Kaap 608 exam III

what is immediate management for a scalp laceration?

1. debride wound

2. direct pressure (10-15 mins)

3. approximate wound (may be accomplished up to 24 hours post-injury)

when should you transport for a scalp laceration?

if there are any visible or palpable bony defects

what are the different types of skull fractures?

1. depressed

2. linear

3. basilar

how common are skull fractures?

third most common fracture site for children and adolescents

why do scalp lacerations bleed significantly?

the head and face is highly vascularized

what are signs and symptoms of a skull fracture?

- bleeding

- ecchymosis

- pain

- headache

- nausea

- blurred vision

- diminished pupillary reaction to light

- Battle's sign

what is Battle's sign?

bruising behind the ears

what is immediate management for skull fractures?

1. avoid direct pressure

2. transport

what is the frequency of concussions?

about 2/3 of ED visits are related to concussions (age <19)

what are the risk factors for concussions?

- previous history of concussion

- young age

- high risk sport participation (soccer, football, hockey)

what do you have to be careful of with concussion patients?

- post-concussive syndrome

- second impact syndrome

what are signs and symptoms of concussions?

1. physical changes

2. cognitive changes

3. behavioral changes

what is involved in a concussion assessment?

- life threatening injuries are assessed first (cervical spine and hemorrhage)

- remove patient from participation and assess in a quiet space

- no definitive test exists, use combination of assessments

what are examples of concussion assessments?

- SCAT-6

- SAC

- King Devick

- BESS

-VOMS

what are factors to consider for transporting a concussion?

- prolonged LOC >1 minute

- suspected c-spine injury

- high impact or high risk mechanism for intracranial bleed

- suspected skull fracture

- post-traumatic seizure

- significant worsening of condition -- persistent nausea and vomiting, focal neurologic deficits, deteriorating neurological status including slurred speech, inability/difficulty walking, worsening mental status

what is normal intracranial pressure?

7-15 mm Hg

what are the signs and symptoms of intracranial pressure?

- headache

- nausea/vomiting

- confusion

- double vision

- unequal pupil size

- seizures

what is immediate management for intracranial pressure?

transport

what is the mechanism for an intracerebral contusion?

direct blow or acceleration/deceleration injury

what are signs and symptoms of an intracerebral contusion?

- sleepiness

- dizziness

- confusion

- nausea/vomiting

- coordination difficulties

- seizures

- tinnitus -- ringing in the ears

- loss of consciousness

what is immediate management for intracerebral contusion?

immediate medical referral

what is a hematoma?

collection of dry blood

what is the mechanism for an epidural hematoma?

- focal injuries often caused by a linear and direct impact force

- associated with skull fractures and lacerations

what are signs and symptoms of an epidural hematoma?

- headache

- nausea/vomiting

- seizures

- focal neurologic deficits -- aphasia, weakness, numbness, visual field disturbances

what is immediate management for an epidural hematoma?

1. stabilize ABCs

2. Immobilize

3. Transport immediately

what is the frequency of subdural hematomas?

leading cause of sports related fatalities

what is a subdural hematoma?

bleeding collects under the inner layer of the dura mater but external to the brain and arachnoid membrane

what are risk factors for subdural hematoma?

- head trauma

- post-surgical complications

- anticoagulation drug therapy

- non-traumatic cerebral aneurysm

what are signs and symptoms of a subdural hematoma?

- deteriorating neurological function

- decreasing LOC

- decreasing or irregular respiration

- decreasing or irregular heart rate

- unequal, dilated, unreactive pupils

what is immediate management of subdural hematoma?

1. assess ABCs and LOC

2. head injuries can escalate quickly, be prepared to transport

what is a primary headache?

headache is the pathology, no other condition caused it

what is a secondary headache?

felt as a result or symptom of a different pathology (whiplash, environmental changes, TBI)

where will you feel pain for a sinus headache?

pain is usually behind the forehead or cheekbones

where will you feel pain for a cluster headache?

pain is in and around one eye?

where will you feel pain for a tension headache?

pain is like a band squeezing the head

what is a migrane?

pain, nausea, visual changes are typical of classic form

what does SSNOOP stand for?

S - systematic signs and symptoms

S - systemic disease

N - neurological signs and symptoms

O - onset sudden

O - onset in individuals over 40 years

P - previous headache pattern

what is an ischemic stroke?

gradual onset and more long-term injury, blockage stops the flow of blood to an area to the brain

what are risk factors for an ischemic stroke?

