Rosen's Part II - Section 1 Gen.Concepts. CRACKcast.org
This continues through chapters 36-40 in Rosen's. Part II on general trauma concepts
Terms in this set (67)
General approach to the multi-trauma patient?
Circulation: control deadly bleeding
Disability (GCS/Pupils/Gross Motor)
Secondary survey ; AMPLE hx ; Investigate
Prepare your team!
Control deadly bleeding - TQs, bind pelvis, scalp lacs,
Decompress the chest
Bind the pelvis
4 main categories of indications for Trauma Team Activation:
PHYSIOLOGIC indications for trauma team activation:
-Systolic BP <90
-RR <10 or >30
-GCS <12 or focal neurological signs
ANATOMIC indications for trauma team activation:
-amputation proximal to elbow or knee
-2 or more long bone #s
-tension pneumo or hemothorax
-suspected spinal injury with deficit
-suspected penetrating injury
MECHANISTIC indications for trauma team activation:
-ejection from vehicle
-high speed MVC or roll-over
-fall > 20ft or 6m
-severe deceleration injury
-bicycle or motorcycle crash
-2nd or 3rd degree burns >10% BSA
*special considerations: >60, <16 years, pregnancy
LOGISTICAL indications for trauma team activation:
-whenever the emergency physician needs more help or resources
General approach to multi-trauma patients:
Prepare your team, assign roles
Listen to story, vitals en route, vitals now
(w/ appropriate interventions)
-Airway - patent? FBs? ventilating? (intubate?)
-Breathing - WOB? trachea midline? chest sounds? subcut
air? (chest tube?)
-Circulation - deadly bleeding? monitor? IV? abdo pain?
(fluids, blood, TXA, thoracotomy?)
-Disability - GCS, pupils, power movement x4 (collar?)
-Expose patient/Environmental (logroll, tx hypothermia?)
-head to toe assessment, log roll if not done yet, FAST
-AMPLE hx, tetanus?
-CT panscan vs CT focused, X-ray of focal injuries/pain
(chest, limbs, pelvis).
-trauma labs (include lactate, INR, fibrinogen, G&S, BHCG)
-pain, nausea, pressor support, abx, fluids, steroids?
-admit, transfer, discharge?
List 5 commonly missed traumatic injuries:
1. scalp lacerations
2. extremity fractures
3. urethral injuries
4. posterior injuries
5. Injuries in axilla, groin, or buttocks
PENETRATING chest trauma... Crack the chest or not? That is the question... how do you decide?
Indications for thoracotomy in penetrating trauma:
BLUNT chest trauma... Crack the chest or not? That is the question. How do you decide?
Blunt trauma with:
1. Signs of life on arrival to the ED (any 1 of):
● blood pressure
● cardiac rhythm
● respiratory effort
● U/S ECHO showing cardiac activity or tamponade
2. Less than 10 mins of paramedic-based CPR
● can consider doing thoracotomy
**Consider intubating, giving IV fluids, and needling both chests or bilateral finger thoracostomy
Contraindications to do thoracotomy in ED:
-no signs of life on scene and in the ED
-CPR (despite signs of life initially) > 10 mins
-system or department reasons
Threshold of fetal viability? How can you guestimate?
>24 weeks or >500g
estimated by uterine fundus being ABOVE umbilicus
List 4 unique considerations in the management of pregnant trauma patient:
1. Supine hypotensive syndrome (of pregnancy)
2. Physiologic alterations: incr blood vol. may mask shock,
incr cardiac output by 40% --> incr bleeding, less venous return --> incr. blooding from leg wounds)
3. Pulmonary considerations: decr. FRC, incr O2 consumption, incrased ventilation leads to hypoCO2, difficult BVM --> so be quick to tube
4. GI considerations: reduced sphincter tone leads to incr. apiration risk, incr acid production --> early decompression
What are signs a fetus is in distress (in traumatic injury of mom)?
