1. True or false? Al- though the mecha- nism of injury may be similar to those for the younger pop- ulation, data shows increased mortality with similar
... [Show More] severi- ty of injury in older adults.
2. In the elderly pop- ulation, what is de- creased physiologi- cal reserve?
3. Pre-existing condi- tions that affect mor- bidity and mortality include:
4. What is the most common mecha- nism of injury in the elderly?
5. In the elderly popu- lation, what are risk factors for falls?
6. Most of elderly traf- fic fatalities occur in the daytime and on weekends and typ- ically involve other vehicles. Why?
True
aging is characterized by impaired adaptive and homeostatic mechanisms that caused an increased susceptibility to the stress of injury. Insults tolerated by the younger population can lead to devastating results in elderly patients.
cirrhosis, coagulopathy, COPD, ischemic heart dis- ease, DM
Fall. Nonfatal falls are common in women and frac- tures are common in women who fall. Falls are the most common cause of TBI.
advanced age, physical impairment, history of previ- ous fall, medication use, dementia, unsteady gait, and visual, cognitive impairment
Older people drive on more familiar roads and at lower speeds and tend to drive during the day. Older people have slower reaction time, a larger blind spot, limited cervical mobility, decreased hearing, and cognitive impairment.
7. True
True or False? Mortality associated with small to mod- erate sized burns in older adults remains high
8. Spilled hot liquids on the leg, which in younger patients may re-epithelialize due to an adequate
number of hair folli- cles, will result in a full thickness burn in older patients.
9. Airway-patients may have dentures that may loosen or ob- struct the airway. If dentures are not ob- structing the airway, leave them in place for what?
10. When preforming rapid sequence in- tubation, the dose of benzos, barbi- turates, and other sedatives should be reduced to what per- centage to minimize the risk of cardiovas- cular depression?
11. Functional changes in cardiac system in- clude declining func-
this is true
bag mask ventilation, as it improves mask fitting.
20-40%
this results in lack of classic response to hypovolemia, risk for cardiac ischemia, elevated BP at baseline, and increased risk of dysrythmias.
tion, decreased sen- sitivity to cate- cholamines, athero- sclerosis of coro- nary vessels, in- creased afterload, fixed heart rate (beta blockers)
12. Functional changes in pulmonary sys- tem include de- creased elastic re- coil, reduced resid- ual capacity, de- creased gas ex- change and de- creased cough re- flex
13. Functional changes in renal system in- clude loss of re-
nal mass, decreased GFR, and decreased sensitivity to ADH and aldosterone
14. Functional changes to MSK include loss of lean body
mass, osteoporosis, changes in joints and cartilage, c spine degenerative changes and loss of skin elastin and sub- cutaneous fat
thus they are at increased risk for respiratory failure, increased risk for pneumonia, and poor tolerance to rib fractures
resulting in drug dosing for renal insufficiency, de- creased ability to concentrate urine, increased risk for AKI and urine flow may be normal with hypovolemia
resulting in increased risk for fractures, decreased mobility, difficulty for oral intubation, risk of skin injury, increased risk for hypothermia, challenges in rehabil- iation
15. 15.
Functional changes in Endocrine system include decreased production and response to thyroxin and decreased dehydroepiandros- terone (DHEA)
16. True or false: Arthri- tis can complicate the airway and cer- vical spine. Pa- tients can have multilevel degenera- tive changes affect- ing disk spaces and posterior elements associated with se- vere central canal stenosis, cord com- pression, and myelo- malacia
17. In elderly pop- ulation, due to their changes in pulmonary system, placing a gauze be- tween gums and cheek to achieve
seal when using bag valve mask ventila- tion is okay. In ad- dition, because ag- ing causes a sup- pressed heart rate
resulting in occult hypothyroidism, relative hypercorti- sone states and increased risk of infection
true
respiratory failure may present insidiously in older adults.
response to hypox- ia......
18. Age related changes Elderly patients have a fixed heart rate and fixed car-
in the cardiovascu- lar system place the elderly trauma pa- tient at significant risk for being inac- curately categorized as hemodynamically stable.
19. Do no equate blood pressure with shock in older patients
20. what 2 factors place elderly patients at risk for intracranial hemorrhage?
21. Loss of subcuta- neous fat, nutritional deficiencies, chronic medical conditions place elderly pa- tients as risk for hy- pothermia and com- plications for immo- bility.
22. True or False: Fall prevention is the mainstay of reduc- ing the mortality as- sociated with pelvic fractures.
diac output, thus, their response to hypovolemia will involve increasing their systemic vascular resistance. Furthermore, since older patients have HTN, an ac- ceptable BP may truly reflect a hypotensive state. A systolic BP of 110 is to be utilized as the threshold for identifying hypotension in patients 65 and older.
BP in older patients may look normal due to the medications they are on. Use lactate and base deficit to evaluate for evidence of shock
aging causes dura to become more adherent to the skull increasing risk of injury and older patients are on anticoagulant and antiplatelet medications.
Rapid evaluation and when possible early liberation from spine boards and cervical collars will minimize complications.
true
23. 23.
poor hygiene, dehy- dration, oral injury, contusions affecting the inner arms, inner thighs, palms, soles, scalp, ear, nasal bridge and temple injury from being struck while wear- ing glasses, contact burns and scalds.
These are all signs
of ?
24. True of false: ear- ly activation of the
trauma team may be required for elderly patients who do not meet traditional cri- teria for activation
25. Common mecha- nisms of injury in- clude falls, MVC, burns, and penetrat- ing injuries
26. The best initial treat- ment for the fetus
is to provide opti- mal resuscitation of the mother. True or False?
