upon arrival in the trauma bay. What preexisting patient characteristics should you consider that may affect this patient's outcome?
Current anti platelet therapy, beta blockade, and anticoagulation
Adjuncts used during the primary survey
ECG Pulse ox CO2 monitoringV Ventilatory rate ABGs Foleys (UOP) Gastric catheter FAST or eFAST DPL
Ancillary studies to confirm brain death?
EEG: no activity at high gain CBF studies Cerebral angiography
What's a C/I to NGT insertion?
Fracture of the cribriform/midface fracture (insert OG instead)
Diagnosing brain death
GCS = 3 Nonreactive pupils Absent brainstem reflexes (oculocephalic corneal, doll's eyes, and no gag reflex) No spontaneous ventilatory effect on formal apnea testing Absence of confounding factors such as alcohol or drug intoxication or hypothermia
A 48-year-old female falls from a balcony. She was witnessed striking her head on the steps after an ~8' fall. The patient briefly lost consciousness and is found confused, lying at the bottom of the steps. Her eyes are open, and she is rubbing her forehead. The most important finding related to this patient's long-term outcome is
GCS score
Possible causes of confusion after traumatic event?
Hemorrhage Brain injury Stroke Intoxication
Hypotension + pelvic fracture =
High mortality
Trauma triad of death
Hypothermia Acidosis Coagulopathies
Causes of PEA?
Hypovolemia Hypoxia Hydrogen acidosis Hypo/hyperkalemia Hypoglycemia Hypothermia Toxins Tamponade Tension pneumo Thrombosis
Indications of a thoracotomy
Immediate return of > 1500 ml of blood or significant bleeding Persistent blood transfusions Penetrating anterior chest wounds medial to the nipple line Posterior wounds medial to the scapula
Potentially life threatening extremity injuries
Marjor arterial hemorrhage Bilateral femoral fractures Crush syndrome
What's the most common cause of a tension pneumothorax?
Mechanical positive-pressure ventilation in patients with a visceral pleural inury
MIST for obtaining info from EMS
Mechanism and time of injury Injuries found and suspected Symptoms and signs Treatment initiated
While assessment and management of a pregnant mother continues, what steps should be taken to evaluate the fetus?
Monitoring fetal heart tones frequently (monitoring for fetal distress and abnormal fetal heart tones) Early obstetrical consult
What's the difference between active and passive rewarming?
Passive involves placing the patient in an environment that reduces heat loss and relies on patient's intrinsic thermoregulartory mechanisms Active involves supplying a heat source (warm IVFs, warmed packs of high vascular flow and initiating circulatory bypass)
A patient arrives in your hospital after a fall from 20 ft landing on his right side. He has been intubated and two large-bore IVs have been started. His o2 sat is 82%, he has a good capnography waveform, and significant deformity to right chest wall. He has no breath sounds on the right. His BP is 75/30. Your next step should be to
Perform a needle decompression or finger throacostomy on the right side
A right thigh deformity is noted and splinted. Distal pulses intact. What additional radiographic tests need to be done?
Pevlic x-ray with pelvic binder to any fracture
Patients with cerviacl fractures above C6 require special consideration prior to transportation due to?
Potential progression to respiratory failure
Bronchial intubation of the right or left mainstem bronchus can easily occur during infant endotracheal intubation because:
The trachea is relatively short.
Abdomen stab wound
Visceral injury
What situations requires Rh immunoglobulin administration to an injured woman?
positive pregnancy test, Rh negative, and has torso trauma
Hemorrhage of 20% of the patient's blood volume is associated usually with
tachycardia
IVF in pregnancy
Patients requiring larger fluid requirements when hypotensive avoid dextrose
An 18-year-old male was the unrestrained driver in a MVC involving contact with a tree, He is being transported to the ED by ambulance after a prolonged extrication process. He is receive oxygen by mask and IVF via one large-bore IV, and he is immobilized on a long spine board. How would you prepare for arrival of this patient?
Airway equipment for possible intubation IV equipment to place a second IV and get blood work Lab/Xray available Monitor equipment ready Notify blood bank and have transfusion protocol available Consider appropriate transfer
What is the primary difference b/t the presentation of airway injury in patients with burns compared to other forms of trauma?
Airway injury can develop over time due to edema from burn injury
Prehospital phase should include what interventions and considerations?
Airway maintenance Breathing support Control of bleeding and shock Immobilization Immediate transport to closest appropriate facility
What's the most common location of all spinal injuries?
C5
How is an open joint injury confirmed?
CT or saline/dye injection
Preexisting conditions that impact morbidity and mortality of trauma patients?
Cirrhosis Coagulopathy COPD Ischemic heart disease DM
Fall from heigh
Head injury Axial spine injury Abdominal visceral injuries Fractured pelvis or acetabulum Bilateral LE fractures
MVC vs pedestrian
Head injury Traumatic aortic disruption Abdominal visceral injuries Fractured lower extremities/ pelvis
Triad of largyneal fracture
Hoarseness Subcutaneous emphysema Palpable fracture
A 22-year-old female presents after jumping from the 3rd story of a building in a suicide attempt. She's stable, but GCS is 13. Both ankles are swollen. Her pulses intact. Initial chest and pelvis films are normal. Ankle films reveal bilateral calcanea fracture. What additional work-ip is important to undertake in this patient?
Radiographic work-up of the spine to rule out occult injury
Why do children commonly develop pulmonary contusions following trauma, even in absence of rib fractures?
Ribs of children are primarily cartilaginous therefore bend and allows transmission of kinetic energy to underlying lung rather than absorbing and dissipating energy by fracturing ribs
What's the primary goal of treatment for patient's with suspected TBIs?
To prevent secondary brain injury by ensuring adequate oxygenation and maintain BP that's sufficient to perfuse the brain
A 20-year-old woman who is at 32 weeks gestation, is stabbed in the upper right chest. In the emergency department, her blood pressure is 80/60 mm Hg. She is gasping for breath, extremely anxious, and yelling for help. Breath sounds are diminished in the right chest. The most appropriate first step is to:
perform needle or finger decompression of the right chest
Definitive airway
A tube placed in the trachea with the cuff inflated below the vocal cords, the tube connected to a form of oxygen-enriched assisted ventilation and the airway secured in place with an appropriate stabilizing method
What are the uses for ETCO2?
Detect ROSC Confirm ET intubation Help avoid hypoventilation and hyperventilation
How cana circumferential burn injury affect muscle tissue?
Can cause the pressure from burn edema to build to the point that it compromises tissue perfusion, similar to compartment syndrome
A 82-year-old female was found home by family. Her eyes are closed, she extends to pain, and is not speaking
GCS 4
The most significant difference between burn and other traumatic injuries is?
In a burn injury, the full extent of the injury may not be evidence immediately
Cerebral perfusion pressure (CPP)
MAP - ICP
What's a pulse oximetry measure?
Oxygen saturation by relative absorption of light by oxyhemoglobin and deoxyhemoglobin
An 81-year-old female arrives in the ED after a fall from standing. The only visible sign of injury is a large scalp laceration. Paramedics report that she has been getting progressively hypotensive over the past 20 minutes. They infused 2 L NS IVF, after which BP is 135/70. She is somnolent, but arousable. There is some hemorrhage from a large 20 cm scalp laceration. What's the best next step in managing this patient?
Repair the scalp laceration
An 82-year-old female is brought to the ED by ambulance after she tripped while walking her dog. Her VS are RR 22 HR 64 BP 160/80 and GCS 13. What injuries would you suspect in this patient?
