PHTLS

When the application of kinetic energy to the body from either a blunt or penetrating mechanism displaces tissue, this is known as

CAVITATION

Which of the following is an example of the tertiary phase blast injury?

CRUSHING INJURY DUE TO STRUCTURAL COLLAPSE.

The most common threat to life among trauma patients is?

INTERNAL HEMORRHAGE

Your patient is an injured construction worker bleeding profusely from a large laceration to the left thigh. He is confused and has pale, moist skin. Direct pressure applied to the wound by a first responder has failed to control the bleeding. The next st

A TOURNIQUET TO THE LACERATION.

Hypotension due to spinal cord trauma occurs due to interruption of the _______________nervous system pathway.

SYMPATHETIC

The most common fractured ribs are ribs:

4 THROUGH 8.

A hemothorax is differentiated from a tension pneumothorax by:

DULL PERCUSSION ON THE AFFECTED SIDE.

Which of the following mechanisms is most likely to result in cardiac tamponade?

A PATIENT IS STRUCK IN THE LEFT ANTERIOR CHEST BY A NAIL EJECTED FROM A NAIL GUN.

Management of flail chest includes:

PAIN MANAGEMENT
VENTILATORY SUPPORT
100%O2

Which of the following types of traumatic brain injury is most likely to be associated with hemorrhage from the middle meningeal artery?

EPIDURAL HEMATOMA

Which of the following groups of findings represents Cushing's phenomenon?

BRADYCARDIA
ABNORMAL RESPIRATORY PATTERN
ELEVATED BLOOD PRESSURE

Your patient is a 32 year old female who was thrown from a horse and struck her head on the ground. She was not wearing a helmet. She does not respond verbally or open her eyes to painful stimuli, but responds to painful stimuli with decerebrate posturing

20 BPM.

A burn with reddened, glistening base that may have blisters is most characteristic of a

SECOND degree burn.

A chemical solution with a pH of 4.0 is considered an ACID and causes damage to the tissues via

COAGULATION NECROSIS.

An electrical burn caused by superheated air near the source of electricity is an

ARC burn.

Your patient is an 82 year old female who was an unrestrained front seat passenger in a motor vehicle collision. Which of the following is the most reliable indication of shock in this patient?

LEVEL OF CONSCIOUSNESS.

Which of the following findings is not expected in assessment of a pregnant patient?

A DECREASED BLOOD PRESSURE IN THE THIRD TRIMESTER.

Which of the following is contraindicated in the management of a pregnant trauma patient in the third trimester?

SUPINE POSITION.

During the assessment of the trauma patient, auscultation of the lung sounds is first performed during:

THE PRIMARY SURVEY.

Which of the following is indicated for the prehospital management of a circumferential second degree burn extending from the wrist to the elbow in a 70 Kg patient?

A DRY STERILE DRESSING
ANALGESIA

The preferred fluid for resuscitation of the patient with significant burns is:

LACTATED RINGER'S SOLUTION.

Which of the following is the most common cause of spinal injuries?

MOTOR VEHICLE COLLISIONS.

Hypotension in hemothorax is associated with:

THE ABILITY OF EACH SIDE OF THE THORAX TO HOLD UP TO 3 LITERS OF BLOOD.

Cardiac tamponade is suspected with the findings of muffled heart sounds___________, and___________ known as___________.

JUGULAR VEIN DISTENTION, and HYPOTENSION, known as BECK'S TRIAD.

When administering isotonic crystalloid solution, about ___________ will remain in the vascular system after 1 hour.

ONE-THIRD

PASG is contraindicated in patients with

CHEST TRAUMA.

The greatest threat to life from injury to hollow abdominal organ is

PERITONITIS.

IV fluids administered to patients in shock should be _______ in order to ______________ ______________.

WARM, PREVENT HYPOTHERMIA.

During pregnancy, signs and symptoms of shock may appear _______ due to an _________ in maternal blood volume.

LATER, INCREASE

A fractured femur can result in___________________mL of hemorrhage.

1000 TO 2000

A male patient suffered a stab wound to his left flank. He is found to be in stage III shock. During the 25 minute transport to the trauma center, intravenous fluids should be administered at a rate sufficient to maintain a:

SYSTOLIC BP OF 80 TO 90.

The most common type of shock in trauma patients is

HYPOVOLEMIC.

What percentage of blood volume loss in an adult patient is associated with findings of tachycardia (>120/beats/minute), tachypnea (30-40 Breaths/min), and hypotension (systolic BP <90mmHg)?

30 TO 40

Minute volume of ventilation is best represented as

TIDAL VOLUME x ventilatory rate

Which injury is most likely to be sustained by the driver in a lateral impact collision to the left side of the vehicle with no side impact airbags (assuming the driver sits on the left)?

FRACTURED LEFT CLAVICLE.

Give me the general ideas of trauma criteria?

Any patient that has a compromise to Airway, Breathing, Circulation and Deficit. Any Patient that is Altered or

What three areas of a penetrating injury would be trauma criteria?

Thoracic cavity and up. Cranial, between Thoracic and midclavicular line, neck.

For trauma criteria what must the BP be below in an adult? Child?

Adult >90 / Child >70 (Systolic)

What is the trauma criteria for blunt head injury?

ALOC, GCS less than 14, except pt. 1 y/o, seizures, unequal pupils, or focal neurological deficit.

For trauma criteria what should also be present in a Cardiac arrest?

Penetrating torso trauma.

What is the most common threat to life?