27. What happens as the uterus enlarged and the bowel is pushed cephalad.
Elder maltreatment. The presence of physical findings of maltreatment should prompt a detailed history. if history conflicts with findings, immediately report find- ings to authorities.
True. A simple injury such as an open tibia fracture in a frail elderly patient may become life threatening.
common injuries in the elderly include rib fractures, TBI, pelvic fractures
True. Also if xray examination is indicated during the pregnant patient's treatment, it should not be withheld because of the pregnancy.
When the uterus enlarges it pushes the bowel cepha- lad and the uterus lies in the upper abdomen. As a result, the bowel is somewhat protected from blunt abdominal trauma, whereas the uterus and its con- tents (fetus and placenta) become more vulnerable.
28. Amniotic fluid can cause amniotic flu- id embolism and dis- seminated intravas- cular coagulation following trauma if fluid enters maternal intravascular space. True or False
29. By the third trimester, what is the complication of trau- ma to the pelvis of the mother?
30. An abrupt decrease in maternal intravas- cular volume can re- sult in a profound increase in uter-
ine vascular resis- tance reducing fetal oxygenation despite reasonably normal maternal vital signs.
31. Physiological ane- mia of pregnancy
32. Healthy pregnancy patients can lose 1200-1500 mL of
Uterus remains intrapelvic until 12 weeks and then at 20 weeks it is at the umbilicus, and at 34-36 weeks it reaches the costal margin.
True
by the third trimester, the uterus is large and thin walled. In vertex presentation, fetal head is usually in the pelvis and the remainder of the fetus is exposed above the pelvic brim. Pelvic fractures in late gestation can result in skull fracture or intracranial injury to the fetus. Also we can have a placental abruption due to its little elasticity and vulnerability to sheer forces.
this is true
A smaller increase in red blood cell volume can occur resulting in a decreased hematocrit level. Thus, in late pregnancy a hematocrit of 31-33% is normal.
this amount of hemorrhage may be reflected by fetal distress as evidenced by an abnormal fetal heart rate.
blood before ex-
hibiting signs and
symptoms of hypov-
olemia. How can this
manifest?
33. What are some of the WBC increases to 12000 and during labor can be
lab changes in preg- 25000. Fibrinogen and other clotting factors are mildly
nancy? elevated and PT and pTT are shortened, but bleeding
time and clotting time are unchanged.
34. After the 10th week The placenta receives 20% of the patient's cardiac
of pregnancy, car- output during the 3rd trimester. In supine position,
diac output can in- vena cava compression can decrease cardiac output
crease 1.0-1.5 L/min by 30% because of decreased venous return from
because of the in- lower extremities.
crease in plasma
volume and de-
crease in vascular
resistance of the
uterus and placenta.
35. During pregnancy this heart rate must be considered when interpreting
the heart rate in- a tachycardic response to hypovolemia.
creases to a maxi-
mum of 10-15 beats
per minute over
baseline by the third
trimester.
36. Blood pressure falls some women experience hypotension when placed
5-15 mm Hg in sys- in the supine position due to the compression of teh
tolic and diastolic inferior vena cava.
pressures during
second trimester, al-
though it returns to
near normal levels at
term.
37. pre-eclampsia.
hypertension in the pregnant if accom- panied by protein- uria may represent what?
38. EKG findings in pregnant patient
39. Minute ventilation increases primarily due to an increase in tidal volume. Hypocapnia (30 mm Hg) is common in late pregnancy
40. Anatomical alter- ations in the tho- racic cavity seem to account for the decreased residual volume associated
with diphragmatic el- evation and chest
x ray reveals in- creased lung mark- ing and prominence of the pulmonary vessels.
41. In patients with ad- vanced pregnancy, those that require a chest tube place-
ment, where should the test tube be placed?
Flatted or inverted T waves in leads III and AVF and the precordial leads may be normal. Ectopic beats are increased during pregnancy.
Monitor ventilation in late pregnancy with arterial blood gas values. A PaCO2 of 35-40 mm Hg may indi- cate impending respiratory failure during pregnancy. Pregnant patients should be hypocapneic.
oxygen consumption increases during pregnancy and its important when resuscitating injured pregnant pa- tients to maintain adequate oxygenation above 95%
it should be positioned higher to avoid intra-abdomi- nal placement given the elevation of the diaphragm.
42. Urinary system: what happens to the GFR, serum creati- nine and urea nitro- gen levels?
43. When interpreting x ray films of the pelvis in a preg- nant patient, the symphysis pubis widens 4-8 mm and the sacroiliac joint spaces increase by the 7th month
GFR and renal blood increases during pregnancy, whereas levels of the serum creatinine and urea nitro- gen fall to one half of the normal pre pregnancy levels. Glycosuria is common in pregnancy.
keep this in mind
44. Eclampsia Maintain a high index of suspicion for eclampsia when
seizures are accompanied by HTN, proteinuria, hy- perreflexia, and peripheral edema in pregnant trauma patients. This can mimic head injury.
45. External contusions and abrasions of the abdominal wall are signs of blunt uter- ine trauma.
46. Using a shoulder re- straints in conjunc- tion with a lap belt reduces the likeli- hood of direct and indirect fetal injury, presumably because the shoulder belt dissipates decelera- tion forces over a great surface area and helps prevent the mother from flex-
true. Fetal injuries can occur when the abdominal wall strikes an object, such as the dashboard or steering wheel, or when a pregnant patient is struck by a blunt instrument.
the deployment of air bags in vehicles does not ap- pear to increase pregnancy specific risks. Using lap belt alone allows for forward flexion and uterine com- pression with possible uterine rupture or placental abruption. Lap belt worn too high over uterus may produce uterine rupture.
ing forward over the gravid uterus.