The patient may have sustained a TBI and neck, rib, pelvis, long-bone, and/or spine fractures
In a patient with a possible pelvic fracture, how frequently should the pelvis be tested for mechanical stability?
The pelvis should not be tested in a hemodynacilly unstable patient. Mechanical instability of he pelvic ring should be assumed in patients who have suspected pelvic fractures. Avoid manually manipulating the pelvis (dislodge an existing clot)
Healthy pregnant patients can lose _____ ml of blood before exhibiting signs and symptoms of hypovolemia
1200-1500 ml of blood
Trimodal death distribution
1st: seconds to minutes of injury (apnea) 2nd: minutes to several hours (EDH, SDH, liver lac, pelvic fractures, spleen ruptures) 3rd: several days to weeks after injury (sepsis and multi-organ failure)
Cervical spine injuries represent more than 1/2 of all spinal column injuries. What additional injuries are commonly associated with cervical fractures?
25% of all spine injuries have at least a mild brain injury and 10% with a cervical fracture have another noncontiguous spine fracture
A 35-year-old woman who appears to be in the second trimester of pregnancy is brought to the ED following a MVC. VS are RR 28, HR 130, BP 110/50, GCS 7. What lab and radiologic tests should be ordered?
CMP, CBC, blood gas, toxicology, coagulation, Rh status, UA (If Rh- then administer Rh immunoglobulin) Imaging to r/o brain, spine, and abdominal injuries
Inhalation burns
CO poisoning Upper airway swelling Pulmonary edema
A 38-year-old female restrained driver is involved in a high-speed, head-on collision with a truck. Following a prolonged extrication, she noted to have deformity of her right thigh. On arrival, her VS are HR 120, BP 90/50, RR 22, GC 15. 2 large bore IVs are inserted in UE. VS are now HR 13- BP 80/40, RR 24, GCS 14. CXR, pelvis X-ray, and FAST are negative. You suspect the source of hypotension is a femur fracture and bilateral tibial shaft fractures. Transfer is initiated. What antibiotics and at what dose should be given tot he patient?
Cefazolin 3g + ciprofloxacin or gentamicin
An elderly female falls and sustains a hyperextension injury to her neck. Her exam demonstrated decreased strength in UE compared to LE. What is the cause of her unusual neurologic findings?
Central cord syndrome
What should be done about wounds/fractures before transfers?
Clean and dress wounds after external control Administer tetanus Administer antibiotics if needed Splint and tract fractures
How is burn resuscitation affected when the patient also has an injury causing hemorrhage?
Control bleeding and resuscitate the patient per standard ATLS protocol for hemorrhagic shock before starting burn resuscitation
Swollen extremity in region of major muscle group
Crush injury with impending compartment syndrome
What factors would determine mode of transportation?
Distance from referring to accepting facility, weather, availability of ambulance/helicopter, ability to manage intubated patient
Seizures in pregnancy
Eclamptic: Mg Sulfate 4-4 g IV load over 15-20 m Non-eclamptic: lorazepam 1-2 mg/min IV
What are the factors that contribute to the need for an escharotomy?
Edema from the inflammatory response to the burn and reduced elasticity of burned skin (increased pressure in the underlying soft tissue)
A surgical airway is indicated in the presence of
Edema of the glottis Fracture of larynx Severe oropharyngeal hemorrhage that obstructs airway Inability to place an endotracheal tube
What key information should prehospital providers obtain and report to the receiving hospital?
Events associated with injury
What is true regarding the initial resuscitation of a trauma patient?
Evidence of improved perfusion after fluid resuscitation could include improvement in Glasgow Coma Scale score on reevaluation
What's the most common cause of shock after an injury?
Hemorrhage
Hospital preparation for trauma
Resuscitation area Airway équipement Warmed IV crystalloid solution Monitoring devices Protocol for requesting additional assistance Transfer agreements
You'd like to insert a foley catheter for a trauma patient but you notice urethras injury. What test should be performed prior to the insertion of a urinary catheter?
Retrograde urethrogram
What patient sign can be quickly observed to assess a patient's hemodynamic status?
Skin perfusion
Gunshot wounds most commonly injury?
Small bowel (50%) Colon (40%) Liver (30%) Abd vascular structures (25%)
You have completed a secondary survey on a patient who feel from a standing height. You note exquisite tenderness posterolaterally on the left chest wall at 9-11 ribs. This should raise suspicion for what other injury?
Splenic injury
Breathing thoracic injuries
Tension pneumothorax Open pneumothorax Massive hemothorax
What is the goal of burn resuscitation?
To maintain end-organ perfusion in the context of ongoing intravascular fluid loss
In an adult patient with suspected inhalation injury, it is important to?
Use an ETT larger than 7.5 in an adult to enable clearance of secretions
The ability to palpate fetal extremities on the abdominal exam of a pregnant trauma patient is indicative of?
Uterine rupture
A construction worker falls two stories from a building and sustains bilateral calcaneal fractures. In the emergency department, he is alert, vital signs are normal, and he is complaining of severe pain in both heels and his lower back. Lower extremity pulses are strong and there is no other deformity. The suspected diagnosis is most likely to be confirmed by:
complete spine x-ray series
The best assessment of fluid resuscitation of the adult burn patient is:
urinary output of 0.5 mL/kg/hr
Penetrating trauma MOI
Body region Velocity of weapon Caliber
Cold, pale, pulseless extremity
Interrupted arterial blood supply
Most injuries to the tracheobronchial tree occur where?
Within 2.5 cm from the carina
Side impact MVC
Contralateral neck sprain Head injury Cervical spine fracture Flail chest Pneumothorax Traumatic aortic disrution Diaphragmatic rupture Fractured spleen/liver/kidney Fractured pelvis or acetabulum
What does splinting accomplish in patients with musculoskeletal trauma?
Control blood loss, prevent further neuromuscular compromise and soft tissue injury, and reduce the patient's pain
Burn shock is a result of?
Interstitial loss due to inflammation
What's true about tourniquets?
It must occlude arterial inflow
LEMON assessment of difficult intubation
Look externally Evaluate the 3-3-2 rule Mallampati Obstruction Neck mobility
What's a likely injury for an elderly patient who sustains a standing height fall?
Rub and pelvic fractures
Assess basic physiology
SBP < 90 RR < 10 or > 29 GCS < 14
A 19-year-old female stepped off a curb, tripped, and fell. Her VS are normal. She had LOC and brain CT is negative. Her only prior ED visit was for a broken arm sustained in a bike accident 5 years ago. She sees a PCP and Gyn regularly. What's true regarding intimate partner violence for this patient?
Screening for intimate partner violence should be performed on all patients who present to ED
Blunt trauma MOI
Seatbelt use Steering wheel deofrmation Presence/activation of airbags Direction of impact Damage to vehicle Patient position Ejection from vehicle?
"Golden hour"
The time from injury to definitive care, during which treatment of shock and traumatic injuries should occur because survival potential is best; also called the Golden Period.
A 3-year-old falls 10 meters out of an apartment window onto pavement. He does not open his eyes, moans incomprehensibly, and extending abnormally when stimulated. The patient is unresponsive on arrival to the ED, and pupils are unequal. He has blood coming from his right ear, is breathing rapidly, and is pale, with mottled extremities. VS are BP 74/57,HR 156, RR 49. Is this child in shock?
Yes (tachycardia, mottled extremities, and hypotension) indicates significant compromise, likely due to bleeding but other etiology must be ruled out.