Inadequate tissue perfusion

When would a shotgun injury meet trauma criteria?

wounds to the trunk.

A fall from 15 feet is trauma criteria so what type of injuries may also be sustained that APPLY to trauma criteria?

Blunt chest injury- flail chest, abdominal tenderness, spinal fx w/ extremity weakness and sensory deficit.

If the driver of a vehicle is found in the passenger space can't feel his toes and has no radial pulse in left extremity is this patient trauma criteria? How many categories does this patient fall into?

yes/3.

Name some guidelines for trauma patients? transport is advised.

Surviving patients in MVC where fatalities and complaint of injury occur- Pedestrian vs Auto.- ejection from vehicle, extrication, young and old patients w/ medical history

What are indications of use of a PASG?

suspected pelvic fx- profound hypotension (sys <50 to 60)- retroperitoneal hemorrhage.

What are CONTRAindications of use of a PASG?

Penetrating thoracic trauma- splinting of lower extremity fx.- Eviceration of abdominal organs, impaled objects in abdomen- Pregnancy- traumatic cardiac arrest.

When using a PASG what syndrome will occur if you decide to splint a lower extremity?

compartment syndrome.

What is a Colles fracture?

bilateral fracture of wrist- fall w/ outstretched hands

What is Don Juan syndrome?

bilateral heel/ankles/ tib. Fib./Femur/pelvic fall on feet.

What are early signs of increase intracranial pressure?

headache and vomiting

At what height are falls the most significant?

15 feet

In trauma what's the difference between hollow and solid organs?

hollow causes peritonitis - solid organs bleed.

What injuries would occur at the time of impact?

crush or compression injuries.

What is the first action with a severe burn patient?

stop the burning.

When there is a decrease in intravenous pressure what are common S/S?

JVD

When the acute physiologic and structural change occurs in a patient's body when an external source of energy dissipates faster than the bodies ability to sustain and dissipate it?

trauma

Kehr's sign is associated with what organ?

spleen

When giving analgesic therapy what is the goal in prehospital care?

diminish pain to a tolerable level (control not abuse)

What medication may cause a delay in healing?

corticosteroid

What is the best treatment for commotio cortis?

CPR and AED

What kind of hypovolemic shock comes from external bleeding?

exogenous hypovolemic shock

What is the first action for external bleeding?

direct pressure and elevation.

Compartment syndrome can occur in what type of injuries?

Closed Injuries

What is the difference between retrograde and antegrade amnesia?

retro- is cant remember before- ante- cant remember after.

When a patient has chemical burns to the eyes what is the treatment?

Constant flushing with IV fluid and continuous irrigation.

What are the most critical burn patients?

Patients with a significant MEDICAL ILLNESS

In a femur fracture where is it most likely to break?

Femoral Neck

What is most important in treating a patient in shock?

Recognize S/S of shock at earliest phase and immediate treatment before damage occurs.

The process in which the muscles are crushed past repair

tissue necrosis develops and causes release of harmful products?, Rhabdomylosis

Also known as Periumbilical ecchymosis?

Cullens Sign

Class I Hemorrhage

up to 15% blood loss, minimal tachicardia, no measurable changes in BP or pulse pressure, or RR

Class II Hemorrhage

15-30% Most adults are capable of compensating, incresed RR, Tachycardia, narrowed pulse pressure,

Class III Hemorrhage

30-40% no longer able to compensate for volume loss, hypotension occurs, HR >120 BPM, RR 30-40, severe anxiety or confusion

Class IV Hemorrhage

more than 40% loss, severe shock, HR >140 BPM, RR >35, confusion lethargy, decresed systolic blood pressure, typically in the range of 60 mm Hg.

Ratio for loss blood replacement

3 litres of electrolyte solution replacement for each liter of blood lost

Distributive Shock

uncontrolled vasodialation causes reduced resistance causing a decrease in the diastolic blood pressure

Distributive Shock

Decrease in preload+decrease in cardiac output

Psychogenic Shock

Vasovagal - stimulation of the tenth cranial nerve (vagus nerve) produces bradycardia. May also cause vasodilation.
Typically occurs in a very brief period.

Septic Shock

Cytokines released because of an infection can cause damage to blood vessel walls and cause vasodilation

Anaphylactic Shock

Respiratory distress, airway obstruction and vasodilation

Potential Blood loss from a single femoral fracture

30-40%

Amount of blood loss that can happen before signs of compensatory mechanisms fail and BP become <90 mmHq

Greater than 30%

Hypertension medications that may prevent compensatory tachycardia to maintain BP

Beta Adrenergic blocking agents and calcium channel blockers

Managing Volume Resuscitation
Uncontrolled hemorrhage-suspected chest, abdomen, retroperitonium

Maintain a systolic bp 80-90 or MAP 60-65

Managing Volume Resuscitation
CNS injuries or TBI

maintaining the systolic BP (SBP) above 90 or MAP 85-90

Managing Volume Resuscitation
Controlled Hemorrhage
large scalp or extremity controlled with a tourniquet, PT falls into class II,III,IV shock

rapid bolus of 1-2 litres

Three responses of initial fluid bolus
Rapid Response

vital signs return indicating that PT lost less than 20%
PT is best managed at SBP between 80-90, IV fluid should be titrated

Three responses of initial fluid bolus
Transient Response

Vital signs improve (pulse slows, BP increases) however PT shows deterioration. PT has typically lost 20-40% of blood volume

