PMS III Week 6 (Intro to Trauma)

first line of defense

Physical & mechanical barriers

-Tightly bound epithelial cells fight off bacteria

-Skin, GI, GU, and respiratory tract

Biochemical barriers are substances meant to trap or destroy pathogens

-Mucus, perspiration, saliva, tears, earwax

If these barriers are invaded, the second line of defense is activated, and inflammation occurs

Second Line of Defense - Signs and Microcirculatory Changes

Inflammatory Signs: Redness, Heat, Swelling, Pain

Microcirculatory changes:

-Blood vessel dilation (increase blood flow)

-Increased vascular permeability

-Migration of WBC to site of injury (pus = dead WBC)

image of pathophysiology with cellular injury and pathogenic invasion

pain can arise directly from neuro injury but also inflammation

Stress Response to Injury

The body's stress response is initiated by the CNS and the endocrine system

Typically begins in the limbic system

Results in release of catecholamines from the adrenal gland and ultimately the release of cortisol

stress response lead to release of catecholamines which stimulate 2 classes of receptors - α & β

identify the role of α1, α2, β1, and β2

α1 - Increases smooth muscle contraction

α2 - GI & vessel muscle contraction, platelet aggregation, insulin secretion

β1 - Increases cardiac contraction (contractility and rate)

β2- Bronchial, vessel, GI/GU muscle relaxation, gluconeogenesis, releases insulin

Epinephrine works on?

Norephephrine works primarily on?

» Epinephrine works on α & β

» Norephephrine works primarily on α

epinephrine has a greater influence on?

greater influence on cardiac action

norepinephrine has a greater influence on?

primarily effects blood pressure through vessel smooth muscle contraction

cortisol

allows for gluconeogenesis and elevation of blood sugar

Systemic Reaction to Trauma/Stress

cardiovascualr

•Increased cardiac output

•Increased blood pressure

•Increased cardiac contractility

Systemic Reaction to Trauma/Stress

pulm

bronchodilation

Systemic Reaction to Trauma/Stress

GI

liver increases gluconeogenesis

Systemic Reaction to Trauma/Stress

MSK

decrease glucose uptake in skeletal muscle and adipose

Systemic Reaction to Trauma/Stress

integumentary

•Piloerection (goosebumps)

•Increase sweat gland action

Systemic Reaction to Trauma/Stress

immune

•Anti-inflammatory effects

•Decreased circulating WBCs

Systemic Reaction to Trauma/Stress

endocrine

•Decreased insulin excretion by pancreas

•Hyperglycemia

Systemic Reaction to Trauma/Stress

renal

•Increased water retention

•Decreased urinary output

Patients who arrive in the trauma bay have injuries that exceed their natural defenses and have triggered the stress response

Multisystem trauma patients presenting in shock are at risk of?

Multisystem trauma patients presenting in shock are at risk of total disruption of their homeostasis

SHOCK

3 risk factors to patients' mortality ?

-Coagulopathy (hypercoagulation bc platelets DON'T work --> can't clot)

-Hypothermia

-Acidosis (circulating blood is acidic, heart does not function properly)

Coagulopathy

presentation? what do we do to help patient?

Severely injured trauma patients are at risk of HYEPRcoagulopathy bc clotting factors do not work when their body temperature is lowered

To prevent coagulopathy, we need to focus on rewarming the patient to avoid worsening hypothermia and stop blood loss

Hypothermia

presentation? how do we help patient?

May be present when the patient arrives

Can develop in ER if patient is left uncovered

Measures to rewarm patient should be taken:

-Temperature of trauma bay >80ºF

-Administer warmed fluids (around 102)

-Apply warm blankets

-Control hemorrhage rapidly

Acidosis

what occurs? can lead to?

Inadequately perfused cells are deprived of essential substrates for normal aerobic metabolism and energy production

Anaerobic metabolism occurs and lactic acid is formed resulting in metabolic acidosis

Prolonged acidosis can lead to end organ damage and multisystem organ failure

Blunt vs Penetrating Trauma

Blunt Trauma - A direct blow

Ex: falls, motor vehicle collisions (MVC), motorcycle crash (MCC)

Penetrating Trauma - enters into body cavity

Ex: GSW, stab wounds (SW), impalements

Sometimes combined!

