JIBC PCP - PARA 1252 Trauma

What are the components of the "Trauma Triad of Death?"

1) Coagulopathy 2) Acidosis 3) Hypothermia Hypothermia impedes the coagulation cascade since heat is no longer able to add energy to the chemical reactions in the cascade. Coagulopathy leads to decreased perfusion which causes acidosis. Administration of acidic solutions such as NS also contributes to acidosis. Acidosis causes vasodilation which further contributes to hypothermia and coagulopathy.

What are the 3 stages of shock progression? Briefly describe them.

1) Compensated Shock - The body is able to compensate and maintain adequate perfusion. 2) Decompensated Shock - The compensatory mechanisms are failing and the tissues are beginning to die. 3) Irreversible Shock - Significant and irreparable tissue death.

What are the two main categories of SCI? Briefly define them.

1) Complete SCI - Permanent loss of all spinal cord-mediated function below the injury site. 2) Incomplete SCI - Some cord-mediated functioned is maintained after the injury.

Define the following: 1) Paresthesia 2) Priapism 3) Myotomes 4) Dermatomes 5) Ptosis

1) Paresthesia - Pins and needles sensation 2) Priapism - Sustained erection in the absence of appropriate stimulation 3) Myotomes - A group of muscles innervated by a single spinal nerve (Myo = Muscle and Tome = Thin Segment) 4) Dermatomes - A group of skin that is connected to a single spinal nerve (Derma = Skin) 5) Ptosis - Drooping of the eye lid

What is 'paper bag syndrome?" When is it likely to occur?

A barotrauma to the lungs caused by a sudden onset of force during an impact. In a front-end collision, many occupants take a gasping breath in. This hyperinflation of the lungs increases the likelihood that they may rupture if additional force is applied to them, such as the rapid force of a steering wheel to the chest.

What is subcutaneous emphysema? Where/why is it typically found?

A characteristic crackling sensation felt on palpation of the skin caused by the presence of air in the soft tissue. It is typically found on the chest when trauma to the lungs causes air to leak into the thoracic cavity.

What is a focal brain injury? What are the two main categories?

A focal brain injury is a specific, clearly defined brain injury. 1) Cerebral Contusion - Brain tissue is bruised and damaged in a specific area. Associated with more long-term damage than a concussion. Caused by the same MOI as concussions. 2) Intracranial Hemorrhage - Hemorrhage in the cranial vault.

Briefly define central cord syndrome.

A form of incomplete SCI where the central spinal cord is compressed. Edema or hemorrhage from hyperextension injuries can add pressure to the central cervical segments. This is more common in patients with arthritis due to increased spondylosis.

What is flail chest?

A major injury to the chest wall resulting from blunt force trauma. Defined as two or more adjacent ribs fractured in two or more places.

What is Beck's Triad? When would we see it?

Beck's Triad is a series of findings for cardiac tamponade. It include: 1) JVD 2) Hypotension 3) Muffled heart sounds

What is the cardiac output equation?

CO = SV x HR

Describe cerebral perfusion pressure (CPP) and why it is important.

CPP is the net pressure of blood flow perfusing the brain. It is calculated using the following equation: CPP = MAP - ICP. This pressure needs to be maintained in order to provide adequate perfusion to brain tissue.

What is comotio cordis?

Cardiac arrest induced by a blow to the thorax during repolarization. This can cause V-fib which responds very well to rapid defibrillation.

How many vertebrae are in each category?

Cervical = 7 Thoracic = 12 Lumbar = 5 Sacral = 5 (Fused) Coccyx = 4 (Fused)

What is compartment syndrome?

Compartment syndrome develops due to increased pressure within the soft tissue. When bleeding and inflammation occur, perfusion to the area is reduced due to the increased pressure. This can cause a build-up of metabolic by-products in the effected compartment.

What is posterior cord syndrome?

Typically associated with extension injuries. Damage to the dorsal columns (area that deals with touch sensitivity) results in decreased touch sensation and proprioception. This condition is relatively rare.

