Trauma/Burns

LeFort Fractures

-three types of fractures that escalate in amount of damage done to bones in the face

-requires an extensive amount of force to obtain

-causes a lot of bleeding

-airway (SALAD technique)

-OG tube

MAP goal for trauma patients with s/s of hypovolemia

60 mmHg

pale/white feet and ankles

What is an ominous sign in a trauma patient?

blood loss of 30-40%

Class III blood loss

HR/SBP

shock index calculation

GCS Adult

GCS Child

Revised Trauma Score

Penetrating Trauma

-stab wounds (what type of knife?)

-gun shot wound (what type of gun and caliber?)

• leading cause of death in 15-25 yr olds

-permissive hypotension

Cardiac Tamponade

-Beck’s Triad

-confirmation via ultrasound

tx:

• supportive measures

• pericardiocentesis

Beck’s Triad

• narrow pulse pressures

• JVD

• muffled heart tones

Pericardiocentesis

Equipment:

• 10-60 cc syringe

• spinal needle

1. identify xiphoid process

2. point the spinal needle toward the left shoulder at a 45 degree angle

3. placed pressure on xiphoid, advance the catheter slowly while pulling back on the syringe

4. once you have blood return, evacuate the volume & reassess your patient

Tension Pneumothorax

• severe respiratory distress

• decrease or absent breath sounds

• tracheal shift = late finding

• subcutaneous air

• High plateau pressure [Pplat]

Hemothorax

• decreased breath sounds

• midline/shifting trachea

• flat neck veins

• decreased LOC

Tx:

• chest tube

• fluid replacement/PRBC/FFP

• chest rube should be clamped @ 1500 cc initial output to avoid reexpansion pulmonary edema

Chest Tube Procedure

• 4-5th intercostal space

• incision over 5th rib

• grab Kelly clamp, hold your fingers 2-3 cm from the distral end of the kelly clamp prior to insertion into the chest cavity

• slide the kelly clamp over the top of the rib, pushing into he pleural space, while maintaining your index finger at the 2-3 cm mark on the kelly clamp

• remove finger, spread incision site, replace finger, retract kelly clamp, confirm placement in the chest cavity with finger

• clamp the distal end of the chest tube with the kelly clamp, the blunt end of the kelly clamp is extended past the distal end of the chest tube

• Size = ETT size x 4

• Suture in place

• connect heimlich valve

• reassess

Flail Chest

• paradoxical movement

• respiratory distress

• tachypnea

• grunting

• accessory muscle use

• chest pain

Tx:

• self-splinting

• intubation

• placed injured site down

• be aggressive w/ pain management

Pelvic Trauma

• stable

• unstable

  • ant/post compression

  • lateral compression

  • vertical shear (often fatal)

• disrupted pelvis can hold 4000 cc or 80% of blood volume

Tx:

• compression of pelvis (pelvic binder)

• check for blood @ the meatus

• have them lift their leg up

  • can do it = no pelvic fracture

Rule of 9s

Escharotomy

• gently run scalpel across skin in ‘w’ pattern across chest

• skin will ‘pop’

• patient will not feel this and no bleeding

kg x TBSA x 4 mL

Parkland Formula

½ of it

How much of the parkland formula should be given within the first 8 hours?

all of it

How much of the Parkland formula should be given within 24 hours?

0.5 mL/kg adults and 1 mL/kg Peds

What is the target urine output for a burn patient?

Phase 1: 0-36 hours

• electrolyte imbalance after burns

• hyponatremia & hyperkalemia

• intravascular loss

• increased vascular permeability

• cellular edema

• interstitial osmotic pressure increase

Phase 2: 3-7 days

• electrolyte imbalance after burns

• hypernatremia, hypokalemia, hypophosphatemia, hypomagnesmia, & hypocalcemia

• reabsorption of cellular edema

• urinary retention - stimulation of ADH

Rhabdomyolysis

• extensive muscle damage often causes myoglobinuria

• if left untreated, results in acute tubular necrosis & renal failure

Tx:

• fluid! fluid! MORE fluid!

• monitor urine output (1-2 mL/kg/hr)

• NaHCO3- to alkalinize the urine

• mannitol

• diuretic (lasix)

Damage control resuscitation

-concept of treating hemorrhagic shock

-early transfusion of PRBCs, plasma, and platelets (1:1:1) or whole blood

-restricting crystalloids to a SBP of 90-100

-while also preventing/correcting hypothermia and coagulopathy

Linear

Most skull fractures are:

Diastatic Skull fracture

• separation of the bones at the suture line or a marked separation of bone fragments

• facial fractures play a role in this

Basilar Skull Fracture

-occurs from direct injury to the base of the skull and/or extension of fractures of the calvaria

-s/s:

• Battle sign

• hemotypanum

• CSF leaking from the nose or ears

• raccoon eyes (1-2 days after injury)

Pneumocephalus

-air in the cranial vault

-think of how this affects the patient during flight due to Boyle’s law

Subdural Hematoma

• collection of blood in the potential space between the arachnoid mater and the dura mater

• crescent shaped appearance on the CT

• acute = high morbidity and mortality

• often associated with cerebral contusion and edema

Epidural Hematoma

-collection of blood between the skull and the outer layer of the dura

-often caused by disruption of the branch of the middle meningeal artery

s/s:

• transient LOC

• recovery with lucid period

• secondary onset of headache

• decreasing LOC again

• maybe fully unconscious or never unconscious

• Peds: only warning may be bradycardia or early papilledema

• dilation of ipsilateral pupil

• Cheyne-stokes respirations

• bradycardia

• death

Subarachnoid Hemorrhage

-blood collecting between the arachnoid membrane and the pia mater

-identified in 30-40% of TBIs

-increased risk for seizures and cerebral vasospasm

Diffuse Axonal Injuries

occurs when the delicate axons of the brain are stretched and damaged as a result of rapid movement of the brain

• multiple neurological deficits

• range from headache to respiratory compromise

HIGH mortality rate

dura mater, subdural space, arachnoid mater, subarachnoid space, pia mater

Name the layers of the brain starting from the skull down