Many patients with c-spine fractures have
a second, noncontiguous vertebral column fracture
A young woman sustains a severe head injury as the result of a motor vehicle crash. In the emergency department, her GCS is 6. Her blood pressure is 140/90 mm Hg and her heart rate is 80 beats per minute. She is intubated and mechanically ventilated. Her pupils are 3 mm in size and equally reactive to light. There is no other apparent injury. The most important principle to follow in the early management of her head injury is to
avoid hypotension
A 56-year-old man is thrown violently against the steering wheel of his truck during a motor vehicle crash. On arrival in the emergency department he is diaphoretic and complaining of chest pain. His blood pressure is 60/40 mm Hg and his respiratory rate is 40 breaths per minute. What best differentiates cardiac tamponade from tension pneumothorax as the cause of his hypotension?
breath sounds
A hemodynamically normal 10-year-old girl is hospitalized for observation after a Grade III (moderately severe) splenic injury has been confirmed by computed tomography (CT). What mandates prompt celiotomy (laparotomy)?
development of peritonitis on physical exam
A 7-year-old boy is brought to the emergency department by his parents several minutes after he fell through a window. He is bleeding profusely from a 6-cm wound of his medial right thigh. Immediate management of the wound should consist of:
direct pressure on the wound
Extremity bleeding control order
1) Manual pressure to the wound 2) Pressure dressing 3) Compression of the artery proximal to the injury 4) Tourniquet application
Tourniquet use
1) Tightening tourniquet until bleeding stops 2) Ensure arterial inflow is occluded 3) Document time of application 4_ Obtain immediate surgical consult and transfer patient, if necessary 5) If time to surgery is prolonged in stable patient, consider one attempt to deflate tourniquet 6) If tourniquet use if prolonged, consider chose of life over limb
What's the preferred method of vascular access for a patient involved in a MVC?
2 large bore PIVs in the antecubital veins
Parkland formula
2-4 ml of LR x patient's weight (kg) x % TBSA for 2nd and 3rd degree burns with 1/2 administered in the 1st 8h and the 2nd 1/2 administered during the subsequent 16h
Where is the ideal location for needle decompression of a tension pneumothorax?
5th intercostal space, slightly anterior to midaxillary line
A 25-year-old man, injured in a motor vehicular crash, is admitted to the emergency department. His pupils react sluggishly and his eyes open to pressure. He does not follow commands, but he does moan periodically. His right arm is deformed and does not respond to pressure; however, his left hand reaches purposefully toward the stimulus. Both legs are stiffly extended. His GCS score is:
9
An ABI < ___ indicates abnormal arterial flow secondary to injury or PVD.
< 0.9
A 38-year-old female restrained driver is involved in a high-speed, head-on collision with a truck. Following a prolonged extrication, she noted to have deformity of her right thigh. On arrival, her VS are HR 120, BP 90/50, RR 22, GC 15. 2 large bore IVs are inserted in UE. VS are now HR 13- BP 80/40, RR 24, GCS 14. CXR, pelvis X-ray, and FAST are negative. You suspect the source of hypotension is a femur fracture and bilateral tibial shaft fractures. How much blood loss would you expect from this patient's extremity injuries and what's the best way to control it?
A femur fracture can result in blood loss up to 2 L and each tibial fracture can cause up to 1.5 L of blood loss. Fracture immobilization is the best control.
How should femur and tibial shaft fractures be stabilized?
A traction splint should NOT be used. Tibial fracture should be placed in a long leg splint. A femur and tibial fracture should be placed in a long leg posterior splint. Open fractures should be covered with moist saline gauze before placed in splint. Neurovascular exams should be performed before and after splint placement
A 29-year-old M jumps from the 1st story of a burning house. His clothes are on fire. Bystanders extinguished the flames. He is conscious, agitated, and complaining of abdominal and leg pain. The patient's head and upper body appear to be extensively burned. The patient is now intubated with IV access. A foley is placed with minimal dark urine output. The estimate of burn size is 45% TBSA. How should the patient's burn wound be managed in the initial stages?
ABC management in addition to stopping the burning process, cleansing the wound, protecting it from infection, and preventing hypothermia
A 3-year-old falls 10 meters out of an apartment window onto pavement. He does not open his eyes, moans incomprehensibly, and extending abnormally when stimulated. The patient is unresponsive on arrival to the ED, and pupils are unequal. He has blood coming from his right ear, is breathing rapidly, and is pale, with mottled extremities. The patient is intubated and IV access is obtained. He's given crystalloid and blood with good response. HR 110 and BP 90/60. CXR shows pulmonary contusions. What are the priorities in evaluating a small child with multi system trauma?
ABCDE
What suggests sufficient ventilation?
ABG or continual end-tidal carbon dioxide analysis
Retroperitoneal organs
Abdominal aorta IVC Duodeum Pancreas Kidneys Ureters Posterior aspects of ascending/descending colon Bladder Rectum Reproductive organs
A patient's CXR reveals left pneumothorax. Additionally, the left diaphragm is obscured and there is an air fluid level in the left hemithorax. You decide to place a chest tube. The patient is at increased risk for damage to
Abdominal contents that have become displaced into the chest cavity
In addition to VS and GCS score, what information would be helpful to obtain in order to evaluate pregnant trauma patients?
Additional scene information: whether/how the patient was restrained and MOI
A 38-year-old male presents to the ED after a head-on, high-speed collision. His vitals are HR 130, BP 156/90, RR 20, and O2 sat 92% on 15L of O2. His voice is raspy and he complains of chest pain that radiates to his back. A CXR shows a widened mediastinum, obliteration of the aortic notch, and depression of the left mainstream bronchus. You should
Administer agents to manage his pain and lower his HR and BP (aortic disruption)
What's normal UOP?
Adult: 0.5 ml/kg/hr Child: 1-2 ml/kg/hr
A 35-year-oldman was ejected from a MV. On arrival, his VS are BP 80/40, HR 110,RR 24, GCS 15. Airway and breathing are intact. He complains of severe back pain, has no sensation below umbilicus, has lower thoracic tenderness, and is unable to move LE. Chest and pelvic X-rays are normal. Along with IVFs, what is most appropriate treatment for this patient's hypotension?
Although this patient likely has a spinal cord injury, perform a FAST exam or DPL to r/o other etiology.
ABCDEs of injury prevention
Analyze injury data (local injury surveillance) Build local coalitions (hospital community partnerships) Communicate the problem (injuries are preventable) Develop prevention activities (create safer environments) Evaluate the interventions (ongoing injury surveillance)
A 25-year-old ale arrives at the ED following a motorcycle crash. BP is 80/60, HR 140. Airway and breathing are controlled. There are no open wounds. The abd is not distended. Both legs are externally rotated but soft. The pelvis is tender. The scrotum is swollen and ecchymotic. While vascular access is obtained, what the next most appropriate step?
Application of a pelvic binder
A 50-year-old male arrives to the ED following fall of 26'. He hs gurgling respirations and is not responsive to voice. VS are BP 80/5-, RR 30, HR 138, O2 sat is undetectable. Your hospital does not have surgical capabilities. The first step in management is
Application of oxygen and securing an airway
Geriatric trauma patients are at greater risk of mortality from rib fractures than younger individuals because they?
Are at a greater risk of developing pneumonia
What info should be provided to the receiving facility for a transferring patient?
As much info as possible! Event of injury, patient exam, treatments done, responses of treatments, tests and results, and possible injuries
When treating a severely injured child, it is very important to rapidly establish the patient's weight in order to determine equipment size, drug doses, and resuscitation volumes. What are options for estimating weight quickly or determining appropriate equipment size?
Asking parent or caregiver Using a length-based pediatric resuscitation tape Using the formula (2 x age in years + 10)
What statement concerning intraosseous infusion is TRUE?
