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Internal Blood Loss: rib, radius or ulna, humerus, tibia or fubula, femur, pelvis
rib: 125, radius or ulna: 250-500, humerus: 500-750, tibia or fubula: 500-1000, femur: 1000-2000, pelvis: 1000-massive
In an open fracture, a bone punctures the skin and the end can be contaminated with bacteria from the skin or environment.
Contraindications to use of traction splint
-suspected pelvic fracture
-suspected femoral neck (hip) fracture
-avulsion or amputation of the ankle and foot
-suspected fractures adjacent to the knee
Isolated fracture of the inferior or superior rami which are generally minor and do not require surgical stabilization.
These fractures occur when the head of the femur is driven into the acetabulum of the pelvis.
Pelvic ring fractures
Fractures of the pelvic ring are typically classified into three categories. Life-threatening hemorrhage is probably most common with vertical shear fractures, but it may be associated with each type of pelvic ring fracture.
3 categories of pelvic ring fractures:
1. Lateral compression fractures
2. anterior-posterior compression fractures
3. vertical shear fractures
1. Lateral compression fractures- occur when forces are applied to the lateral aspects.
2. anterior-posterior compression fractures- occur when forces are applied in an anterior or posterior direction.
3. vertical shear fractures- (worst of all) occur when a vertical force is applied to the hemi-pelvis. Blood vessels are often torn resulting in severe hemorrhage.
How do you splint dislocations?
Splint dislocations in "position found." However, when pulse is absent or weak, gentle manipulation of the joint can be done to try to return blood flow.
Life takes precedence over limb
When faced with a critically injured trauma PT with extremity injuries that are not bleeding, the focus should be on maintaing vital functions through resuscitation, and only limited measures should be taken to address the extremity injuries.
Analgesics should not be administered when...
1. the PT presents with or develops signs and symptoms of shock.
2. pain is significantly relieved with stabilization and splinting.
3. the PT appears under the influence of drugs or alcohol.
-for use in PTs with moderate to severe pain.
-dosage should be titrated to the PT's response to pain and physiological status.
-can be given IV, IM, SQ
-Adult dosage: 2.5 to 15 mg, administered slowly over several minutes while monitoring PT for relief.
-has rapid onset and does not cause increase in release of histamine (as morphine does), which can exacerbate hypotension in hypovolemic PTs.
-adult dosage: 50 to 100 mcg
-child dosage: 1 to 2 mcg/kg
As analgesics manage pain, sedatives address the anxiety. Sedatives include...
Sedatives include diazepam (Valium), midazolam (Versed), Iorazepam (Ativan), and alprazolam (Xanax) are the best known and have benefit of ante grade amnesia.
Management of amputated part
1. clean amputated part with lactated Ringer's (LR) solution.
2. wrap part in sterile gauze moistened with LR and place in plastic bag or container.
3. label bag or container, and place it in outer container filled with crushed ice.
4. DO NOT place directly on ice.
5. transport along with PT to closest facility possible.
referes to a limb-threatening condition in which the blood supply to an extremity is compromised by increased pressure in that limb.
Crush syndrome occurs when destruction of muscle releases the molecule myoglobin, when released from damaged muscle is capable of causing damage to the kidneys and acute renal failure. Traumatic injury to the muscle causes release of potassium as well which can result in life-threatening cardiac dysrhythmias.
Even with mangled extremity, the focus is still on the primary survey to rule out or address life-threatening conditions. Hemorrhage control may require use of tourniquet. The mangled extremity should be splinted if PT's condition allows. Transport to level 1 TC.
Functions of skin
includes protection from the external environment, regulation of fluids, thermoregulation, sensation, and metabolic adaptation.
When a burn occur to PTs, the elevated or freezing temperature, radiation, or chemical agent causes the proteins in the skin to be severely damaged, resulting in protein denaturation.
A full-thickness burn has three zones of tissue injury.
1. zone of coagulation- region of greatest tissue destruction. This zone is necrotic and is not capable of tissue repair.
2. zone of stasis- cells in this zone are injured, but not irreversibly. Immediately after injury, blood flow to this region is stagnant.
3. zone of hyperemia- minimal cellular injury and is characterized by increased blood flow secondary to an inflammatory reaction initiated by the burn injury.