What is the most significant factor influencing energy in trauma.

Velocity. An increase in velocity will have an exponential increase on Kinetic Energy. Speed kills!!

What is crush syndrome?

When tissue necrosis begins to develop due to compartment syndrome, the muscle begins to release harmful substances such as potassium, purines, phosphate, lactic acid, myoglobin, thromboplastin, creatine, and creatine kinase. The process of this toxic release is called rhabdomyolysis. Once the limb is freed from entrapment, this build of of toxins is released, flooding the rest of the body with harmful substances. Progression of Crush Syndrome: 1) Body part is trapped for more than 4 hours 2) Rhabdomyolysis occurs 3) The trapped part is freed 4) By-products of metabolism and harmful products from necrosis are released. Possibly resulting in cardiac arrest, dysrhythmias, kidney damage, hyperkalemia, and hyperphosphatemia.

What are three things required for adequate perfusion?

1) A functioning pump (the heart) 2) Adequate fluid volume 3) Intact vasculature with the ability to adapt as needed (constrict/dilate)

What are the two major classifications of trauma?

1) Blunt 2) Penetrating

List the 4 main categories of shock.

1) Cardiogenic Shock 2) Obstructive Shock 3) Distributive Shock 4) Hypovolemic Shock

What are catecholamines?

Hormones created by the adrenal medulla that create a sympathetic nervous response. The chief catecholamines are epinephrine, norepinephrine, and dopamine.

Define and describe hypoperfusion.

Hypoperfusion is a lack of adequate blood flow to the organs. Reduced blood flow decreases the levels of oxygen and nutrients that the tissues receive causing ischemia.

What is the formula for calculating MAP?

MAP = DBP + (SBP-DBP)/3 OR MAP = (SBP + 2DBP)/3

What is a myocardial contusion.

Myocardial contusion is bruising to the heart's tissue caused by blunt trauma. In rapid deceleration, the heart can slam into the thoracic cavity and become confused. This can cause issues with cardiac perfusion. Complications are similar to those found in an MI.

What nerve innervates the diaphragm? What vertebrae is it found in?

Phrenic nerve. C3-C5

List and describe the components of blood

Plasma - A watery fluid that accounts for more than one-half of the blood's fluid volume. RBCs (Erythrocytes) - Cells containing hemoglobin which are transported to the cells in the plasma. WBCs (Leukocytes) - Fight infection. Several types exist including granulocytes (neutrophils, eosinophils, and basophils), monocytes, and lymphocytes (T cells and B cells). Platelets - Small cells in the blood which are essential for clot formation.

What is a primary (direct) brain injury? What is a secondary (indirect) brain injury?

Primary Brain Injury - Injury resulting instantaneously from impact to the head. Secondary Brain Injury - Consequence of the primary injury including edema, hemorrhage, increased ICP, ischemia, hypoxia, hypoglycemia, hypotension, and infection.

What type of motor vehicle collision has the lowest mortality?

Rear-End

Define rubor, tumor, dolor, and calor as they relate to inflammation.

Rubor = Redness Tumor = Swelling Dolor = Pain Calor = Warmth

What is the target SBP for a TBI.

110-120 mmHg

What is a normal ICP in adults?

5-15 mmHg

What is the critical minim threshold for CPP in adults?

60 mmHg

What is potential energy?

Stored energy in a stationary object. (I.E. A stretched elastic, a coiled compressed spring, or a car that is suspended over the edge of a bridge).

Define Brown-Sequard Syndrome

This condition results from a penetrating trauma that partially cuts (hemisection) the spinal cord. The damaged side will present with motor loss, as well as all the symptoms associated with posterior cord syndrome (loss of sensation to light touch and loss of proprioception). The non-injured side presents with loss of sensation to pain and temperature.

What is a positive "Babinski Reflex?"

Toe extension in response to stimulation of the sole of the foot in patients above the age of 2. This is a sign of a CNS disorder.

List some common criteria that would deem a trauma patient as "unstable."

