Surg Oral Exam: 5. Shock, Trauma, Burns
Terms in this set (63)
27 year-old woman arrives to the ED via ambulance. Found in a flaming car at the scene of a motor vehicle accident.
"I would first assess the patient's general appearance and vital signs to determine if there is any need for immediate resuscitation."
Differential diagnosis for Trauma?
Treat Trauma first: Basilar skull fracture (raccoon eyes, Battle's sign, otorrhea, rhinorrhea), Spinal trauma, Urethral injury (contraindication for Foley placement), Pelvic fracture, Open fracture +/- pulseless extremity, Hemo/pneumoperitoneum, hemo/pneumothorax, hemopericardium (i.e. blood and air in places they don't belong)
Differential diagnosis for Burns?
Thermal, chemical, and electrical (electrical burns are typically much deeper than they appear, beware of ongoing burn)
If patient was in an enclosed space (house, car), maintain high suspicion for inhalational injury
Differential diagnosis for Shock
Distributive (Septic, Anaphylactic)
What are the ABCDEs?
Airway, Breathing, Circulation, Disability, and Environment
How do you assess the Airway?
If the patient is awake/talking = good airway.
Consider indications for intubation, Hypoxia (refractory), Hypercarbia Inability to protect airway/impending respiratory failure, Operations (anesthesia)
Inhalational injury (check for singed facial hair, burns to oropharynx, production of carbonaceous sputum). Major face, head, or neck trauma. Paralysis ➔ decreased ventilation. Circumferential burn to thorax
Steps to intubate?
Usually endotracheal [ET]: preoxygenate with bag valve mask, perform rapid sequence intubation (with cricoid pressure and C-spine stabilization), suction as needed
Only hear breath sounds on the right. next steps?
Right mainstem bronchus intubation - draw back the ET tube a bit and auscultate again
Unable to intubate. Next steps?
Cricothyroidotomy by making VERTICAL incision between the cricoid and thyroid cartilage
How do you assess Breathing?
● Resp Rate and SpO2
● Listen to breath sounds,
● Inspect for chest wounds, tracheal deviation, symmetric chest rise, checking end tidal CO2,
What are signs of pneumothorax? Tx?
Unilateral breath sounds + hypotension/tachycardia
Tx. Perform needle thoracostomy then reassess for breath sounds.
- 14-16 gauge angiocatheter in 2nd ICS at midclavicular line
- 36 French tube in 5th intercostal space, anterior axillary line, then connect to water seal
If still unilateral, look for leak, bag ventilate, and get x-ray
How do you assess Circulation?
Check pulses, BP (keep cuff away from injuries), skin color, capillary refill
In trauma, place 2 large bore IVs in the bilateral antecubital fossae and give 2L NS "wide open". Send Type and Cross.
If peripheral circulatory access unavailable?
Central line or saphenous vein cut-down
If further volume resuscitation? massive transfusion protocol?
2L NS --> begin blood --> 1:1:1 PRBCs:FFP:platelets
How to estimate TBSA? What is Parkland Formula? Next steps?
Rule of 9s (2nd degree - 9% for head, 9% for each arm, 18% for front torso, 18% for back torso, and 9% for each leg) or palm size (~1% TBSA)
Parkland = 4 mL/kg x Wt (kg) x TBSA (%)
Half in first 8 hours, 2nd half over next 16 hours
Place foley and titrate to 30-50 mL/hr to avoid fluid overload. Send type and cross.
What do you do for burns?
Check for circumferential burns w/decreased peripheral pulses ➔ perform escharotomy (full-thickness longitudinal incision with scalpel or Bovie)
How does shock progress?
tachycardia ➔ hypotension ➔ decreased UOP ➔ mental status changes ➔ signs of end-organ hypoperfusion
What is fluid management in shock?
- Give crystalloids 3:1 after blood loss
- If albumin <2 ➔ give colloid
- If Hct <25% ➔ Give PRBCs
- If PTT >35 and/or PT >15 ➔ give FFP
- If platelets <50,000 ➔ give platelets
- Consider Swan-Ganz catheter if still hemodynamically unstable --> CVP 12-15
How do you assess Disability?
Assess for gross neurologic deficits
- Calculate GCS (Eyes - spontaneous,speech, pain, no; verbal - A&O, confused, inapp words, incomp sounds, no; Motor - obeys, to pain, withdraws, decorticate, decerebrate, no)
if <8, intubate the patient,
- Monitor for symptoms of increased ICP (vomiting, altered mental status, papilledema)
How do you assess environment/ exposure?