Aspiration of bone marrow confirms appropriate positioning of the needle.
What visceral injuries are more common in children?
Blunt pancreatic injuries Small bowel perforations near ligament of Treitz Mesenteric and small bowel avulsions Bladder rupture Enteric disruption Penetrating injuries to perineum Rupture of hollow viscus
The patient is unable to move his legs. He can move his fingers and wrists bilaterally. He has weal triceps extension on the left. He is unable to move right elbow. He is able to feel his fingers and thumbs bilaterally, but not feel anything above his elbow. Where is the suspected spine lesion?
C6 or C7
A 50-year-old male is brought to your facility, which is a small community hospital without surgical services. He was involved in a MVC in which his car sustained significant front-end damage. The patient was not wearing a seatbelt and complains of abdominal pain. He has a GCS of 13. What are the most radiographic studies should the patient have before transfer?
CXR, pelvis x-ray, and FAST exam
Electrical burns
Cardiac arrhythmias Myonecrosis Compartment syndrome
What's true about hypervolemia associated with pregnancy?
Cardiac output increased by 1-1.5 L/min after the 10th week of pregnancy due to the increase in plasma volume and decrease in vascular resistance
A 65-year-old female who takes warfarin was involved in a MVC. She initially presented complaining of sternal pain. BP deteriorated to 90/60 after arriving to the ED
Cardiac tamponade
Frontal impact MVC
Cervical spine fracture Flail chest Myocardial contusion Pneumothroax Traumatic aortic disruption Fractured spleen or liver Posterior fracture/dislocation hip/knee Head injury Facial fractures
Rear impact MVC
Cervical spine injury Head injury Soft tissue injury to neck
Which type of thoracic spinal fracture is associated with MVC with restrained passengers using lap belt, a forward flexion mechanism, likely visceral organ injury, and frequent need for internal fixation?
Chance fracture
What are the major areas of internal hemorrhage?
Chest Abdomen Retroperitoneum Pelvis Long bones
Special populations that may have physiological responses that do not follow expected patterns
Children Pregnant females Elderly Obese individuals Athletes
An important immediate treatment of intracranial hemorrhage in elderly patients is?
Correct all sources of coagulopathy
What's a characteristic that is shared by all traumatic aortic disruption survivors?
Contained hematoma
A 40-year-old M involved in a MVC is evaluated in a rural hospital without spine surgical capacity. The patient has a clear C-spine fracture at C4 on plain film and the inability to move any extremities and sensation limited to supraclavicular region. He is having difficulty breathing with a RR 30. BP 80/40 and HR 50. What should be performed prior to transfer?
Crystalloid bolus, initiate pressers, intubate, and then transfer patient once he is hemodynamically stable
While supine, vena cava compression can cause?
Decrease cardiac output by 30% because of decreased venous return from the lower extremities
A 23-year-old male fell from a bike, striking his head on the curb. He was not wearing a helmet. The patient has a 10 cm laceration to the temporal-parietal region of the left scalp. He is initially able to say hi name. VS are HR 115, BP 100/60, oxygen sat 88%, GCS initially 12. 2 hours after transfer to a local hospital, he has sonorous respirations, a HR of 120, BP 100/70, and GCS of 6. What are the signs that the patient's injury is progressing?
Decreased GCS indicates worsening intracranial pathology with possible intracranial HTN and impending herniation
What pitfalls may you face when intubating an elderly patient?
Decreased chest wall and pulmonary compliance Decreased mucus clearance Diminished functional residual capacity Increased work of breathing
When do you provide burn resuscitation?
Deep partial and full thickness burns larger than 20% TBSA
Likely causes of elderly patient's decline in mental status?
Delirium Dementia Pain medication Sedatives Increase ICP Decreased cerebral perfusion pressure
Rapid triage and transport issues during secondary survey
Depressed skull fracture or penetrating injury Eye injury, open fractures, ongoing nasopharyngeal bleeding Neck hematoma, crepitus Multiple rib fractures, flail chest, pulmonary contusion, widened mediastinum Rebound or guarding of abdomen Laceration of perineum Neurologic deficit Complex or multiple fractures, bony spine injuries Multiple comorbities, pregnancy, burns
What info should be recorded on the trauma flow sheet?
Depth and extent of burn Fluids given UOP Any significant interventions, including escharotomies
A 45-year-old male with a BMI of 48 was working in an industrial plant when 2 pieces of wood flew off a sa and struck him in the abdomen and right chest. CXR demonstrates rib fractures. What's true about this scenario?
Despite multiple imaging studies, detection of intestinal and retroperitoneal injuries may be difficult
Breathing treatments that must be established before transfer
Determine rate and administer supplementary oxygen Provide mechanical ventilation when needed Insert chest tube
What types of intracranial hemorrhage can be identified on CT scan?
Epidural Sudural Intra-ventricular Subarachnoid Intra-parenchymal
A patient arrives after a blow to the right temporal region secondary to a tree limb striking him while chopping down a tree. He was intubated in the field for a declining mental status. His PE reveals 6 mm and non-reactive right pupil and a 4 mm L pupil with brisk reaction to 2 mm. His GCS reveals extensor posturing with no eye opening, and he is intubated. The presumed extent of his intracranial injury is most likely?
Epidural hematoma causes same side pupil dilation and opposite side weakness
What indicates that the endotracheal tube is in the proper position?
Equal breath sounds bilaterally Carbon dioxide monitor (capnograph or colorimetric CO2 device) Confirmed with CXR
Thermal burns
Eschar on extremities or chest
A 54-year-old male arrives to ED at small hospital without surgical capabilities. He was involved in MVC in which he was the driver of a car that Tboned a delivery truck at 55 mph. He has GCS of 8, decreased breath sounds on the left, abdominal tenderness. BP 95/65, HR 110. What are the priorities of management?
Establish airway and insert chest tube. Resuscitate and stabilize prior to transporting patient to adequate hospital
What're the leading causes of unsuccessful resuscitation in pediatric patients with severe trauma?
Failure to secure a compromised airway Failure to support breathing Failure to recognize and respond to intra-abdominal and intracranial hemorrhage
A patient is brought to the emergency department after a motor vehicle crash. He is conscious and there is no obvious external trauma. He arrives at the hospital completely immobilized on a long spine board. His blood pressure is 60/40 mm Hg and his heart rate is 70 beats per minute. His skin is warm. What do you expect to see with the patient?
Flaccidity of the lower extremities and loss of deep tendon reflexes are expected.
A 56-year-old male archer was riding a horse when it bucked and the saddle struck him in the chest wall. You note paradoxical chest wall movement on the left anterior chest. CXR is negative.
Flail chest due to costochondral disruption
What factors are associated with progression of secondary brain injury?
Hypotension and hypoxemia
PITFALL: unsuccessful intubation
Identify patients with difficult anatomy Identify the most experienced/skilled airway manager on team Ensure appropriate equipment is available Be prepared to prefer a surgical airway
A 35-year-old female is brought into the hospital after being lost for two days while snowmobiling in -30 C weather. She has a core body temperature of 30 C and her toes are frozen. How and when should rewarming start
Immediate active rewarming
Identify the responsibilities of a referring physician in a patient transfer situation?