-Inadequate respirations -Pulseless limbs after realignment -Major hemorrhage -Decreased LOC -Multi-System Trauma -Literally, anything that you cannot fix on your own

Define the following terms: 1) Contusion 2) Ecchymosis 3) Erythema 4) Abrasion 5) Avulsion 6) Hematoma

1) Contusion - Closed wound where the skin is not broken but damage has occurred to the tissue underneath. 2) Ecchymosis - Black & blue discoloration of the skin due to leakage of blood into the tissues. 3) Erythema - General redness of the skin due to dilation of the superficial capillaries. 4) Abrasion - Scrapping of the epidermis and the upper levels of the dermis. 5) Avulsion - Forceful tearing away or separation of the body tissue; may be partial or complete. 6) Hematoma - Collection of blood beneath the skin or trapped within a body compartment.

What are the 5 phases of a collision?

1) Deceleration of the vehicle 2) Deceleration of the occupant 3) Deceleration of the internal organs 4) Secondary impacts (From inside the vehicle) 5) Additional impacts (from outside the vehicle)

Define the following terms: 1) Diplopia 2) Nystagmus 3) Hyphema 4) Anisocoria

1) Diplopia - Double vision 2) Nystagmus - Repetitive, uncontrolled movement of the eye 3) Hyphema - Bleeding into the anterior portion of the eye 4) Anisocoria - Pupils of unequal size

What are the 4 types of intracranial hemorrhage?

1) Epidural hematoma - Accumulation of blood between the skull and dura mater. It usually results from a linear fracture and can cause rapid death. 2. Subdural hematoma - Accumulation of blood beneath the dura mater. It usually occurs in falls or injuries with rapid deceleration. 3. Subarachnoid hematoma - Bleeding occurs in the subarachnoid space. Caused by trauma or aneurysm rupture. Usually results in death. 4. Intracerebral Hemorrhage - Bleeding within the brain tissue itself. Often caused by penetrating trauma or rapid deceleration. Can commonly be caused by a stroke. Usually results in death.

List/locate as many face bones as you can.

1) Frontal bone = forehead 2) Nasal bones = top of the nose 3) Vomer bone = midline bone that divides the nasal cavity 4) Middle & Inferior Nasal Concha = Curved bone shelves in the nasal breathing passage 5) Lacrimal Bone = Medial eye bone by the nasolacrimal duct. 6) Ethmoid Bone = Superior/posterior to the lacrimal bone 7) Zygomatic Bone = Cheekbone 8)Maxillae Bone = Upper jaw 9) Mandible = Lower Jaw 10) Palatine Bone = Hard palate 11) Sphenoid Bone = Posterior to the palatine. Connects the face to the skull at the temporal bone.

What are the 5 types of MVI impact paterns?

1) Frontal or head on 2) Lateral or side impact 3) Rear impact 4) Rotational 5) Rollover

List the 4 types of motorcycle impacts.

1) Head-on Impact 2) Angular Impact 3) Ejection 4) Laying the Bike Down

What are 5 factors that affect the severity of a fall injury?

1) Height - How far did they fall from? 2) Position - How were they oriented on impact? (Children tend to fall head first because they have huge disgusting heads) 3) Area - How great of an area struck at the time of impact? A greater surface area will help dissipate force. 4) Surface - What did they land on? Foam pits are better than asphalt. 5) Physical Condition - Physical condition of the patient. Do they have good muscle mass that can help them decelerate? Do they have osteoporosis? Kids are also more elastic and can tolerate some falls better.

What are the 5 stages/processes of wound healing?

1) Hemostasis - The initial process to stop blood loss. 2) Inflammation - Granulocytes and macrophages travel to the site for phagocytosis and to release chemotactic factors to attract other immune cells. Granulocytes degranulate releasing histamine and other chemical mediators. 3) Epithelialization - The production of a new layer of epithelial cells on the skin's surface. Cells from the stratum germinativum (lowest layer) multiply and redevelop over the edges of the wound. Scar tissue results from a build-up of collagen in larger wound sites. 4) Neovascularization - New blood vessels form and expand from other vessel sites like tree roots. 5) Collagen Synthesis - Collagen, a fibrous, structural protein, is synthesized by fibroblasts. Collagen acts as a structural support for new tissue.