First-degree burns (superficial burns)
involves only the epidermis and are characterized as being red and painful.
Second-degree burns (partial-thickness burns)
involves the epidermis and varying portions of the underlying dermis. Appear as blisters or as denuded, burned areas with a glistening or wet-appearing base.
Third-degree burns (full-thickness burns)
appear as thick, dry-white, leathery burns. In severe cases skin will have a charred appearance with visible thrombosis of blood vessels. Involves entire thickness of skin. Can be disabling and life threatening.
involves not only all layers of skin, but also underlying fat, muscles, bone, or internal organs.
Highest priority in burned PTs?
Airway! Heat from fire can cause edema of the airway above the level of the vocal cords and can occlude the airway. Intubate as soon as airway swelling is expected.
Treatment for burns that involve >20% of body
Establishment of two large-caliber IV catheters capable of the rapid flow rate needed for large-volume resuscitation.
a surgical procedure that involves making an incision through the hardened burn eschar, allowing the burn and chest to expand and move with the PT's respiratory movements.
In "Disability" Assessment for burned PTs..
it is vital to assess for other, less obvious internal injuries that may be more immediately life threatening than the burn injuries. Evaluate the PT for neurologic and motor deficits. Identify and splint long bone fractures. Perform spinal immobilization of necessary.
In "Expose" portion of assessment for burned PTs..
-every square inch of the PT should be exposed.
-burned PTs are not able to retain their own body heat and are extremely susceptible to hypothermia.
Rule of Palms
-Male Palm alone: 0.5% BSA
-Female Palm alone: 0.4% BSA
-Male full hand: 0.8%
-Female full hand: 0.7%
Initial step in the care of a burn PT...
to stop the burning process by irrigating with copious volumes of room-temp water. In PTs with large burns, cooling could cause hypothermia.
Administration of large amounts of IV fluids needed over course of the first day post burns to prevent...
hypovolemic shock. After a burn, the victim loses a substantial amount of itravascular fluid in the form of obligatory whole-body edema, as well as evaporative losses at the site of the burn.
-4ml/kg/% burned area
-Half of this fluid in first 8 hours
-Remaining in hours 8-24
-Lactated Ringers is preferred
Burned Pediatric PTs require larger volumes of IV fluid. Children have less metabolic reserves of the molecule glycogen in their livers to maintain adequate blood glucose during the periods of burn resuscitation.
Children should receive 5% dextrose containing IV fluids at a standard rate in addition to burn resuscitation fluids.
PTs with both thermal burns and smoke inhalation will require..
Significantly more fluid than the burn PT without smoke inhalation.
Why is it that in many cases the extent of apparent tissue damage does not accurately reflect the magnitude of the injury?
As the electricity courses through the PT's body, deep layers of tissue are destroyed despite seemingly minor injuries on the surface.
Electrical and crush injuries share many similarities.
In both injuries, there is massive destruction of large muscle groups with resultant release of both potassium and myoglobin.
Circumferential burns of the chest can constrict the chest wall and prevent sufficient..
Any PT with burns to the face or soot in the sputum is at risk for a smoke inhalation injury; but absence of these signs does not exclude the diagnosis of a toxic inhalation. Three elements of smoke inhalation:
thermal injury, asphyxiation, delayed toxic-induced lung injury
Carbon monoxide (CO) and cyanide gas (CN)
-CO binds to hemoglobin with greater affinity than O2
-Treatment is 100% oxygen 40-60 min.
Toxin-Induced Lung Injury
-Takes several days for signs and symptoms to occur
-Causes death of cilia cells and floods lungs. Could cause life-threatentin pneumonia.
Initial and most important element in caring for a PT with smoke exposure...
need for orotracheal intubation
detention of nuclear weapon kills by three mechanisms:
thermal burns from initial firestorm, supersonic destructive blast, production of radiation.
Radiation exposure PT, Initial priority..
Remove the PT from the source of contamination, remove contaminated clothing, irrigate PT with water.
Symptoms of radiation exposure
few hours after exposure, PT will experience nausea, vomiting, and cramping abdominal pain. Aggressive fluid management is required to prevent the development of renal failure. Bone marrow is extremely sensitive to radiation and will stop producing white blood cells.