Initiating transfer during resuscitation Consult with receiving physician Maintain familiarity with transporting agencies Select appropriate transportation Determine level of care required during transfer Stabilize the patient's confiriotn Provide patient summary Ensure adequate trained personnel accompanying patient Ensure pediatric patients are transferred to facilities with special expertise when available
Airway treatments that must be established before transfer
Insert airway or ETT with low GCS or the potential to deteriorate Provide suction Place gastric tube in all intubated patients and those with gastric distention
A 22-year-old male is hit by a car while traveling downhill on a skateboard. He was found unconscious at the scene and arrives with bag-mask ventilation by the EMS crew. He only mumble incoherently, does not open his eyes, and only flexes to pain. Upon arrival in the ED, the primary goal is
Intubate the patient
SBP > 160 or DBP > 110 in pregnancy
Labetalol 10-20 mg IV bolus
Pale or white distal extremity
Lack of arterial blood flow
What statements regarding abdominal trauma in the pregnant patient is TRUE?
Leakage of amniotic fluid is an indication for hospital admission.
A 40-year-old woman who was a restrained driver in a motor vehicle crash is evaluated in the emergency department. She is hemodynamically normal and found to be paraplegic at the level of T10. What precaution should be taken during evaluation and management?
Log rolling using 4 people is a safe approach to restrict spinal motion when moving her.
What injuries are at high risk of compartment syndrome in trauma patients?
Long bones Crush injuries Circumferential thermal burns Prolonged ischemia to the limb
For a patient who is gurgling, initial assessment for ventilation should include
Looking for symmetrical chest rise and listening for breath sounds
A 46-year-old male sustained a gunshot wound to the chest
Massive hemothorax
Circulation thoracic injuries
Massive hemothorax Cardiac tamponade Traumatic circulatory arrest
Kleihauer-Betke test
Maternal blood smear allows evaluation of amount of fetal blood in maternal circulation if large fetomaternal transfusion is suspected
Main causes of fetal death of pregnant trauma patients are?
Maternal shock Maternal death Abruption placentae
A patient with a simple pneumothorax
May be watched for progression if pneumothorax is small (<15%) and patient is stable and does not require transfer
What unique elements of AMPLE history should you be alert to in an elderly patient?
Medications (beta blockers and anticoagulation) Automatic implantable cardioverter-defibrillator, pacemaker, artificial valves/stents Last meal (they may have delayed gastric emptying)
What CT scan findings are indicative of severe head injury that may require intervention?
Midline shift (> 5mm), loss of definition of the basil cisterns, and severe skull fractures with intrusion into the brain matter
Simplest way to remove tar from trauma patient?
Mineral oil
What is the most effective method for initially treating frostbite?
Moist heat
A 35-year-old female is brought into the hospital after being lost for two days while snowmobiling in -30 C weather. She has a core body temperature of 30 C and her toes are frozen. How should the toes be thawed?
Moist rewarming
What precautions should be taken while a pregnant trauma patient is undergoing CT scan?
Monitoring VS, if she becomes hemodynamically unstable, remove the patient During brain and spine imaging, the abdomen should be shielded
What are the initial management options for moderate brain injury?
Monitoring for decompensation is important and requires hospital admission, ongoing neurologic exam, possible further CT imaging
Do the vast majority of thoracic injuries (blunt and penetrating) require operative intervention?
No, most are treated with technical procedures
Will retroperitoneal injuries prevent with obvious signs of peritoneal irritation?
No, retroperitoneal structures are separated from anterior peritoneum by the intraperitoneal viscera, therefore no peritonitis may be present
On exam, an unrestrained driver is hoards and has minimal subcutaneous neck emphysema. This patient likely has a/an
Obstructed airway
A 12-year-old male complains of LUQ tenderness and L shoulder pain 8 hours after playing rugby. ABCDE are normal. Circulatory assessment remains normal. Abdominal exam reveals mild LUQ TTP without peritoneal signs. FAST demonstrated fluid in the hepatorenal space and the plenorenal recess. What's the appropriate next step?
Observation
A 10-year-old male struck his head while diving into pool. On exam, he demonstrates weakness in all extremities. Cervical spine films show no fracture. Whats the next step in management.?
Obtain urgent spine surgery consultation
Special patient considerations
Older adults and children Anticoagulation and bleeding disorders Burns Open fractures or vascular compromise ESRD Pregnancy > 20 wks
How does hypovolemia from burn injury differ from hypovolemia from other forms of trauma?
Other trauma usually result in hemorrhagic volume loss, however burn hypovolemia is due to inflammatory changes and capillary leak
When is a retrograde urethrogram mandatory?
Patient is unable to void, requires pelvic binder, or has blood at the meatus, scrotal hematoma, or perineal ecchymosis
The removal of spine boards early is particularly important in geriatric patients because?
Patients are at increased risk of pressure ulcers
What's an indication for rapid sequence intubation?
Patients who need airway control, have intact gag reflex, especially those who have sustained head injury
Assess anatomy of injury
Penetrating injury to head, neck, torso, and extremities Flail chest > 1 proximal long bone fracture Crushed, degloved, or mangled extremity Amputation Pelvic fractures Open or depressed skull fracture High risk MVC Auto vs peds
A 7-year-old M is struck by car while riding a bike. Upon arrival to ED, he is tachycardic, hypotension, and hypoxic. He has diminished breath sounds a large contusion of the right side. The most appropriate next step is?
Perform immediate needle thoracostomy of the right chest
A 17-year-old male is brought to a 20 bed hospital following a snowmobile crash. Hospital has CT and ultrasound capabilities. VS are SBP 85, HR 120, GCS 15. Patient is breathing shallow. Unstable pelvis and deformity of left thigh. What's priorities of management?
Perform primary survey: establish airway, obtain IV access, apply pelvic binder, and begin IVF resuscitation
What do you need to remember when treating an open pneumothorax?
Place a dressing on the site and only secure is on 3 sides so air can escape, then place a chest tube
A 5-year-old boy is struck by a car and brought to the ED. He is lethargic but withdraws from painful stimuli. VS are BP 90, HR 160, RR 40, and oxygen sat 85%. The best option for establishing vascular access after experienced nurses have failed to obtain PIV on two attempts is?
Placement of intraosseous device into proximal tibia
Decreased or absent breath sounds over one or both hemithoraxes should alert the examiner to the presence of?
Pneumothorax, hemothoax, contusion, or flail chest
What is the purpose of intubation in a comatose patient?
Prevent hypoxia and secondary brain injury occurs with a protection of the airway
A 33-year-old woman who is 28 weeks pregnant by dates presents with a 4 cm stab wound to the left chest superior and lateral to the nipple. Her BP is 78/40, HR 14-, RR 30. She is awake and talking but confused, pale, and diaphoretic. Her oxygen sat is 92% on 15 L. She has markedly decreased breath sounds on left, dullness to percussion, and active air exchange via the open wound in her chest. What's the appropriate next step?
Rapid decompression of the left chest with tube thoracotomy accompanied by occlusive dressing of the stab wound
PITFALL: progressive airway loss
Recognize the dynamic status of the airway Recognize the injuries that can result in progressive airway loss Frequently reassess the patient for signs of deterioration of the airway
Compared to a younger patient, a geriatric trauma patient with a pelvic fracture is more likely to?
Require blood transfusions
What are the initial management options for severe brain injury?
Requires a center with neurosurgical support and associated aggressively treat intracranial swelling, osmotic intravascular fluid management, and rapid surgical intervention
Classifications of responses of children to fluid resuscitation
Responders: stabilized by crystalloid fluid OR crystalloid and blood resuscitation Transient responders: install response to crystalloid and blood, but then deteriorates Nonresponders: doesn't respond to crystalloid or blood infusion
The best initial treatment for pregnant trauma patients is?
Resuscitate the mother and consult surgeon and obstetrician
What treatment measures is essential in maintaining cerebral perfusion pressure?