- dyslipidemia

- diabetes

- smoking

what is a hemorrhage stroke?

sudden onset and can recover faster, weakened or diseased blood vessels rupture

what are risk factors for a hemorrhage stroke?

drug use

what is immediate management for a stroke?

1. transport immediately to hospital with advanced stroke care

2. FAST -- facial drop, arm weakness, speech difficulty, time to call 911

what are the types of seizures?

- general

- focal onset

- unknown onset

how long do seizures usually last?

3 minutes and can occur in clusters

what are causes of seizures?

- congenital disorders

- metabolic abnormalities

- toxins

- infections

- inflammatory conditions

- hypoglycemia

- hyponatremia

- hypernatremia

what is immediate management for a seizure?

- depends on cause, if physical convulsions protect patient from injury but do not restrain

- hypoglycemic -- administer simple carbohydrate

- advanced emergency treatment for some seizures -- diazepam suppository

- immediate advanced medical care transport for long-duration, frequent seizures, presentation change, those experiencing a seizures without known disorder

what are ocular indicators of closed head injury?

- anisocoria -- unequal pupil size, <3mm

- unequal movement

- unequal alignment, differing directions

- inability to follow finger motion

- bleeding under conjunctiva that obscures the sclera (white part of the eye)

- protrusion or bulging

what is a corneal abrasion?

occurs when the epithelium of the eye's surface is injured

what are signs and symptoms of a corneal abrasion/ foreign object in the eye?

- pain

- blurred vision

- sensation of foreign body in the eye

- photophobia -- light sensitivity

- tearing

what is immediate management for a corneal abrasion/ foreign object in the eye?

- irrigate the eye (from nose outward)

- assess motion, pupillary reaction, visual acuity

- if impaled -- leave object, bandage, cover with moist sterile dressing, transport immediately

what is the frequency of retinal detachment?

incidence of 2.9/100,000 - age 10-19

what are signs and symptoms for retinal detachment?

- shadow or curtain falling over visual field

- floaters

- abnormal flashes of light

what is the mechanism for retinal detachment?

blunt trauma

what is immediate management for retinal detachment?

1. refer to ophthalmologist

2. avoid pressure

3. minimize eye movement

what is hyphema?

bleeding into the anterior chamber of the eye

what is the mechanism for hyphema?

blunt trauma to eye or orbital socket

what are signs and symptoms of hyphema?

- visual sign of blood in eye

- cloudy or blurry vision

what is immediate management for hyphema

1. eye shield over injured eye and cover the eye

2. refer to opthalmologist

what is the most common facial fracture?

inferior margin orbital fractures

what is the frequency of facial fractures?

4-18% of sport fractures

what are risk factors for facial fractures?

sport participation with high velocity projectiles

where do mandibular fractures occur most frequently?

typically occur at or just inferior to the condyle

what are the specifics for maxillary fractures?

Le Fort fractures types I-III

what is a concomitant injury?

a secondary injury occurring at the same time as a primary injury

what is an example of a concomitant injury?

head and cervical spine

what are signs and symptoms of facial fractures?

- difficulty breathing and or speaking

- blurred or double vision

- numbness

- pain

- malocclusion

- blow out fracture -- difficulty or inability to look upward

what is immediate management for facial fractures?

1. place in a seated position unless suspected cervical spine injury

2. assess airway, circulation

3. address bleeding and transport if necessary

how do you reduce dental injury risk?

use properly fitted mouth guards

immediate management for dental injuries?

depends on injury, referral within 24 hours or less

dental injury categories

- tooth fractures

- root fractures

- tooth displacement

who is more susceptible to soft tissue injury (laryngeal)

children

what is the frequency of laryngeal injuries?

mortality of laryngeal injury is 17.9%

what are signs and symptoms of laryngeal injuries?

- hoarseness

- stridor

- dyspnea

- hemoptysis

- dysphonia

- respiratory distress

- anterior neck tenderness

- subcutaneous emphysema

what is immediate management for laryngeal injuries?

1. maintain a patent airway and refer for advanced medical care

2. if airway is good, evaluate cervical spine

3. apply ice if soft tissue injury

4. recommend vocal rest, humidified air, soft foods

what are common mechanisms of spine injury?

1. axial loading -- compression force (buckling effect, "spearing")

2. forced flexion

3. tension

4. horizontal shearing

what is the prevalence of acute cervical spine injuries?

- cause an estimated 6000 deaths and 5000 new cases of quadriplegia per year

- male to female ratio is 4:1

- approximately 80% of patients are ages 18-25

- cervical spine rates were highest in football, wrestling and girls gymnastics

what is a spinal column injury?

disruption of ligamentous and boney structures surrounding the cord (isolated injury or associated with cord injury)

what is a spinal cord injury?

neurologic soft tissue injury (isolated cord injuries are rare)

what are the clinical indicators of a spine injury?

