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1 Trauma Review

2 Trauma______________________________________ Injury caused by an object breaking the skin and entering the body.______________________________________ Injury caused by the collision of an object with the body in which the object does not

enter the body.Serious/Life Threatening problems:Occur in less than _________% of all trauma patients.Must recognize difference between serious & non-serious problems and triage your care.

3 Serious trauma is a surgical disease; its proper care is immediate

______________________________________ intervention to repair internal hemorrhage

sites.

4 Trauma Scoring SystemsUsed to apply “scores” to trauma patients that can immediately indicate the

______________________________________ of injury.Two most common scoring systems are:

– ______________________________________ Coma Scale– ______________________________________ Trauma Scale

5 Glascow Coma Scale (GCS)

6 Revised Trauma Score

7 Pediatric GCS

8 Pediatric RTS

9 Abbreviated Injury Scale (AIS)An anatomical scoring system Injuries are ranked on a scale of ___________ to ____________

– 1: ______________________________________ – 5: severe– 6: ______________________________________

Represents the “threat to ______________________________________ ” and is not meant to represent a comprehensive measure of severity

10 Abbreviated Injury Scale (AIS)AIS Score Injury

1 Minor2 Moderate

3 Serious4 Severe

5 Critical

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6 Unsurvivable

11 Injury Severity Score (ISS)Anatomical scoring system that provides an overall score for patients with

______________________________________ injuriesEach injury is assigned a AIS score and is allocated to one of ___________ body regionsOnly the highest AIS score in each region is usedThe 3 most severely injured body regions have their score

______________________________________ and added together Score ranges from ___________ to ___________

12 Injury Severity Score (ISS)6 Body Regions of the ISS: ______________________________________ and Neck FaceChest ______________________________________Extremity ______________________________________

13 Injury Severity Score (ISS) If an injury is assigned an AIS of 6, the ISS score is automatically ___________

(unsurvivable)The only anatomical scoring system in use and correlates with

______________________________________ , morbidity, hospital stay, and other measures of severity

It’s weakness is an error in application of the _______________ system

14 Example of ISS

15 Trauma Triage Criteria Indicating Immediate TransportMOI-Adults: >___________’ fall Pedestrian/Bicyclist versus autoThrown or run over by vehicleStruck by vehicle traveling >____________mph

Motorcycle impact >20 mph ______________________________________ from a vehicle

16 Trauma Triage Criteria Indicating Immediate TransportMore MOI-Adults: Severe vehicle impact

>____________ mph>____________” intrusion>____________” vehicle deformity

______________________________________ with signs of serious impactDeath of another occupant ______________________________________ time >20 minutes

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17 Trauma Triage Criteria Indicating Immediate TransportMOI-Pediatrics: >____________’ fallBicycle collisionVehicle collision at medium speedAny vehicle collision involving an ______________________________________ infant

or child

18 Physical Findings in Need of Immediate TransportRevised Trauma Score <____________ Pediatric Trauma Score <____________Glasgow Coma Scale <____________ Systolic blood pressure <____________ systolicRespiratory rate <____________ >____________

19 Physical Findings in Need of Immediate Transport >2 ______________________________________ long bone fractures Flail chest ______________________________________ fractureLimb ______________________________________ Burn > ____________ % BSABurn to face or airway Penetrating trunk, neck and ______________________________________ trauma

20 ALS Care in Trauma

21 Fluid Replacement IVs should be established ______________________________________ on all major

trauma patients unless extenuating circumstances Fluid replacement requires approximately ____________ times the amount of blood loss.

3:1 Fluid resuscitation is ____________ cc/kg to maintain systolic BP at ____________ -

____________ mmHgAvoid raising BP above 110Multiple IVs accomplish fluid replacement quickerUse ______________________________________ bore IV catheters

22 EKGsMonitoring of EKG is ______________________________________ in major traumaMost dysrhythmias associated with trauma are related to volume loss (or vessel

expansion) or due to respiratory problems Fluid replacement and ______________________________________ control are utilized

first for treatment of dysrhythmias ______________________________________ utilized as last resort

23 Drug Therapy in Trauma ______________________________________ is NEVER used for hypovolemic shock

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– Ok for septic, cardiac, and neurogenic shockUtilize ______________________________________ per protocol ______________________________________ arrest is worked the same as non-

traumatic with the exception of fluid replacement as required

24 Blunt Trauma

25 Automobile CrashesTypes of Impact: ______________________________________ : 32%Lateral: 15% ______________________________________ : 38%