Three responses of initial fluid bolus
Minimal or no response

No change in PT after 1-2 liter Bolus

Leading cause of TBI

MVC

Three seperate membranes that surround the brain

meninges

Outer most meninges

Dura mater- composed of tough fibrous tissue

The inner most meninges that is directly in contact with the brain

Pia Mater-

Vessels that lay on top of the Pia Mater

Cerebral Blood Vessels

The meninge that lays in the middle between the dura and pia matter

Arachnoid membrane-loosely covers the brain and its blood vessels

MAP-Mean Arterial Pressure

The average pressure for the entire cardiac cycle
MAP=Diastolic Pressure + 1/3 of the Pulse Pressure

PP- Pulse Pressure

The difference between the systolic and diastolic
PP= Systolic (SBP) - Distolic (DBP)

CPP- Cerebral Perfusion Pressure

The amount of pressure it takes to push blood through the cerebral circulation. CPP=Mean Arterial pressure (MAP) - Intercranial pressure (ICP)

CPP- is normally below ? mmHg

CPP is normally 15 mmHg or below

Autoregulation

The brain changes the cerebral blood vessel resistance (CVR) to compensate for changes in the cerebral pulse pressure (CPP)

For neurological injured PT's the systolic blood pressure is best if maintained at or above

90 mmHg

Hyperventilation and TBI

Hyperventilation can reduced CBF by causing vasoconstriction due to hypocapnia, PaCO2 >35 increases risk of cerebral ischemia

Primary Brain injury

The direct trauma or mechanical injury, includes contusions, hemorrhages and lacerations

Secondary brain injury

pathologic mechanisms that related to intercranial mass effect, elevated ICP, and herniation, hemotoma, hypoxia and hypotension

Mass effect

The effect of a growing mass or tumor

Uncal Herniation

temporal lobe epidural hematoma forces pressure on the medial portion of the temporal lobe (uncus) which in turn puts pressure on the 3rd cranial nerve causing dilation or blown pupil on the side of the herniation. May also cause loss of function of the m

Final stage of uncal herniation

The RAS is affected patient lapses into coma

decorticate posturing

flexion of the upper extremities with rigidity and extension of the lower extremities.

decerebrate posturing

all extrem become flaccid and motor activity is absent

Cheyne strokes ventilation

repeating cycle of slow hallow breaths that become deeper and more rapid and then return to slow

Central neurogenic hyperventilation

rapid deep breaths

Ataxic breathing

erratic ventilatory efforts that lack any discernible pattern

Cushings phenomenon

greatly increased arterial blood pressure and the resultant bradycardia (increase BP + decreased HR) may occur with severely increasing ICP

Hypercapnia (high CO2)

causes vasodilation

Hypocapnia (low CO2)

causes vasoconstriction

When people have 20 mmHg CO2 in their blood (half of the official norm),

they have about 40% less blood supply to the brain in comparison with normal conditions

Indication of TBI
Hemiparesis

One sided weakness

Indication of TBI
Hemiplegia

One sided paralysis

Indications for a nose fracture

ecchymosis, edema, nasal deformity, swelling, epistaxis

Epidural Hematoma
1-brief Loss of consciousness
2-Lucid Interval
3-Rapid decline in level of consciousness

The period of time after a brief loss of consciousness where the PT may be oriented, lethargic or confused followed by a rapid decline of consciousness

Subdural Hematoma

Account for 30% of TBI-Generally results from venous blood from bridging viens that are torn during a violent blow to the head.

Epidural Hematoma

Account for 2% of TBI-Arterial blood starts to dissect or peal the dura off of the inner table of the skull creating an epidural space filled with blood

Epidural Hematoma Signs

Altered LOC, dilated and sluggish non reactive pupil on the side of herniation, hemiparesis or hemiplegia on opposite side of injury.

Subdural Hematoma

Can be chronic or acute. Pt on coumadin are at high risk of un identified subdural hematomas that may be chronic. Often may be confused with stroke, infection or general decline of PT

Cerebral Contusions

actual bleeding into the substance of the brain, CC's often take 12-24 hrs to appear on CT scans, only indicator is a depressed GCS of 9-13

Subarachnoid Hemorrhage

rarely causes mass effect and does not require surgery, it does increase the risk of cerebral contusion by 63-73%

Normal ventilatory rates
Adults=

10 BPM

Normal ventilatory rates
Children=

20 BPM

Normal ventilatory rates
Infants=

25BPM

Warning signs of possible ICP

Decline in GCS
sluggish or non reactive pupils
Hemiplegia or hemiparesis
Cushings phenomenon

Osmotherapy

the use of osmotically active agents that may assist in the treatment of intracranial hypertension`

Number of cervical vertebrae

7

Number of thoracic vertebrae

12

Number of lumbar vertebrae

5

Number of coccygeal vertebrae

4

Number of pounds the human head averages

16-22 pounds

Space between the spinal cord and the spinal canal wall

3mm

Name of the 1st cervical vertebrae

Atlas

Name of the 2nd cervical vertebrae

Axis

Function of the ascending nervee tracts

Sensory impulses from body parts through the cord up to the brain

Function of the descending nerve tracts

impulses from the brain through the cord down to the body

Dorsal root=

sensory

Ventral root=

motor

Dermatome

The sensory area on the body for which a nerve root is responsible

The phrenic nerve originates from

the cervical vertebrae c2-c5

Skeletal Injuries
Compression

Compression fractures that produce wedge compression or total flattening of the body of the vertebra

Skeletal Injuries
Fractures

Produce small fragments of bone that may lie in the spinal canal near the cord

Skeletal Injuries
Sublaxation

a partial dislocation of the vertebra from its normal alignment in the spinal column

Skeletal Injuries
Overstretching

Tearing of the ligaments and muscles producing instability between the vertebrae

Skeletal Injuries
Percentage of falls from a height greater than 15 feet involve an associated lumbar spine fracture

20%

Cause and Symptoms
Anterior Cord syndrome

Results from bony fragments or pressure on spinal arteries
Symptoms-loss of motor function and pain, temperature and light touch PT's will have some light touch sensations such as vibration.