Severity of chemical burns is determined by 4 factors:
nature of the chemical, concentration of the chemical, duration of contact, and mechanism of action of the chemical.
Acids damage tissue by:
Alkali burns destroy tissue by:
Acids damage tissue by: coagulative necrosis
Alkali burns destroy tissue by: liquefaction necrosis
-inadequate amounts of oxygen in the blood
-excessive carbon dioxide in the blood
-excessive acid in the blood
-inadequate amounts of oxygen reaching the body's organs and tissues
How many pairs of ribs are there?
There are 12 paired ribs. The upper 10 pairs attach to the spinal column in the back and either the sternum or the rib above in the front. The lower two pairs of ribs only attach in the back to the spine.
Do the lower two pairs of ribs break easily?
The lower two pairs of ribs (floating ribs) do not break easily as they are somewhat flexible being that they only connect to the spine in the back. They shield the organs of the upper abdomen such as the spleen and liver.
-parietal pleura lines chest cavity
-visceral pleura lines the lungs
The most important mechanism to ventilation is...
the pleural fluid which creates surface tension, which serves to oppose the elastic nature of the lungs, preventing their otherwise natural tendency to collapse.
trachea, main bronchi, heart, major arteries and veins to and from the heart, as well as esophagus
-ventilation plus the delivery of oxygen to the cells.
-the use of oxygen by the cells to produce energy.
The brainstem controls ventilation through...
monitoring of the partial pressure of arterial carbon dioxide (PaCO2) and oxygen (PaO2) by specialized cells known as chemoreceptors which are located in the brain stem and in the aorta and carotid arteries.
Baroreceptors recognize changes in..
blood pressure and direct the heart to change the rate and forcefulness of its beating to return blood pressure to normal.
Bleeding in the alveoli caused by a blunt force trauma which prevents gas exchange.
Rib fractures occur most often in which ribs?
4-8 laterally, where they are thin and have less overlying musculature.
Fractures to lower ribs may result in...
injuries of the spleen and liver and may indicate the potential for other intra-abdominal injuries.
Occurs when two or more adjacent ribs are fractured in more than one place producing a segment of the chest wall that is no longer in continuity with the rest of the chest. The force necessary to produce this is transmitted to underlying lung tissue resulting in pulmonary contusion.
air in the pleural space which disrupts the adherence between the pleural membranes created by the thin film of pleural fluid.
open pneumothorax (sucking chest wound)
involves a pneumothorax associated with a defect in the chest wall that allows air to enter and exit the pleural space from the outside.
Bleeding into the pleural space. May be caused by penetrating wounds to the chest causing lacerated tissues and torn blood vessels. Each pleural space can hold 3,000 ml of fluid. Blood may also flow into alveoli preventing gas exchange.
Occurs when there is continued entry of air into the chest cavity without any exit which causes pressure buildup in the pleural space. This may also decrease venous return to the heart and start to cause shock. In extreme causes may cause JVD and tracheal shift.
Decompression should be performed when three findings are present...
1) worsening respiratory distress or difficulty ventilating with BVM
2) unilateral decreased or absent breath sounds
3) decompensated shock (systolic BP <90)
Before attempting needle thoracostomy...
-remove or burp dressing to see if that works
-also make sure ET tube is not in right main stem
Needle decompression is performed through...
second or third intercostal space in the midclavicular line of the involved side of the chest. Use large bore (10- to 16-guage) intravenous needle that is at least 8cm in length.
The heart muscle is bruised, with varying amounts of injury to the myocardial cells. Usually results in sinus tachycardia or VT or VF.
Rupture of the supporting structures of the heart valves or the valves themselves typically renders the valves incompetent.
Blunt cardiac rupture
A rare event, occurs in less than 1% of PTs with blunt chest trauma. Most of these PTs will die at the scene from exsanguination or fatal cardiac tamponade.
Occurs then the heart allows fluid to acutely accumulate between the pericardial sac and the heart. This rising pericardial pressure impedes venous return to the heart and leads to diminished cardiac output and BP.