– Left & Right – Front & RearRear-end: 9% ______________________________________ : 6%

26 Frontal ImpactDown-and-Under

-Knee, ______________________________________ , and hip fracture-Chest trauma-Steering Wheel

-Paper Bag SyndromeUp-and-Over

- ______________________________________ legs = Bilateral femur fracture- ______________________________________ organ rupture and liver laceration-Similar chest trauma

27 Frontal Impact ______________________________________

-Due to up-and-over pathway-Contact with the vehicle & ______________________________________ object

28 Lateral Impact 15% of MVC’s but 22% of deaths ______________________________________ extremity injuryRib, clavicle, humerus, pelvis, femur fractureLateral ______________________________________

-Ruptured diaphragm, Spleen fracture, Aortic injuryEVALUATE the ______________________________________ occupant

29 Rotational and Rear-end ImpactRotationalVehicle struck at ______________________________________ angleLess serious injuries unless strike a ______________________________________ objectRear-end Seat propels the occupant ______________________________________Head is forced backwards

-Stretching of neck ______________________________________ and ligaments

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-Hyperextension & hyperflexion of neck

30 Rollovers ______________________________________ points of impactEjection or partial ejectionType of injuries are related to the specific vehicle

______________________________________ Less injury with ______________________________________

31 Automobile CrashesVehicle Crash Analysis: ______________________________________Crumple Zones ______________________________________Deformity of VehicleUse of ______________________________________ Intoxication Fatal Accidents: >50% involved ______________________________________ Also highly involved in recreational accidentsRule out other causes first

32 Automobile CrashesVehicular Mortality ______________________________________ : 48% ______________________________________(Torso): 37% Spinal & Chest fracture: 8% ______________________________________ fracture: 2%All Other: 5%

33 Crash EvaluationCollision QuestionsHow did collision occur? ______________________________________? ______________________________________? Similar/Different sized? ______________________________________ collisions?

34 Crash Evaluation1 ______________________________________ of Crash

Weather & visibility? ______________________________________ involved?Medical conditions? Skid marks?

2 Auto Interior ______________________________________ of windshield? Steering wheel ______________________________________ ? ______________________________________ deformity?

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Intrusion?

35 Motorcycle Crashes Serious injuries can occur with high and low speed collision.Types of Impact: FrontalAngular ______________________________________Ejection

-Initial Bike/Object Collision-Rider/ ______________________________________ -Rider/ ______________________________________

36 Pedestrian Accidents______________________________________ :Adults turn awayBumper strikes lower legs firstVictim rolls up and ______________________________________ and thrownChildren:Children turn ______________________________________ ______________________________________, Pelvis often injuredThrown away or run over

37 Recreational Vehicle AccidentsLack ______________________________________ and restraint systemTypes of Vehicles

-Snowmobiles-Boats and personal ______________________________________ -ATV’s

38 Other Types of Blunt Trauma

39 Falls ______________________________________ of FallLanding Area

- ______________________________________ Type- ______________________________________ Part

Elderly-More prone to falls-More prone to serious injuries from minor falls

40 Sports InjuriesVarious Injury Patterns: Produced by extreme exertion, fatigue or direct trauma ______________________________________, deceleration, compression, rotation,

hyperextension, or hyperflexion ______________________________________, neurological defect or decreased mental

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status require physician follow-up Protective Gear ______________________________________ injury pattern

41 Helmet RemovalRemove helmet only if:

-Fits too ______________________________________ -Unable to control ______________________________________ if left on-If helmet is removed, remove shoulder pads simultaneously

Remove ______________________________________ only if possible If tight, remove face mask and ______________________________________ in placeTake helmet to hospital if possibility of head injury

42 Crush SyndromeCauses include structural collapse, explosion, industrial; or agriculturalGreat force to ______________________________________ tissue and bones

-Tissue stretching and ______________________________________ -Extended pressure results in ______________________________________

metabolism distal to compression-Return of blood flow, ______________________________________ to entire body-Severe hemorrhage due to severe damaged blood vessels

43 Management of Crush Syndrome IV: _________________ml/kg of NS or D51/2NSAVOID ____________ or K+ based solutionsAfter bolus, continuous infusion of 20ml/kg/hrConsider ________________________________________________________ to

counteract acidosis at 1mEq/kgConsider Calcium Chloride to counteract hyperkalemia

44 Management of Crush SyndromeConsider ______________________________________ to decrease edemaConsider analgesics for pain

– Prior to ______________________________________ if possibleManage injuries as appropriate

