Download TRAUMA - 1234key.com

Used to design public policy, legislation
and injury prevention programs
 Gathers Data such as
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Incidence
Prevalence
Age
Sex
Race/Ethnicity
Geographic distribution
Morbidity and Mortality
Trauma is a disease that remains the
leading cause of death for all Americans
Regardless of gender, race or economic
status
 Leading Cause of death for ages 1-45yrs

› (see chart pg 234)

1-3 yrs= MVA
› Due to unrestrained/ or improperly restrained

15-24= Accidents related to Drugs and
Alcohol
› Due to poor judgment and risk-taking behavior
Age

16-19= MVA
› Due to inexperience, lack of seatbelt usage,
etoh with driving

75+= “injuries”
› Due to frailer health, pre-existing conditions,
Falls (most common cause in 65+ age group)
› Drivers 65+ have the highest death rate, per
mile driven (except for teenagers)
› More likely to sustain a C-Spine injury
Race
Gender

Males are 2.5 times more likely to be
injured than females
› Related to their participation in hazardous
activities, and greater risk taking

The Auto vs Ped, and MVA death rate is
2x higher across the life span compared
to women

African American- Homicide, MV (65+),
and auto/ped
White/Native American- Suicide
Hispanic- Pedestrian, Homicide
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
Fire Arms
 Alcohol
 Geography –Urban vs Rural
 Chronology- Weekends and Holidays

Beware of Adrenaline- pt may at first
appear uninjured
 MOI- What is the Mechanism Of Injury,
and does the injury match?
 Trauma Team Criteria?

A-Airway
 B-Breathing
 C-Circulation
 D-Disability
 E-Exposure/Environment
 F-Full Vitals, Family
 G-Give comfort measures
 H- Head to Toe/ History
 I-Inspect Posterior Surfaces

Trauma Assessment
http://www.youtube.com/watch?v=Lc
dLqfdIkFc

Alert (minor)
Ejection
Death in same pass space
Extrication <20min
Falls <20ft
Rollover w/ injury
Auto Ped/Bike <5mph
Ped thrown or run over
MCA <20mph
Age >59 with blunt injury to
chest/abd
› Children <5yrs
› 2 long bone Fx
› Pregnancy 23wks +
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Activation (major)
› GCS <13
› Airway Compromise
 Intubated PTA
› BP <90s
 Age specific in kids
› Penetrating injuries to head,
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neck, torso, and extremities
prox to elbow and knee
Traumatic Full Arrest
Paralysis
Amputation prox to wrist
and ankle
Bone Injury:
 Pelvic FX, open skull
› Transferred receiving blood
› MD discretion
Treatment of trauma patients depends
on identifying all injuries and rapidly
intervening to correct those that are “life
threating”
 Consideration of mechanisms of injury is
essential to identifying patients with
possible underlying injuries who require
further evaluation and treatment

Leading Cause of Death and permanent
disability- considered a MAJOR public
health problem
 2 million people every year

› 8x more than cancer, 34x more than HIV
50,000 deaths, 200,000 hospitalizations,
1million ER visits
 $60 billion in costs in 2000

› Average lifetime cost per survivor $111,578
› Average cost per fatality $454,717
Injuries can occur to the skull, brain, soft
tissues, vascular structures, and cranial
injuries
 Mechanism are varied

› Car crashes, sports, falls, penetrating wounds
› High risk behaviors include ETOH abuse,
drugs
Classified by:
 Mechanism
› Blunt or Penetrating

Severity
› Mild, Moderate or Severe

Type
› Fracture, focal brain injury, diffuse brain injury

GCS is 14-15
› Usually discharged after short observation
Normal pupils, may be asymptomatic,
intact orientation/memory
 Eg: Scalp Lacerations

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GCS 9-13
› High potential for
increased ICP
Associated with
Structural
injury/damage
 May require more
frequent monitoring
 Eg: Contusion

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GCS- 8 or less
› Associated with Severe structural damage
High mortality rate
 Usually have long term or permanent
cognitive and physical disabilities

› Aggressive initial management to ensure
adequate oxygenation and preventing HTN
is essential