Abnormal fetal HR (not 120-160)
Decreased HR variability
Late decelerations (fetal hypoxia)
Decreased fetal movement
Clinical presentation of placental abruption
(it is a clinical diagnosis):
2. Painful, vaginal bleeding
3. abdominal cramping
4. uterine tenderness, contractions
5. Maternal shock
Management of placental abruption:
Expectantly until 32 weeks after which OB may elect to C/S
Complications of placental abruption:
1. premature labour
2. stillbirth (exponential rise in fetal mortality)
3. maternal coagulopathy (DIC)
What is a safe radiation dose in pregnancy?
Fetal demise RARE with <10 rads (equivalent to 2 CT abdos)
chest Xray = 5 milli-rads
pelvis Xray = 200-2000 milli-rads (0.2-2 rads)
CT head = 50 milli-rads
CT abdomend = 3 rads
CT pelvis = 3-9 rads**
What is the primary screening investigation modality for major abdominal injury in pregnant patients?
(~97% acurate for detecting intrabdominal injuries in blunt trauma)
How does primary and secondary survey change in prenant trauma patients?
Key: mother is main priority from the start
Primary Survey: ABCT+UFO
-Airway: secure and airway early, RSI
-Breathing: Give O2! Goal PaCO2 30mmHg
-Circulation: HR and BP not good predictors, uterine bleed?
-Tilt the mom!
-Uterus above umbilicus - fetus likely viable (>24wks)
-Detailed maternal /OB hx - weeks pregnant, GTPAL, vaginal bleeding? discharge? contractions? fetal movement?
-Pelvic exam - signs of ferning? cervical dilation? GBS status? RH status? Bimanual exam for pelvic bone protrusion.
-Fetal evaluation: FHR, movement
Key consideration for RH negative moms following any abdominal trauma:
Mom should receive Rhogam (RhIG) within 72 hrs of incident at a 300mcg dose.
How is feto-maternal hemorrhage diagnosed and managed?
Most concern when > 12 weeks into pregnancy.
● Do Kleihauer-betke test for transplacental bleeding
-Quantifies the amount of fetal-maternal hemorrhage (>5 mL)
-8-30% incidence after trauma
●all Rh neg. mothers with any abd. trauma should receive RhIG within 72 hrs of the incident at a 300 mcg dose (protects against 30 ml of blood)** --Regardless of a negative KHB test!
Indications for post-mortem C-Section:
-Must start within 4 min of maternal cardiac arrest
-Present fetal heart tones
-Greater than 24 wks gestation
Post-mortem C-section procedure:
Ensure high quality CPR is underway!
midline vertical incision from epigastrium to symphysis pubis
vertical incision of the uterus
clamp and cut cord
Should be less than 3 minutes
Can you safely electircally cardiovert a pregnant woman?
Yes. No harm to fetus shown with shocks up to 300J.
Are tetanus shots safe for mom in prenancy?
List 4 anatomic/physiologic differences between kids and adults in relation to trauma management:
1. Force more widely distributed through a child's more fragile frame = more injuries to bone, viscera, spinal cord
2. Kids have larger BSA = lose heat faster
3. Higher metabolism = greater proportional demand for fluids, lytes, O2, and glucose
4. Capacity to maintain BP despite 30-40% blood loss
-SERIAL vitals and basically no role for inotropy
List 8 airway differences that distinguish kids from adults:
What are some potential fluid therapies for hemorrhagic shock in kids and their doses?
-standard trauma/resus room protocol : MOVIE
-10-20ml/kg of crystalloid IV bolus repeated up to 3x then:
○ PRBCs: 10 ml/kg
○ FFP: 25 ml/kg
○ Platelets: 10 ml/kg
List 3 ideal IO sites in kids:
-proximal medial tibia
-anterior distal femur
List 6 indications for laparotomy in peds trauma:
1. hemodynamic instability despite aggressive resuscitation
free fluid on FAST and instability
2. massive bleeding (intraperitoneal)
3. pneumoperitoneum / intraperitoneal bladder rupture / grade V renovascular injury
4. gunshot wound
List 6 signs of elevated ICP in infants (0-1 yrs):
1) full fontanel
2) split sutures
3) altered state of consciousness
4) paradoxical irritability
5) persistent emesis
6) setting sun sign
List 9 signs of elevated ICP in children:
2) stiff neck
4) altered mental status
5) persistent emesis
6) cranial nerve involvement
8) hypertension, bradycardia, hypoventilation
9) decorticate and decerebrate posturing
List the 5 layers of the scalp and describe 3 types of extra cranial bleeding in pediatrics:
-Loose Connective Tissue
-hematoma, freely mobile and crosses suture lines
-blood UNDER periosteum = does NOT cross suture lines
-scalp bleeding can be profuse and lead to shock in infants
-clearly seen on CT as a brain parenchymal injury
-neuro features with altered MS
What features of skull fractures in kids are associated with BAD outcomes?