What are the physiological responses in Cushing's Triad?

1) Increased BP 2) Irregular breathing pattern, bradypnea, or apnea 3) Bradycardia

Briefly describe the different Le Fort Fractures.

1) Le Fort I - Horizontal fracture to the maxilla that involves the hard palate and inferior maxilla. 2) Le Fort II - Pyramidal fracture involving the nasal bone and inferior maxilla. 3) Le Fort III (Craniofacial Disjunction) - Fracture of all midfacial bones, separating the entire mid-face from the cranium.

What are the 4 types of skull fractures?

1) Linear - No skull displacement. Approximately 80% of all skull fractures. Most common in the temporal-parietal region 2) Depressed - Depression in the skull. The frontal and parietal are most susceptible. 3) Basilar - Associated with high energy mechanism. Often present with CSF leakage, battle sign, and periorbital ecchymosis. 4) Open - An open wound to the cranial vault. Bad for infections, but good for reducing ICP.

What are the top 5 causes of trauma death?

1) MVCs 2) Falls 3) Poisoning 4) Burns 5) Drowning

What are the indications for TXA?

1) Major trauma patients with ongoing, significant, uncontrolled internal or external hemorrhage; and; 2) 12 or above; and, 3) Systolic blood pressure less than 90 mmHg or Heart rate greater than 110 beats per minute; and, 4) Are within 3 hours from the time of injury and on route to a receiving hospital.

Briefly list and define the three categories of diffuse axonal injury (DIA)

1) Mild DIA - Minimal axonal damage. Most common in blunt head trauma. Brief DLOC, confusion disorientation, and amnesia. Minimal or no long-term impairment. 2) Moderate DIA - Axonal damage and petechial (spotty) bruising to the brain. Associated with basilar skull fractures. Immediate loss of consciousness, persistent confusion, cognitive impairment, frequent periods of anxiety, uncharacteristic mood swings, & sensory/motor deficits. Permanent neurological impairment likely.' 3) Severe DIA - Severe disruption of many axons in both cerebral hemispheres with damage spreading to the brainstem. Immediate and prolonged loss of consciousness, posturing, and other signs of increased ICP. Survival is unlikely.

What are the 6 P's of compartment syndrome?

1) Pain 2) Paresthesia 3) Paresis (partial paralysis due to nerve damage) 4) Pressure 5) Passive stretch pain 6) Pulselessness

What are the 5 mechanisms of blast injury?

1) Primary Blast Injury - Damage from the blast pressure wave (made worse by water). 2) Secondary Blast Injuries - Damage from flying debris. 3) Tertiary Blast Injuries - Injuries from being hurled by the force of the blast (action movie stars are not affected by this mechanism). 4) Quaternary (miscellaneous) Blast Injuries - Burns, inhalation injuries, crush injuries, and anything else resulting from the blast that doesn't fall into any of the other categories. 5) Quinary Blast Injuries - Caused by biological, chemical, or radioactive that have been added to an explosive device. Associated with terrorist bombings (i.e. "Dirty Bombs")

List and define key parts of the eye.

1) Sclera - White of the eye 2) Cornea - Transparent anterior portion of the eye that overlies the iris and pupil 3) Conjunctiva - Delicate mucous membrane that covers the sclera. and internal surface of the eyelids. 4) Iris - Pigmented part of the eye. Contains muscles and blood vessels to constrict the pupil. 5) Pupil - Adjustable opening in the iris. Allows light to pass through to the lens. 6) Lens - Transparent structure that alters its thickness to focus light onto the retina. 7) - Retina - Posterior aspect of the interior globe. A delicate, 10-layered structure of nerve tissue that extends from the optic nerve. Receives light and converts it to nerve signals. 8) Anterior Chamber - Area between the lens and cornea. Filled with aqueous humour. 9) Posterior Chamber - Area between the lens and the retina. Filled with vitreous humour.