Sedation, mannitol, and IVF will help decrease ICP or increase MAP
A patient with a known cervical spine fracture who is being transferred from a rural hospital to definitive care should be transported in which way?
Semi-regid collar and head restraint
Why is the issue of iatrogenic hypothermia important?
Shown to increase trauma related mortality, which is preventable
If a burn patient's urine were reddish-brown in color, what would change in your burn resuscitation?
Signifying myoglobinuria secondary to rhabdomyolysis should be treated with aggressive IVF and possible mannitol
ABLS indications for early intubation
Signs of airway obstruction TBSA > 40-50% Extensive and deep facial burns Burns inside the mouth Significant edema or risk for edema Difficulty swallowing Signs of respiratory compromise Decreased LOC Anticipated patient transfer of large burn with airway issue without qualified personnel to intake en route
A 25-year-old male presents after a motorcycle crash. VS are BP 128/70, HR 124, GCS 15. He complains of R leg pain. On exam, the patient is found to have proximal right thigh deformity. Distal pulses intact. What's the best initial magement of this patient's symptoms?
Splint the extremity and administer a small dose of an IV narcotic, like fentanyl
A 29-year-old woman is the restrained driver in a head-on collision. Airbags deployed. ABCDE are normal. The patient complains of lower abd and back pain. A lower abd contusion is present and associated with tenderness. There is no evidence of diffuse peritonitis. Your institution has NOT surgical capabilities. What's the most appropriate treatment plan?
The patient should be urgently transferred for surgical intervention
Immediate lifesaving measures for patients with burn injuries
Stopping the burn process Recognize inhalation injury Assuring an adequate airway Oxygenation and ventilation Rapidly initiating IVF
What's the most appropriate means to restore cardiac output and end organ perfusion in hemorrhagic shock?
Stopping the source of bleeding and ensuring appropriate volume repletion
Pulmonary contusion/flail chest is best treated by?
Supplemental oxygen, pain control, and recognition if the patient is unable to ventilate properly
DDX for blood in gastric aspirate in a trauma patient
Swallowed blood Traumatic gastric tube placement UGI injury
A geriatric trauma patient falls from her wheelchair at a nursing home. She presents with a GCS score of 13, The patient is likely suffering from a?
TBI
What're the early clinical manifestations of shock?
Tachycardia and cutaneous vasoconstriction
Why is info about mechanism of injury so important?
The patient's condition is greatly influenced by MOI. It can enhance the understanding of the patient's condition and anticipated injuries
A helmeted 28-year-old male fell from scaffolding. A bystander witnessed the fall and reports that the patient landed head first, causing his neck to hyperextend. His VS are BP 90/62, HR 58, RR 28, GCS 15. The patient is alert and following commands. His breathing is shallow and he is not moving his arms or legs. What injuries has this patient likely incurred?
The initial assessment raises concerns for a spinal cord injury. However, complete a primary and secondary survey to rule out additional life-threatening injures.
A 35-year-old woman who appears to be in the second trimester of pregnancy is brought to the ED following a MVC. She is unconscious and immobilized on a long spine board. How might the patient's pregnant affect the performance of the primary survey?
The priorities are the same: ABCDE. Care must be taken to interpret VS.
A 22-year-old female in the 3rd trimester of her pregnancy presents after MVC. Her VS are BP 100/70, HR 120,RR 22. FHR found to be 90. What statement about FHR is correct?
This is abnormally low FHR likely presents impair oxygen flow to the fetus from the placental vasculature (sensitive to catecholamine surge during trauma causing increased uterine vascular resistance and decreased fetal oxygenation)
What is a common finding associated with traumatic asphyxia?
Upper torso, facial, and arm plethora with petechiae secondary to acute temporary compression of SVC. Massive swelling and cerebral edema may be present.
A 34-year-old in her 3rd trimester of pregnancy was found unconscious in her backyard. She apparently fell from a second-story porch. EMD reports seizure activity. VS BP 174/90, HR 118, GCS. Which test might help determine if the patient's seizure activity is due to eclampsia?
Urine test for protein
A 45-year-old female is involved in a MVC and brought to a local ED with limited capabilities. She does not remember the event and has repetitive questioning. You would like to get a CT scan of the head, but the technician must be called in from home, which will take at least 30 minutes. You should
Transfer the patient to a higher level of care
All open fractures and open joint injuries require
Up to date tetanus vaccine IV antibiotics (1st generation cephalosporin)
A 28-year-old male, helmeted motorcyclist was in a high speed MVC, striking head-on into the side of a vehicle. He arrives on a backboard and with a cervical collar in place via pre-hospital BLS transport. Vitals are: BP 100/75, HR 115, RR 20, GCS 15. The patient reports a brief loss of consciousness and is complaining of pain in the chest, abdomen, and pelvis. What's the interpretation of the VS and the initial therapy?
VS are consistent with hemorrhagic shock from intraabdominal or pelvic sound Maintain IV/IO access and initiate volume resuscitation, including blood transfusion if indicated Pelvic binder application may be appropriate
What diagnostic studies should be conducted prior to transfer?
X-rays of chest, pelvis, and extremities Blood work Determine cardiac rhythm,, and hemoglobin saturation
For the patient with severe traumatic brain injury, profound hypocarbia should be avoided to prevent:
cerebral vasoconstriction with diminished perfusion
The physiological hypervolemia of pregnancy has clinical significance in the management of the severely injured, gravid woman by:
increasing the volume of blood loss to produce maternal hypotension.
A patient arrives in the emergency department after being beaten about the head and face with a wooden club. He is comatose and has a palpable depressed skull fracture. His face is swollen and ecchymotic. He has gurgling respirations and vomitus on his face and clothing. The most appropriate step after providing supplemental oxygen and elevating his jaw is to:
suction the oropharynx
A 50-year-old female involved in a MVC is brought to your facility, a small community hospital with general surgical but no neurosurgical capability. It was reported that there was significant damage to the driver's side of the care with a starred windshield. The patient's GCS of 8, decreased breath sounds on the left, abdominal tenderness. On FAST, she clearly has fluid in her peritoneum. What are the priorities prior to sending this patient to a facility that has neurosurgical capabilities?
ETT, chest tube, and exploratory laparotomy
An elderly patient is transferred from a long-term care facility after being found down. In addition to a hip fracture, you find the patient is wearing soiled clothes and a soiled diaper, has dry mucus membranes, and tenting skin. You should evaluate the patient for?
Elder maltreatment
Lab values changed during pregnany
Elevated WBC (12000-25000) Mildly elevated fibrinogen and other clotting factors Shortened PT and PTT (bleeding and clotting times unchanged) Decreased Hct (32-42%)
A 20-year-old is brought to ED after his shovel hits a 14,000 volt underground wire and he suffers an electrical contact injury to his arms. He is covered in powdered cement from the work site. How should be be initially treated?
Establish ABCs Brush powder off before irrigating Monitor due to electrical injuries later manifesting
A 35-year-old woman who appears to be in the second trimester of pregnancy is brought to the ED following a MVC. VS are RR 28, HR 130, BP 110/50, GCS 7. What are the first steps in primary survey in this patient?
Establish definitive airway and stabilize cervical spine Placing a orogastric tube may be advised as it's likely to reflux gastric contents If the patient becomes hypotensive, elevate the patient's right side to displace uterus off IVC
Musculoskeletal adjuncts to the primary survey may include?
Proper application of a splint can help control blood loss, reduce pain, and prevent further neurovasculr compromise
A 6-year-old boy walking across the street is struck by the front bumper of a sports utility vehicle traveling at 32 kph (20 mph). What's true about this patient?