45 Penetrating Trauma

46 Physics of Penetrating TraumaGreater the ______________________________________ the greater the energy

– Double mass = double KEGreater the speed the greater the energy

– Double ______________________________________ = 4x increase KE Small & Fast bullet can cause greater damage than large and slow.Different bullets of different weights traveling at different speeds cause different injuries

47 Physics of Penetrating TraumaEnergy and VelocityLow Energy/Low Velocity

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– ______________________________________ and arrowsMedium Energy/Medium Velocity Weapons

– ______________________________________, shotguns, low-powered rifles– 250-400 mps

High Energy/High Velocity– ______________________________________ Rifles– 600-1,000 mps

48 Damage PathwayProjectile Injury Process:Tip impacts tissueTissue pushed ______________________________________ and to the sideTissue collides with adjacent tissue

- ______________________________________ wave of pressure forward and lateral-Moves perpendicular to bullet path

Rapid ______________________________________ , crushes and tears tissue ______________________________________ forms behind bullet pulling in debris with

suction.

49 Damage Pathway ______________________________________ Injury: Damage done as the projectile

strikes tissue Pressure Shock WaveHuman tissue is ______________________________________ -fluidSolid and dense organs are damaged greatly

Temporary Cavity: Due to ______________________________________ ______________________________________ Cavity: Due to seriously damaged tissueZone of Injury: Area that extends beyond the area of permanent injury

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51 Ballistics Cavitation

52 Low-Velocity WoundsObjects

- ______________________________________, Ice-picks, Arrows-Flying objects or debris

Injury limited to tissue impacted-Object pathway-Object ______________________________________ or moved

Attacker Characteristics- ______________________________________ : forward, outward and crosswise- ______________________________________ : overhand and downward

53 Specific Tissue & Organ Injuries ______________________________________ of tissue affects the efficiency of energy

transmission

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- ______________________________________ : Strength and elasticity of an objectConnective Tissue (muscles, skin, ligaments, etc.)

-Absorbs energy and limits tissue damageOrgans

-Solid Organs: Dense and low ______________________________________ - ______________________________________ Organs

-Fluid filled: transmit energy = increased damage-Air filled: absorbs energy = less damage

54 Specific Tissue & Organ InjuriesLungs:Air in lung absorbs energy Pneumothorax or ______________________________________ can resultBone:Resists displacement until it ______________________________________ Alters ______________________________________ path

55 General Body RegionsExtremities Injury limited to ______________________________________ of tissue 60-80% of injuries with <10% mortalityAbdomen (Includes Pelvis)Highly susceptible to injury and ______________________________________ ______________________________________ perforation: 12-24 hrs peritoneal

irritation

56 General Body RegionsThorax:Rib impact results in ______________________________________ energyHeart & great vessels have extensive damage due to lack of fluid

______________________________________ Any large chest wound compromises ______________________________________

57 General Body RegionsNeck:Damages ______________________________________ and Blood VesselsNeurological problems ______________________________________ neck woundHead:Cavitational energy trapped inside ______________________________________ Serious bleeding and lethal

58 Some 90 percent of penetrating trauma mortality involves the head,

______________________________________ , and abdomen.

59 Entrance Wound Characteristics Size of ______________________________________ profile for non-deforming bullets

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Deforming ______________________________________ may cause large woundsClose Range

- ______________________________________ Burns (Tattooing of powder)-1-2 mm circle of discoloration- ______________________________________subcutaneous emphysema

60 Exit Wound CharacteristicsCaused by the passage of the projectile and the

______________________________________ Appears to be “Blown” outward

- ______________________________________ waveALWAYS check GSW victims for ______________________________________

wounds

61 An exit wound may more accurately reflect the potential

______________________________________ caused by a bullet’s passage through the

body than an entrance wound.

62 Special Concerns with Penetrating TraumaScene Size-Up:Law-Enforcement: DO NOT ENTER UNTIL SCENE IS SAFE! ______________________________________ : Victim or AssailantAssailants If a crime scene

- ______________________________________ -Do not disturb evidence-Retain clothing, etc.-Limit ______________________________________ involvement

63 Special Concerns with Penetrating TraumaPenetrating Wound AssessmentTry to determine the ______________________________________ of the object and

consider damage to organs and vessels in that pathwayBut, remember objects are often ______________________________________ or

splinter Internal Organ Injury PotentialEntrance & Exit Wounds

64 PROVIDE RAPID TRANSPORT FOR ANY GSW TO HEAD, CHEST, OR ABDOMEN.

TREAT AGGRESIVELY FOR ______________________________________ !!