47. Penetrating injury to pregnant women
48. carefully observe pregnant patients with even minor in- juries since occa- sionally minor in- juries are associ- ated with placental abruption and fetal loss.
49. Failure to displace the uterus to the left side in a hy- potensive pregnant patient
50. Due to increas-
es intravascular vol- ume, pregnant pa- tients can lose a sig- nificant amount of blood before tachy- cardia, hypotension, and other signs of hypovolemia occur. Thus, what do stable vital signs in a preg- nant patient indicate about the fetus?
As uterus grows larger, other viscera are protected from penetrating injury. Dense uterine musculature in early pregnancy can absorb significant amount of en- ergy from penetrating objects decreasing their veloci- ty and lowering risk of injury to other viscera. However, fetal outcome is generally poor with penetrating injury to uterus.
True. AND to optimize outcomes for mother and baby, clinicians must assess and resuscitate the mother first and then assess the fetus before conducting second survey of the mother.
logroll all patients appearing clinically pregnant (sec- ond and third trimester) to the left 15-30 degrees and elevate the right side 4-6 inches and support with a bolstering device to maintain spinal motion restriction and decompression of the vena cava.
The fetus may be in distress and the placenta de- prived of vital perfusion while the mother's condition and vital signs appear stable. Administer crystalloid fluid resuscitation and blood to support the physiolog- ical hypervolemia of pregnancy. vasopressers should be an absolute last resort in restoring maternal blood pressure as they further reduce uterine blood flow, resulting in fetal hypoxia.
51. What does a normal fibrinogen level indi- cate in a pregnant patient?
Fibrinogen level may double in late pregnancy and a normal level may indicate early disseminated in- travascular coagulation
52. Most common cause maternal shock and maternal death. Placental abrup-
of fetal death?
53. Signs of uterine rup- ture
54. Perform continuous fetal monitoring with a tocodynamometer beyond 20-24 weeks of gestation.
55. REMEMBER: mater- nal bicarbonate is low during pregnan- cy to compensate for respiratory alka- losis.
tion is second. Placental abruption is suggested by vaginal bleeding, uterine tenderness, frequent uter- ine contractions, uterine tetany, and uterine irritability (uterus contracts when touched). In 30% of cases of abruption, bleeding may not occur. Uterine ultrasound may be helpful in diagnosis, but is NOT definitive.
abdominal tenderness, guarding, rigidity, or rebound tenderness. Signs of peritonitis are hard to tell due to expansion and attenuation of the abdominal wall musculature. Other findings include abdominal fetal lie (oblique or transverse lie), easy palpation of the fetal parts because of their extrauterine location and inability to readily palpate the uterine fundus when there is fundal rupture. Xray evidence of rupture in- clude extended fetal extremities, abnormal fetal posi- tion, and free intraperitoneal air.
Patients with no risk factors for fetal loss should have continuous monitoring for 6 hours, whereas, patients with risk factors for fetal loss or placental abruption should be monitored for 24 hours. RISK FACTORS ARE: heart rate > 110, an injury severity score >9, evidence of placental abruption, fetal heart rate >160 or less than 120, ejection during MV, and motorcycle or pedestrian collisions
17-22 in pregnant patient. (non pregnant patient is 22-28)
56. Fetal heart rate is a sensitive indica-
tor of maternal blood volume status and fetal well being.
57. If a DPL is to be placed in a pregnant trauma patient, place the catheter above the umbilicus using the open technique. Be alert to uterine contractions which suggest early labor and tetanic contrac- tions which suggest placental abruption.
58. Bleeding in 3rd trimester may in- dicate placental abruption and im- pending death of the fetus, a vaginal exam is vital
59. Admission to hospi- tal for pregnant pa- tients:
60. With extensive pla- cental separation or amniotic fluid embolization, wide-
spread consumptive coagulopathy can
normal range for fetus is 120-160. abnormal heart rate, repetitive decelerations, absence of accelera- tions or beat to beat variability and frequent uterine activity can be signs of impending maternal and or fe- tal decompensation (hypoxia or acidosis) and should prompt immediate obstetrical consultation.
evidence of ruptured chorioamniotic membranes in- clude amniotic fluid in vagina evidenced by a pH of 4.5
however, avoid repeating vaginal examination, CT ab- dominal imaging can be done and radiation doses less than 50mGy are not associated with fetal anom- alies or higher risk of fetal loss.
vaginal bleeding, uterine irritability, abdominal ten- derness, pain or cramping, evidence of hypovolemia, changes in or absence of fetal heart tones and or leakage of amniotic fluid
immediately perform uterine evacuation and replace platelets, fibrinogen, and other clotting factors.
emerge rapidly caus- ing depletion of fib- rinogen, other clot- ting factors, and platelets.
61. As little as 0.01mL of RH+ blood will sensitize 70% of Rh- women.
62. Intimate partner vio- lence in pregnant pa- tient:
63. What is the differ- ence between burns and other injuries?
64. Flame injury is more evident than most chemical injuries.
65. Factors that in- crease the risk of up- per airway obstruc- tion are:
66. How do you decont- aminate burn areas?
All pregnany RH negative trauma patients should re- ceive RH immunoglobulin therapy unless injury is re- mote from the uterus (isolated distal extremity injury)
injuries inconsistent with history, diminished self im- age, depression or suicide attempts, self abuse, fre- quent ED visits, symptoms suggestive of substance abuse, isolated injuries to the gravid abdomen, parter insists on being present for the interview and exam and monopolizes discussion
The biggest difference is that the consequences of burn injury are directly linked to the extent of the inflammatory response to the injury. The larger and deeper the burn, the worse the inflammation.