Basics of Trauma (ABCDEs)

A - airway

B - breathing

C - circulation

D - disability

E - exposure

primary vs secondary vs tertiary surveys

Primary survey - the quick initial exam, ABCDE evaluated (and resolve ABCDE FIRST)

Secondary survey - the follow-up, more detailed exam (complete H&P done!!)

Tertiary survey - done approx. 24 hours after injury, detects additional injuries (can be done even if pt is intubated)

A- Airway

Inadequate delivery of air to the lungs prevents oxygenated blood from getting to the brain and vital structures

First area of assessment and frequent reassessment

Examine for patency and obstruction

physiologic signs of airway obstruction

hypoxia

-Patient agitated

-Low pulse oximetry

-Cyanosis (late finding)

physiologic signs of airway obstruction

hypercarbia

Not enough carbon dioxide being expelled

-Patient obtunded

-Monitor capnography / end tidal CO2

O2 can't get in, CO2 can't get out

physiologic signs of airway obstruction

abnormal sounds

-Stridor

-Gurgling

-Snoring

-Hoarseness

Managing Airway Obstruction

-Clear the airway

-Head tilt, jaw thrust

-Suction

-Administer oxygen

-Open and secure an airway (if excessive bleeding, for example)

-Insertion of artificial airway

-Prevent excessive movement of

cervical spine (cervical collar)

-Call anesthesia STAT

B - Breathing

Evaluation of breathing & ventilation

-Adequate gas exchange within alveoli

-Alterations may be due to chest trauma or destruction of alveoli

Examination includes observation of chest wall expansion, assessing breath sounds

Initial diagnostics may include checking ABG! esp if considering vent/intubation

alterations in ventilation: hypoxemia

not enough oxygen being absorbed in alveoli

alterations in ventilation: hypoxemia

pulse oximetry, ABG results?

Pulse Ox

-Goal above 95%

-COPD above 92%

ABG Results

-Normal PaO2 80-100

alterations in ventilation: hypercapnia

not enough CO2 being offloaded through alveoli

alterations in ventilation: hypercapnia

ABG results?

-Normal PaCO2 35-45

-Tachypnea

managing breathing abnormalities

-supplemental O2

-insertion or nasal or oropharyngeal airway

-definitive airway

-mechanical ventilation

-management of chest trauma

C - Circulation

Is the patient perfusing?

Includes monitoring of vital signs

-Blood pressure

-Pulse rate and

character

-Respiratory rate

-Pulse pressure (SBP-DBP)

circulation exam includes

-Auscultation heart

-Palpating central and distal pulses (may be decreased in the periphery)

-Capillary refill

Shock

classifications/types of shock

An abnormality in the circulatory system that results in inadequate organ perfusion and tissue oxygenation

Shock in trauma patients is classified as hemorrhagic or non-hemorrhagic

Types of shock: hypovolemic, cardiogenic, neurogenic, septic, anaphylactic

Shock associated with injury is most often ?

Shock associated with injury is most often hemorrhagic/hypovolemic in nature.

any patient who is cool to the touch and tachycardic should be considered in shock

________ may be the first sign of shock

tachycardia may be the first sign of shock

Hypovolemic Shock: what happens as a patient loses blood volume?

As a patient loses blood volume:

•The body attempts to preserve cardiac output

•HR increases... Tachycardia may be the first sign of shock

•The body attempts to maintain venous return

Shock is not simply a change in one vital sign but recognizing inadequate tissue perfusion! Relying solely on BP can delay recognition.

Amount of circulating blood volume determined by?

Amount of circulating blood volume determined by cardiac output

Class 1 Shock

Class 1 -

Class 2 Shock

Class 2 - 15-30% loss

-Tachycardia, tachypnea, decreased pulse pressure

-Most patients stabilize with IV fluids (NS or LR, euvolemic IVF)

Class 3 Shock

Class 3 - 31-40% loss

-Non perfusing tissues

-Tachycardia, tachypnea, decrease blood pressure

-Requires blood product AND 1 L bolus of NS or LR!

Class 4 Shock

Class 4 - >40% loss

-Immediate life threat

-Needs rapid transfusion and surgical interventions (more than 1 unit, not JUST RBCs... involves PRBC, FFP, platelets, cryoprecipitate, etc!)

Shock Classes - Comparing 1-4

D - Disability

•A rapid neurologic evaluation to determine a patient's LOC

•Also includes assessing pupillary size and reaction

•Lateralizing signs (elicit pain --> is only one side reacting? and how?)