Cause and Symptoms
Central cord syndrome

usually occurs with hyperextension
Symptoms include weakness or paresthesia (tickling, tingling, burning, pricking, or numbness) in the upper extremities but normal strength in the lower extremities

Cause and Symptoms
Brown Sequard syndrome

Caused by penetrating injury and involves hemi-transection of the cord.
Symptoms include complete cord damage and loss of function of the affected side with loss of pain, temp and sensation on the opposite side of the injury

Conditions that should mandate spinal immobilization

Altered LOC
Spinal Pain or tenderness
Neurologic deficit or complaint
Anatomic deformity of the spine

Pulmonary Volume Terminology
Dead Space

Amount of air brought into the lungs that does not have the opportunity to exchange oxygen and carbon dioxide

Pulmonary Volume Terminology
Minute Volume (Ve)

Total volume of air moved into and out of during a 1 minute interval.

Pulmonary Volume Terminology
Tidal Volume (Vo)

Amount of air that is inhaled then exhaled druing a normal breath (.4-.5 litres)

Pulmonary Volume Terminology
Total Lung Capacity (TLC)

Total volume the lungs contain when maximally inflated. This volume declines with age from 6 L. in young adults to 4 L. in elderly.

Pulmonary Contusion

Blunt force can tear lung tissue resulting in bleeding into the alveoli

Thoracic Trauma
Assessment
Four components to the phys exam

Observation, palpation, percussion, auscultation

Trauma is the leading cause of death from ages ________

1 to 44 y/o

Trauma is the _______ leading cause of death in all age groups

third

Highway safety act year

1966

Trauma care systems planning and development act year

1990

children under 5 y/o account for ___% of drowning deaths and __% of fire related deaths

25%
15%

Regional trauma center
All types of specialty surgical care 24/7
suite, surgeons, blood, CT, X-ray in house

Level I Trauma Center

Trauma Center
Area trauma center
most common trauma emergencies w/ surgical capability 24/7

Level II

Trauma Center
Community trauma center
Specialized ED & some surgical capability

Level III

Trauma Center
Trauma Facility
Small community hospitals
stabilize and transfer

Level IV

%_ of unintentional deaths

63%

% of homicide

14%

Injury Prevention
Engineering examples

Building safety, alarms,

Injury Prevention
Enforcement examples

seatbelt laws, helmet

Injury Prevention
Education examples

programs, boat safety

Injury Prevention
Economics examples

Funding, tax, grants for programs

Quality Improvement

Examining performance and trying to improve Pt care

Quality Assessment

Evaluate calls to determine if standard of care not met

Purpose of 506

To establish criteria and standards which ensure that Pt's are appropriately triaged transported

506- Paramedics shall make base hospital contact when...

meet guidelines
medics judgement in Pt's best interest need Tx

506 If an EMT has a hypotensive Pt w/ life threatening injuries what do they do...

Tx to closest trauma center, not MAR

506 Pt's who fall into rapid Tx category will require rapid Tx if Tx times does not exceed ___ minutes.........

20min
Pt's can be Tx an additional 10 min to a max of 30 min

506 Trauma Tx adults w/ a BP of <___ and ped w/ BP <__

Adult <90
Ped <70

506 Tx Pt w/ a GSC of ___

less than or equal to 14

501

Hospital Directory

502

Pt Destination

503

Guidelines for Hospitals requesting diversion of ALS Units

504

Trauma Pt Destination

808

Base Hospital Contact & Tx Criteria

exchanged between a moving object and the body or the body and a stationary object

Crash

Drugs, alcohol and pre-existing conditions can affect the ....

Precrash

3 impacts of the actual crash

object
occupant
organs

Postcrash

IOS
assessment
Management
Transport

up and over injuries

Head, face, neck, chest, diaphragm, abdomen, pelvis

Up out of seat and over steering wheel injuries

Laryngeal fx if neck hits steering wheel

Lateral impact injuries

Arm, clavicle, humerus, ribs, spleen, hip, femur

Rotational impact injuries

shearing forces (heart, kidneys, liver)
spinal
cervical

rollover you are ___X's more likely to die

6

kinetic energy formula

KE=1/2mv(squared)

stopping distance formula

mass x deceleration x force x mass x acceleration

less injury if energy can change form __________

before the collision
(example: bending of metal frame)

What type of shock is it, aortic perforation (small hole)?

hemorrhagic

What type of shock is it, dysrhythmia?

cardiogenic

What type of shock is it, fluid has not been lost from the vascular system; the problem is with the size of the container?

distributive

What type of shock is it, heart loses its efficiency as a pump?

cardiogenic

What type of shock is it, injury interrupts the spinal cord sympathetic nervous system pathway?

distributive / neurogenic

What type of shock is it, interference with the pump action?

cardiogenic

What type of shock is it, typically mediated through the parasympathetic nervous system?

distributive / psychogenic (vasovagal)

What type of shock is it, life-threatening infections?