A reaction to a change
in any one of the 3 fixed
brain volumes
› Brain, CSF, or blood
If not immediately
corrected will
compromise cerebral
blood flow
 Normal ICP is 0-15,
greater than
20=intracranial
hypertension

Early S/S ~ HA, N/V, ALOC, pupils sluggish
 Late S/S ~ Pupils fixed/dilated, arousable
only to deep stimuli (gcs <8), posturing,
temperature changes

› Cushings Triad (High blood pressure,
bradycardia, irregular resp rate)

Treatment
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Monitor ABC’s
Prepare for intubation (propofol)
Medicate with benzo’s
Mannitol?
Decrease stimulus
Consider insertion of ICP monitor
Decrease metabolic demands of the brain
 Maintain normal temperature
 Maintain normal glucose
 Prevent seizures (Dilantin)
Linnear skull
fracture
 Non-displaced,
most common
type, usually
benign


Depressed skull
fracture
› Damages underlying
brain tissue and
vessels by
compression or
laceration. May
precipitate seizures

Basilar skull fracture
› May occur in anterior, posterior or middle
fossa. Leads to infection, hematoma, CSF
leakage, SZ
› S/S ~ ALOC, pupil change, CSF leak, Battle
sign, Raccoon eyes, change in mentation
 Change in mentation or combative
behavior, is hallmark
› Avoid nasal intubation or NGT
Bruise on the surface of the brain
 Occurs from movement of the brain
within the skull
 Coup and Contrcoup
 S/S are ALOC, N/V, vision changes,
weakness, and speech deficit

Collection of blood between skull and dura
 Usually r/t laceration of the middle
meningeal artery assosciated with a
temporal or parietal skull fracture
 Mortality is 50%
 S/S ~ Initial period of unconsciousness, lucid
interval (5 min-6 hrs), rapid
unconsciousness, unilateral fixed or dilated
pupils, Cushing’s Triad
 TX: prepare for evacuation/OR

Collection of blood between dura mater
and subarachnoid layer
 Usually caused by trauma
 Usually venous, therefore a slower bleed
 S/S ~ HA, drowsiness, confusion, steady
decline in LOC, unilateral fixed and/or
dilated pupils
 TX: ABC’s, prep for OR (most successful if
done within 4hrs of injury)

Collection of blood between arachnoid
mater and the pia mater
 Caused by aneurysm rupture, AV
malformation.

› Aneurysm can be caused by valsalva, sexual
activity, heavy lifting, or excitement

Usually 40-60 y/o. 12% die before
reaching hospital, 30% that survive have
severe neurologic deficits

S/S ~
› “Worst headache of my life”
› Accompanied by N/V or sudden seizure
› Meningeal signs (fever, nuchal rigidity)
Traumatic, reversible neurological event
when there is a temporary loss of
consciousness and retrograde amnesia
 S/S ~ dizziness, N/V, loss of memory of
event
 CT to r/o bleed
 Education to return if s/s
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Widespread disruption of neurologic
function without any focal lesions noted
S/S
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immediate LOC lasting days-months
May see posturing
Loss of brain stem reflexes (no gag/cough)
HTN, hyperthermia, excessive sweating
TX: ABC’s prepare for intubation,
mannitol
Damage of spinal cord tissue r/t
penetrating trauma, fracture, or
dislocation
 Most often in males 15-35 y/o
 Costs: $218-741,000 for first year with
lifetime cost just under $3,000,000yr!

Sensory
Dermatomes
Observe for obvious signs of
Spinal injury, including deformity
of the vertebral column,
cervical edema, and wounds
 Ventilatory pattern may
indicate spinal injury
 Can they feel pain, or move
arms and legs?
 Priapism
 Spinal fluid leakage
Inspection

Palpation

Diaphoretic above level of injury
› Indicates sympathetic injury
(above T4)