Completely uncover patient and evaluate for any unseen injuries (be sure to continue to protect the C-spine)
o Wash off any chemicals
o Maintain body temperature (prevent coagulopathy) - Use warm IV fluids, lights, blankets, warmed ventilator air
o Monitoring: Continuous pulse ox, place EKG leads, non-invasive BP cuff, NG tube, Foley if unable to urinate on own and no urethral injury
- Quick labs: type and cross, ABG/VBG to quickly assess for acidosis
- Eventually you'll need a CBCP, PT/PTT, BMP, ionized Ca
- In burns, add: carboxyhemoglobin, urine myoglobin, cardiac enzymes
- Give tetanus booster
After resuscitation in a trauma patient, what is the next step?
"I would then take a brief history from the patient, any family or friends present, and EMS personnel. I would want to elicit the following information during my history"
AMPLE: Allergies, Medications, PMH/Pregnancy, Last meal, Events
Questions in Shock (Associated Sx, PMH, PSH, Meds, Allergies, FH, SH, ROS)
Question #1: What happened to the patient recently (surgery, trauma, infection, etc.)?
o Surgery details (type, I/O's, complications, etc.), transfusion, bee stings/other exposures
•Question #2: Cardinal symptoms or other history suggestive of non-hypovolemic shock
o Associated sx: fevers/chills, chest pain, dyspnea/cough, nausea/vomiting, paralysis/paresthesias, wheezing/itching/cramps
o PMH: Recent infectious illness, cardiovascular disease, adrenal insufficiency, immunosuppression, bleeding disorders
o PSH: Surgery, recent lines/IR procedures
o Meds: Corticosteroids, antihypertensives, anticoagulation
o Allergies: Bee stings, food, antibiotics, contrast, medications
o FH: cardiovascular disease, bleeding disorders
o SH: smoking, EtOH, IV drug use
o ROS: constitutional, cardiovascular, pulmonary, GI, GU, neuro
After collecting a trauma HPI, what is the next step?
I would then move on to perform a complete head to toe physical exam with log rolling, looking for missed any missed injuries and incorporating imaging (FAST, CXR, pelvic XR) along the way. I would begin my exam by reassessing the patient's vital signs
- HEENT - pupil size, papilledema, TMs, basilar skull fracture (racoon eyes, battle's sign, otorrhea, clear rhinorrhea), Fluorescein eye exam if there are facial burns.
- MSK - palpate spine, pelvis, look for open fracture, pedal pulses (CV)
- Rectal - Rectal tone, high riding prostate
- Urethra - bloody
- Skin - TBSA (rule of 9s)
- FAST exam
What are the locations for a FAST exam?
subxiphoid/pericardial, hepatorenal, splenorenal, pelvic
What is a secondary survey?
FAST, CXR, pelvic XR
If no ultrasound, what next to assess intrathoracic bleeding?
Diagnostic peritoneal lavage (DPL)
o 10mL blood or enteric contents on initial aspiration
o Presence of bile, bacteria, or food
o Or, any of the following after infusing 1L of 0.9% NS
Amylase >175 IU/mL
What is a first degree burn?
painful, dry, red, no blisters
What is a second degree burn?
painful, tense, swollen, mottled, with blisters or open and weeping
What is a third degree burn?
painless, insensate (burned through the nerves), swollen, dry, mottled white/charred (looks like dried and leathery)
What labs for burns?
T&C, ABG, CBCP, PT/PTT, BMP, ionized Ca
add a COHgb, urine Mgb, and cardiac enzymes
What labs for shock
T&C, ABG, CBCP, PT/PTT, BMP, ionized Ca
add lactate, cardiac enzymes, blood Cx (in sepsis, before Abx), fibrinogen/D-dimers (for DIC in sepsis), pre- and post-op Hct (where applicable, for a baseline value)
Studies for trauma?
• FAST, CXR, pelvic XR (secondary survey).
• Pulmonary edema suggestive of cardiogenic shock
• Add transthoracic echocardiogram (TTE)/ transesophageal echocardiogram (TEE) if murmurs or EKG changes noted
• Add CT if etiology still unclear and pt is stable enough to undergo exam.
What are the next steps if FAST or DPL is positive?
- prep --> large midline incision -> pack all 4 quadrants and unpack looking for bleed
What is Silver sulfadiazene (Silvadene)?
Painless, poor eschar penetration, ineffective against Pseudomonas, typically for 2nd degree burns
SE: idiosyncratic neutropenia
CI: Sulfa allergy
What is Mafenide acetate (Sulfamylon)?
Painful, good eschar penetration, broad coverage (except ineffective against Staph.), typically for 3rd degree or heavily contaminated burns
SE: Allergy (7% prevalence), acidosis
What is Polymyxin B?
painless, narrow spectrum (Gram negative only), used for facial burns
What is Bacitracin?
broad spectrum, used on cartilage
What is Neosporin?