Beck's triad is a constellation of findings indicative of cardiac tamponade
1) muffled heart sounds
3) low BP
the clinical situation in which an apparently innocuous blow to the anterior chest results in sudden cardiac arrest.
Traumatic aortic disruption
results from a deceleration/acceleration mechanism of significant force.
Signs of traumatic aortic disruption
-pulse quality may be different between two upper extremities (stronger in right arm than left)
-pulse quality may differ between upper (brachial artery) and lower extremities (femoral artery).
-BP may be higher in upper extremities than lower extremities.
The mechanism is abrupt, significant increase in thoracic pressure resulting from a crush to the torso. This results in blood being forced back out of the heart and into the veins in a retrograde direction.
Blunt diaphragmatic injury results from the application of sufficient force to the abdomen to increase abdominal pressure acutely, abruptly, and sufficiently to disrupt the diaphragm. Use of PASG is contraindicated.
Hold in which the spinal cord passes through. Spinal cord starts at brainstem and goes down to L2.
Descending nerve tracts
are responsible for carrying motor impulses from the brain through the cord down to the body, and they control all muscle movement and muscle tone.
-Dorsal root is for sensory impulses.
-Ventral root is for motor impulses.
cartilage between each vertebral body. These discs act as shock absorbers. If damaged, the cartilage may protrude into the spinal canal, compressing the cord or the nerves that come through the intervertebral foramina.
the sensory area on the body for which a nerve root is responsible. Nipple level (T4), umbilicus level (T10), phrenic nerves arising form cord between C2-C5.
compression of the spine which may occur when the head strikes an object, or PT sustains a fall from a substantial height and lands in standing position.
-excessive flexion (hyperflexion)
-excessive extension (hyperextension)
-excessive rotation (hyper-rotation)
all cause bone damage and tearing of muscle and ligaments, resulting in impingement on or stretching of the spinal cord.
Sudden or excessive lateral bending requires more or less movement than flexion or extension before injury occurs?
Distraction (over-elongation of the spine)
occurs when one part of the spine is stable and the rest is in longitudinal motion. Common in children's playground injuries and in hangings.
occurs at the time of impact or force application and may cause cord compression, direct cord injury (usually from sharp unstable bony fragments or projectiles), and interruption of the cord's blood supply.
occurs after the initial insult and can include swelling, ischemia, or movement of body fragments.
-Cord contusion (spinal shock)
-Cord concussion results from the temporary disruption of the spinal cord functions distal to the injury.
-Cord contusion involves bruising or bleeding into the tissue of the spinal cord, which may also result in a temporary loss of cord functions distal to the injury.
Anterior cord syndrome
is a result of bony fragments or pressure on spinal arteries. Symptoms include loss of motor function and pain, temperature, and light touch sensations. However some light touch, motion, position and vibration sensations are spared.
Central cord syndrome
occurs with hyperextension of the cervical area. Symptoms include weakness or paresthesia in the upper extremities but normal strength in lower.
causes by penetrating injury and involves hemi-transection of the cord, involves only one side of the cord. Symptoms include complete cord damage and loss of function on the affected side, with loss of pain and temperature sensation on the other side.
Conditions in which blunt trauma requires spinal stabilization
2) Spinal pain or tenderness
3) Neurological deficit or complaint
4) Anatomical deformity of the spine
5) Reliability of PT (Intoxication, distracting injury, communication barriers)
Anaerobic metabolism (alternate power source)
occurs without the use of oxygen. It is the back-up power system in the body and uses stored body fat as its energy.
What is the major by-product of anaerobic metabolism?
excessive amounts of acid. If anaerobic metabolism is not reversed quickly, cells cannot continue to function and will die.
Which organs are most sensitive to ischemia (lack of oxygen)
-Heart, brain, lungs (4-6 minutes)
-Kidneys, liver, GI tract (45-90 minutes)
-Muscle, bone, skin (4-6 hours)
The Fick Principle: 3 components necessary for oxygenation of the body cells
1) on-loading of oxygen to red blood cells in the lung
2) delivery of RBCs to tissue cells
3) off-loading of oxygen from RBCs to tissue cells
Distributive (vasogenic) Shock
related to abnormality in vascular tone arising from several different causes.
Isotonic Crystalloid Solutions
-Balanced salt solutions comprised of electrolytes.