Poikilothermic- assumes
temperature of surroundings
› Hypothermia
Sensory status- sharp or dull
 Sacral and Perineal sensations
 Entire column should be
palpated for pain, tenderness
and step-off deformity
 *use log-roll technique*
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3view XR- must see C7-T1 junction
 Swimmers View- Open Mouth view
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› Used for C1,C2 views
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CT-“Recons”
› Done at same time as Chest/Abd CT
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MRI- used for suspected Cord injury
› Not good at bony injuries
› SCIWORA (Spinal Cord Injury without
Radiologic Abnormality)

Methylprednisolone- reduces
biochemical responses when given
within 8hrs of injury
› Suspected to cause infection, PNA, decub
etc.
Foley- for incont, or to monitor output
 NG/OG with intubation
 Warming blanket/fluids- pt can’t
thermoregulation
 Hypothermia???
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Halo/cervical tongs- provides c/s
traction
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When complete spinal cord injury
occurs, all motor and sensory function
below the level of injury is lost
› Immediate onset

S/S: Flaccid paralysis, a-reflexia,
bowel/bladder dysfunction, disruption
in thermoregulation
›
Neurogenic shock (above T6) s/s include
sypathetic NS causes Bradycardia and
Hpotension
• Results from
hyperextension
• Bowel and
bladder fx
intact
• Results from
disruption of the
anterior spinal artery
• Can feel vibration,
touch, and pressure
• Posterior cord
syndrome light
touch impaired
by not lost
 Results from Hemisection
of the cord
 Most common from
penetrating injury
 Ipsilateral (same side)
paresis or hemiplegia
and total loss of function
 Contralateral (opposite
side) has decreased
sensation to pain and
temperature changes
Complication of injury at or above T6
 Life Threating injury- occurs when
sympathetic stimulation leads to massive
uncontrolled cardiovascular response
 Common Causes: Full bowel or bladder
at the time of injury


S/S
› sudden severe HA
› HTN
› sweating
› flushing above level of injury
› coolness below level of injury
› Anxiety
› Blurred vision

TX-ABC’s, raise HOB, identify cause, foley
Some of the
most life
threatening
injuries
 Have a lot
of
concurrent
injuries


Pulmonary System

Cardiovascular
System
ABC’s
 Auscultation of lung sounds
 Inspect chest wall integrity
 Ultrasound (FAST Scan) of heart and
lungs

Chest
Wall
Injuries
Most common type of blunt chest injury
 S/S – SOB, localized pain with movement,
chest wall ecchymosis or contusion
 Bony crepitus
 Usually does not require treatment other
than pain meds
 Elderly may need admission

Defined as fractures in 2 or more
adjacent ribs in 2 or more places, or
bilateral detachment of the sternum
from costal cartilage.
 Usually associated with Massive crush
injury, high speed MVC.
 Will see paradoxical movement to
affected area

YouTube - Flail Chest

Decreased incidence with increased use
of seatbelts, shoulder restraints and air
bags
› Usually caused by steering wheel impact,
sporting injury or falls

Increased potential for cardiac or
pulmonary injury

Result of severe crush injury to the thorax
› Long period of time, such as being pinned

Pathology:
› Direct increase in thoracic and superior vena
cava pressure from the injury
› Combined with closure of the glottis

S/S
› Severe cyanosis of face and neck
› Subconjunctival and retinal hemorrhages
› Transient LOC, SZ, or blindness
Pulmonary
Injuries
Rare and Life threating
 Caused by “clothesline” type injuries
 Females with long narrow necks are
predisposed
 s/s:

› Hoarseness, stridor, hematoma, ecchymosis,
tenderness, sq emphysema, crepitus, or loss of
landmarks

Tx:
› NPO, HOB 30-45degrees, O2, ETT, Tracheostomy
Accumulation of air in the pleural space
 S/S – SOB, tachycardia, tachypnea,
decreased or absent breath sounds on
the injured side, chest pain
 Chest tube is indicated for PTX of usually
greater than 10%
 Needle decompression or chest tube
insertion


“sucking chest wound”
› May see bubbles or hear a “hissing” sound
Usually result of penetrating chest wound
 Apply 3 sided dressing, allowing air out
but not in
 If penetrating object still in place *DO
NOT REMOVE*

Life threating
 Accumulation of air in one pleural space
forces thoracic contents to the opposite
side of the chest

› Air can get in but not out

Immediate needle decompression is
required
An accumulation of
blood in the pleural
space
 S/S – SOB,
Tachypnea, chest
pain, decreased
breath sounds
 TX – chest tube with
suction. May need to
consider autotransfusion or O.R.


