What are the ABCDEs of trauma resuscitation?

A airway intact?

B breathing okay?

C circulation okay? (& C-spine?)

D disability (anything not working?)

E exposure (seeing all of the patient)

What is the best radiology study for the initial evaluation of possible head injury?

Noncontrast head CT

(US can only be used in very young infants with open fontanelles & is not recommended for head trauma evaluation)

When should you obtain an emergent MRI?

For possible spinal cord compression

(if MRI is available – the images are much better than CT images)

What X-rays should be ordered for every major trauma patient?

C-spine

Chest

Pelvis X-ray or CT abdomen/pelvis

(others as needed, depending on injuries)

In general, what is the correct management for a patient with penetrating abdominal trauma?

Exploratory laparotomy

How do you treat an open pneumothorax?

(2 techniques)

• Use an occlusive dressing to cover three sides of the wound (air gets out, but not into the chest)

• Intubation and positive pressure ventilation may also be needed

What is the other name for an open pneumothorax?

A sucking chest wound

(the diameter of the opening determines how much sucking it will do – bigger is worse)

What is the correct treatment for an unstable patient thought to have cardiac tamponade?

Pericardiocentesis

Can penetrating trauma cause cardiac tamponade?

Yes – usually left chest trauma

What are the five physical findings you should expect with cardiac tamponade?

(The first three are known as “Beck’s triad.”)

1. Hypotension

2. Distended neck veins

3. Muffled heart sounds

4. Pulsus paradoxus

5. Clear lung sounds

How do you treat massive hemothorax?

• Chest tube and volume support

• If the bleeding does not stop shortly after insertion of the chest tube, clamp it and get the patient to the OR

What is the most common cause of a fever in the first 24-h post-op?

Atelectasis

What is a flail chest?

An injury that produces a segment of the chest wall that moves independently from the rest of the chest wall (due to rib fractures)

How do you get a flail chest?

You break multiple, adjacent ribs in at least two places

(This allows that segment of chest to “float free” from the rest of the ribs)

Why is flail chest a bad thing?

It causes inadequate respiration due to –

1. Pain

2. Pulmonary contusion

3. Probable shunting due to

paradoxical motion

(when the patient tries to breathe in, that part of the chest wall goes in rather than expanding out with the rest)

How do you treat flail chest?

1. Pain meds

2. Try to prevent paradoxical motion

(lie the patient on the injury, or

sand bag the area)

3. Intubation

4. Positive pressure ventilation is

often necessary

What is the most common cause of death that immediately follows a motor vehicle collision?

Head injury

What is the most common cause of death that immediately follows a fall from a significant height?

Head injury

What puts a patient at risk for aortic rupture?

Rapid deceleration

(the aorta is “tethered” at the ligamentum arteriosum, and the rapid rotation can damage it)

What typically causes diaphragmatic rupture?

Blunt trauma

Which side of the diaphragm usually ruptures?

Left side

What is the best thing to do with an avulsed (permanent) tooth?

Replace it in the socket ASAP

Is it alright to clean an avulsed tooth, if it has gotten dirty?

Gentle saline wash is alright, if necessary

(but never scrub a tooth!!!)

What is the best thing to do with an avulsed permanent tooth if the patient cannot keep it in the socket (due to patient age, associated fracture, etc.)

1. Put it in “Hanks’ solution”

2. Put it in milk if you don’t have

the special solution

What is the best thing to do with an avulsed deciduous tooth?

Nothing – See a dentist for follow-up

What should you do for a choking victim who is still breathing?

Observe only.

They will usually clear the object on their own.

What should you do for a choking victim who stops breathing?

• Heimlich if they stop breathing

• Abdominal thrust if they pass out

• Back blows are for very young children

What are the signs of a tension pneumothorax?

(3)

Tracheal deviation

Hypotension

Faint heart sounds

(& sometimes heart sounds in an unusual location)

How is tension pneumothorax diagnosed?

Clinically!!!

(You are supposed to initiate treatment before an X-ray is taken)

How is tension pneumothorax treated?

Needle thoracostomy initially,

 then

Chest tube (to water seal)

A proper lateral C-spine X-ray must include what portions of the spine?

C1 – T1

(Top of T1, not necessarily the whole thing)

What position should the C-spine be in when the lateral X-ray is taken?

Neutral

(Avoid hyperflexion or hyperextension)

If you suspect pneumothorax, but can’t see it on the chest X-ray, what study should you order?

Exhalation chest X-ray

(this makes the pneumo bigger and easier to see)

Why does a tension pneumothorax get worse as time passes?

Air goes into the abnormal space, but cannot escape, worsening the pressure on normal structures with each breath

In a tension pneumothorax, what do you expect in terms of pulsus paradoxus?

The patient should have it

(not all of them do, of course)

What is pulsus paradoxus?

Drop in systolic BP >10 mmHg during inspiration

What is often noticed about the neck veins of patients with tension pneumothorax?

Distended neck veins

(too much pressure for the blood to enter the atrium)

In tension pneumothorax, should the diaphragm on the affected side be high or low?

Low –

that side of the chest is full of air under pressure

In a tension pneumothorax, heart sounds are often distant, but the lungs are _______________?

Hyperresonant

(more empty area than usual)

If a tension pneumothorax causes tracheal deviation, which direction will the trachea go? Toward or away from the site of the tension pneumothorax?

The trachea moves away from the tension pneumothorax

(the pressure pushes it)

What is the hallmark on EKG for pericardial tamponade?