-Lactated Ringer's (LR) solution is isotonic crystalloid of voice for shock bc its composition is most similar to composition to blood plasma.
-0.9% sodium chloride (NS) is acceptable but may cause hyperchloremia
Within 30-60 minutes only about 1/4-1/3 crystalloid solution remains in cardiovascular system.
Administer 3:1 solution to blood loss. If possible heat IV fluids to 102*F
Hypertonic Crystalloid Solution
contain extremely high concentrations of electrolytes compared to blood plasma.
Synthetic Colloid Solutions
When administered to a PT in hemorrhagic shock, synthetic colloid solutions draw fluid from the interstitial and intracellular spaces into the intravascular space, thereby producing expansion of blood volume.
outermost layer composed of tough fibrous tissue and is applied to the inside of the skull.
Peritoneal cavity (true abdominal cavity)
contains the spleen, liver, gallbladder, stomach, portions of the large intestine, most of the small intestine and female reproductive organs (uterus and ovaries).
Retroperitoneal space (potential space behind "true" abdominal cavity)
contains the kidneys, ureters, inferior vena cava, abdominal aorta, pancreas.
-inflammation of the peritoneum or the lining of the abdominal cavity
What is the most reliable indicator of the presence of hypovolemic shock from an unexplained source.
Findings from the physical examination that support a diagnosis of peritonitis include..
-significant abdominal tenderness on palpation or with coughing
-diminished or absent bowel sounds
ecchymosis involving the flanks. Indication for retroperitoneal bleeding that may not show for hours.
ecchymosis around the umbilicus. Indication for retroperitoneal bleeding that may not show for hours.
How much fluid can the adult peritoneal cavity (abdomen) hold before showing any signs of dissension?
1.5L (1500 ml)
Untrasound has become the primary bedside modality used to assess...
trauma PTs for intra-abdominal hemorrhage.
In absence of TBI, the target systolic BP for PTs with intra-abdominal bleed is...
80-90mm Hg. (PTs with TBI aim for 90mm Hg)
Do not attempt to replace protruding tissue. Instead, cover with clean dressing moistened with saline. Wet dressings may be covered with a large, dry dressing to keep the PT warm.
a natural biological process that is sometimes referred to as a process of "biological reversal" that begins during the years of early adulthood.
Changes caused by aging include...
Decreased (brain mass, depth perception, pupillary response, respiratory vital capacity, renal function, total body H2O, hearing, cardiac stroke volume & rate, elasticity of skin, 15-30% body fat) etc.
A PT who has previously had an acute MI sustains permanent heart damage and therefore...
the resultant reduced cardiac capacity continues for the rest of the PT's life, affecting the heart and, because of the ensuing chronic impairment of circulation, other organs as well.
It may be hard to get a good seal on a geriatric PT with a BVM because of...
edentulism (changes in the contours of the face which result from resorption of the mandible, in part because of absence of teeth).
In geriatric PTs, the increased stiffness in the chest wall is associated with..
a reduction in the ability to expand the chest wall and a stiffening of cartilaginous connections of the ribs.
The alveolar surface area decreases with age;
it is estimated to decrease by 4% for each decade after 30 years of age.
In geriatric PTs, a lower baseline oxygen saturation is a normal finding because...
as the body ages, its ability to saturate hemoglobin with oxygen decreases.
What is the primary cause of death in the elderly population?
Diseases of the cardiovascular system.
-a narrowing of the blood vessels, in which the inner layer of the artery wall thickens as fatty deposits build up within the artery.
Why might the baseline normal blood pressure of the elderly trauma PT be higher than in younger PTs?
Calcification of the arterial wall reduces the ability of the vessels to change size in response to endocrine and central nervous system stimuli.
-with age, the heart itself shows an increase in fibrous tissue and size. Atrophy of the cells of the conduction system results in the increased incidence of cardiac dysrhythmias.
In the elderly PT, this reduced circulation contributes to cellular hypoxia.
The result is cardiac dysrhythmia, acute heart failure, and even sudden death.
In elderly PTs, the reduced circulation and circulatory-defense responses, coupled with increasing cardiac failure..
produce a significant problem in managing shock. Care must be taken when treating hypotension and shock so as not to cause volume overloading with aggressive fluid resuscitation.