65 Penetrating Wound CareFacial Wounds: Facial Wounds can make for difficult ______________________________________

- ______________________________________ chest-Pass ET through bubbling tissue

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-Consider LMA or Combi-tube-Consider ______________________________________

66 Soft Tissue Injuries

67 Penetrating Wound CareChest Wounds: Pneumothorax

-3-sided ______________________________________ dressing-Needle ______________________________________

Pericardial ______________________________________

68 Penetrating Wound CareImpaled ObjectsLow-energyDO NOT REMOVE………UNLESS

-In ______________________________________ -Interferes with ______________________________________

69 Hemorrhage1 ______________________________________ : Bright red and spurting

______________________________________ : Darker red and flowing ______________________________________ : Darker red and oozing

70 Controlling External BleedingExternal bleeding is controlled by:Direct, even ______________________________________ and elevation Pressure dressings and/or ______________________________________ ______________________________________ It will often be useful to combine these methods.

71 Tourniquet If direct pressure fails, apply a tourniquet ______________________________________

the level of bleeding.Used only on ______________________________________ It should be applied quickly and not ______________________________________ until

a physician is present.

72 Applying a Commercial TourniquetBSIHold direct pressure over wound Place tourniquet around the extremity just ______________________________________

the bleeding siteClick the buckle into place and ______________________________________ the strap

tightTurn the dial ______________________________________ until pulses are no longer

palpable below the tourniquet or until bleeding is controlled

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73 Releasing a Commercial TourniquetTo release the tourniquet at the hospital, or if instructed by medical control, push the

______________________________________ button and pull the strap back. Caution: bleeding may rapidly return upon tourniquet release and may need to be rapidly

______________________________________

74 Making and Applying a Tourniquet (1 of 2)

Fold triangular bandages to ___________” wide and 6 to 8 layers thickWrap the bandage around the extremity ______________________________________

just above the bleeding siteTie one knot in the bandage. Place a stick or rod on the knot and tie the ends of the

bandage ______________________________________ the handle

75 Making and Applying a Tourniquet (2 of 2)

______________________________________ the handle to tighten the tourniquet until bleeding stops

______________________________________ the handleWrite “____________” and exact time on a piece of tape and apply to patient’s foreheadA great alternative is the use of a BP cuff

76 Making a Tourniquet

77 BP Cuff as TourniquetBP cuff will work well for a tourniquet Pressure the cuff about ___________-_____________mmHg above systolic BPMake sure cuff does not ______________________________________ Continuously monitorMust use ______________________________________ cuff for large lower extremities

78 Tourniquet PrecautionsDo not apply a tourniquet directly over any

______________________________________ .Make sure the tourniquet is tightened securely.Use wide ______________________________________ under tourniquet if possibleNever use wire, rope, a belt, or any other narrow material.Do not ______________________________________ the tourniquet.

79 Pain and Edema Control ______________________________________ packs ______________________________________ pressure over woundConsider ______________________________________ if approved by medical control

– Must be cognitive of the possible effects on BP and perfusion

80 Anatomical Considerations Scalp:Rich supply of blood vessels In some cases, ______________________________________ can develop

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Can be severe and difficult to controlWith Skull Fracture

-Gentle ______________________________________ pressure around the wound-Pressure on local arteries

Without Skull Fracture use ______________________________________ pressure

81 Anatomical Considerations Face:Heavy bleedingAssess and protect the ______________________________________ Blood is a ______________________________________ irritant

– Be alert for nausea and vomitingEar or Mastoid:Cover and Collect ______________________________________ Do NOT stop ______________________________________

82 Anatomical Considerations Neck:Consider circumferential bandage with little or no

______________________________________ -Protect trachea and carotids- ______________________________________ and dressing

Occlusive dressing if lacerated vesselShoulder:Care to avoid ______________________________________ to trachea and anterior neck

83 Anatomical Considerations Trunk:Minor wounds: Dressing and ______________________________________ Major wounds: Circumferential wrapGroin & Hip

- ______________________________________ by following contours of body-Movement can increase ______________________________________ of bandage

84 Anatomical Considerations Elbow and Knee:Circumferential wrap and splint

– ______________________________________ reduces movement– Position of ______________________________________

Hand and Finger:Bulky dressing Position of functionAnkle and Foot:Circumferential ______________________________________

85 Complications of BandagingAlways assess before and after:

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-Pulse- ______________________________________ function- ______________________________________

Developing ischemia-Pain, pallor, tingling, loss of pulse, decreased capillary refill

Is dressing ______________________________________ appropriate to injury?