QRS complexes that alternate between large amplitude and small amplitude

What is the special name for QRS complexes that alternate between large amplitude and small amplitude?

Electrical alternans

In electrical alternans, how much does the width of the QRS vary?

It doesn’t –

only the amplitude varies

Supposedly, why does electrical alternans occur?

The heart is swinging back and forth through the fluid-filled pericardial sac

Aortic dissection due to trauma is associated with what types of fractures, especially?

1st or 2nd rib fractures

Aortic dissection due to trauma usually follows what type of injury?

Rapid deceleration

Traumatic aortic dissection usually begins at what anatomic location?

Between the ligamentum arteriosum & the left subclavian

(has to do with where the artery is “tethered”)

What is the classic physical finding for aortic dissection?

BP is different in the two arms

(in reality, this finding is neither sensitive nor specific)

What findings on chest X-ray suggest aortic dissection?

(3)

1. Wider than normal mediastinum

2. Indistinct aortic knob

3. Esophageal deviation to the right

If an aortic dissection patient develops a new heart murmur, what does this most likely indicate?

The dissection has gone backward and damaged the aortic valve

Neurological findings, particularly paralysis of one or both lower extremities, can be a presentation of aortic dissection. How?

The dissection has cut off circulation either to a limb, or to some of the arteries feeding the spinal cord

Generally, what is the best way to diagnose aortic dissection?

CT with contrast

(TEE/US can also be used, but CT often gives more information faster)

Rarely, an aortic dissection patient might also be hoarse. Why?

Pressure on the recurrent laryngeal nerve

(it wraps around the ligamentum arteriosum on that side)

Rarely, an aortic dissection patient might present with neck swelling, ruddy complexion, and distended head & neck veins. Why?

Mass effect from the dissection creating SVC syndrome

What are the three categories you are checking when you use the Glasgow Coma Scale?

1. Eye opening

2. Motor response

3. Verbal response

How many points do you get on the Glasgow Coma Scale if you’re dead?

Three

(There is no zero in the scale)

What is a perfect score on the Glasgow Coma Scale?

Fifteen

(Five per category)

If a patient with head trauma requires intubation, what medication are you supposed to give first?

Lidocaine, 1 mg/kg

(It “blunts” the increase in ICP with laryngoscopy)

If you are doing a very brief trauma survey, you won’t have time to do the Glasgow Coma Scale. What should you use instead?

AVPU evaluation

(The choices are:

A – alert

V – verbal but not totally alert

P – pain response

U – unresponsive)

Which three medications are most standard for rapid sequence intubation (RSI) in children?

Succinylcholine (short acting paralytic)

Atropine for children ≤1 year old (bradycardia prevention)

An induction agent given before the paralytic (choices include etomidate, propofol, ketamine, thiopental, or fentanyl)

Which benzodiazepine medication was very commonly used in RSI, but is no longer recommended as a first line choice?

Midazolam (Versed^®)

(onset too slow & potency too variable between individuals)

Atropine used to be given routinely to older children with RSI. Why is it used less now?

Data have not clearly supported its effectiveness in preventing bradycardia in children older than 1 year

Atropine is still definitely useful for reducing secretions

For which kids should atropine nearly always be used, if doing an RSI?

Those ≤1 year old

Consider in children <5 years old if succinylcholine will also be given

Following RSI, what medications need to be given, for patient safety & comfort?

A longer lasting paralytic –

Most often Rocuronium is used

&

Something for agitation/pain –

Most often fentanyl is used

Succinylcholine should not be used in which patients?

Burn & crush injury more than 24 h prior to intubation (the K+ takes time to rise)

Known or suspected hyperkalemia

Open globe injury (eye)

What alternative paralytic can be used in patients for whom succinylcholine is contraindicated?

Rocuronium

What is the main negative to using the alternative paralytic agent in RSI?

Much longer duration of action

(if intubation unsuccessful, patient cannot breathe on his or her own for at least 30 min)

(Note: a reversal agent has been developed called Sugammadex. It is in use in the EU, but not yet in the US)

Surgical cricothyroidotomy should not be done in children less than what age?

8 years

When should you choose a needle cricothyroidotomy, rather than a more definitive airway?

If you cannot intubate the trachea, and the bag-valve-mask technique is not working well (for example, with significant orofacial trauma)

Especially in a child, inability to obtain IV access should make you consider what other options?

Intraosseous or central venous access (intraosseous is usually quicker and better in kids)

If a patient is hypotensive, the first (and second) thing you should do to try to fix the pressure is ______________?

Fluid boluses –

Give normal saline or lactated ringers

If you are treating a hypotensive pediatric patient, how should you “dose” the fluid resuscitation?

20 ccs per kilogram

(can dose repeatedly)

What must you watch out for if you use a central line to deliver fluids?

(2)

1. Many central lines are long – the longer the tube, the slower the fluid flows

2. Many central lines have multiple lumens – more lumens mean smaller lumens, and this slows fluid delivery

If a patient is hypotensive, is it acceptable to give pressors as a first response?

NO! Fill the tank first!

(Give fluids first)

How much fluid should you give a hypotensive adolescent/adult, in general, when you are initially trying to correct hypotension?

One liter –

Okay to repeat

(most trauma sources now recommend leaving the pressure a little low, rather than aggressively fluid resuscitating to normal BP)

If crystalloid does not correct hypotension, what type of fluid should be given next?

Blood – packed RBCs usually

(whole blood is also fine, but rarely used)

Pain in the shoulder following trauma can sometimes be a sign of what abdominal problems?

Diaphragmatic irritation from blood in the belly