distributive / septic

What type of shock is it, loss of circulating blood?

hypovolemic / hemorrhagic

What type of shock is it, loss of vascular tone?

distributive / vasogenic

What type of shock is it, spinal cord trauma?

distributive / neurogenic

What type of shock is it, valvular disruption?

cardiogenic

What type of shock is it, vascular container enlarges without a proportional increase in fluid volume?

distributive

What type of shock is it, vomiting, or diarrhea?

hypovolemic

What type of shock is it, simple fainting?

distributive / psychogenic (vasovagal)

What type of shock is it, severe infections?

distributive / septic

What type of shock is it, allergic reactions?

distributive / anaphylactic

Allergies are acquired following?

initial exposure to an allergen

How does the body respond to hypoperfusion?

vasoconstriction, tachycardia, tachypnea

The attraction of leukocytes to the site of inflammation (like chumming the waters for sharks) during degranulation is called what?

chemotaxis

The cardinal sign of overhydration is?

edema

The prime determinants of cellular perfusion are?

the heart, the fluid volume, the blood vessels, and the cells of the body

What are colloids?

fluid solution that contains molecules (usually proteins) that are too large to pass out of the capillary membrane, thus remain in the vascular compartment. Large protein give it a very high osmolarity.

What are the classic S/S of anaphylactic shock?

hives, itching, respiratory distress, airway obstruction, vasodilation erythema (redness / flushing)

What are the classic signs of the inflammatory response?

Rubor, Tumor, Dolor, Calor, Function loss

What are the three primary PHTLS categories of shock?

cardiogenic, distributive, hypovolemic

What is an IO?

the technique of administering fluids, blood and blood products, and medications into the intraosseous space of a long bone

What is apoptosis?

normal, genetically programed cell death

What is blood tubing?

macrodrip administration set with duel piercing spikes

What is left ventricular hypertrophy?

increase in the size of the cells increasing the size of the left ventricle

What is normal saline?

isotonic, 0.9% sodium chloride

What is the most common cause of shock in the trauma patient?

blood loss/ hypovolemia

What is used prehospital isotonic, hypertonic or hypotonic?

isotonic

When oxygen does not reach the cell, what happens to the cell?

hypoxia

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

osteomyelitis

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

Rami fracture

Isolated fracture of the inferior or superior rami which are generally minor and do not require surgical stabilization.

Acetabular fracture

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 whe

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.

Morphine

-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.

Fentanyl

-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 direct

Compartment Syndrome

referes to a limb-threatening condition in which the blood supply to an extremity is compromised by increased pressure in that limb.

Crush Syndrome

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 whi

Mangled extremity

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 lev

Functions of skin

includes protection from the external environment, regulation of fluids, thermoregulation, sensation, and metabolic adaptation.

denaturation

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 stagn

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.

Fourth-degree burns

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.

Escharotomy

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

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.

Parkland formula

-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..

Tidal Volume

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)

-Asphyxiants
-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

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

Neutralizing agents for chemical burns are avoided because..

the neutralizing process produces heat

-Hypoxia
-Hypercarbia
-Acidosis
-Shock

-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
-visceral pleura

-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.

mediastinum contains...

trachea, main bronchi, heart, major arteries and veins to and from the heart, as well as esophagus

-Respiration
-Cellular respiration

-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.

pulmonary contusion

Bleeding in the alveoli caused by a blunt force trauma which prevents gas exchange.

4 components to physical examination

observation, palpation, percussion, auscultation

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.

atelectasis

collapse of the alveoli

Flail Chest

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 resul

pneumothorax

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.

hemothorax

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.

tension pneumothorax

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

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.

Cardiac contusion

The heart muscle is bruised, with varying amounts of injury to the myocardial cells. Usually results in sinus tachycardia or VT or VF.

Valvular rupture

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.

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
2) JVD
3) low BP

Commotio cordis

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

Traumatic Asphyxia

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.

Diaphragmatic Rupture

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.

Vertebral Column

-7 Cervical (C1-atlas) (C2-axis)
-12 Thoracic
-5 Lumbar
-5 Sacral
-4 Coccygeal

Sacrum supports...

between 70-80% of body's total weight.

Foramen magnum

Hold in which the spinal cord passes through. Spinal cord starts at brainstem and goes down to L2.

Ascending nerve tracts

carry sensory impulses from the body parts through the cord up to the brain.

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
-Ventral root

-Dorsal root is for sensory impulses.
-Ventral root is for motor impulses.

Intervertebral disc

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.

Dermatome

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.

axial loading

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?

Less

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.

Primary injury

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.

Secondary injury

occurs after the initial insult and can include swelling, ischemia, or movement of body fragments.

-Cord concussion
-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

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.

Brown-S�quard syndrome

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

1) ALOC
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)

Aerobic Metabolism

describes the use of oxygen by cells

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

Hypovolemic Shock

Loss of circulating blood volume

Distributive (vasogenic) Shock

related to abnormality in vascular tone arising from several different causes.

Cardiogenic Shock

related to interference with the pump action of the heart.

Class 1 (Early) shock

Blood loss: up to 750ml (15%)
Pulse rate: <100

Class 2 (compensated) shock

Blood loss: 750ml-1500ml (15-30%)
Pulse rate: >100

Class 3 (decompensated) shock

Blood loss: 1500-2000ml (30-40%)
Pulse rate: >120
*Decrease in BP

Class 4 (irreversible) shock

Blood loss: >2000ml (>40%)
Pulse rate: >140

FiO2

>0.85

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 hyper

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.

