Trauma Midterm

How to treat open chest wound/open pneumothorax

• treat immediately

• convert wound to a closed injury

• place on high flow O2 via NRB/BVM

• open doesn’t usually progress to tension

Asphyxia

• induced by traumatic injury that forcefully compresses the thoracic cavity

• does not allow for space for the thorax to expand

Simple pneumothorax

• frequent DX in blunt chest trauma pts

• accumulation of air/gas in pleural cavity

• air enters through a hole in the chest wall or lung

• causes lung collapse on affected side

• in hospital treatment — chest tube

Open pneumothorax

• occurs when a chest wall defect allows air into thoracic space

• results from penetrating and blunt chest trauma

• negative pressure draws air into pleural space

• as size increases, lung loses ability to expand

• if hole is larger than glottis opening, air is more likely to enter chest wall

• creates a sucking chest wound

open pneumothorax physical assessment shows

• chest wall defect

• impaled object

• sucking chest wound

• bubbling wound

• subcutaneous emphysema

Hemothorax

• occurs when potential space between the parietal and visceral pleural is violated

• commonly caused by lung parenchuma tearing

• collection of blood compresses and displaces lung

• hemopneumothorax

• blood and air in the pleural space

• massive hemothorax

• accumulation of more than 1500ml of blood in pleural space

Tension pneumothorax

• life threatening condition from air accumulation within pleural space

• as air accumulates, pressure builds against surrounding tissue

• compresses the lung, diminishing ability to oxygenate blood and eliminate CO2

Signs of tension pneumothorax

• absence of breath sounds on affected side

• unequal chest rise

• pulsus paradoxus

• tachycardia

• ventricular fibrillation

• JVD

• narrow pulse pressure

• tracheal deviation

• hypotension in a late finding

Commotio cordis

• cardiac arrest caused by a direct blow to the thorax during the repolarization period

• result of chest wall impact directly over the heart

• sports where contact with high speed objects to occurs

Mediastinum

• important anatomy of the thorax that is vital to life

• heart

• lungs

• bronchi

• great vessels

Heart in mediastinum

• pericardium — membranous lining; surrounds heart and space containing it

• pericardial fluid — functions as lubricant; permits heart to move easily against lungs during contractions

• epicardium — covers heart’s outer surface

• endocardium — inner most layer of the heart lining the chambers/valves of the heart

Great vessels in mediastinum

• large arteries and veins that enter and leave heart

• aorta

• superior and inferior vena cava

• pulmonary veins and arteries

• during injury to these vessels pt’s will suffer a quick death

Rib fractures

• most common thoracic injury

• pain contributes to

  • inadequate ventilation

  • self-splinting

  • atelectasis

  • pneumonia from inadequate respiration

rib fractures treatment

• treat the pain

• breathing exercises to ensure inflation of lungs

• rib plating — sx procedure to realign and attach broke fragments of ribs

which ribs are the most commonly fractured ribs?

4-9

Compensated shock

• agitation, anxiety, restlessness

• sense of impending doom

• weak, rapid (thready) pulse

• clammy (cool, moist) skin

• pallor with cyanotic lips

• shortness of breath

• nausea, vomiting

• delayed capillary refill in infants and children

• thirst

• normal BP

decompensated shock

• altered mental status (verbal to unresponsive)

• hypotension

• labored or irregular breathing

• thready or absent peripheral pulses

• ashen, mottled, or cyanotic skin

• dilated pupils

• diminished urine output (oliguria)

• impending cardiac arrest

Treating hemorrhagic shock

• XABCD

• stop the bleeding

• replace the blood: IV fluid— use cautiously

• oxygen

• warm the pt

• rapid transport to appropriate trauma center

• prevent further injury

• tourniquets

If commercial torniquet not available

apply a triangular bandage and a stick or rod— bp cuff can be used as well

junction torniquet

• used when the hemorrhage is inguinal or axillary

• belt system holds the device in place

• pump inflates a compression device to put pressure on the deep vessels

Class 1 hemorrhage

Mentation: slightly anxious

Ventilatory rate: 14-20 breaths/min

Pulse: < 100 beats/min

BP: normal systolic/diastolic

Pulse pressure: normal

Skin: warm, dry

Urine output: >20 ml/hr

class 4 hemorrhage

Mentation: difficult to arouse

Ventilatory rate: >35 breaths/min

Pulse: >140 beats/min

BP: decreased

Pulse pressure: decreased

skin : cool, diaphoretic, pale

Urine output: <5 ml/hr

Force of trauma and energy that related to traumatic injury mechanisms

Someone falls on an air mattress from 10 ft, wont sustain a lot of injury, air would absorb energy// as opposed to concrete surface, our body cannot handle the energy transition

