Trauma

Patient Presentation

  • Initial Concerns:
    • Irregular respirations
    • Large temporal contusion
    • Open, mid-shaft femur fracture
    • Extensive blood loss

Patient Vital Signs Analysis

  • Vital Signs:
    • Blood Pressure: 170/50
    • Heart Rate: 60 BPM
    • Respiratory Rate: Irregular
  • Significance of Vitals:
    • These vitals can indicate shock or a severe neurological condition.

Cushing's Triad

  • Definition:
    • A late response to increased intracranial pressure (ICP), typically due to brain trauma, hemorrhage, or tumors.
  • Mechanism:
    • Body raises blood pressure to maintain cerebral perfusion while slowing the heart rate to balance pressure.
  • Clinical Importance:
    • Presence indicates a severe condition requiring urgent care.
  • Key Measurements:
    • Cerebral Perfusion Pressure (CPP): 70-90 mmHg
    • Mean Arterial Pressure (MAP): 60-159 mmHg
    • ICP: 0-15 mmHg

Intubation Preparation

  • Patient Details:
    • Ben, 10 years old, weighs 35kg
  • Airway Equipment Choices:
    • Laryngoscope Size: 2 MAC
    • Endotracheal Tube (ETT) Size: 6
    • ETT Depth: 18 cm
  • Intubation Capability:
    • Respiratory Therapists (RTs) can intubate this patient.

Post-Intubation Management

  • Medications Administered:
    • Hypertonic saline
    • Mannitol (25% solution at 0.5g/kg over 30 minutes) to control ICP
  • Subsequent Actions:
    • Transfer to trauma center via 30-minute flight
    • Stabilization of femur fracture
    • Peripheral IV started; blood transfusion at 10ml/kg for the first hour
    • Continuous monitoring of MAP and CPP

Differential Diagnosis & Expected Complications

  • Expected Issues:
    1. Brain injury
    2. Fractures
    3. Flail chest
    4. Pneumothorax
    5. Hypovolemic shock
    6. Spinal cord injury

Traumatic Brain Injury (TBI)

  • Definition:
    • An acute alteration in brain function or evidence of brain pathology due to an external force.
  • Common Symptoms:
    • Loss of body function (focal or general)
    • Cell damage, inflammation, and vasospasm
    • Headache, nausea & vomiting, dizziness, confusion, memory loss, mood changes, etc.

Acute Pathophysiology of TBI

  • Metabolic Changes:

    • Decrease in cerebral metabolic rate of glucose (CMRg) after traumatic brain injury.
    • Recovery is compromised with subsequent injuries, indicating a metabolic window of vulnerability.

  • Glucose Utilization Post-Injury:

    • After injury, NAD+ levels drop, forcing utilization of the pentose phosphate pathway for DNA repair and to combat oxidative stress.

Importance of Calcium in TBI

  • Role in Neuronal Function:
    • Calcium is crucial for neuron communication
    • Excess calcium post-injury increases ATP use and glucose demand.
  • Age-Dependent Recovery Patterns:
    • Adults experience prolonged calcium levels post-injury compared to children, which recover faster due to lower protein levels managing excess calcium.

Compartment Syndrome

  • Definition:
    • Edema within the limb’s connective tissue layers leads to decreased circulation
  • Management Challenges in Pediatrics:
    • Adjust assessment techniques; children's expressions may differ (3 A's instead of 6 P's).

Flail Chest

  • Definition:
    • Injury with the fracture of at least 3 consecutive ribs in multiple places causing instability
  • Associated Complications:
    1. Reduced chest expansion
    2. Ineffective cough
    3. Impaired ventilation outcomes: risk of pneumonia, atelectasis

Pulmonary Embolism (PE)

  • Definition:
    • Sudden blockage in lung artery typically caused by deep vein thrombosis (DVT).
  • Signs & Symptoms:
    • Sudden shortness of breath, cough with bloody sputum, chest pain that worsens with breathing.

Hypovolemic Shock

  • Definition:
    • Fluid loss leading to circulatory dysfunction, risking underperfused organs.
  • Signs & Symptoms Assessment:
    • Vital signs, labs (hematocrit, hemoglobin), consciousness, skin color.

Long-term Management and Prognosis of TBI

  • Assessment Tools:
    • Glasgow Coma Scale (GCS); CT scans for identifying primary injuries.
  • Long-term Outcomes:
    • Cognitive and social function assessments over time, management of TBI effects in the context of child development.