Monitor IV lines closely to ensure they do not become dislodged as the patient becomes more edematous. Regularly check ties securing ET or NG to ensure they are not too tight.
increasing burn size and depth, burns to the head and face, inhalation injury, associated trauma, and burns inside the mouth. Airway can become obstructed form direct injury such as inhalation injury, but also from massive edema resulting from burn injury.
Completely remove the patient's clothing to stop burn- ing process, but do not peel off adherent clothing.
Synthetic fabrics can ignite, burn rapidly at high temps and melt into hot residue that continues to burn the patient. brush any dry chemical powder from wound. rinse with copious amounts of warm saline irrigation
67. hoarseness, stridor, accessory respirato- ry muscle use, ster- nal retraction are signs of what?
68. A carboxyhemoglo- bin level greater than what percentage in- dicates a patient was involved in a fire and has inhalation injury?
69. Indications for ear- ly intubation in burn patients:
70. Patient with inhala- tion injury are at risk for bronchial ob- struction from se- cretions and debris and they may require bronchoscopy.
71. Direct thermal injury to the lower airway is very rare and es- sentially occurs only after exposure to su- perheated steam or ignition of inhaled inflammable gases.
or rinsing in a warm shower. once the burning process has been stopped, cover the patient with warm, clean, dry linens to prevent hypothermia.
airway obstruction. Clinical manifestations of inhala- tion injury may be subtle and may not show up within the first 24 hours. do not wait for the xray to show evidence of pulmonary injury or changes in blood gas because airway edema can preclude intubation and a surgical airway will be required.
10%
full thickness circumferential neck burns, signs of air- way obstruction, extent of the burn > 40%, burns inside the mouth, difficulty clearing secretions or swal- lowing, decreased level of consciousness,
Make sure to place an adequately sized airway tube
hypoxia, carbon monoxide poisoning, and smoke in- halation injury.
Breathing concerns arise from what 3 general causes:
72. Always assume CO exposure in patients who were burned in enclosed areas. Pa- tients with CO levels less than 20% may not show any symp- toms
73. Cyanide inhalation poisoning can occur in confined spaces and sign of poten- tial toxicity is per- sistent profound un- explained metabolic acidosis.
74. American Burn As- sociation states 2 re- quirements for diag- nosis of smoke in- halation injury:
75. The treatment of smoke inhalation in- jury is supportive.
HA and nausea (20-30%), confusion (30-40%), coma (40-60%) and death (>60%). Cherry red skin color in patients may only be seen in moribund patients.
Measurements of arterial PaO2 do not reliably predict CO poisoning b/c a partial pressure of only 1 mm Hg results in an HbCO level of 40% or greater. Pulse ox cannot be relied on to rule out carbon monoxide poi- soning b/c we cant distinguish oxyhemoglobin from carboxyhemoglobin. A discrepancy between pulse ox and arterial blood gas may be explained by presence of carboxyhemoglobin.
THERE IS NO ROLE for hyperbaric oxygen therapy in the primary resuscitation of a patient with critical burn injury.
1. exposure to combustible agent
2. signs of exposure to smoke in the lower airway, below the vocal cords, seen on bronchoscopy.
A chest Xray and arterial blood gases should be or- dered to evaluate the pulmonary status of a patient with smoke inhalation injury, but normal values on admission DO NOT exclude an inhalation injury.
Any patient with smoke inhalation injury and signifi- cant burns greater than 20% TBSA should be intubat- ed. IF the patient's hemodynamic condition permits and spinal injury has been excluded, elevate the pa-
tient's head and chest 30 degrees to help reduce neck
and chest wall edema.
76. True or false: Clin- True. urine output monitoring is 0.5mL/kg/hr in adults
icians should pro- and should be maintained at 30-50cc/hr to minimize
vide burn resuscita- over resuscitation
tion fluids for deep
partial and full thick-
ness burns larger
than 20% TBSA
77. in a burn patient, therefore an ECG should be performed for cardiac
cardiac dysrhytmias rhythm disturbances. Persistent acidemia in patients
may be the first sign with burn injuries may be due to under resuscitation
of hypoxia and elec- or infusion of large volumes of saline.
trolyte or acid base
abnormalities.
78. Tachycardia is a Adjust the fluid rate up or down based on the urine
poor indication for output and recognize that factors such as inhalation
resuscitation in the injury, age of patient, renal failure, diuretics, and alco-
burn patient. hol can affect the volume of resuscitation and urine
output.
79. True of false: Burn true
patients should get
tetanus.
80. Partial thickness are characterized as either superficial partial thick-
burns ness (moist, painfully hypersensitive, , potentially blis-
tered, homogenously pink, and blanch to touch) or
deep partial thickness ( drier, less painful, potentially
blistered, red or mottled in appearance, and do not
blanch to touch)
81. Full thickness burns appear leathery and skin may be white or translucent
or waxy white. surface area is painless to light touch
or pinprick and generally dry
82.
Compartment syn- drome in burn pa- tients:
83. compartment syn- drome may be pre- sent with circumfer- ential chest and ab- dominal burns
84. Partial thickness burns are painful when air currents pass over the burned surface.
85. electrical burns are more serious than they appear on the body surface and ex- tremities, particular- ly the digits.