Energy dissipation

process by which KE is transformed into mechanical energy

factors affecting energy dissipation in a crash

• vehicles angle of impact

• differences in sizes of the two vehicles

• restraint status and protective gear of occupants

• protective devices can manipulate the way energy is dissipated

• rapid deceleration dissipates tremendous force

energy

• different forms of energy produce different kinds of trauma

  • mechanical

  • chemical

  • thermal

  • electrical

  • barometric

Preferred fluid resuscitation for pt in hemorrhagic shock

blood

How does trauma cause anaerobic metabolism

an injury that affects any of the components that aerobic respirations depends on will affect energy production

Anaerobic metabolism

• metabolic process that functions in the absence of oxygen

• instead uses stored glucose in the form of glycogen for energy production

• capable of sustaining energy requirements only for a short time

• produces only small amounts of energy

  • 19 fold decrease in ATP

  • increased lactic acid as a by-product

best treatment for anaerobic metabolism

• ensure patent airway

• stop hemorrhage

• replace blood

• rapid transport

1st sign of anaerobic metabolism

tachypnea

aerobic metabolism

• most efficient method of energy production

• uses oxygen and glucose to produce energy via chemical reactions

• produces large amounts of energy (ATP)

• waste products

  • carbon dioxide

  • water

aerobic metabolism is dependent on

• adequate and continuous supply of oxygen

• patent airway

• functioning lungs (pulmonary system)

• functional heart

  • pump blood to the cells

• intact vascular system

• adequate supply of RBCs

  • carry and transport oxygen

  • removes waste

Neurogenic shock

• associated with spinal cord injury

• interruption of the sympathetic nervous system resulting in vasodilation

• patient has normal blood volume but vascular container has enlarged, thus decreasing blood pressure

Level I trauma center

highest and most comprehensive, 24/7 care (specialized surgery, research, and rehab); must have robust research,education and surgical residency programs

Level II trauma center

similar to Level I but is not required to have the same research or teaching obligations

Level III trauma center

focuses on initial stabilization and resuscitation of severely injured patients before transferring them to higher-level centers

Level IV trauma center

provides advanced trauma life support, stabilized patients in rural or remote areas, and arranges for transfer to higher-level facilities

Scenarios talking about pt in traumatic injury, and which one will have the most serious injury based on the energy transfer

• a fast traveling car that crashes into a wall will experience more traumatic injuries than a truck traveling at a slower speed that crashes into a wall

• energy/speed matters more than mass in a crash

Golden hour

• prehospital care provider responsibilities

• spend as little time on scene as possible

• expedite field care and transport patient to definitive care

platinum 10

EMS guidelines recommend that trauma center be less than 10 minutes

Seatbelts

• stop the motion of an occupant traveling at the same speed as the vehicle

• limit contact with the interior of the vehicle

• prevent ejection

• associated injuries include cervical fractures and neck sprains

• seatbelts absorb energy — especially important in the back of a car

airbags

• reduced deaths in direct frontal MVC by 30%

• secondary injuries

  • direct contact

  • chemical

frontal

• Front end of vehicle distorts

• Passengers decelerate at the same rate as vehicle

• Abrupt deceleration injuries are produced by a sudden stop of a body’s forward motion

frontal collision common injuries

• head

• torn aorta

• tearing or shearing injuries to internal organs

• crush and compression injuries

down and under pathway

• one of the trajectory in a frontal collision

• all the force is being put on the dashboard and lower extremity

up and over pathway

• one of the trajectory in a frontal collision

• leads to head injuries

rear collision

• have the most survivors

• whiplash injury is common

• energy is imparted to the front vehicle

What happens to a car/ how to be able to stop a car

breaks: once something is in motion, it cannot be stopped unless there is an equal force that stops momentum – breaks have calipers and pads, when we hit break pedal that squeezes break pads against the rotating portion of the wheel, there is a heat transfer into the breaks (that is where the energy goes) → as we squeeze harder, the more compressed those breaks go onto the caliper of the wheel, that’s what stops the car