What is the problem with the fact that elderly PTs' brains shrink by up to 10%?
Allows for more brain movement in response to acceleration/deceleration injuries.
In elderly PTs, the speed with which nerve impulses are conducted along certain nerves decreases.
This causes compensatory functions to be impaired, particularly in PTs with Parkinson's disease, resulting in an increased incidence of falls.
When assessing an elderly PT, any impairment in mentation should be assumed to be the result of...
an acute traumatic insult, such as shock, hypoxia, or brain injury.
Bc of the aging process and the presence of diseases such as diabetes, elderly PTs...
may not perceive pain normally, placing them at increased risk of injury from excesses in heat and cold exposure.
One important thing to remember in elderly PTs; when administering drugs normally cleared by the kidney's...
elderly PTs may have reduced levels of filtration by the kidneys and a reduced excretory capacity.
Elderly people are sometimes shorter than they were in young adulthood because of...
dehydration of the vertebral discs.
the narrowing of the spinal canal which increases likelihood of cord compression without any actual break in the bony cervical spine.
A high level of suspicion for spinal injury is needed during elderly PT assessment because..
more than 50% of vertebral compression fractures are asymptomatic.
As the skin ages, sweat and sebaceous glands are lost.
Loss of sweat glands reduces the body's ability to regulate temperatures. Also, loss of fatty tissue can predispose the elderly PT to hypothermia.
In elderly PTs, organs associated with the immune response (thymus, liver, and spleen) all decrease in size.
This causes increased susceptibility to infection. Sepsis is a common cause of late death after severe or even insignificant trauma in the elderly PT.
Leading cause of trauma death and disability in those over 75 years of age...
Falls. Women are twice as likely to sustain a serious injury than men due to osteoporosis.
Elderly PTs are more susceptible to TBI...
because of the shrinkage of the brain causing the dural bridging veins to become more stretched and, thus, susceptible to tearing. (subdural hemorrhage)
In elderly PTs, vital capacity is diminished by..
50%. Expect lower tidal volumes and lower minute volumes.
HR is a poor indicator of trauma in elderly PTs because...
of the effects of medication and the heart's poor response to circulating catecholamines (Epinephrine).
may causally relate to the events that caused injury and may make blood glucose therapy difficult if their use is unrecognized.
The skeleton of a child is less able to absorb the kinetic forces applied during a traumatic event...
allowing significant force to be transmitted to underlying organs.
In the pediatric PT, the three most common causes of immediate death are..
hypoxia, massive hemorrhage, and overwhelming central nervous system trauma.
A period of hypoxia during multiple or prolonged attempts at placing an advanced airway may...
be more detrimental to the child than simply ventilating the child with a BVM and providing for rapid transport.
In the pediatric PT, tachycardia, although it may by the result of fear or pain, should be considered to be secondary to hemorrhage or hypovolemia until proven otherwise.
A narrowing pulse pressure and increasing tachycardia may be the first subtle signs of impending shock.
If I miss early signs of shock in a child, they may lose enough blood volume to cause compensatory mechanisms to fail.
When this happens, cardiac output plummets, organ perfusion decreases, and the child can rapidly decompensate often leading to irreversible, fatal hypotension and shock.
For a pediatric PT in hypovolemic shock...
administer 20-ml/kg bolus of crystalloid solution (use broselow tape).
Do we withhold fluid from a child with suspected TBI?
NO. Fluid of choice for resuscitation of the child is isotonic crystalloid solutions.
Prevent secondary injuries in children by preventing episodes of...
hypoperfusion, hypoventilation, hyperventilation, and ischemia (inadequate blood supply).
Hyperventilating a PT causes..
a decrease in CO2 level in the blood which will cause vasoconstriction.
Pediatric Verbal Score (GCS)
5) appropriate words or social smile
4) crying but consolable
3) persistently irritable
2) restless, agitated
1) No response
Dealing with children in trauma (Peds in fetus)
1) I am protected from injury.
2) I don't have to worry about my airway.
3) I don't have to worry about my breathing.
4) I'm in a fluid environment.
5) I'm nice and warm.
6) I'm close to mommy (show love).
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