What are the sub classes of distributive shock? Briefly describe each of them.

1) Septic - Caused by widespread infection. Vasodilation and increased vascular permeability. 2) Anaphylactic - Caused by a severe allergic reaction. Vasodilation and increased vascular permeability. 3) Neurogenic - Caused by TBI or SCI. Neurological damage reduces vascular tone and inhibits sympathetic nervous response. 4) Psychogenic - Syncope

Briefly describe the difference between simple pneumothorax, open pneumothorax, and tension pneumothorax.

1) Simple Pneumo - Air build-up between the visceral and parietal pleura. 2) Open Pneumo - A hole in the chest wall allows air to enter the pleural space from the outside. On each inspiration, negative pressure draws air through the new opening. This is a "sucking chest wound." 3) Tension Pneumo - This is a severe progression of pneumothorax where one side of the lung is almost entirely collapsed and the air buildup is putting pressure on other thoracic organs such as the heart and other lungs. Damage to the pleura creates a one way valve which causes air pressure to continuously build up in the pleural space.

Define the Spalding effect, inertial effects, and implosion as they relate to pulmonary contusions.

1) Spalding effect - Pressure waves generated by trauma disrupt the capillary-alveolar membrane causing hemorrhage 2) Inertial effect - Tissue density differences between alveoli and bronchioles cause them to oscillate at different rates. This difference causes tearing 3) Implosion - Gasses in the lungs are compressed by the force of trauma. If the gasses expand too much after compression, they can damage the lung

Name the anatomy of the sternum from superior to inferior.

1) Suprasternal notch - Notch at the top of the sternum anterior to the trachea. 2) Manubrium - Upper plate of the sternum connected to the first rib 3) Angle of Louis - Joint of the manubrium and sternal body 4) Sternal body - Central structure of the sternum with most rib cartridges attached 5) Xiphoid process - Pointy, inferior section of the sternum

List and describe three types of trauma centres.

1) Tertiary Trauma Centre - The highest level of care. Staffed 24/7 to handle all types of trauma. 2) District Trauma Centre - Surgical capabilities for most trauma cases. Have the ability to stabilize specialty or multisystem trauma cases before transport to higher level of care. 3) Primary Trauma Centre - General hospital with the ability to manage minor trauma. Can stabilize and triage more minor trauma for transport to a higher level of care.

What are the three main pathways an unrestrained driver's body might take in a head-on collision? What are some injuries that might be sustained from each pathway?

1) Up and over pathway: Spinal injuries, face/skull injuries, laryngeal fractures, femur fractures, hollow organ rupture, liver laceration, diaphragm rupture, thoracic injuries 2) Down and under pathway: Lower leg fractures, upper leg fractures/dislocations, hip/pelvic fractures, facial fractures, spinal injuries, rib fractures/flail chest, aortic tear, myocardial contusion, and paper bag syndrome. 3) Ejection: All injuries associated with "Up and Over" plus additional injuries from secondary impact after exiting the vehicle.

What are the 3 steps of the clotting process? Describe them.

1) Vascular Phase - As a blood vessel is torn and begins to lose blood, its smooth muscle contracts. This reduces the lumen size and the volume and strength of the blood flowing through it. 2) Platelet Phase - The damage to the tunica intima creates friction which damages the surface of the platelets, making them sticky. The platelets adhere to collagen in the vessel's wall and begin to aggregate, creating an unstable clot. 3) Coagulation - Enzymes are released from either the damaged tissues (extrinsic pathway), the platelets (intrinsic pathway), or both. These pathways eventually lead to the common pathway after the production of factor X. A further series of coagulation leads to the production of fibrin, a strong protein webbing which secures the clot. The coagulation process takes approximately 7-10 minutes.

What is Waddell's triad? How does it differ from adult pedestrian impacts?