• Heat is transferred onto the breaks and that’s how the energy is created into thermal energy – he wants us to understand how a vehicle stops

Pregnancy and trauma

• changes in anatomy effect injuries of both mom and the fetus

• at 38 weeks uterus and fetus are most susceptible to injury

• placenta and uterus highly vascular

• hemorrhage can be hard to determine

• increased falls

• increased violence

injury during pregnancy

• trauma #1 killer of pregnant females

• penetrating abdominal trauma, 36% overall maternal mortality

• gunshot wounds: fetal mortality rates btw 40-70%

• blunt trauma: auto collisions leading cause of maternal and fetal mortality

% of blood loss before s+s in pregnant pts

• pregnant pts may lose 30-35% of their blood volume before signs and symptoms become apparent

• if this happens in third trimester, it may induce premature labor

Mechanism of injury

• understanding the effects of forces + energy transfer will help assess MOI

• kinetics of trauma refers to the study of forces involved in MOI

Primary brain injury

• occurs at the time of injury

• brain bleeds, contusions, and damage to nerve and brain vessels

• neural tissue does not regenerate well, rarely can repair, function of damaged structure of brain is usually permanently lost upon injury

Secondary brain injury

• additional injury that occurs as a result of the progression of an untreated primary injury

• the secondary injury is uninjured at the time of the injury

• can happen from hours to weeks after primary injury

• rapid treatment at skilled trauma facilities gives the best outcomes and prevents worsening secondary injury

coup

injury at site of impact

countrecoup

injury on opposite side of impact

epidural hematoma

• bleeding btw dura mater and skull

• involved arteries

  • middle meningeal artery most common

• rapid bleeding* and reduction of oxygen to tissues

• patients will have a lucid interval

• acute: sudden onset

• time sensitive emergency

• rarer in older adults, usually originating from arterial damage

subdural hematoma

• bleeding within meninges

  • beneath dura mater

  • above arachnoid

• slow bleeding

  • superior sagittal sinus

• signs progress over several days

  • slow deterioration of mentation

• far more common in older adults due to brain atrophy

X

• immediate control life threatening bleeding first (TQ’s, pressure bandages, hemostatic gauze)

Airway

• is it open? will it stay open? suction? airway adjunct needed

• crying or talking indicates airway adequacy

• move from simple to complex

  • position

  • obstruction

Breathing

• exposed chest, listen to breath sounds, palpate chest, seal and stabilize wounds to chest, deliver oxygen if needed

• consider minute volume — the total volume of air inhaled or exhaled from the lungs in one minute

• absent = apnea

• difficulty = dyspnea

• very fast = more than 30 respirations is bad and will lead to acidosis

Circulation

• pulse (15×4 or 30×2), skin color, temperature, and condition

  • normal is 60-10 bpm

• causes of pallor

  • excessive blood loss

  • anaphylaxis

  • hypoglycemia

  • anxiety

Disability

• perform a neurologic evaluation

  • AVPU scale + pupils

  • quick assessment for neurologic deficits

  • GCS

• assess for any gross neurologic deficits

  • have the pt move all extremities

  • assess for motor strength + weakness

  • assess grip strength

  • assess for loss ofsensation

Decision

• transport decision

• identify priority patients — do only what is necessary at the scene, and handle everything else enroute

most severe pneumothorax

tension pneumothorax

Retroperitoneum

• area of the abdominal cavity that is located behind the peritoneum and includes

  • kidneys

  • ureters

  • inferior vena cava

  • abdominal aorta

  • pancreas

  • duodenum

  • colon

  • rectum

• visceral + parietal peritoneum

• peritoneal cavity

Peritoneum

• membrane that lines the abdominal cavity and covers the abdominal organs

• the true abdominal cavity

  • contains liver, spleen, gallbladder, stomach, part of the large intestines, majority of the small intestines, and the female reproductive organs

Cerebral perfusion pressure

the amount of pressure that is needed to push blood through the cerebral circulation (makes sure that there is enough pressure allowing blood flow through the whole brain)

CPP

MAP (mean arterial pressure) - ICP

As ICP increases

CPP decreases (ICP is the main factor that changes CPP)

