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Glasgow Coma Scale - Chance fracture - Transverse fracture through vertebra. In children usually associated with enterc disruption. Seen in motor vehicle accidents involving only lap belt. May be associated with retroperitoneal and Abdominal visceral injuries. Anterior hip dislocation - Flexed, abducted, externally rotated. Burst fracture - Associated with vertebral-axial compression injuries Posterior hip dislocation - Flexed, aDDucted, internally rotated. Anterior shoulder dislocation - Squared off appearance Posterior shoulder dislocation - Lock in internal rotation. Ankle dislocation - Most are Externally rotated, with a prominent medial malleolus. FULL thickness (3rd degree) burn - Dark or white and leathery. Translucent white as well. Painless and generally "dry" Does not blanch with pressure. Very little swelling of burned tissue. Principle Life saving measures for patients with burn injuries include - -Establishing airway control -Stopping the burning. process -Intravenous access Factors that increase the risk for upper AIRWAY OBSTRUCTION in burns include: - -Burns to the head and face
-Burn size and depth -Burns inside the mouth Partial thickness burn - Red remodeled appearance with associated swelling and blister formation. May have weeping or wet appearance and is painfully hypersensitive even to air current. Signs and symptoms and history that suggest INHALATION INJURY include: - These patients should be intubated. Inhalation injury is an indication for transfer to a burn center. Rule of nines - adult - The palm represents 1% of the body total surface area. Symptoms of carbon monoxide poisoning and respective levels - PaO2 does not reliably predict carbon monoxide poisoning because a CO partial pressure of only 1 mmm Hg results in a hemoglobin CO level of 40% or greater. Carbon monoxide has how many times greater affinity for hemoglobin than oxygen - 240 times. It displaces the oxyhemoglobin desaturated curve to the LEFT. Two criteria required for the diagnosis of smoke inhalation injury - -Exposure to a combustible agent -Signs of exposure to smoke in the lower airway, below the vocal cords, by bronchoscopy. Performing this action will help reduce neck and chest wall edema in patients with burn and inhalation injury. - Elevation of the head and chest by 30 degrees. IV fluid administration formula for burn victims - Indicated in burns involving over 20% of the body surface area. *(2-4 mL/kg of LR/NS) (weight in kg) (% area of burn); give 1/2 of this volume in first 8 hours. Remainder in over 16 hours.
Definition of frostbite. - Freezing of tissue with intracellular ice crystal formation, microvascular occlusion, subsequent tissue anoxia. First degree frostbite - Hyperemia and edema without skin necrosis Second-degree frostbite - Large clear vesicle formation accompanies hyperemia and edema with partial thickness skin necrosis 3rd degree frostbite - Full thickness and subcutaneous necrosis occurs, commonly with hemorrhage and vesicle formation. Although a compartment pressure > systolic blood pressure is required to lose a pulse distal to in extremity burn, a pressure of what was in the compartment may lead to muscle necrosis - 30 mm Hg. If a pressure of greater than 30 mm Hg in a burned extremity is present, eschatotomy is indicated. Difference between fasciotomy and eschatotomy - Compartment syndrome is also present with circumferential chest and abdominal burns, which lead to increased peak inspiratory pressures. Eschatotomy in circumferential chest and abdominal burns. - We are generally not needed before the first 6 hours after a burn. Gastric tube placement in burn victims. - Place of burn involves more than 20% of total BSA. Alkali burns to the eyes require how many hours of continuous irrigation - 8 hours. Electrical burns. - Can cause thrombosis and entry to nerves, and digits are especially prone to injury. Patients with electrical injuries frequently require fasciotomies because of the degree of deep tissue injury and should be transferred to a burn center. Immediate ELECTRICAL burn treatment measures. - Attention to airway and breathing, IV line placement, ECG monitoring, and placement of an indwelling Foley catheter.