86 Bandaging AmputationsPatient:Control bleeding by ______________________________________ dressingConsider tourniquet proximal to woundDo not delay ______________________________________ to to locate part

– Have a second unit transport the partAmputated Part:Dry cooling and rapid transport Part in plastic bag (Double bag) Immerse in ______________________________________ water or on iceAvoid direct contact between tissue and cold water or ice

87 Bandaging Impaled Objects Stabilize with ______________________________________ dressing in place Prevent movement of objectConsider cutting or shortening LARGE impaled objects

-Prevent gross movement-Reduce ______________________________________ to patient if cutting torch used

REMOVE ONLY IF:-In cheek and interferes with ______________________________________ -Interferes with ______________________________________

88 Burns

89 Types of BurnsThermal (from heat) ______________________________________Chemical ______________________________________

90 Burn Depth1 Superficial Burn:

1st Degree Burn Involves only ______________________________________ Reddened skin ______________________________________ at burn site

91 Burn Depth1 Partial-Thickness Burn: 2nd Degree Burn

Involves epidermis & ______________________________________

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Intense painWhite to red skin ______________________________________

92 Burn Depth1 Full-Thickness Burn: 3rd Degree Burn

All ______________________________________ layers/tissue may be involvedDry, leathery skin (white, dark brown, or charred)Loss of ______________________________________ (little pain)

93 Body Surface AreaRule of Nines:

-Best used for ______________________________________ surface areas-Expedient tool to measure extent of burn

Rule of ______________________________________ -Best used for burns < ____________ % BSA-Patient’s palm = 1%

94 Extent of Burns (Rule of 9’s)Used to determine percent of body surface that is burned (TBS)Area Adult Child InfantHead 9% 12% 18%Arms 9% 9% 9%Torso (front) 18% 18% 18%Torso (back) 18% 18% 18%Genitalia 1% 1% 1%Legs 18% 16.5% 13.5%

95 Extent of Burns (Rule of 9’s)

96 Systemic Complications ______________________________________Disruption of skin and its ability to thermoregulate

______________________________________Shift in proteins, fluids, and electrolytes to the burned tissueGeneral electrolyte imbalance

______________________________________Hard, leathery product of a deep full thickness burnDead and denatured skin

97 Systemic Complications ______________________________________Greatest risk of burn is infection

Special FactorsAge & ______________________________________

______________________________________ ______________________________________ Abuse

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Elderly, Infirm or Young

98 Burn SeverityMinor Burns: Superficial < __________ % BSA Partial Thickness < __________ % BSA Full Thickness < __________ % BSAModerate Burns: Superficial > __________ % BSA Partial Thickness __________ - __________ % BSA Full Thickness __________ - __________ % BSA

99 Burn SeverityCritical Burns: Partial Thickness > __________ % BSA Full Thickness > __________ % BSA Inhalation InjuryAny partial or full thickness burn involving hands, feet, joints, face, or

______________________________________ Any complicating medical diseases or injuries

100 Burns to the face, hands, feet, joints, genitalia, and circumferential burns are or special

______________________________________ .

101 Assessment of Thermal BurnsOngoing AssessmentNon-critical: Reassess Q ____________minCritical: Reassess Q ______________ min

102 Consideration of Burn Center Partial Thickness > __________ % BSA Full Thickness > __________ % BSA Significant burns to the face, hands, feet, or perineal areaHigh ______________________________________ electrical injuries Inhalation Injuries ______________________________________ burns causing tissue destructionAssociated significant injuries

103 IV Management of Thermal BurnsParkland Burn Formula:__________ mL x Pt wt in kg x % BSA = Amt of fluidNS is fluid of choice Pt should receive ½ of this amount in first __________ hrs.Remainder in __________ hrsConsider 1 hour dose

– __________ ml x Pt wt in kg x % BSA = Amt of fluid

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104 Musculoskeletal Trauma

105 Joint Injuries ______________________________________ : a partial, temporary dislocation resulting

in tearing of a joint capsule’s connective tissues; usually ligaments ______________________________________ : a partial displacement of a bone end

from its position in a joint capsule reducing the joint integrity ______________________________________ : Complete displacement of a bone end

from its position in a joint capsule

106 Bone InjuriesOpen Fracture: bone ends or the forces that caused it penetrate the skinClosed Fracture: bone ends do not penetrate the skin ______________________________________ Fracture: small crack in a bone ______________________________________ Fracture: bone is compressed on itself

