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Torso Trauma and Endocrine Emergency

Terms in this set (45)

What is included in the All Trauma Protocol (ATP)?
1. ABCs, Oxygen, Monitor, IV
2. CBC, CMP, PTT, PT, Type and Screen
3. CXR, Pelvic XR
4. CT Head, C-SPine, Chest, Abdomen and Pelvis WITH IV Contrast
5. Primary and Secondary Survey
6. GCS Rating
Which organs ar most frequently injured in torso trauma?
Liver and Spleen

Then Small and Large intestines
Important History Questions in MVA
1. The extent of vehicular damage
2. Whether prolonged extrication was required
3. Whether the passenger space was intruded
4. Whether a passenger died
5. If pt was ejected from the vehicle
6. Seat belts and airbag deployments
7. The presence of alcohol or drug use
8. Head or spinal cord injury
9. Whether psychiatric problems were evident
Bradycardia in a trauma patient may indicate what?
Free intraperitoneal blood
If you auscultate bowel sounds in the thorax, what could this mean?
May indicate a diaphragmatic injury
What is Commotio Cordis?
Sudden death due to ablunt chest trauma that causes V- Fib.

The trauma is non-penetrating and often innocuous appearing and doesn't seem sufficient to cause major injury.
Treatment for Commotion cordis
V-FIb protocol --> Unsynchronized Cardioversion

Note that CPR is often delayed because observes underestimate the severity of the trauma or believe the wind has been knocked out of the person
If a patient was just in a MVA and begins to complain of Left shoulder pain, though has no signs of trauma to the extremity, what intrabdominal injury should you consider?
SPLENIC injury - subphrenic blood can cause referred pain to Left shoulder
What is a FAST?
Focused Assessment with Sonography for Trauma.

A bedside Ultrasound that is cheap and rapid, noninvasive to detect hemoperitoneum.

Exam is Positive if free fluid is found.
Exam is Negative if no fluid seen.
Exam is Indeterminate if any window can not be adequately assessed.
What are the 4 windows of the FAST exam?
1) Pericardiac
2) Perihepatic
3) Perisplenic
4) Pelvic
What does the PeriCARDIAL window of the FAST exam look at?
Also called "Subxyphoid/Subcostal area"

Chest, anterior, around the Epigastric area
What does the PeriHEPATIC window of the FAST exam look at?
Looks at the RUQ to view the "Right Gutter".

This would show fluid in the Hepatorenal Recess, also called "Morrison's Pouch"
What does the PeriSPLENIC window of the FAST exam look at?
Looks at the LUQ to view the "Left Gutter".

This would should fluid between the Spleen and Kidney.
What does the PELVIC window of the FAST exam look at?
Also called the "Suprapubic" area.

Asses for Bladder or Uterus disruption.
What are Kussmaul Respirations?
Deep, Rapid, Continuous respirations due to metabolic respirations.

Body's attempt to compensate by blowing off CO2.
Clinical Features of DKA
1) Dehydration - due to increase glucose dragging water away

2) Hypotension - due to volume due to water loss

3) Tachycardia - body try to compensate by blowing off CO2

4) N/V - acidosis triggers N/V center in brain

5) Kussmal respiration
Differential Diagnosis for Metabolic Acidosis
Too Much Acid or Too Little Bicarbonate

"MUDPILERS"

Methanol
Uremia
DKA/Alcholic KA
Propylene glycol
Isoniazid (INH), Inhalants, Infection, Iron
Lactic acidosis
Ethylene glycol
Rhabdo/Renal Failure
Salicylates
Work up for DKA
CBC, CMP, PO4, Mg, ASA Level, Ketones, Cardiac, ABG

q1hr Glucose and K+

q2hr Electrolytes

EKG

Urine
What might an EARLY EKG should in DKA?
Since acidosis is forcing K+ OUT of cells and into plasma, may cause HYPERkalemia and thus may see:

PEAKED T WAVES
What might a LATE EKG show in DKA?
HYPOKALEMIA may result due to:

1) Kidneys have detected the acidosis and have begun to excrete large amount of K+
2) Administration of Insulin forces K+ back into cell and thus may see:

FLAT - INVERTED T WAVES
PROMINENT U WAVES
What is D5W?
ISOtonic Solution

- Osmolarity is EQUAL to plasma
- Expands INTRAVASCULAR volume
What is D5 NS?
HYPERtonic Solution

- Osmolarity if HIGHER than plasma
- Draws fluid INTO the Intravascular space from cells and interstitial compartments
When do you NOT give insulin?
If Serum K+ is LESS than <<< 3.3
Once the K+ is > 3.3, what is the dosage for Insulin for DKA?