Rhabdomyolysis and subsequent metabolic acidosis are common complications. Criteria for transfer of a burn victim to a burn center. - Estimating WEIGHT in kilograms for a child - (2× AGE) + 10 Infant blood volume estimate - 80 ml/kg Child blood volume estimate - 70 ml/kg. IO needle size: Infant Child - 18 gauge 15 gauge Packed red blood cell volume transfusion for a child - 10 mL/ kilogram Pediatric verbal score - Impacted fractures - Demonstrate no false motion of the humorous when the shoulder is rotated gently from a flexed elbow. Nonimpacted Fractures - Generally experience pain on movement of the arm. Generally require hospitalization for orthopedic consultation and often operation Fundal height in pregnancy - The amniotic fluid may cause amniotic fluid EMBOLISM and DIC following trauma if the fluid gains access to maternal intravascular space. Physiologic changes in pregnancy - 1.Physiologic changes in
control
- Disability: neurological status
- Environment/Exposure: completely undress the patient but prevent hypothermia Assume a CERVICAL SPINE injury in patients with BLUNT multisystem trauma, especially those with an altered level of consciousness's or a blunt injury about the clavicles. - IV fluid warming temperature in shock - 37 to 40°C Associated with aberrant conduction, premature beats, bradycardia. - hypoxemia, hypothermia hypokalemia. AMPLE history. - Allergies Medications Past illness/Pregnancy, Last meal Environment/events related to injury Frontal impact automobile collision: Bent steering wheel, Knee imprint dashboard Bulls eye fracture windshield - Cervical spine fracture Anterior flail chest
Myocardial contusion Pneumothorax Traumatic aortic disruption Fractured spleen or liver Posterior fracture/dislocation of hip and/or knee Side impact automobile collision - Contralateral next sprain Cervical spine fracture Lateral flail chest Pneumothorax Traumatic aortic disruption Diaphragmatic rupture Fractured spleen/liver and/or Fracture of kidney, pelvis or acetabulum Rear impact automobile collision - Cervical spine injury Soft tissue neck injury Ejection from automobile - Ejection from the vehicle precludes meaningful prediction of injury patterns. Patient at greater risk from virtually all injury mechanisms. Motor vehicle impact with pedestrian. - Head injury Traumatic aortic disruption Blunt force to the neck or Traction injury from a shoulder harness restraint - Can cause carotid disruption dissection or thrombosis. Symptoms may develop late
CO2 capnography - Yellow indicates adequate CO2 levels, violet: too low Definition of Shock - Abnormality of the circulatory system resulting in inadequate organ perfusion and tissue oxygenation. Hemorrhage is the most common cause of shock in the injured/trauma patient. Earliest signs of shock - Tachycardia and cutaneous vasoconstriction. Tachycardia an infant - Greater than 160 beats per minute Tachycardia in a preschool child - Greater than 140 beats per minute Tachycardia in a school age to puberty - Greater than 120 beats per minute Tachycardia in an adult - Greater than 100 beats per minute. Significance of narrowed pulse pressure - Significant blood loss and involvement of compensatory mechanisms. What percent of body weight in kilograms represents the circulating blood volume of an adult (in liters).
- 7%. Example, a 70 kilogram man's total circulating volume is 70 × 7% which equals 4900 ml. Class hemorrhage and hemodynamic effects. - Sepsis Hypovolemic shock - Both are characterized by tachycardia, narrow pulse pressure, cutaneous vasoconstriction, decreased systolic blood pressure, impaired urinary output.
Normal blood volume percentage - 7% of body weight. e.g. a 70 kilogram male has a circulating blood volume of 4.9 liters. Normal percentage blood volume for a child - 8 to 9% of body weight. Blood loss associated with a fractured tibia or humerus - 750 milliliters of blood Blood loss associated with a femur fracture - Up to 1500 milliliters of blood Blood loss associated with pelvic fractures - 2 liters or more. Initial warmed IV fluid bolus for shock. - 1- 2 liters normal saline or LR for adults, and 20 ml/kilogram for pediatric patients. Normal urinary output for adult - 0.5 milliliters per kilogram per hour Normal urinary output for children greater than 1 year of age - 1 milliliter per kilogram per hour Normal urine output for child less than 1 year of age - 2 milliliters per kilogram per hour Responses to initial fluid resuscitation in shock - What needs to happen when there is failure to respond to crystalloid and blood administration in the emergency room in the setting of a motor vehicle accident or trauma resulting in shock. - Depends, but some intervention such as operation or angioembolization to control exsanguinate hemorrhage Three other causes of failure to respond to IV fluids that are not HEMORRHAGIC in origin. - =Tension pneumothorax, =Bunt cardiac injury, =Pericardial tamponade
Absent breath sounds Distended neck veins are seen in what two conditions - Cardiac tamponade Tension pneumothorax Conditions to consider in transient responders in the setting of shock. - 1. Hemorrhagic: Bleeding within the abdomen, pelvis, retroperitoneum, extremity fracture, or obvious external bleeding.