107 Types of FracturesTransverse Fracture: runs perpendicular across the bone ______________________________________ Fracture: runs across a bone at an angle

other than 90°Comminuted Fracture: bone is broken into several pieces ______________________________________ Fracture: a curving break normally

caused by rotation forces

108 Types of Fractures Fatigue Fracture: break in a bone associated with prolonged or repeated stress ______________________________________ Fracture: partial fracture in a child’s bone ______________________________________ Fracture: disruption of the growth plate in

a child’s bone

109 Types of Fractures

110 Care for Specific FracturesPelvis: ______________________________________ Stretcher PASG ______________________________________ ResuscitationFemur:Traction Splints ______________________________________ Fracture versus hip dislocation

111 Care for Specific FracturesTibia/Fibula: Rigid or soft splint ______________________________________ splint without tractionClavicle:Most frequently fractured bone in the body

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Transmitted to 1st and 2nd ribAlert for ______________________________________ injury Sling and swathe

112 Care for Specific Fractures______________________________________ : Sling and swatheRadius/Ulna: Air splint or sling and swathe

113 Care for Specific Joint InjuriesHip Injuries: Immobilize in ______________________________________ positionLong board bind legs together with ______________________________________

between Scoop Stretcher PASGKnee Injuries: Immobilize with ______________________________________ splints in position foundUse of PASG, Air splint, or traction splint (w/o traction) if

______________________________________

114 Care for Specific Joint InjuriesAnkle and Foot Injuries: ______________________________________ splint Rigid or air splintShoulder Injuries:Rigid splints if dislocated ______________________________________ Sling and swathe if dislocated ______________________________________ (pad

between arm and chest)

115 Care for Specific Joint InjuriesElbow Injuries: Sling and Swathe if ______________________________________ Use of Air splint or rigid splints if straightWrist/Hand Injuries:Use of rigid or air splint Sling and swatheLeave ______________________________________ tips exposedFinger Injuries:Use ______________________________________ blades or small maleable splints

116 Musculoskeletal Injury Management Immobilize knee injuries in the position found unless you discover significant distal

circulation, sensation, or motor deficit.Elbow ______________________________________ should not be reduced in the

prehospital setting.

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117 In all joint injuries, be alert for neurological and

______________________________________ compromise

118 Head, Facial, & Neck Trauma

119 Skull Fractures

120 Basal Skull Fracture Signs ______________________________________ Signs

-Retroauricular ______________________________________ -Associated with fracture of auditory canal and lower areas of skull

Raccoon Eyes-Bilateral ______________________________________ Ecchymosis-Associated with ______________________________________ fractures

121 Basal Skull FractureMay tear ______________________________________ Permit CSF to drain through an external passagewayMay mediate rise of ______________________________________ Evaluate for “______________________________________ ” or “Halo” sign

122 Intracranial PerfusionCompensating Mechanisms for Pressure:

1) Compress (______________________________________ ) venous blood vessels2) Reduction in free CSF

-Pushed into ______________________________________ cordBody can only compensate for a limited amount of time

123 Intracranial PerfusionDecompensating for Pressure: Increase in ______________________________________ Rise in systemic BP to perfuse brain which causes in

______________________________________ in ICPDangerous cycle begins

124 Intracranial Perfusion

125 Roles of Carbon DioxideIncrease of CO2 in CSF:Cerebral ______________________________________

– Encourage blood flow– Reduce ______________________________________ – Contributes to ICP

Causes Hyperventilation & HypertensionReduced levels of CO2 in CSF:Cerebral ______________________________________

– Results in cerebral ______________________________________

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126 Factors Affecting ICPVasculature ConstrictionCerebral ______________________________________ Systolic Blood Pressure

-Low BP = Poor Cerebral ______________________________________ -High BP = Increased ICP

Carbon ______________________________________ ______________________________________ respiratory efficiency

127 Signs & Symptoms of Brain InjuryAltered Mental Status

-Altered ______________________________________ -Alteration in ______________________________________ -Amnesia

- ______________________________________ : just before incident- ______________________________________ : just following incident

______________________________________ Reflex-Increased BP-Bradycardia-Erratic respirations

128 Signs & Symptoms of Brain InjuryVomiting:

-Normally without nausea-May be ______________________________________

Body temperature changesChanges in pupil reactivity ______________________________________ posturing: Arms flexed, fists clinched,

and legs extended ______________________________________ Posturing:Stiff and extended extremities

and retracted (extended) head

129 ManagementAirway: ______________________________________ Patient PositioningOPA & NPA UseEndotracheal Intubation

– Orotracheal, Digital, Nasotracheal, Retrograde, ______________________________________