•Spinal cord injury and level

GCS scoring

Eyes

4 Open spontaneously

3 Opens to verbal command

2 Opens to pain

1 Unresponsive

Verbal

5 Speaks spontaneously, makes sense

4 Speaks spontaneously, but is confused

3 Speaks spontaneously, does NOT make sense

2 Makes only sounds (goans, mumbles)

1 Unresponsive

Motor

6 Obeys commands

5 Localizes pain

4 Withdrawal from pain

3 Flexion to pain (turn inward)

2 Extension to pain (turn outward)

1 Unresponsive

GCS LESS THAN ___ = INTUBATE

GCS LESS THAN 8 = INTUBATE

alterations in GCS can be caused by....

-shock (decreased cerebral perfusion)

-direct cerebral injury

-hypoglycemia

-alcohol

-drugs

the goal is to prevent secondary injury!! (anoxic brain injury)

E - Exposure

Facilitate a thorough examination

-Cut off all clothing

-Remove shoes and socks

-Log roll patients to see posterior side

-Be mindful of axilla and groin

Remember: These patients are at significant risk of hypothermia!

DECISION TIME! Treatment after assessing the big picture (VS, PE, Mental status, MOA)

- direct to OR

- imaging in trauma bay

- intubation

- proceed to CT scan

operative interventions for a trauma

- some pts will need to go directly to OR to manage injuries

- damage control surgery

- ongoing resuscitation

patients tend to get more sick before they get better

postoperative complications

Tailor towards your surgical specialty

Most common complications:

•Bleeding

•Pain

•Fever

•Urinary Retention

•Hyperglycemia

•Infection

Postoperative Bleeding

one of the most dangerous and obvious complications ... URGENT, see ASAP

Requires prompt examination

-Focus on dressings, drains, and compartments

-Drain management (to monitor volume)

Diagnostics for Postoperative Bleeding

- serial H&H and tracking trends

- possible CT with contrast (may be needed if there is no drain)... be specific with order too

Postoperative Pain

important to consider multimodal pain regimen such as?

-Oral and IV forms of medication

-Non-narcotic medications: NSAIDs, Toradol, etc.

-Adjuvant therapies

-Repositioning

-Adjustment of splints and wraps

-Augmenting pain medications

-Pain specialists

Fever - Most Common Causes (6 W's)

-Wind: atelectasis (MC IMMEDIATELY POST OP) and pneumonia (prevent atelectasis --> prevent PNA)

-Waves: EKG changes and MI

-Wonder drugs: drug or transfusion (MC) related

-Water: UTI

-Walking: venous thromboembolism

-Wound: infections (POD 5-7)

Postoperative Urinary Retention

Patient unable to void for 6-8 hours, suprapubic pain

if they haven't, do a straight cath

Urinary Retention Management

•Close monitoring for those who have had spinal epidural blocks

•Requires bladder scanning

•Threshold for placing catheters (straight cath- determines need to keep cath in)

•Repeat catherization may require placement of indwelling catheter (Foley)

when does the bladder start over-distending

>300 mL

at this point, have to leave catheter in bc muscle tone in the bladder is decreased (musculature is affected from stretching)

Postoperative Hyperglycemia

Stress and trauma (from surgical intervention) can cause persistent hyperglycemia

liver undergoing increased gluconeogenesis (this is expected after surgery)

Postoperative Hyperglycemia - Management

Management

-Restarting of home oral hypoglycemics

-Insulin sliding scales

Target range below 180

-Persistent hyperglycemia can lead to poor wound healing and increased risk of surgical site infections

Postoperative Hyperglycemia - Management with Insulin

2 blood sugars >200 significantly decreases wound healing

may need to give insulin temporarily while they heal

postoperative infections occurs

typically occurs 7-10 days after surgery

physical signs of postoperative infection

-Erythema surrounding wound

-Purulent drainage / persistent serous drainage

-Fluctuance surrounding or within wound

-Increased HR, decreased BP, fevers

**remember Tylenol can mask a fever**

labwork and imaging for postoperative infection

Labs - Increased WBC

Imaging - Ultrasound or CT scan

treatment for postoperative infection

culture wounds!

- IV or PO antibiotics depending on patient status and site of infection

- Potential drainage of abscess/fluid collections

Postoperative Reassessments

•Frequent rounding on postoperative patients can prevent complications

•Diligent postoperative checks

•Treatment of trauma patients requires continual reassessments

•Tertiary surveys

•Inform attending/surgeons of changes in clinical examinations