86. A clenched hand with a small electri-
Compartment syndrome can result from an increase in pressure inside the compartment that interferes with perfusion to the structures within that compart- ment. In burns, this condition results from a combina- tion of decreased skin elasticity and increased edema in the soft tissue. A pressure > 30 mm Hg within the compartment can lead to muscle necrosis and once the pulse is gone it may be TOO LATE to save the muscle. so recognize the signs early:
pain greater than expected and out of proportion to the injury
pain on passive stretch of the affected muscle tense swelling of the affected compartment
paresthesias or altered sensation distal to the affect- ed compartment
chest and abdominal escharotomies performed along the anterior axillary lines with cross incision at the clavicular line and the junction of the thorax and ab- domen usually relieve this problem. relieve circulato- ry compromise in a circumferentially burned limb by eschartomy and these escharotimies are not needed within the first 6 hours.
gently cover the burn with clean sheets will decrease the pain and deflect air currents. Do not break blis- ters or apply an antiseptic and application of cold compress can cause hypothermia. DO not apply cold water to a burn patient.
current can travel inside blood vessels and nerves and can cause local thrombosis and nerve injury. So a severe electrical injury usually results in contracture of the affected extremity.
true. patients with severe electrical injuries require fasciotomies. Electricity can cause forced contraction
cal entrance wound should alert the clin- ician that a deep soft tissue injury is like- ly much more exten- sive than is visable to the naked eye
87. How do you dissolve a tar burn?
of muscles, doctors need to examine patient for skele- tal and muscular damage, especially for fractures of the spine and rhabdomyolysis
Use mineral oil
88. Abuse and burns circular burns and burns with clear edges and unique
patterns may reflect cigarette burns or iron. Burns on the sole of the feet usually suggest child was placed in hot water. A burn on the posterior aspect of the LE and buttocks
89. Patient with electri- cal burn can develop for acute renal fail- ure
90. Frostbite is due to freezing of tis-
sue with intracellu- lar ice crystal forma- tion, microvascular occlusion, and sub- sequent tissue anox- ia.
91. In frostbite injury, warming large ar- eas can result
in reperfusion syn- drome, with acido-
remember these burns can cause serious muscle damage without showing signs outright. Test urine for hemochromogen and administer proper volume. Assess for compartment syndrome and attach EKG leads as electrical injury can cause arrhythmias.
first degree: hyperemia and edema are present w/o skin necrosis
second degree: large clear vesicles accompany the hyperemia and edema with partial thickness skin necrosis.
third degree frostbite: full thickness skin necrosis in- cluding muscle and bone with later necrosis
treatment is circulating water at constant 40 degrees C or 104F until pink color and perfusion return in
20-30 minutes.
therefore monitor the patient's cardiac status and pe- ripheral perfusion during rewarming.
sis, hyperK and local swelling.
92. Sympathetic block- ade agents and vasodilating agents have shown to be ef- fective in altering the progression of acute cold injury
93. hypothermia is a core temp below 36C or 96.8F
94. Rhabdomyolysis can lead to metabolic acidosis, hyperK, hypoC, and DIC.
95. For MSK trauma, loss of sensation in a stocking or glove distribution is an early sign of....
96. Knee dislocations can reduce spon- taneously and may not present with any gross external or radiographic anom- alies until a physical exam of is joint is perfromed.
97. Blanched skin as- sociated with frac- tures and disloca-
false
hypothermia can worsen coagulopathy and affect or- gan function.
Myoglobin induced renal failure can be prevented with intravascular fluid expansion, alkalinization of the urine by IV administration of Bicarbonate and osmotic diuresis.
early sign of vascular impairment
an ankle brachial index of less than 0.9 indicates ab- normal arterial flow secondary to injury or peripheral vascular disease
the only reason to forgo an xray exam before treating a dislocation or fracture is the presence of vascu-
tions can lead to soft tissue necrosis. The purpose of promptly reducing this injury is to prevent pres- sure necrosis of the lateral left ankle soft tissue
98. Treat all patients with open fractures as soon as possible with iv antibiotics
99. operative revascu- larization to an avas- cular extremity is important to treat emergently.
100. High risk activities that can cause com- partment syndrome include:
101. Compartment syn- drome is a clinical diagnosis and pres- sure measurements are only an adjunct to aid in its di- agnosis. a pressure greater than 30 can cause anoxia.
lar compromise or impending skin breakdown, often seen with fracture dislocations of the ankle
cephalosporins are necessary for all open fractures
muscle necrosis begins where there is a lack of blood flow for 6 hours. is there is an associated fracture deformity, correct it by gently pulling the limb out to length, realigning the fracture and splinting the injured extremity. This maneuver can restore the blood flow
excessive exercise burns
severe crush injury to muscle
localized prolonged external pressure to an extremity increased capillary permeability secondary to reper- fusion of ischemic muscle.
the absence of a palpable distal pulse is an uncom- mon or late finding and is not necessary to diagnose compartment syndrome.
Capillary refill times are also unreliable
weakness or paralysis of the involved muscle is a late sign and indicates nerve or muscle damage
the lower the systemic pressure, the lower the com- partment pressure that causes compartment syn- drome
102. risk of tetanus: wounds that are more than 6 hours old
contused or abraded more than 1cm in depth from high velocity missiles due to burns or cold significantly contaminated
ischemic tissue or denervated wounds
103. True or false? on page 162. To ex- clude occult dislo- cation and concomi- tant injury, x ray films must include the joints above and below the suspected fracture site
104. do not apply traction to patients with an ipsilateral tibia shaft fracture.