How long do you continue use?
Give REGULAR Insulin 0.1 units/kg body weight per hour.

Continue insulin until after 2 blood draws 1 hour apart shows:
1) Anion Gap is CLOSED
OR
2) Ketone bodies gone
In the treatment of DKA, when should Sodium Bicarb be given?
ONLY if the pH is LESS than <<< 6.9
Which has a greater mortality? DKA or HHS?
HHS
How does HHS differ from DKA?
BOTH have Hyperglycemia, however, HHS has the following characteristics:

- GREATER degree of Hyperglycemia
- ABSENCE or lesser degree of Acidosis
- GREATER degree of Altered mental status
Would you see Kussmaul respirations in HHS?
Nope. remember that in HHS there is usually NO acidemia since this likely occurs in Type 2 DM who still have a little amount of insulin.
What are the clinical manifestations of hypoglycemia?
- Sweating
- Shaking
- Nausea
- Dizziness
- Confusion
- Anxiety
- Blurred vision
- Headache
- Weakness
What is the definition of hypoglycemia?
Blood sugar LESS than 50, however "relative" hypoglycemia can occur with any BS that is <50% of "patient normal"
What is Whipple's Triad?
Criteria that suggests patients symptoms result from hypoglycemia:

1) Documented Low Blood sugar
2) Symptomatic at time of Low Blood sugar
3) Relief of symptoms after glucose intake
Differential for Low serum glucose?
SAD LIFE

Sepsis
Addison's Disease (Cortisol deficiency)
Drugs - DM drugs, Stimulants, INH, HIV meds

Liver - cirrhosis depletes glycogen stores and ability for gluconeogenesis
Insulin
Fasting
EtOH
What is the treatment for hypoglycemia?
1) IV Dextrose or IM/SC Glucagon

For refractory cases administer:
1) IV Glucagon
2) IV Hydrocortisone 100 mg
What are the 3 main symptoms of Wernicke's encephalopathy?
1. Ophthalmoplegia
2. Ataxia
3. Confusion
What re the 6 major symptoms of Korsakoff's syndrome?
1. Anterograde amnesia
2. Retrograde amnesia
3. Confabulation
4. Minimal content in conversation
5. Lack of insight
6. Apathy
What is Thyrotoxicosis?
Also known as Thyroid storm, this is caused by a HYPERthroid state.

MC presents in Graves' Disease (IgG Antibody the mimics TSH)

Has high mortality despite treatment.
What are some precipitants of Thyroid storm?
Infection (often viral)
Trauma
DKA
MI
CVA
PE
Surgery
Iodine administration

Amiodorone
Clinical features of Thyroid storm?
- Hyperthermia/Fever
- Tachycardia with possibly A-fib
- Diaphoresis
- Altered mental status

On exam may see:
- Exopthalmos (Grave's Disease)
- Palpable goiter
- Hyperdynamic goiter
What labs should you order for Thyroid storm and what will it show?
TSH with T4

HIGH T4
LOW TSH
Treatment for Thyroid Storm
1) ABC
2) Monitor pulse and watch for V-Tach and A-fib
3) Decrease T4 synthesis -- Propythioracil (PTU) or Methimazole
4) Prevent release of hormone -- Iodine or Lithium carbonate
5) Prevent peripheral effects of T3/T4 and prevent conversion-- Propanolol or Esmolol
What is Mxydema?
Rare, life threatening expression of HYPOthyroidism.

Most often seen in Elderly more in Winter.

Hallmark is:
1) Hypothermia
2) Altered mental status
What are precipitants of Myxedema?
Infection,
CHF
Drugs (Beta-Blockers blocks peripheral iodination*, Lithium)
Trauma
Exposure to cold environment.
Clinical manifestations
1) Hypothermia***
2) Altered mental status **

Bradycardia
Hypoglycemia
Hyponatremia
Hypotension
Hypoventilation

LATE signs:
puffiness of the nose, lips, hands, tongue due to deposits of mucin
Lab findings in Mxydema
LOW T3/T4
HIGH TSH

Hyponatremia
Hypoglycemia
Treatment of Mxydema?
1. ABC's w/ Cardiac monitoring
2. PASSIVE rewarming of the patient
3. Hydrocortisone
4. Administer Thyroxine (T4)
5. Administer Triiodothyronine (T3)
6. May need hypertonic solution to correct hyponatremia
7. Antibiotics for infection if suspected
8. Other Side treatments for infection, respiratory failure, and cardiac arrhythmias
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