Normal intracranial pressure in adults

< 15 mmhg

MCI Start triage

Prioritizing sick and injured

Green – minor

Yellow - delayed

Red - immediate

Black - deceased

30-2-can do

30 respirations

2 is for capillary refill and pulse

EMS scene size up

• starts at dispatch

• look, listen, smells

• rapid 5 second “sick or not sick” assessment

  • LOC

  • color of skin

  • work of breathing

• safety (info that should be communicated with dispatch)

  • traffic — highway design/vehicle positioning

  • crowds — mitigating them

  • hazards — minimize them

  • weather — protect yourself

  • light — flashlight

• call for additional resources

First impact MOI

vehicle strikes body with its bumpers

second impact MOI

adult is thrown on hood/grille of vehicle

third impact MOI

body strikes the ground or some other object

Index of suspicion

medical term for the level of awareness or concern a clinical has for potentially serious, hidden, or underlying injuries or illnesses in a patient, based on initial findings

high index of suspicion

• the provider considers a serious diagnosis likely and initiates further investigation, even if symptoms seem minor or vague

• a paramedic has a high index of suspicion for internal bleeding in a patient who was in a high impact car crash, even without obvious external injuries

Eupnea

normal breathing rate and pattern

Tachypnea

• increased respiratory rate

• fever, anxiety, exercise shock

Bradypnea

• decreased respiratory rate

• sleep, drugs, metabolic disorder, head injury, stroke

Apnea

• absence of breathing

• deceased patient, head injury, stroke

Hyperpnea

• normal rate, but deep respirations

• emotional stress, diabetic ketoacidosis

Cheyne-stokes

• gradual increases an decreases in respirations with periods of apnea

• increasing intracranial pressure, brain stem injury

Biot’s

• rapid, deep respirations (gasps) with short pauses between sets

• spinal meningitis, many CNS causes, head injury

Kussmaul’s

• tachypnea and hyperpnea

• renal failure, metabolic acidosis, diabetic ketoacidosis

Apneustic

• prolonged inspiratory phase with shortened expiratory phase

• lesion in brain stem

GCS

Neurological tool used to objectively assess and monitor the level of consciousness in patients with acute brain injury, trauma, or non-traumatic coma

Lowest total GCS value is 3 (completely unresponsive patient)

Maximum GCS value is 15 (conscious, but not necessarily fully oriented patient)

Report each best response for GCS

Evaluates eye response, verbal response and motor response

flail chest

• may result from blunt force mechanisms

• two or more adjacent ribs fractures in two or more places

  • location and size affect degree that chest wall and air movement are impaired (flat sternum = most extreme)

• underlying pressure causes paradoxical movement of segment and rest of chest wall

• may not be initially apparent

• palpate rib cage fractures and crepitus

• pneumothorax or hemothorax may occur if bone fragments are driven into the body

• pain may prevent adequate tidal volume

flail chest management

• positive pressure ventilation (PPV)

• positive end-expiratory pressure

flail chest assessment and management

• palpation may reveal

  • crepitus

  • tenderness

  • dissection of air into tissue

• ausculation

  • decreased or absent breath sounds

• poses a threat to pt’s ability to breathe

  • intubation and PPV are indicated

  • goal is an SpO2 of at least 95% with supplemental oxygen and positive pressure ventilations

Upper airway

• from mouth to nose to larynx

• includes nasal cavity, oral cavity, pharynx

• larynx joins upper and lower airways

• pharynx - nasopharynx, oropharynx, hypopharynx

lower airway

everything below larynx

parenchyma

• two pulmonary lobules; anatomic division of lungs

• further divided into lobes

alveoli

• respiratory bronchioles divide into alveolar ducts

• alveolar ducts terminate into alveoli sacs

• individual alveoli are sites of primary gas exchange

• surfactant layer to prevent atelectasis

Bronchi

• larger, cartilage-supported airways branching directly from the trachea

• gives rise to bronchiole structures supported by smooth muscle

bronchioles

• smaller, cartilage-free branches arising from the bronchi that lead to the alveoli

• after about 22 division, give rise to respiratory bronchi that have limited capacity for gas exchange

Trachea bifurcates at…

carina into two mainstem bronchi

Right mainstem bronchi is often the site of…

aspirated foreign bodies