105. Laryngeal Trauma presents as hoarse- ness, subcutaneous emphysema, and palpable fracture
106. LEMON assessment for difficult airway
107. Do not give a nasopharyngeal air- way to someone suspected of hav- ing a cribriform plate fracture.
true. unless life threatening, splinting of extremity in- juries should be done during the secondary survey.
true
true. sounds of airway obstruction and include snor- ing, gurgling, stridor, hoarseness, cyanosis, agitation
Look, evaluate 3-3-2 rule, mallampati, obstruction, neck mobility
also do not give nasotracheal intubation to patients with basillar skull fracture
108. definitive airway
A tube placed in the trachea with the cuff inflated below the vocal cords and the tube connected to oxygen enriched assisted ventilation and airway secured in place.
109. patients use the gum elastic bougie when vocal cords cannot be visualized on di- rect laryngoscopy.
110. Reliable ways to de- tect proper intuba- tion
111. definitive control of hemorrhage and restoration of ad- equate circulating
volume are the goals of treating hemor- rhagic shock.
112. An injured patient who is cool to the touch and is tachy-
using the GEB has allowed for rapid intubation of nearly 80% of prehospital patients in whom laryn- goscopy was difficult. A GEB inserted into the esoph- agus will pass its full length without resistance
proper placement of the tube is suggested but not confirmed:
1. hearing equal breath sounds bilaterally
2. detecting no borborygmi (rumbling or gurgling nois- es) in the epigastrium. the presence of this with inspi- ration suggestion esophageal intubation and warrants removal of tube
3. A CO2 detector ideally capnograph or colorimetric CO2 monitoring device. If CO2 is not detected in ex- haled air, then esophageal intubation has occurred.
4. Proper position of the tube is best confirmed via chest xray
never give vasopressors as the first line treatment as they worsen tissue perfusion. most injured pa- tients who are in hemorrhagic shock require early surgical intervention or angioembolization to reverse the shock state. The presence of shock in a trauma patient warrants the immediate involvement of a sur- geon.
relying solely on BP as an indicator of shock can delay recognition of the condition b/c compensatory mecha- nisms can prevent measurable fall in systolic pressure
cardic should be considered to be in shock until proven otherwise. Massive blood loss may only produce a slight de- crease in HCT/Hgb.
113. Tachycardia, muffled heart sounds, dilat- ed engorged neck veins, hypotension and insufficient re- sponse to fluid ther- apy is what?
114. Acute respiratory distress, subcuta- neous emphysema, absent unilateral breath sounds, hy- perresonance to per- cussion, and tra- cheal shift sup- ports the diagnosis of????
115. isolated intracranial injuries do not cause shock, unless the brainstem is in- jured. A narrowed pulse pressure is not seen in neurogenic shock.
until up to 30% of the patient's blood volume is loss. A narrowed pulse pressure suggests significant blood loss and involvement in compensatory mechanisms.
tachycardia is diagnosed as > 100 in adults
> 160 in infants
>140 in preschool aged children
>120 in children from school age to puberty.
cardiac tamponade, which is commonly caused by penetrating thoracic trauma, but can result from blunt injury to the thorax. Definitive treatment is operative intervention as pericardiocentesis is temporary mea- sure.
Tension pneumothorax differs because it presents with distended neck veins and hypotension as well as absent breath sounds and hyperresonant percussion
tension pneumothorax. needle or finger decompres- sion temporarily relieves this life threatening condition and follow this with a chest tube
The classic presentation of neurogenic shock is hy- potension (due to loss of sympathetic tone) without tachycardia. A narrowed pulse pressure is not seen in neurogenic shock. The failure of fluid resuscitation to restore organ perfusion and tissue oxygenation suggest either continuing hemorrhage or neurogenic shock
116. 116.
Less than 15% blood loss. no change in HR, BP, pulse pres- sure, RR, urine out- put.
117. 15-30% blood loss. increase in heart rate. decrease in pulse pressure. BP, RR, urine output do not change
118. 31-40% blood loss. heart rate increase, respiratory rate in- crease, blood pres- sure decrease, pulse pressure decrease, urine output and GCS decrease
119. > 40% blood loss. heart rate increase, RR increase, BP de- crease, pulse pres- sure decrease, urine output and GCS de- crease
120. A chest xray must be obtained after at- tempts at inserting a subclavian or IJ to document posi-
tion of line and eval- uate for pneumo or hemothorax.
this is class 1 hemorrhage and requires monitoring with base deficit of 0- -2
class II hemorrhagic shock. possible need for blood products, but mostly crystalloid fluid and base deficit of -2 to -6. anxiety, fear
class III and this is the least amount of blood loss that consistently causes a drop in systolic blood pressure. blood products needed and base deficit is -6 to -10
MTP and base deficit is -10 or less
do not use sodium bicarb to treat metabolic acidosis from hypovolemic shock
121. 121.
Hypothermia can be prevented and re- versed by storing crystalloids in a warmer or infusing them through intra- venous fluid warm- ers.
122. Massive fluid resus- citation with the re- sultant dilution of platelets and clot- ting factors (severe hemorrhage and in- jury results in con- sumption of coag- ulation factors and early coagulopathy) contributes to coag- ulopathy in injured patients.
123. Older patients are unable to increase their HR when stressed by blood volume loss. A sys- tolic BP of 100 may represent shock in an elderly patient. Due to medications, HR may not increase in the elderly popula- tion when in shock.
124. Patients suffering from hypothermia and hemorrhagic
blood products cannot be store in a warmer, but they can be heated by passage through intravenous fluid warmers. Fluids should be warmed to 39C or 102.2F before infusing them.
The response of elderly patients, athletes, pregnant patients, patients on medications, hypothermic pa- tients, and patients with pacemakers or implantable devices may have different set of vitals in response to shock.