Leading cause of TBI in children and adults

adults- MVC
children- falls

dura mater

outermost layer composed of tough fibrous tissue and is applied to the inside of the skull.

mean arterial pressure

Average pressure for the entire cardiac cycle.

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.

-peritonitis
-sepsis

-inflammation of the peritoneum or the lining of the abdominal cavity
-massive infection

What is the most reliable indicator of the presence of hypovolemic shock from an unexplained source.

Intra-abdominal bleeding

Findings from the physical examination that support a diagnosis of peritonitis include..

-significant abdominal tenderness on palpation or with coughing
-involuntary guarding
-percussion tenderness
-diminished or absent bowel sounds

Grey-Turner's sign

ecchymosis involving the flanks. Indication for retroperitoneal bleeding that may not show for hours.

Cullen's sign

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)

Abdominal evisceration

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.

senescence (aging)

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.

The more pre-existing conditions a trauma PT has...

the higher his or her mortality rate.

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.

Atherosclerosis

-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.

myocardial hypertrophy

-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.

Maximal heart rate begins to decrease at age 40.

Calculated by 220-age

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.

osteoporosis

loss of bone mineral caused by aging.

Elderly people are sometimes shorter than they were in young adulthood because of...

dehydration of the vertebral discs.

spinal stenosis

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 assessment with geriatric trauma PTs, first consider...

MOI

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.

Leading cause of trauma death in the geriatric population between 65-74 years of age...

MVCs

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).

Beta blockers

These drugs inhibit the body's normal sympathetic compensatory mechanisms.

Calcium channel blockers

may prevent peripheral vasoconstriction and accelerate hypovolemic shock.

Nonsteroidal anti-inflammatory agents

may contribute to platelet dysfunction and increase bleeding.

Anticoagulants

may increase blood loss.

Hypoglycemic agents

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.

Early and adequate resuscitation...

is the key to increased survival of children with CNS trauma.

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

For pediatric PTs with a closed head injury, what should the target ETCO2 be?

30 to 40 mm Hg

The most common cause of death in the pediatric PT is...

TBI

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).

Pregnant Women...

�HR will increase 15-20 by 3rd trimester
�BP will decrease 5-15 mm Hg in 2nd trimester
�BP will go back to normal by 3rd trimester
�Pregnant women can have 50% more blood volume
�30-35% blood loss before showing signs/ symptoms

Level 1 Trauma Center

Regional Trauma Center, All types of specialty surgical care 24/7, (Surgical suites, Surgeons, Blood, CT, X-Ray ... all in house), Tertiary - all levels of care
Ex... County USC, Cedars, UCLA- Ronald Regan, UCLA- Harbor General

Level 2 Trauma Center

Area Trauma Center,
Most common trauma emergencies with surgical capabilities 24/7, (can handle most common types of trauma)
Ex.... St. Francis

Level 3 Trauma Center

Community Trauma Center,
Specialized ED and some surgical capability
(the speciality staff is on call and has 30 mins to get to hospital)

Level 4 Trauma Center

small community hospitals, (they have to stabilize and transfer)
Have ER DR but no surgeon

What are run sheets used for?

QI, Research, Trauma Registry,

What are the 4 E's?

Engineering -(roads, airbags, pool alarms)
Enforcement -(laws)
Education -(safety classes)
Economics -(government grants)

What is an injury?

being hurt or killed

What is trauma?

inflicted wounds or injury

What is an accident?

an event that is unforeseen or without apparent cause

What is a disease?

an unhealthy condition, illness, or disorder

Why is the Highway Safety Act of 1966 important?

lead to development of EMS
"White Paper" - Accidental Death & Disability, The Neglected Disease of a Modern Society

Why is the American College of Surgeons important?

1990: trauma care systems planning and development act
(established guidelines, funding and state-level leadership for the development of trauma systems)

What are the leading causes of death in adults & children?

Adults - MVC
Children - Falls

In trauma how many die in 1st hr?

50%
Fix = Injury Prevention

In trauma how many die in 4 hrs?

30%
Fix = good prehospital and hospital care

In trauma how many die days or weeks later?

20% (due to hypoxia, hypotension, end organ failure)
Fix = aggressive shock management

What is Precrash?

Age, medical hx, drugs, alcohol

What are the 3 phases of a Crash?

1. car into tree
2. person into steering wheel
3. organs into body

What is the main purpose of car restraints?

to slow the occupant down with the vehicle

Platinum 10 mins are used for what?

1. identify life-threats
2. perform key interventions
3. rapid extrication were indicated
4. timely transport to an appropriate facility
5. early notification to the receiving facility

Trauma is the leading cause of death in what age group?

1 - 44

What is anatomical trauma criteria?

Specific injuries (bi-lat femur fx)

What is mechanical trauma criteria?

Type of incident / MOI (blunt head, penetrating trauma, PSI)

What is physiological trauma criteria?

vitals signs (ALOC, hypotension GCS < 15)

What is newtons 1st law?

Body at rest will remain at rest and a body in motion will remain in motion until acted upon by an outside force

What is law of conservation?

Energy cannot be created or destroyed, but can change forms.
Car breaks = friction = heat = fire

What is the formula for kinetic energy?

1/2 of mass x velocity(squared)

What is more important velocity of mass?

velocity

If you increase the stopping distance what happens to the potential for injury?

potential for injury is decreased

What is important info in regards to GSWs?

hand guns & rifles - velocity
shotguns - what was the distance

What is permanent cavitation?

tissue that is destroyed and not coming back

What is temporary cavitation?

tissue that falls back into place
6x the diameter of per,anent caviation

Concerns with up & over injuries?