______________________________________

130 ManagementBreathing:Oxygen: NRB @ 15lpmVentilate @ ___________ - ___________ bpm

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– Do NOT ______________________________________Circulation: ______________________________________ control Fluid resuscitationConsider ______________________________________

131 Management______________________________________ ManagementReduces cerebral perfusion & hypoxiaConsider early management with 2 large bore IV’s and

______________________________________ fluids-Maintain SBP 90-100 mmHg

Consider ______________________________________

132 Medications: Oxygen Primary 1st line drugAdminister high flowHyperventilation is ______________________________________

– Reduces circulating CO2 levelsNRB: 15 LPMBVM: ___________ - ___________ times per minuteKeep SaO2 > __________%

133 Other Medications______________________________________Used to reduce EdemaExamples

– Mannitol– ______________________________________ Furosemide)

134 Other MedicationsSedatives:Used for sedationExamples:

– ______________________________________ (Valium)– ______________________________________ (Versed)– ______________________________________

135 Other Possible Medications ______________________________________ : decreases oral and nasal secretionsD50W: if hypoglycemicThiamine (B1 vitamin): for ETOHTopical Anesthetic Sprays

– Reduces Gag Reflex– ______________________________________ or Benzocaine

136 Spinal Trauma

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137 General S/S of Spinal InjuryExtremity ______________________________________ Pain with & without movementTenderness along spine Impaired breathing Spinal deformity (rare) ______________________________________ ______________________________________Loss of bowel or bladder controlNerve impairment to extremities

138 Spinal Shock ______________________________________ insult to the cordAffects body below the level of injuryAffected area may be:

– Without ______________________________________– Loss of movement (Flaccid paralysis)– Frequent loss of bowel & bladder control– Priapism– Hypotension ______________________________________ to vasodilation

139 Spinal shock is a temporary form of ______________________________________ shock

that presents with

hypotension, bradycardia, and the signs and symptoms of cord injury.

140 Neurogenic Shock Spinal-Vascular ShockOccurs when injury to the spinal cord disrupts the brain’s ability to control the body

-Loss of ______________________________________ tone-Dilation of arteries and veins

- ______________________________________ vascular space-Results in relative ______________________________________-Reduced cardiac preload-Reduction of the ______________________________________ of contraction

141 Neurogenic ShockAutonomic Nervous System (ANS) loses sympathetic control over adrenal medulla

-Unable to control release of ______________________________________ & norepinephrine

-Could depress ______________________________________

142 S/S of Neurogenic Shock ______________________________________HypotensionCool, Moist & Pale skin above the injury

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Warm, Dry & Flushed skin below the injury ______________________________________ in males

143 Movement of the Spinal Injury PatientAny movement MUST be ______________________________________Move patient as a unitNO ______________________________________ PUSHING

– Move patient up and down to prevent lateral bendingRescuer at the head “CALLS” all movesALL MOVES MUST be slowly executed and well coordinatedConsider the ______________________________________ positioning of the patient

prior to beginning move

144 Types of MovesLog Roll ______________________________________ SlideRope-Sling SlideOrthopedic Stretcher ______________________________________ -Type ImmobilizationRapid ExtricationLong Spine Board ______________________________________ Injury Immobilization

145 During all movement of a spinal injury patient, keep the spine in the

______________________________________, in-line position by keeping the patient’s eyes

facing directly forward, and the shoulders, pelvis, and toes in the same

______________________________________.

146 ManagementMedications & Neurogenic Shock: Fluid Challenge

- ______________________________________ Solution:-250 ml initially-Monitor response and repeat as needed

PASG- ______________________________________ -Research shows no positive outcome

______________________________________ to increase BP

147 Thoracic Trauma

148 Flail Chest Segment of the chest that becomes free to move with the pressure changes of

______________________________________ ______________________________________ or more adjacent rib fracture in two or

more places

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Serious chest wall injury with underlying pulmonary injury-Reduces volume of ______________________________________-Adds to increased mortality

______________________________________ flail segment movement Positive pressure ventilation can restore tidal volume

149 Flail Chest

150 Over time, the muscles splinting the flail segment will fatigue and

______________________________________ respiration will become more evident.

151 Simple PneumothoraxAKA: Closed Pneumothorax

-Can easily progress into ______________________________________ Pneumothorax-Occurs when lung tissue is disrupted and air leaks into the