YouTube - Chest Tube Insertion..!
Potentially leathal
 75% of pts with chest injury

› 40% mortality
Contusions occur when underlying lung
parenchyma is damaged, causing
edema and hamorrhage
 Tx:

› Semi-fowlers, suction, ETT (for severe hypoxia)
› Usually improve in 3-5 days
Potentially life
threatening injury
 S/S – SOB,
difficulty
swallowing, abd
pain, bowel
sounds heard in
the lower to
middle chest,
decreased lung
sounds on injured
side

Cardiac and
Great Vessel
Injury
Collection of blood
in pericardial sac
 S/S- Hypotension,
tachycardia or
PEA, SOB, cyanosis

› Beck’s Triad ~
Hypotension, JVD,
muffled heart tones
http://www.youtube.com/watch?v=T1LbBxxwjak
Immediately fatal
in most cases,
usually die at the
scene
 Dx done by CXR

Caused by
penetrating or
blunt trauma
 S/S ~
hypotension,
decreased LOC,
chest pain,
decreased
quality of femoral
pulses

Significant source of morbidity and
mortality
 Patients usually have a lot of pain and
high risk for bleeding

Peritoneum
 Solid Organs

› Liver, spleen, gallbladder

Hollow organs
› Stomach, Bowels, Bladder

Reproductive Organs
› Uterus, ovaries, penis,
testes

Vascular Structures
› Abdominal Aorta
History
 Mechanism

› Blunt, Penetrating, MVA

Auscultation
› Abdominal quadrants

Palpation
› Start away from area of
pain

Foley
› Check for bleeding first and do rectal for
prostate placement

NG/OGT
› When to use NG vs OG tubes
Wound Care
 Medications

› Pain, ABX

Diagnostics
› XR, CT, FAST, MRI, ANGIO, DPL, Labs
Associated with
fractures to 11th and
12th ribs
 S/S ~ LUQ abd pain,
left shoulder pain,
abd wall rigidity.
 Severe injuries
require surgery

Scaled 1-5
(p308)
 RUQ abd pain,
abd wall
rigidity,
rebound
tenderness
 Can have
diffuse right
shoulder pain

Occur in less than 1% of trauma injuries
 Assess for Seatbelt Sign
 S/S ~ peritoneal irritation manifested by
abd wall muscle rigidity, pain,
hypovolemic shock, gross blood from
rectum
 Triple contrast CT


http://www.youtube.com/watch?v=FXto
TrLuFj8
Most common is blunt contusion
 S/S Gross or microscopic hematuria
 Flank or abd tenderness
 Ecchymosis over flank area
 1-5 Levels (pg310)

› 1=Minor, 5=Major

Bones
› Cancellous (spongy)
 Skull, vertebrae, pelvis, ends of long bones
› Cortical (dense)
 Long Bones
Ligaments & Tendons- connect bones
together
 Joints

› Nonsynovial (non-movable)
› Synovial (freely movable)
ABCs
 Stabilize and control bleeding
 Assess for edema, deformity, abrasion,
laceration, puncture
 Focused neurovascular

› Pain, pulses, paralysis, parasthesia, pallor
(5p’s)
ASAP
 Soft splints (pillows), hard splints
(fiberglass), Traction splint (reduce
angulation)
 Neurovascular checks pre and post
 Elevate and Ice after splint


Immediate treatment required for
following› Open Fracture
› Pulseless extremity
› Compartment syndrome
› Hemorrhaging
Affects 60-80% of population beginning
at ages 30-40
 May be chronic or acute
 Concern is to R/O serious injury/disease
 Red Flags

› Trauma, age >50, fever, cancer, muscle
weakness or inability to move, loss of
sensation, weight loss

TX ~ Rest, Ice, NSAIDS, usually resolves
Loss of anatomical position of
2 bone surfaces
 Medical emergency due to
risk for nerve and blood vessel
damage
 Usually requires conscious
sedation
 Affects shoulder, ankle,
patellar, elbow

High incidence of recurrence
 Specific mechanisms or historical facts may
be suggestive of certain types of
dislocations, such as lightning injuries,
electrical injuries, and seizure with posterior
dislocations
 throwing a ball or a punch or forceful
pulling of the arm with an anterior
dislocation
 axial loading of an extremely abducted
arm with inferior dislocation.