Laryngeal fx (may hear stridor)
Sub-Q Emphysema
Diaphragmatic tear

Concerns with down & under injuries?

Pelvic fx
Femur fx
Patellar fx

Concerns with lateral impacts?

Less metal to protect people in car
Look for injuries to that same side of body

Concerns with rotational forces?

shearing forces to heart, liver, kidneys

What % of ejection victims die?

75

How much more likely are you to die if you are involved in a rollover?

6x

Concern with rear impacts?

whiplash injuries

Good thing about wearing helmets?

they save lives & decrease injuries

Auto vs. Ped facts?

Child - Freeze & stand there, get drug under car, multi-system trauma
Adult - turn & run, extremity trauma

Important aspects of falls?

15 feet or 3x their height & the surface they land on = (severity of fall)
Body part they land on = (type of injury)

what are the 5 phases of bast injuries?

1. Primary - pressure wave, effects hollow organs
2. Secondary - Bomb fragments
3. Tertiary - person in thrown, or falling debris
4. Quaternary - heat/thermal burns
5. Quinary - bio/chemical/implanted objects sprayed from the object

What is an intimate injury?

Stabbing... Look for than one wound, be cautious of "cone of injury, any direction", length of knife?

In regards to violence what should you do?

1. DONT BE THERE!!!!
2. Retreat
3. Defuse the situation (word ninja)
4. Defend yourself

30 - 2, Can Do = what color?

Green

30 - 2, Cant Do = what color?

Yellow

Deficit to 30 - 2, Can Do (ALOC, Respirations, Circulation) = what color?

Red

What is the goal of the primary assessment?

to find & correct life threats

What is the most common threat to life?

inadequate tissue perfusion/shock (a early sign is ALOC)

If you dont know ______ then your already behind the 8 ball?!

the MOI

Injury to solid organs = ?

hemmorage

Injury to hollow organs = ?

infection/peritonitis)

What is Grey Turners sign?

ecchymosis at the flank due to retroperitoneal bleed

What is Cullens Sign?

ecchymosis at the umbilicus due to retroperitoneal bleed

Mass pants can be used for what?

1. belly, retroperitoneal, pelvis bleed w/ BP less than 90 & pelvis fx stabilization
2. wide spread hemorrhage with BP less than 60
(NOT FOR USE ON PENETRATING TRAUMA)

What is the % for Fi02?

at least 85%

What is the % for SP02?

95%

Can you typically remove impaled objects?

Only if it is occluding the airway otherwise No, it maybe stopping the bleeding!!

Abdominal evisceration key points are what?

1. moist sterile dressing
2. occlusive dressing
3. keep PT warm
4. keep PT still

What is more important minute volume or tidal volume?

Minute volume

What is the most important mechanism for ventilation?

the plural linings staying intact

In the PHTLS world what are the essential airway skills?

bls skills

What is the PHTLS airway key factor?

Dont do the same thing over & over, try something different

In PHTLS what is the best ET-Tube confirmation in a PT with a pulse?

capography

What is the best ET-Tube confirmation in a PT without a pulse?

lung sounds

If you cant intubate or ventilate then what?

needle / surgical cric

Normal capography value?

35-45

Closed head injury capography range is what?

35 or less

What is the most common type of shock?

hypovolemic / hemorrhagic

What is most sensitive to ischemia?

The brain, heart and lungs (can last about 4-6 mins w/o 02)

What the 2nd most sensitive to ischemia?

The kidneys, liver & GI tract (can last 45-90 mins w/o 02)

What is the least sensitive to ischemia?

Skin and bones (can last 4-6 hrs w/o 02)

What is cell & organ death?

1. it starts with aerobic to anaerobic metabolism 2. Na and H20 go into the cell (edema)
3. Potassium and lactic acid leak out of cell and enter blood stream (makes body acidic & hyperkalemic)

What happens during the ischemic phase?

vascular sphincters shut closed

What happens during the stagnant phase?

Sphincters relax and blood pools in the extremities

What happens during the wash out phase?

systemic acidosis

What is Shock Class 1?

1-15% 750 ml compensated> HR normal

What is Shock Class 2?

15-30% 750-1500 ml> HR greater 100

What is Shock Class 3?

30-40% 1500-2000ml (BP goes down here)> HR greater 120

What is Shock Class 4?

greater than 40% 2L or more> HR greater 140

What systolic BP number do you want to see in a trauma and/or traumatic brain injury patient?

Trauma 80-90
TBI 90-100
(just shoot for BP or 90 systolic, & titrate your fluid bolus to meet these values)

How warm should you warm your fluids to if possible?

102 degrees

What is the ratio of fluids given to blood lost during trauma?

3:1
(3 liters of fluid per 1 liter of blood)

Distributive Shock key factors are what?

1.vasodilation below the injury site
2. warm skin below the injury site
3. Bradycardia & Hypotension
4. Priapism
(Difference between this and hemorrhagic shock is the bradycardia due to parasympathetic system)

What is the TX for rib fx?

1. pain management
2. positive pressure ventilation

How do you treat a sucking/open chest wound?

First action is to cover it
Make occlusive dressing
Diameter of sucking chest wound is about 2/3 size trachea

Signs of hemothorax are?