1) fracture over a vascular channel
2) a depressed fracture
3) a diastatic fracture-- one that crosses through/along suture lines. Leptomeningeal cysts (growing fractures) may develop (>2mm of separation)
4) fracture extending over the area of the medial meningeal artery (risk of epidural bleed)
5) rhinorrhea, otorrhea
Describe the management of elevated ICP in kids:
-hyperventilate for temporary fix
-craniotomy/burr holes if necessary
-Mannitol (0.5 g/kg IV)
-rapid osmotic diuresis
-Hypertonic saline (0.1-1 mL/kg of 3% saline)
-Pentobarbital/phenobarbital-lowers cerebral metabolism
-Treat seizures aggressively
List 11 anatomical differences that distinguish peds spines from adult ones:
1. higher fulcrum C2-3 (higher c spine injuries)
2. larger head size- greater flexion and extension injuries
3. smaller neck muscle mass
4. increase interspinous lig. flexibility
5. flatter facet joints
6. incomplete ossification at multiple bony sites
7. anterior surfaces of the vertebral bodies are more wedge shaped
8. Epiphytes of spinous processes tips mimic fractures
9. Narrow preodontoid space
10. Pseudosubluxation of C2-3 seen on 40% of kids 8-12 yrs
11. Pre-vertebral space varies with respiration
Key considerations with spinal injury in pediatric trauma:
-They are rare
-Higher cord injuries are more common than lower cord
-SCIWORA (Spinal Cord Injury without Radiography Abnormality) -found in 25-50% of spinal injuries
How do you determine between true subluxation and pseudosubluxation at C2-3 in kids?
Pseudosubluxation of the c-Spine at C2-3 is common in kids
spinolaminar line of C1-3, If the line crosses C2's anterior cortical margin by less than 2 mm, (and no cervical soft tissue swelling and no fracture is seen) the image demonstrates pseudosubluxation. If not... true sublux
What is Power's ratio?
Two ways to choose size of chest tube in kids:
2 x ETT size
4 x ETT size
List pediatric-specific cardiovascular and abdominal injury patterns associated with classic mechanisms of trauma:
Lap belt use:
-small bowel injury/hematoma
Bike handlebar injuries:
-spleen, kidney, intestinal tract
List 5 or more risk factors for FALLS in the elderly:
-impaired thirst mechanism - dehydration - orthostatic drops
-reduced respiratory reserve
-cardiac disease - poor CO, arrythmias
-arthritis/osteophytes - poor mobility
-loss of fine motor skills
Specific considerations for elderly trauma patients:
normal vitals should NOT be reassuring
often difficult airway (dentures, stiff neck, obese)
faster apneic desat, higher risk of hypotension
less RSI meds needed (try to avoid succ)
low FRV, consider high flow
Quick to tire with WOB
blunted stress response, less CO reserve
previous HTN may mask hypotention as normotension,
Pt on anticoagulation?
elderly at incr risk of spine # (C, T, L, S) or SCIWORA, watch out for TBI (CT every head)
increased risk of hypothermia (thin skin, less fat/muscle,impaired thermoregulation), remove from backboards ASAP, tetanus UTD?