What thickness is required for skin grafting of body and face?
o Split-thickness for most of the body (w/meshing for larger areas)
o Full-thickness for face (better cosmesis)
How to treat 1st degree burn?
keep clean, Neosporin, pain control
How to treat 2nd degree burn?
unroof blisters, apply Silvadene, pain control
Deep 2nd degree will need skin grafting
How to treat 3rd degree burn?
occlusive dressings (increase epithelialization, decrease fluid loss) with BID wet saline dressing changes
Within 1 week, excise the eschar and do skin grafting
Monitor for compartment syndrome
How to treat chemical burns?
flush area with NS for >1hr
How to treat electrical burns?
perform early escharotomy +/- fasciotomy
o EKG (arrhythmias)
o Muscles damaged more than skin, TBSA often underestimates burn severity
Look for entry/exit points
Monitor urine for Mgb
o Long-term complications include myelitis, cataracts
Complications of burns?
Contractures, Myoglobulinemia, Acidosis (bicarbonate), local infection (Staph, Pseudomonas; Bx; Escharotomy, topical antibiotics).
How to manage general shock?
Continually assess response to treatment using UOP, BP, HR, mental status
- Treat hypovolemia first
- Pressors (MAP, VC - phenylephrine) and inotropes (contract - dobutamine, dopamine)
↑HR, ↓CO, ↓BP, ↑SVR, ↓CVP
o Etiology: Hemorrhagic, third spacing, diarrhea/vomiting, inadequate resuscitation, burns, pancreatitis
Stop any bleeding, resuscitate with 3:1 LR (and pRBCs if Hct<30)
If still unstable after 4-6L crystalloid and 4-6U pRBCs, ➔ OR
↑HR, ↑CO, ↓BP, ↓SVR, ↓CVP
- Et: infection (GN) ➔ inflammation ➔ vasodilation
- S/Sx: diaphoresis, flushed, warm
tachycardia/tachypnea, high-output HF --> decreased CO
- Tx: EARLY antibiotics (vanc, gent, metro), IVF, hydrocortisone, vasopresin, change all lines. Give phenylephrine and dobutamine if no response to 2L fluid.
- Monitor for DIC - hemolysis, ARDS, DKA, MOSF
↑HR, ↓CO, ↓BP, ↑SVR, ↑PCWP, ↑CVP
o Et: Intrinsic: MI, CHF, valvular disease, arrhythmia; Extrinsic: Tension PNX, cardiac tamponade, increased abdominal pressure
o Tx: Cause-specific (i.e. catheterization, pericardiocentesis, etc.)
Inotropes/diuretics PRN (e.g. Dobutamine + Lasix)
Last resorts: Intra-aortic balloon pump, left ventricular assist device (LVAD)
o Et: decreased sympathetic tone 2/2 spinal cord injury, spinal anesthesia
o Tx: IVF, phenylephrine
Wheezing, urticaria, abdominal cramps, vomiting with cardiogenic or distributive shock?
o Et: IgE mediated hypersensitivity
o Tx: IM epinephrine, albuterol, diphenhydramine, H1 blockers, hydrocortisone, pressors
Chest tube output criteria for OR?
o Blunt trauma: >1500 mL frank blood immediately or >200 mL/hr for 2 hours
o Penetrating trauma: >1000 mL frank blood immediately or >200 mL/hr for 4 hours
How do you estimate SBP based on palpable pulses?
Carotid >60, femoral >70, radial >80, DP/PT >90 mmHg
How to use BP cuff as tourniquet?
Inflate to 30-60 mmHg greater than SBP
Patient lost <750 mL blood (<15%), Pulse <100, no change in BP, and Pulse pressure is normal or high. They are slightly anxious. What class of shock is this?
Class I Shock
Pt can compensate
Patient lost 750-1500 mL blood (15-30%), Pulse >100, no change in BP, and Pulse pressure is low. They are mildly anxious. What class of shock is this?
Class II Shock
Pt can compensate
Patient lost 1500-2000 mL blood (30-40%), Pulse >120, Low BP, and Pulse pressure is Low. They are anxious, confused. What class of shock is this?
Class III Shock
Pt cannot compensate
Patient lost >2000 mL blood (>40%), Pulse >140, Low BP, and Pulse pressure is low. They are Confused and lethargic. What class of shock is this?
Class IV Shock
Pt cannot compensate
What is SIRS criteria?
2 of following:
Fever (T>38 or <36)
Tachypnea (RR>20 or PaCO2<32)
WBC >12 or <4
What is Sepsis?
SIRS + identified source of infection
What is Severe Sepsis?
Sepsis + organ dysfunction or hypotension
SBP <90 or 40-point drop
What is Septic Shock?
Severe Sepsis + hypotension despite fluid resuscitation
What is multi-organ dysfunction syndrome?
Septic Shock with evidence of 2+ organs failing