1. Diminished or absent lung sounds
2. Hemodynamic compromise
3. Flat neck veins
4. Dull to chest percussion
(3L of blood in each plural cavity, JVD is not a reliable source)

What are signs of Beacks Triad?

(penetrating trauma causes cardiac tamponade)
1. Muffled heart tone
2. JVD
3. Hypotension
4. 50cc of fluid can cause of dysrhythmias
5. 300cc or fluid can causes PEA

What is a pulmonary contusion?

blood filled alveoli, causes a decrease in 02 & C02 exchange

What is traumatic asphyxia?

related to crush injury, blood is unable to drain from head and top half of body

What is an aortic rupture?

a tear in the aorta, bleed out fast, your ****ED!!

What happens in Tracheobronchial Detachment?

1. Detachment usually occurs at the carina
2. Air leaks into the chest cavity
3. pneumothorax / tension

What happens in Commotio Cordis?

1. impact to chest
2. heart goes into v-fib
3. is survivable of recognized early, need to do CPR and defibrillate ASAP

If patient is shocky and you suspect a bleed but cant find it, where should you assume it is?

abdominal until proven other wise!!
1. abdominal pain and tenderness are an early sign
2. abdominal distension are late signs

What are the important time frames of protection during pregnancy?

1. up to 12 weeks fetus is protected by the pelvis
2. up to 20th week fetus is at the umbilicus
3. up to the xiphoid process by week 38

What are signs of Cushings Tirad?

1. hypertension
2. bradycardia
3. Ab. Normal Respirations
4. +1 (ALOC, Blown Pupils ect.) = brain steam herniation

What is autoregulation?

CPP increases due to ICP increase

What is a potent vasodilator?

C02

What is broken in a basilar skull fx?

Cribriform plate (look for blood/fluid from nose and/or ears w/o direct injury to nose or ears)

Important facts of an epidural bleed are what?

1. Fast bleeds (medial meningeal artery)
2. Usually die in about 1 hr
3. Lucid intervals (knockd out, wake up & act normal, knock back out)

What are important facts about subdural bleeds?

1. slower bleeds (bridging veins)
2. doesnt usually experience lucid intervals

What is a primary brain injury?

the insult to the brain itself (ex. gsw to head)

What is the secondary brain injury?

something we can prevent (ex. hypoxia post primary injury)

What is retrograde amnesia?

forgetting what happened before the accident happened

What is anterograde amnesia?

cant remember the accident or post accident

Where is the atlas?

C1

Where is the axis?

C2

Where is the odontoid process?

is off the axis C2, allows head rotation 180 degrees

What are the biggest vertebra?

Lumbar, they carry the most weight

How many pairs of spinal nerves do we have?

31 pairs

Where do the motor nerves travel?

the ventral root, up the front of the body

Where do the sensory nerves travel?

the dorsal root, up the back of the body

What are dermatomes?

the bodies sensory boarders
T4 - nipple line down
T10 - umbilicus down

C 3-5 are what nerves?

the phrenic never, control the diaphragm

What is axial loading?

spinal cord compression (ex. shallow water diving accident, leading on head & pressing down)

What is a distracting injury?

the spinal cord in stretched or disconnected (ex. hanging accident)

Do you need to C-Spine a penetrating injury?

No, unless there is a neuro deficit

What happens during an anterior cord injury?

Loss of motor, pain, and temp.
(involves injury to spinal arteries)

What happens during central cord injury?

1. hyperextension of spinal cord
2. weakness in the upper extremities, but good lower extremity function
3. loss of bladder control

What happens during Brown Sequard injury?

1. loss of function on one side of the body
(typically from penetrating injury)

On a stable patient what do you do before moving he patient?

splint fxs and pain meds

Ligaments connect what?

bone to bone

Tendons connect what?

muscle to bone

What is a subluxation injury?

dislocation partially out of the socket

What is compartment syndrome?

The tissues is tight (ex. circumferential burns)
1. after 6 hrs there is lots of damage to tissue

What is crush syndrome?

1. release of pressure from compartment syndrome
2. lactic acid rushes into the body

Second degree burns?

1. affect the epidermis
2. blisters

Third degree burns?

1. affect down to the dermis
2. waxy and leathery looking

Fourth degree burns?

1. affect down to the bone and muscle

Nerves are a good conductor for what type of burns?

electrical burns

The hands, feet, face, and gentilia are what kind of burns?

speciality type of burns

What is the fluid formula for fluids in the burn patient?

4cc/kg/BSA = amount in 1st 24 hr period
(divide # by 2 = amount in first 8 hrs)
(divide # by 8 = amount in 1st hr)

What 3 things affect the severity of radiation?

1. distance
2. shielding
3. time

What is toxic inhalation?

death by delayed respiratory compromise post fire exposure

What is important about acid burns?

coagulate necrosis

What is important about alkaline burns?

liquefaction necrosis

In reference to hemorrhagic shock, Class II hemorrhage would be defined by a blood loss of _____ to _____ mL.

Class II hemorrhage is evidenced by a blood loss of between 750mL and 1500mL or 15% to 30% of total blood volume.
Reference: PHTLS, 6th Ed., Mosby, 2007 (pg. 170)

In reference to hemorrhagic shock, Class III hemorrhage would be defined by a blood loss of _____ to _____ mL.

Class III hemorrhage is evidenced by a blood loss of between 1500mL and 200mL or 30% to 40% of total blood volume.
At this stage, hypotension is likely, HR is typically >120, and the patient has tachypnea reaching rates between 30-40. UOP will typically f