A pulmonary contusion may be present in the absence of rib fractures.
A 23-year-old male fell from a bike, striking his head on the curb. He was not wearing a helmet. The patient has a 10 cm laceration to the temporal-parietal region of the left scalp. He is initially able to say hi name. VS are HR 115, BP 100/60, oxygen sat 88%, GCS initially 12. 2 hours after transfer to a local hospital, he has sonorous respirations, a HR of 120, BP 100/70, and GCS of 6. What the initial priorities in the management of this patient?
Airway protection with a subglottic device Oxygenation to prevent hypoxia Maintain SBP > 100 mmHg
In an agitated trauma patient who refuses to lay down
Assessment of airway adequacy may include suctioning
Adjuncts of ventilation problems
Pulse ox to measure oxygen saturation and gauge peripheral perfusion Capnography to assess adequacy fo ventilation
A 28-year-old male, helmeted motorcyclist was in a high speed MVC, striking head-on into the side of a vehicle. He arrives on a backboard and with a cervical collar in place via pre-hospital BLS transport. Vitals are: BP 100/75, HR 115, RR 20, GCS 15. The patient reports a brief loss of consciousness and is complaining of pain in the chest, abdomen, and pelvis. What're the priorities for management?
Rapidly assess ABCs Auscultate the lungs, provide supplemental oxygen, and apply pulse ox
A 36-year-old female was involved in an altercation, sustaining a knife wound to the chest, below the left nipple. She is mildly short of breath with an oxygen sat of 92%. BP is 115/80.
Simple pneumothorax
Eight life-threatening injuries during the secondary survey?
Simple pneumothorax Hemothorax Flail chest Pulmonary contusion Blunt cardiac injury Traumatic aortic disruption Traumatic diaphragmatic injury Blunt esophageal rupture
A 29-year-old M jumps from the 1st story of a burning house. His clothes are on fire. Bystanders extinguished the flames. He is conscious, agitated, and complaining of abdominal and leg pain. The patient's head and upper body appear to be extensively burned. What are the unique considerations that a burn injury adds to the initial management of this patient?
Some interventions to be considered are early intubation and initiation of burn resuscitation.
A patient was found 10' from his motorcycle, laying on his right side. He was wearing a helmet. He was going ~45 mph. He had brief LOC. He states he has no allergies, medications that he takes, no current illness. Last meal was 6 hours ago. Based on mechanism, what intra-abdominal and/or pelvic injuries is he likely to have sustained?
Visceral lacerations (liver/spleen) Bowel visceral/vascular injuries Retroperitoneal visceral/vascular injuries (kidneys/adrenal) Pelvic fractures
How should fluids be administered in trauma patients with shock?
Warm IVFs If unresponsive to initial IVF, give blood transfusion immediately
Possible adjuncts to secondary survey
X-rays of spine and extremities CT scans of head, chest, abdomen, spine Contrast urography and angiography TEE Bronchoscopy Esophagoscopy
A 64-year-old man involved in a high-speed car crash, is resuscitated initially in a small hospital without surgical capabilities. He has a closed head injury with a GCS score of 13. He has a widened mediastinum on chest x-ray with fractures of left ribs 2 through 4, but no pneumothorax. After initiating fluid resuscitation, his blood pressure is 110/74 mm Hg, heart rate is 100 beats per minute, and respiratory rate is 18 breaths per minute. He has gross hematuria and a pelvic fracture. You decide to transfer this patient to a facility capable of providing a higher level of care. The facility is 128 km (80 miles) away. Before transfer, you should first:
call the receiving hospital and speak to the surgeon on call
A 33-year-old woman is involved in a head-on motor vehicle crash. It took 30 minutes to extricate her from the car. Upon arrival in the emergency department, her heart rate is 120 beats per minute, BP is 90/70 mm Hg, respiratory rate is 16 breaths per minute, and her GCS score is 15. Examination reveals bilaterally equal breath sounds, anterior chest wall ecchymosis, and distended neck veins. Her abdomen is flat, soft, and not tender. Her pelvis is stable. Palpable distal pulses are found in all 4 extremities. Of the following, the most likely diagnosis is:
cardiac tamponade
A 23-year-old man sustains 4 stab wounds to the upper right chest during an altercation and is brought by ambulance to a hospital that has full surgical capabilities. His wounds are all above the nipple. He is endotracheally intubated, closed tube thoracostomy is performed, fluid resuscitation is initiated through 2 large-caliber IVs. FAST exam does not reveal intraabdominal injuries. His blood pressure now is 60/0 mm Hg, heart rate is 160 beats per minute, and respiratory rate is 14 breaths per minute (ventilated with 100% O2). 1500 mL of blood has drained from the right chest. The most appropriate next step in managing this patient is to:
urgently transfer the patient to the operating room
What are the initial treatment options that may protect the brain from ongoing swelling?
Decreasing agitation with sedation, reducing cerebral swelling with mannitol, or hypertonic saline. A neurosurgeon can drain CSF.
What are the symptoms of inadequate ventilation?
Difficulty breathing SOB Request to sit up to breath
What is the best way to manage rapid external blood loss?
Direct manual pressure on the wound
Common causes of deterioration in intubated patients
Dislodgement Obstruction Pneumothorax Equipment failures
Following the successful endotracheal intubation of an obtunded 2-year-old male involve in MVC, he is transported to CT scanner. During transport, there is a sudden deterioration of oxygen saturation. The most likely cause of this deterioration is?
Dislodgment of tube
A 10-year-old M arrives to ED after bike accident. He's complaining of upper abdominal pain. VS HR 115 BP 100/65. CT shows large splenic laceration with contrast extravasation. He returns to ED from radiology, his HR increased to 150 BP drops to 70/45. What's the appropriate next step?
Administer 20 ml/kg isotonic IVF bolus and 10 ml/kg pRBCs. The patient should undergo an emergent laparotomy/splenectomy.
A 24-year-old male arrives in ED already intubated. He has significant crepitus of the right chest wall and diminished breath sounds. You place a chest tube and note a large amount of bubbling in the water seal chamber. His O2 saturation remains at 85% and he has goodCO2 return on capnography. The most likely cause of his low oxygen saturation is
Tracheobronchial tree injury
A patient was found 10' from his motorcycle, laying on his right side. He was wearing a helmet. He was going ~45 mph. He had brief LOC. He states he has no allergies, medications that he takes, no current illness. Last meal was 6 hours ago. How would the risk of intra-abdominal injury change if the patient described stroking the handlebar into the epigastrium?
A direct blow to the epigastrium would raise the risk of a pancreas, duodenal, or small bowel injury
What's true regarding serum fibrinogen levels in pregnant patients?
A normal serum fibrinogen level late in pregnancy may indicated early disseminated intravascular coagulation
A 30-year-old male presents with a 2 cm stab wound to the mid-abdomen, 3 cm to the right of the umbilicus. VS are BP 85/60, HR 130, RR 25, GCS 14. Neck veins are flat. Chest exam is CTAB. The abdomen is tender. What's the ONE BEST therapy to treat this patient's injury?
Airway appears intact. Breathing has increased rate. Circulation demonstrated hemorrhagic shock. Penetrating abdominal injury with shock is one of the indications for emergent laparotomy.