- altered LOC and or bilateral neurological symptoms

- pain along the spine with or without palpation

- obvious deformity along the spine that is a result of a dislocated or fractured vertebra

what is the emergency care for spinal injuries?

1. CABN - circulation, airway, breathing, neurological

2. consider MOI, physical or mental status, body position, complaints of neurological symptoms, mid-line spine tenderness

3. activate spinal motion restriction protocols

what is the decorticate position?

- person is stiff with bent arms, clenched fists, and legs out straight

- arms are bent in toward the body and the wrists and fingers are bent and held on the chest

- posturing is a sign of severe damage in the brain

what is the decerebrate position?

- ams and legs being held straight out, the toes being pointed downward, and the head and neck being arched backwards

- muscles are tight and held rigidly

- usually means there is severe damage to the brain

how can you manage the airway for a spinal injury?

- remove protective equipment to assess the airway

- attempt open airway with jaw thrust first

- if airway cannot be opened the head tilt chin lift is the last option

- airway adjuncts can be used to maintain airway

what is cervical inline stabilization?

- traditional hand hold

- modified trap squeeze -- preferred method, but cannot be used if the patient is prone

what should you keep in mind when performing cervical inline stabilization?

- do not apply traction

- attempt to align spine in neutral position

- do not align in neutral if there is resistance, airway becomes compromised, or patient expresses pain or apprehension

how could SMR be performed for supine patients?

- technique should be selected based on available and trained personnel

- multiperson lift and slide -- preferred method

- straddle lift and slide

- log roll

how could SMR be performed for prone patients?

- to avoid multiple movements of the patient wait to log roll until all equipment is on-site

- log roll is the only option

- never log roll across the face

- log roll pull is the preferred method

how could SMR be performed for standing or seated patients?

- kendrick extrication device -- outdated

- general SMR principles apply

- manual inline stabilization

- cervical collar

- strapping techniques

name possible SMR equipment

- rigid cervical collar

- rigid board - traditional spine board, vacuum mattress, scoop stretcher

- AED and pocket mask

- straps and head blocks

- equipment removal tools

- cell phone or other communication device

- trained personnel

what are possible strapping techniques?

1. spider straps

2. speed clips

3. 7 strap method

4. 3 strap method -- not recommended

what are guidelines and recommendations for treating spinal injuries?

- decisions on equipment availability and standard protocols should be made in the EAP

- identify personnel

- supine patient -- multiperson lift and slide

- prone patient -- LR pull

- decision to remove equipment

- ridged device and strapping technique

how should you make the decision to remove equipment?

- type of equipment the athlete is wearing -- helmet, shoulder pads

- status of the patient -- airway and cardiovascular needs

- rescuer's experience vs hospital staff

- advantages of removing on field

- disadvantages of removing on field

what should be considered with face mask removal?

- faster to just take the helmet off with face mask in place

- if transporting with equipment on, face mask must be removed completely

- takes >30-45 seconds for face mask removal

- possible equipment -- screwdriver, cutting tools, pruning shears, pin or specific tool (quick release)

what should be considered with helmet removal?

- faster to remove helmet with face mask on

- cut chin strap

- deflate or cut cheek pads - most likely no longer required

- manual inline stabilization transferred to rescuer 2

- rescuer 1 can then rotate the helmet forward slightly while sliding the helmet off -- avoid placing head into flexion

what should be considered with shoulder pad removal?

- helmet must be removed prior

- know the athlete's equipment

- removal techniques

what are guidelines and recommendations for equipment removal?

- if transporting with equipment on, the face mask must always be fully removed

- use a multitool approach for face mask removal

- cut chinstrap instead of unsnapping

- flat torso may reduce amount of motion during removal

- limit evidence to advocate one technique over others

- be familiar with several techniques, equipment may limit techniques

what splits the abdominal cavity into quadrants?

- linea alba (anatomical line) lies from the xiphoid to the pubic juncture

- divides the line through the umbilicus

what is in the upper right quadrant?

- liver

- gallbladder

- tail of the pancreas

- small intestine

- transverse colon

- ascending colon

what is in the upper left quadrant?

- spleen

- stomach

- small intestine

- transverse colon

- descending colon

what is in the lower right quadrant?

- appendix

- distal right ureter

- right ovary

- right fallopian tube

- small intestine

- ascending colon