Blood volumes may increase 15-20% in athletes, car- diac output can increase 6 fold and the rest HR can be 50. Trained athletes have a remarkable ability to compensate for blood loss and they may not manifest the usual way to hypovolemia, even with significant blood loss.
When a patient fails to respond to fluid therapy one or more of these causes may be: tension pneumothorax, cardiac tamponade, undiagnosed bleeding, unrecog-
shock do not re- spond as expect- ed to the admin- istration of blood products and flu- id resuscitation. IN
hypothermia, coagu- lopathy may develop and worsen.
125. Tracheobronchial in- jury will present with hemoptysis, cervical subcutae- nous emphysema, tension pneumotho- rax, and/or cyanosis.
126. what are these signs and symptoms describing? chest pain, air hunger, tachypnea, respira- tory distress, tachy- cardia, hypotension, tracheal deviation away from side of injury, unilateral ab- sence of breath sounds, neck vein distention, cyanosis (late manifestation), hyperresonance on percussion
127. pain, difficulty breathing, tachyp- nea, decreased breath sounds on
nized fluid loss, acute gastric distention, MI, diabetic acidosis, neurogenic shock
A bronchoscopy can confirm the diagnosis, but these patients require immediate surgical consultation. intu- bation of these patients may be difficult, so they may need fiber optic assisted ET
tension pneumothorax. initially, you can do a needle decompression or finger thoracostomy. place tube in afterwards
these are signs and symptoms of an open pneu- mothorax. sterile occlusive dressing large enough to overlap the wound's edges and tap it securely on 3 sides
affected side, and noisy movement of air through chest wall injury
128. Causes of Pulseless Electrical Activity
129. Massive hemotho- rax is suggest-
ed when a pa- tient is in shock
and has decreased breath sounds or dullness to percus- sion on one side of the chest with col- lapsed neck veins
130. muffled heart sounds, hypoten- sion, and distend- ed necks veins may not always be pre- sent in cardiac tam- ponade. Kussmaul's sign (rise in venous pressure with inspi- ration when breath- ing spontaneously) is a true paradoxi- cal venous pressure abnormality that is associated with tam- ponade
131. potentially life threatening injuries that should be iden-
hypovolemia, hypokalemia, hyperkalemia, hypo- glycemia, hypothermia, toxins, cardiac tamponade, tension pneumothorax, thrombosis
chest tube at the fifth intercostal space at the midaxil- lary line and you get a return of 1500mL or 1/3 or more of the patient's blood in the chest, that indicated the need for urgent thoracotomy. persistent need for blood is an indication for a thoracotomy. color of the blood is a poor indicator of the necessity for thoracotomy.
The presence of hyperresonance on percussion in- dicated tension pneumothorax whereas presence of bilateral breath sounds is cardiac tamponade. FAST can identify cardiac tamponade. if FAST is unavail- able, use echo or pericardial window. definitive treat- ment is surgery so thoracotomy or sternotomy.
simple pneumothorax, hemothorax, flail chest, pul- monary contusion, blunt cardiac injury, traumat-
tified on secondary survey
132. pulmonary contu- sion can occur with rib fractures and flail chest (two or more adjacent ribs frac- tured in two or more places).
133. Blunt cardiac in- jury can present with hypotension, dysrhythmias, EKG changes, premature ventricular contrac- tions, unexplained sinus tachycardia, AFib, bundle branch block, elevated cen- tral venous pressure without any obvious cause may indicate right ventricular dys- function secondary to contusion.
134. Traumatic aortic dis- ruption- most sur- vive if they have
an incomplete lacer- ation near the lig- mentum arteriosum. commonly caused by vehicle collision or fall from a great height. have a high index of suspicion if
ic aortic disruption, traumatic diaphragmatic injury, esophageal rupture
initial treatment includes humidified oxygen, ade- quate ventilation, and cautious fluid resuscitation. de- finitive treatment includes pain control, adequate oxy- genation
cardiac troponins can be diagnostic in an MI but have little role in diagnosing blunt cardiac injury. patients with a blunt injury to the heart diagnosed by conduc- tion abnormalities are at increased risk for sudden dysrhythmias and need to be monitored for 24 hours.
Look for widened mediastinum on chest xray, oblit- eration of the aortic knob, deviation of the trachea
to the right, depression of the L mainstem bronchus, elevation of R mainstem bronchus, deviation of the esophagus to the right, left hemothorax, presence of the pleural or apical cap, fractures of the first or second rib or scapula, widened paraspinal interface, widened paratracheal stripe.
history has deceler- ating force.
135. In a traumatic aor- tic rupture, heart rate and blood pres- sure control can de- crease the likelihood of rupture.
136. Diaphragmatic in- jury-displaced bow- el, stomach, and na- sogastric tube on left side.
137. esophageal injury- clinical picture is a patient with a left pneumothorax
or hemothorax with- out a rib fracture who has received
a severe blow to
the lower sternum or epigastrum and is in pain or shock out of proportion to the ap- parent injury
138. injuries to
the retroperitoneal structures are dif- ficult to recognize because they occur deep within the ab- domen and may not initially present with signs or symptoms of peritonitis.
definitive treatment is surgery.