A pattern of injuries resulting from a child pedestrian being struck by a vehicle. Children tend to turn and face an oncoming vehicle. 1) The bumper hits the pelvis and femurs instead of the knees and tibialis. 2) The chest and abdomen hit the grille or low on the hood of the car (Sternal rib fracture). The child is pushed out or down instead of up and over like an adult. 3) The head strikes the vehicle and then the ground. The child may be dragged or run over.

What is the "Golden Hour" of trauma management?

A term used to identify an ideal timeline for patient transport to a surgical facility. Patients brought to a surgical unit within one hour of the injury have a greater likelihood of survival.

What is a TBI?

A traumatic brain injury (TBI) is a condition where sudden damage causes a decrease in brain function.

Describe aerobic and anaerobic metabolism

Aerobic metabolism uses oxygen and glucose to create ATP. Anaerobic metabolism burns sugars without the presence of oxygen. This inefficient process has byproducts such as lactic acid.

What is neurogenic shock?

An inability to maintain sympathetic tone due to loss of nerve function. The parasympathetic nervous system dominates and produces a shock state.

What is Newton's first law?

An object at rest stays at rest and an object in motion stays in motion with the same speed and in the same direction unless acted upon by an unbalanced force.

Define decorticate and decerebrate posturing.

Decorticate - Flexion of the arms and extension of the legs Decerebrate - Extension of the arms and legs.

What is a diffuse brain injury? What are the two main catagories?

Diffuse brain injury is any injury that affects the entire brain. They are classified as either: Cerebral Concussion - Caused by the brain being jarred in the skull. Coupe/contrecoup type of injury. Diffuse Axonal Injury (DIA) - Similar to a concussion but also involves stretching, shearing, or tearing of nerve fibres with damage to the nerve axon.

What is anterior cord syndrome?

Disruption of the blood flow from the anterior spinal artery. This artery provides blood to the anterior 2/3 of the spinal cord. This condition is typically caused by flexion injuries. Patients will lose sensation below the injured site.

What types of energy are used to deploy an air bag

Electrical energy sends a signal from the sensors to the airbag. Then, chemical energy is used to detonate the blast filling the bag with nitrogen.

What is Newton's second law? How does this apply to trauma?

Force = mass x acceleration (or deceleration). A car going 50km/h that gradually applies the brakes and slows down over the course of 100m will not have the same force as a car traveling 50km/h that suddenly strikes a bridge pillar and is stopped instantly.

Explain the the mechanisms that increase ICP and the possible result of that process.

The cranial vault is an enclosed, non-playable space with a fixed volume (Monro-Kellie Hypothesis). Hemorrhage or swelling in the cranial vault increases intracranial pressure. This increase in pressure will continue to take up volume in the cranial vault and push out other matter such as blood or the brain itself.

What is kinetic energy? BONUS: What is the formula for kinetic energy?

The energy of an object in motion. KE = (M/2)*(V^2)

What is a coupe injury? What is conta-coupe?

The initial impact of the brain against the skull. Contra-coupe is the second collision due to recoil in the opposite direction.

What are meninges?

The membranes that surround the brain and spinal cord. Dura mater, arachnoid, and pia mater (external to internal).

What is cavitation?

The outward motion of tissue due to a projectile's passage, resulting in a temporary cavity and vacuum.

What is brisance?

The shattering effect of a shock wave and its ability to cause disruption of tissues and structures.

What are the possible complications of administering a NS bolus.

There are three key issues that relate directly to the trauma triad of death. 1) NS is acidotic (approximately 5.5 pH) which will contribute to the metabolic and possible respiratory acidosis brought on by trauma. 2) NS is typically stored at room temperature which is significantly colder than your patient's blood. This contributes to hypothermia. 3) NS will dilute clotting factors in the blood further contributing to coagulopathy. Furthermore, rapidly increasing blood pressure can push out loose platelet clots before they have a chance to fully stabilize. **Please note, this does not mean that NS is always bad. We just need to have an understanding of some of the complications so that we are aware of the risk vs benefit of a NS bolus in a trauma patient.