General trauma assessment must be
completed to r/o other injury
(distracting)
 Extremity exam (PMSC)

› Pulse, Motor, Sensation, Cap refill
S/S ~ pain, deformity, edema, spasm,
numbness, tingling, crepitus
 TX: Immobilze, splint, pain meds, ice,
elevate

Considered contaminated because of
possibility of foreign materials
 Graded from 1-3
 Patient will require pain meds, antibiotics,
and tetanus prophylaxis
 Usually are in surgery for copious
irrigation within 24 hours

Need to know history of injury
 Straight or guillotine cut has best
replantation potential
 Contraindications include: de-gloved,
mangled, crushed body part, or
mishandling of body part
 Consider transfer to re-implantation
center


For body part
› Gently lift of contaminates (no soap, no
betadine, no peroxide)
› Wrap in saline soaked gauze and place in
dry plastic bag and seal
› Place bag on top of ice
› Avoid submersion in ice water and avoid dry
ice
Caused by prolonged entrapment or
crushing blow
 Cellular destruction and damage to
vessels and nerves make crush injuries
difficult to treat


6 P’s
› Pain
› Pallor
› Paresthesias
› Pulses
› Pressure
› Paralysis

Steinman Pin
› Provides temporary reduction of long bone
fx’s, until open reeducation or internal
fixation can be done

Casts
› Place splint if severe swelling expected
Clean skin well prior to placement
 Education pt to look for compartment
syndrome and not to scratch inside cast


Crutches
› Proper fit is key

Cane
› Minimal assistance
Walker
 Wheelchair

› May be used temporarily until ambulation
therapy or training complete

Principle
facial
bones
include
frontal,
nasal,
maxilla,
zygoma,
and
mandible

ABCs
› Mandibular fx may cause tongue to be
displaced blocking the airway
› Remove dentures or other foreign bodies
Suction secretions
 Palpate facial structures
 Check vision and perception
 Obvious deformity or inury


Repair Lacerations within 8-12hrs
› Unless combative- wait until more
cooperative

Road Rash
› Debridement done asap

Hematomas
› Should be drained and dressed to prevent
scaring

Avulsions
› May require plastic surgery followup
Mainly R/T MVA, altercations
 S/S

› Pain, tenderness (often referred to ear)
› Inability to open mouth (trismus)
› Malocclusion
› Ruptured TM or blood behind TM
› Numbness to lower lip

TX:
› Assure airway clearance
› Prep for OR
› Possibly wiring of the jaw in the ED
“Blowout” fracture
 Usually caused by ball, baseball bat, or
other blunt blow
 High risk for nerve and tissue
damage/entrapment
 S/S

› Double vision, facial anesthesia, pain, limited
vertical eye movement, enopthalmos

TX
› Ice to area
› ABC’s/CSP
› Instruct not to blow nose
› Pain meds, antibiotics
› Prep for OR ~ usually a few days after once
swelling has gone down
Mainly R/T MVA, altercations
 Sometimes presented with orbital fx
 S/S ~ pain, assymmetry of the face,
flattened cheek, epistaxis, double vision,
numbness to cheek
 TX: ABC’s, ice, eventual OR

R/T MVA, assaults
 Classified into “LeFort” 1, 2, or 3

› LeFort 1 ~ transverse detachment of entire
maxilla above teeth at level of nasal floor
› LeFort 2 ~ fracture of midface that involves a
triangular segment of the mid face and
nasal bones
› LeFort3 ~ complete separation of the cranial
attachments from the facial bones

S/S
› Facial edema
› Nasal swelling
› Malocclusion
› Nasal swelling
› CSF rhinorrhea (II, III)
LUNCH