The appearance of peritoneal lavage fluid in the chest tube also confirms diagnosis
presence of mediastinal air also suggests diagnosis and definitive treatment is direct repair of the injury.
the retroperitoneal space is NOT sampled by DPL or FAST
139. physical exam find- ings suggestive of a pelvic fracture in- clude:
140. signs of urethral in- jury include:
141. DPL: Aspiration of gastrointestinal con- tents, vegetable fibers, or bile through the lavage mandate laparoto- my. Aspiration of 10cc or more of blood in hemody- namically abnormal patients requires la- porotomy.
ruptured urethra, scrotal hematoma or blood at the urethral meatus, discrepancy in limb length and ro- tational deformity of a leg w/o obvious fracture. use pelvic binder that is centered at the greater trochanters rather than over the iliac crests.
blood at the uretheral meatus, ecchymosis or hematoma of the scrotum and perineum. Palpation of the prostate gland is NOT a reliable sign of urethral injury.
a retrograde urethorgram is mandatory when the pa- tient is unable to void, requires a pelvic binder, or has blood at the meatus, scrotal hematoma, or perineal ecchymosis. confirm an intact urethra before inserting a urinary catheter.
performed rapidly, invasive procedure
sensitive for detecting intraperitoneal hemorrhage low specificity
requires gastric and urinary decompression not repeatable
a positive DPL is an indication for laparotomy
contraindications include previous abdominal opera- tions, morbid obesity, advanced cirrhosis, pre-existing coagulopathy.
142. FAST noninvas and can be done rapidly repeatable
does not assess retroperitoneal structures. obesity can degrade images obtained by FAST
143. indications for a la- parotomy:
Blunt abdominal trauma with hypotension, positive FAST
hypotension with an abdominal wound that pene- trates anterior fascia
gunshot wounds that traverse the peritoneal cavity evisceration
bleeding from stomach, rectum, or GU tract peritonitis
free air of hemidiaphragm
contrast CT showing rupture GI tract, bladder injury Aspiration of gastrointestinal contents, vegetable fibers, or bile through the lavage mandate laparotomy. Aspiration of 10cc or more of blood in hemodynami- cally abnormal patients requires laparotomy.
144. Diaphragm injuries elevation or blurring of the hemidiaphragm, hemo-
thorax, an abnormal gas shadow that obscures the hemidiaphragm, or a gastric tube in the chest
145. Duodenal injuries- a bloody gastric as- pirate or retroperi- toneal air on ab- dominal CT or radi- ograph should raise suspicion
146. Any early normal serum amylase lev- el or an elevated amylase level does not conclude pan- creas injury
classically seen in unrestrained drives involved in frontal-impact MVC and patients who sustain direct blows to the abdomen from bicycle handlebars.
147. uncal herination ipsilateral pupillary dilation associated w/contralateral
hemiparesis and loss of pupillary response to light
148. ICP normal is 10. > 22 has poor outcomes. increased ICP decreases cerebral perfusion pressure. monroe kellie doctrine states that total volume of intracranial contents must remain constant because cranium is a rigid container incapable of expanding.
149. CPP= MAP -ICP
150. Indications for CT scanning
151. Goals of treatment of brain injury
a MAP of 50-150 is autoregulated to maintain a con- stant cerebral blood flow.
GCS of 8 or less= severe brain injury GCS of 9-12= moderate
GCS of 13-15= mild
GCS < 15 at 2 hours after injury
suspected open or depressed skull fracture any sign of basilar skull fracture
emesis more than 2 episodes age > 65
anticoagulant use LOC > 5 minutes amnesia before impact
systolic BP > 100 temp 36-38
Glucose 80-180
Hgb > 7
PaCO2 35-45
ICP 5-15
pulse ox > 95 NA 135-145
152. TBI treatment IV fluids & hypertonic saline (do not give hypotonic
fluids or glucose containing fluids because this can harm the injured brain)
Avoid hyponatremia reversal of anticoagulants
Hyperventilation to keep PaCO2 at 35-temporizing measure
Mannitol-do not give to patients with hypotension
153. reversal agents: aspirin/plavix: platelets
warfarin: FFP, vitamin K, Prothrombin Complex
Heparin or LMWH: Protamine Sulfate Direct thrombin inhibitors: Idarucizumab Rivaroxaban: N/A
154. Neurogenic shock loss of vasomotor tone and sympathetic innervation to
the heart. Injury T6 and above can cause impairment of the sympathetic pathways. We get hypotension and bradycardia.
Neurogenic shock is not reversed with fluid resuscita- tion alone. Vasopressors may be required.
spinal shock refers to the loss of muscle tone (flaccid) and reflexes immediately after injury
155. Central cord syn- drome
156. Anterior Cord Syn- drome
157. Brown-Sequard Syn- drome
158. Atlanto Occipital Dislocation
loss of function in upper extremities > lower extrem- ities occurring after a hyperextension injury, forward fall resulting in facial impact.
injury to the motor and sensory pathways in the an- terior part of cord. paraplegia and bilateral loss of pain and temp. However, position, vibration, and deep pressure sense are preserved (sensations from dor- sal columns). commonly due to cord ischemia
results from hemisection of the spinal cord. Ipsilateral motor loss and loss of position sense and contralat- eral loss of pain and temp
this is commonly seen in shaken baby syndrome due to severe traumatic flexion and distraction. Most pa- tients with this injury die of brainstem destruction and apnea or have profound neurological impairments.
159. Jefferson Fracture Burst fracture of C1 due to axial loading, which occurs
when a large load falls vertically on the head in a relatively neutral position. Disruption of anterior and posterior rings of C1
Fracture best seen on an open mouth view of the C1-C2 region on CT
160. Hangman Fracture this involves the posterior elements of C2, the pars
interarticularis and this type of fracture is caused by an extension type injury
161. Chance Fracture transverse fractures through the vertebral body seen
after MVC where patient was restrained by only an improperly placed lap belt.
Chance fractures can be associated with retroperi- toneal and abdominal visceral injuries. these are un- stable and require internal fixation
162. NEXUS Neurological deficit ethanol intoxication distracting injury
unable to provide history spinal tenderness midline [Show Less]