Rapid triage and transport issues during primary survey
Airway compromise, high risk for loss of airway Tension pneumothorax, hemothorax, open pneumothorax, hypoxia Hypotension, pelvic fracture, vascular injury, open fracture, abdominal distention/peritonitis GCS < 13, intoxicated, evidence of paralysis
Primary survey
Airway maintenance with restriction of cervical spine motion Breathing Circulation Disability Exposure/Environmental control
Airway thoracic injuries
Airway obstruction (laryngeal injury, posterior dislocation of clavicular head, or penetrating trauma) Tracheobronchial tree injury
Your institution does not have surgical capabilities. You have intubated a 25-year-old man who was in a rollover MVC. You have also placed bilateral chest tubes for pneumothoraxes. The patient's SBP is continually < 90 and HR > 140. Potential therapy and evaluation includes
Activation of massive transfusion protocol, application of pelvic binder, and CXR
A 78-year-old ale is found down in the bathroom with a large left scalp laceration from striking the corner of the sink. He arrives in the ED with a BP 180/90, HR 60, dilated, non-responsive right pupil. The most likely finding on the patient's CT scan will be
Illustrtive of impending uncle hernia associated with Cushing response (high BP + bradycardia)-- associated with a large subdural hematoma with midline shift
What are two interventions for treating rhabdomyolysis?
Increase IVF to target UOP of 100 ml/hr which washes out the myoglobin before it settles Administer mannitol which acts as a free radical scavenger and osmotic diuretic therefore increasing UOP and washing out myoglobin
Reperfusion syndrome
Indicated by acidosis, hyperkalemia, and local swelling; therefore monitor the patient's cardiac status and peripheral perfusion during rewarming
Leading cause of trauma deaths worldwide
MVCs
A 3-year-old falls 10 meters out of an apartment window onto pavement. He does not open his eyes, moans incomprehensibly, and extending abnormally when stimulated. The patient is unresponsive on arrival to the ED, and pupils are unequal. He has blood coming from his right ear, is breathing rapidly, and is pale, with mottled extremities. VS are BP 74/57,HR 156, RR 49. What steps and maneuvers would you use to manage this patient's airway?
Maintain airway with chin-lift and jaw-thrust with assisted ventilation using bag mask with placement of laryngeal mask or ETT
The immediate treatment of electrical injury consists of?
Maintaining UOP of 100 ml/hr
What's critical management for trauma patients, especially those with sustained head injuries?
Maintaining oxygenation and printing hypercarbia
A CT scan reveals intracranial hemorrhage and swelling with collapse of the 3rd and 4th cventricles and impending uncle herniation. What treatment measures are appropriate?
Mannitol, hypertonic saline, and phenytoin are initial management of intracranial HTN
A 63-year-old male fell off a ladder. Witnesses report loss of consciousness. His eyes open to voice, he localizes to pain, and has garbled speech
GCS 11
A 56-year-old male repeats questions, his eyes are open, and he moves to command
GCS 14
A 17-year-old female was struck by a vehicle while crossing the road. Upon arrival she is moaning, her eyes open, and she withdraws to painful stimuli
GCS 8
A trauma patient opens her eyes, moans, and withdraws from pain. What is her GCS score?
Eye opening: 2 Verbal response: 2 Best motor response: 4 Total = 8
What are the initial management options for mild brain injury?
Monitoring isnt' required but know long-term effects can manifest over time
A conscious infant with bulging fontanelles or suture diastases should be assumed to have?
More severe injury and requires early neurosurgical consultation
A helmeted 28-year-old male fell from scaffolding. A bystander witnessed the fall and reports that the patient landed head first, causing his neck to hyperextend. His VS are BP 90/62, HR 58, RR 28, GCS 15. The patient is alert and following commands. His breathing is shallow and he is not moving his arms or legs. What type of shock does this patient exhibit?
Neurogenic
Absent spontaneous extremity movement in unconscious patient
Neurologic and/or muscular impairment
PITFALL: equipment failure
Test regularly Ensure spare equipment and batteries are readily available
The patient is unable to move his legs. He can move his fingers and wrists bilaterally. He has weal triceps extension on the left. He is unable to move right elbow. He is able to feel his fingers and thumbs bilaterally, but not feel anything above his elbow. Why is there a difference b/t the PW findings for the UE on PE?
The difference between the PE findings for the UE is likely due to initial inflammatory response, edema, and/or the presence of an incomplete spinal cord injury.
When applying the Rule of Nines to infants
The head is proportionally larger in infants than in adults
Which patients should you consider transferring, and what tests should be performed prior to transfer?
The patients whose injuries exceed your ability to care for them, either sue to specialize needs, or resource availably. Only perform testing that enables the referring physician to resuscitate, stabilize, and ensure the safer transfer of the patient
After being involved in a motor vehicle crash, a 25-year-old man is brought to a hospital that has surgery capabilities available.. Computed tomography of the chest and abdomen shows an aortic injury and splenic laceration with free abdominal fluid. His blood pressure falls to 70 mm Hg after CT. The next step is:
perform an exploratory laparotomy
A healthy young male is brought to the emergency department following a motor vehicle crash. His vital signs are a blood pressure of 84/60, pulse 123, GCS 10. The patient moans when his pelvis is palpated. After initiating fluid resuscitation, the next step in management is:
placement of a pelvic binder
The most important, immediate step in the management of an open pneumothorax is:
placement of an occlusive dressing over the wound
A 22-year-old female athlete is stabbed in her left chest at the third interspace in the anterior axillary line. On admission to the emergency department and 15 minutes after the incident, she is awake and alert. Her heart rate is 100 beats per minute, blood pressure 80/60 mm Hg, and respiratory rate 20 breaths per minute. A chest x-ray reveals a large left hemothorax. A left chest tube is placed with an immediate return of 1600 mL of blood. The next management step for this patient is:
prepare for an exploratory thoracotomy
A 22-year-old man is hypotensive and tachycardic after a shotgun wound to the left shoulder. His blood pressure is initially 80/40 mm Hg. After initial fluid resuscitation his blood pressure increases to 122/84 mm Hg. His heart rate is now 100 beats per minute and his respiratory rate is 28 breaths per minute. A tube thoracostomy is performed for decreased left chest breath sounds with the return of a small amount of blood and no air leak. After chest tube insertion, the most appropriate next step is:
re-examine the chest
A 22-year-old man sustains a gunshot wound to the left chest and is transported to a small community hospital no surgical capabilities are available. In the emergency department, a chest tube is inserted and 700 mL of blood is evacuated. The trauma center accepts the patient in transfer. Just before the patient is placed in the ambulance for transfer, his blood pressure decreases to 80/68 mm Hg and his heart rate increases to 136 beats per minute. The next step should be to:
repeat the primary survey and proceed with transfer
What findings in an adult is most likely to require immediate management during the primary survey?
respiratory rate of 40 breaths per minute
A 39-year-old man is admitted to the emergency department after an automobile collision. He is cyanotic, has insufficient respiratory effort, and has a GCS score of 6. His full beard makes it difficult to fit the oxygen facemask to his face. The most appropriate next step is to:
restrict cervical motion and attempt orotracheal intubation using 2 people
A trauma patient presents to your emergency department with inspiratory stridor and a suspected c-spine injury. Oxygen saturation is 88% on high-flow oxygen via a nonrebreathing mask. The most appropriate next step is to:
restrict cervical motion and establish a definitive airway
A 32-year-old man's right leg is trapped beneath his overturned car for nearly 2 hours before he is extricated. On arrival in the emergency department, his right lower extremity is cool, mottled, insensate, and motionless. Despite normal vital signs, pulses cannot be palpated below the right femoral artery and the muscles of the lower extremity are firm and hard. During the management of this patient, what is most likely to improve the chances for limb salvage?
surgical consultation for right lower extremity fasciotomy