- Nonhemorrhagic: Tension pneumothorax or cardiac tamponade NONresponder to IV fluids. Diagnostic consideration - Blunt cardiac injury. Intraosseous needle size. - 18 gauge spinal needle with stylet. Physical signs suggesting a pelvic fracture on physical exam - Scrotal hematoma, Blood at the urethral meatus Perineal hematoma, Leg length difference Mobile or high-riding prostate gland, Gross or occult blood in the stool. Accurate lines of the sacrum - To treat an open book fracture of the pelvis - Life-threatening thoracic injuries that need to be addressed in the primary survey - Airway obstruction
Tension pneumothorax Open pneumothorax Flail chest and pulmonary contusion Massive hemothorax Cardiac tamponade Most common cause of tension pneumothorax - Mechanical ventilation with positive pressure ventilation in patients with visceral pleural injury Flail chest - Flail chest radiograph - Initial treatment of flail chest - Adequate ventilation, humidified oxygen, fluid resuscitation. Later, analgesia. Short Term intubation and ventilation may be necessary. Local nerve block preferred over IV narcotics. MASSIVE hemothorax definition - > 1500 milliliters of blood or one third or more of the patient's total blood volume in the chest cavity. Neck veins can be distended (if concomitant tension pneumothorax) or flat (if blood loss results in hypovolemia). Treatment of MASSIVE hemothorax - Restoration of blood volume (crystalloid then type specific blood) and decompression of the chest cavity. 36 or 40 French chest tube required MASSIVE Hemothorax. Indications for thoracotomy: - If Greater than 1500 ml of fluid is immediately evacuated. Less than 1500 milliliters of fluid evacuated but continued blood loss of 200 milliliters per hour for 2 to 4 hours
Radiologic signs on chest x-ray in traumatic aortic rupture that indicate the likelihood of major vascular injury - Widened mediastinum Obliteration of aortic knob. Deviation of trachea to the RIGHT Depression of left main stem bronchus Obliteration of space between the pulmonary artery and the aorta. Deviation of esophagus to the right Widened paratracheal stripe Presence of a plural or apical cap. Left hemothorax Fractures of first or second rib or scapula Traumatic diaphragmatic injury on the left. What action should you pursue - Insert a nasal gastric tube. If it appears in chest wall cavity on chest film the need for special contrast studies is eliminated. Suspect blunt esophageal rupture when you see the following - Left pneumothorax or hemothorax without a rib fracture History of a severe blow to the LOWER sternum or epigastrium. Pain or shock out of proportion to the apparent injury. Particulate matter in the chest tube after blood begins to clear. Presence of mediastinal air. Treatment of blunt esophageal rupture - Wide drainage of the pleural space and mediastinum, with direct repair of the injury through thoracotomy. Causes of subcutaneous emphysema - Blast injury. Airway injury. Lung injury. The emphysema itself is generally not treated but underlying causes need to be addressed and treated.
Fractures involving ribs 1 through 3, sternum, scapula and clavicle can be associated with - Great vessel trauma or airway obstruction. Pneumothorax. Pulmonary contusion. Middle rib fracture, 4 through 9, can be associated with - Pneumothorax hemothorax pulmonary contusion. Fracture involving ribs 10 through 12 can be associated with - Hepatosplenic trauma Mediastinal widening - Great vessel injury Sternal fracture Thoracic spine injury. Mediastinal air - Esophageal disruption Tracheal injury Pneumoperitoneum. Air fluid level in the chest - Hemopneumothorax or diaphragmatic rupture. Disrupted diaphragm - Indicates adominal visceral injury X-ray findings in diaphragmatic ruptured - Elevation, irregularity or obliteration of diaphragm. Mass like density above the diaphragm. Air or contrast containing stomach or bowel above diaphragm. Pleural effusion. Fracture of the scapula - Great vessel injury, airway injury, pulmonary contusion.
-Gunshot wound with transperitoneal trajectory -signs of peritoneal irritation -signs of fascial penetration. Management options for flank and back stab wounds and gunshot wounds. - Initially, serial physical exams if patient is asymptomatic except for local pain If patient becomes symptomatic: laparotomy. Triple contest CT scan. More fully evaluates the retroperitoneum. Earlier diagnosis in relatively asymptomatic patients. DPL can also be used as an early screening test. If it is positive, urgent laparotomy. Indications for laparotomy in abdominal and pelvic trauma. - Duodenal injury or trauma - -Suggested by free air on flat plate or upright of the abdomen -Bloody gastric aspirate. Diagnosed using upper gastrointestinal series or double contrast CT scan. Direct blows to the back or flank resulting in hematomas or ecchymosis. - Gross hematuria and microscopic hematuria with an episode of indicate they are at risk for NONRENAL abdominal injuries. Order a CT scan with IV contrast. Anterior urethral injuries or distuptions - Usually present in patient with anterior pelvic fractures from a straddle injury. Usually an isolated finding only.
Posterior urethral injury - Usually associated with multisystem injuries and pelvic fractures. Blunt injury to the intestines is associated with linear ecchymosis on the abdominal wall or a chance fracture - Classic sign of uncal herniation - Ipsilateral dilated pupil with contralateral hemiparesis. What is the normal intracranial pressure in the resting state. - Normal 5 to 15 mm Hg Physical signs of a basilar skull fracture - Raccoons eyes Otorrhea Battle's sign CSF leakage from nose Definition of MINOR traumatic brain injury GCS in 13 and 15 - History of disorientation, and amnesia, or transient loss of consciousness in a patient who is conscious and talking. CT scan indicated in the setting of minor traumatic brain injury (GCS 13-15) when the following are seen: - *GCS of less than 15 two hours after injury *Suspected open or depressed skull fracture *Any signs of basilar skull fracture *Vomiting more than 2 episodes *Age more than 65 years *Loss of consciousness more than five minutes *More than 30 minutes amnesia before impact *Dangerous mechanism of trauma