Some specific disorders you need to watch for when dealing with elderly patient trauma:
1. Traumatic brain injury - contusion, bleed, skull #
2. Thoracic trauma - rib/sternal #, pneumothorax (in COPD)
3. Upper extremity - distal radius > humeral head > elbow
4. Lower extremity - akle #, hip/pelvic #, tibia plateau #
What are the 3 most common C-spine injuries in the elderly?
Central cord syndrome
weakness in arms > legs
often no fracture but have preexisting stinal stenosis
usually stable, but need early mobilization
Cervical distraction and extension injuries
from forehead/face trauma
Three types of odontoid fractures:
What are the 3 key aspects to injury control?
: education, public law enforcement
: trauma systems, EMS, guidelines for care
: physio, OT, mental health
What makes up the injury triangle?
What can you do as a health care provider to help injury prevention?
What does one need to have consciousness?
Functioning RAS (in brainstem) and cerebral cortices.
List 7 causes of altered LOC in the trauma patient:
5. Post-intoxicating drugs
6. Brain/brainstem compression from mass effect
List 5 brain herniation syndromes:
1. Uncal herniation
2. Central transtentorial herniation
3. Upward transtentorial herniation
4. Downward cerebellar-tonsillar herniation
5. Cingulate-subfalcine herniation
List 3 general ways to decrease ICP:
2. Diuretics or osmotic agents
3. CSF drainage
In head injuries, what are the secondary systemic insults we want to desperately avoid to prevent further neurologic damage?
1. Hypotension (SBP <90 mmHg)
2. Hypoxia (PaO2 <60 mmHg)
4. Hyperthermia (>38.5 deg)
In a healthy brain, describe how PO2, PCO2, MAP, and ICP all relate to the amount of blood getting to brain tissue (CBF):
- inverse - if oxygen content decreases, vasodilation and CBF increases
- direct - if CO2 content decreases , vasoconstriction and CBF decreases
- direct - if systemic BP increases, CBF goes up
- inverse - if ICP increases, CBF declines.
Indications for ICP monitoring (2 of them)?
1. Severe head injury (GCS <9)
2. Moderate head injury (GCS 9-12) who cannot be monitored with serial neurological exam
Canadian CT Head Rule:
Remember: this is for whether or not to image someone with a MINOR head injury (GCS 13-15) after witnessed LOC, amnesia, or confusion.
What is a concussion?
Complicated minor traumatic brain injury, most commonly from collision sports. Leads to short-lived distortion of axons with neurotransmitters in an elevated/hypermetabolic state for WEEKS post-injury. This can cause secondary damage if not allowed to heal.
Main Sxs of Post-Concussive Syndrome?
-Sensory hypersensitivity (photophobia, phonophobia)
-Mood changes, irritability
ED management of
(GCS <8 or intracranial contusion/hemorrhage on CT):
(shock etiology? Keep SBP >90 mmHg)
(Goal PaCO2 in acute setting=30-35 mmHg)
(controversial) - mannitol/hypertonic saline
Cool the patient?
(weak evidence, maybe helps brain)
- if indicated...benzos/barbituates
- if open or depressed skull #
List 6 indications for starting seizure prophylaxis in traumatic head injury patients:
1. Depressed skull #
2. paralyzed/intubated pt.
3. Any seizure at any time (or hx of same)
4. PENETRATING brain injury
5. Any brain bleed (epidural, SDH, ICH)
6. Severe head injury: GCS <8
ED management of
-Watch for deterioration in first 48hrs! Serial neuro checks
-Admit for close observation, even if CT head normal
ED management of mild TBI (GCS 14-15, a clinical diagnosis):
-F/U if worsening sx
Complications arising after traumatic head injury?
-CNS infection - meningitis, brain abscesses, osteomyelitis
Tell-tale clinical features of basial skull fracture?
-Blood in ear canal (Hemotympanum )
-Battle's sign (retro auricular hematoma)
-Racoon's sign (periorbital ecchymosis)
-Cranial nerve deficits:
■ Facial paralysis
■Decreased auditory acuity
Cerebral edema on CT?
3 key points in identifying cerebral edema on CT:
1. Sulcal effacement
2. Loss of gray-white differentiation
3. Ventricular compression