______________________________________ space

152 Simple PneumothoraxProgressive Pathology:Air accumulates in pleural space, ______________________________________

collapsesAlveoli collapse (atelectasis), reduced gas exchangeVentilation/Perfusion ______________________________________

-Increased ventilation but no alveolar perfusion-Reduced respiratory efficiency results in

______________________________________-Typical MOI: “Paper Bag Syndrome”

153 Simple (closed) Pneumothorax

154 Open PneumothoraxAKA: ______________________________________ Chest Wound Free passage of air between atmosphere and pleural spaceAir replaces lung tissue ______________________________________ shifts to uninjured sideAir will be drawn through wound if wound is ___________ diameter of the trachea or

larger

155 Open PneumothoraxSigns/Symptoms Penetrating chest trauma Sucking chest wound ______________________________________ blood at wound site Severe ______________________________________ ______________________________________

156 Open Pneumothorax

157 Tension Pneumothorax

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Buildup of air under pressure in the ______________________________________.Excessive pressure reduces effectiveness of respirationAir is unable to ______________________________________ from inside the pleural

space Progression of Simple or Open Pneumothorax ______________________________________ Life Threat

158 Tension Pneumothorax

159 Tension PneumothoraxSigns/Symptoms ______________________________________, cyanosis, hypoxiaDistended neck veinsTracheal shift away from affected side (late sign) Possible ______________________________________ emphysema ______________________________________ sounds, absent lung soundCool, clammy skinHypovolemiaAMS ______________________________________

160 Physical Findings of Tension Pneumothorax

161 HemothoraxAccumulation of ______________________________________ in the pleural space Serious hemorrhage may accumulate 1,500 mL of blood

-Mortality rate of 75%-Each side of thorax may hold up to 3,000 mL

Blood loss in thorax causes a decrease in ______________________________________ volume-Ventilation/Perfusion Mismatch & Shock

Typically accompanies pneumothorax– ______________________________________

162 HemothoraxSigns/SymptomsBlunt or penetrating chest trauma ______________________________________

-Dyspnea-Tachycardia-Tachypnea- ______________________________________-Hypotension

______________________________________ to percussion over injured side

163 Physical Findings of Massive Hemothorax

164 Pericardial Tamponade

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Restriction to cardiac filling caused by blood or other fluid within the ______________________________________

Occurs in <2% of all serious chest trauma-However, very high ______________________________________

Results from tear in the coronary artery or ______________________________________ of myocardium-Blood seeps into pericardium and is unable to escape-200-300 ml of blood can restrict effectiveness of cardiac contractions

-Removing as little as __________ ml can provide relief

165 S/S of Pericardial Tamponade1 Dyspnea

Possible cyanosisBeck’s Triad______________________________________Distant ______________________________________ tonesHypotension or narrowing ______________________________________ pressure

Weak, thready ______________________________________ Shock

2 ______________________________________ signs: decrease or absence of JVD during inspiration

Pulsus ParadoxusDrop in SBP >10 during ______________________________________Due to increase in ______________________________________ during inspiration

166 Physical Findings of Cardiac Tamponade

167 Traumatic AsphyxiaResults from severe ______________________________________ forces applied to the

thoraxCauses ______________________________________ flow of blood from right side of

heart into superior vena cava and the upper extremities

168 Traumatic AsphyxiaSigns & SymptomsHead & Neck become ______________________________________ with blood Skin becomes deep red, purple, or blueNOT RESPIRATORY RELATED JVDHypotension, Hypoxemia, Shock Face and tongue ______________________________________ ______________________________________ eyes with conjunctival hemorrhage

169 General Management of the Chest Injury PatientEnsure ABC’sHigh flow O2 via NRB ______________________________________ if indicated; consider RSI

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Consider overdrive ventilation-If tidal volume less than 6,000 mL-BVM at a rate of __________-__________-May be beneficial for chest contusion and rib fractures-Promotes oxygen perfusion of alveoli and prevents

______________________________________

170 General Management of the Chest Injury PatientAnticipate ______________________________________ Compromise Shock Management

-Consider ______________________________________ only in blunt chest trauma with SP <60 mm Hg

-Fluid Bolus: 250-500ccAUSCULTATE! AUSCULATE! AUSCULATE!

171 Management of Flail Chest Place patient on ______________________________________ of injury

-ONLY if spinal injury is NOT suspectedExpose injury siteDress with ______________________________________ bandage against flail segment

-Stabilizes fracture siteHigh flow O2Assist ventilations; ______________________________________ as needed

172 Management of Open Pneumothorax1 High flow O2

Cover site with sterile ______________________________________ dressing taped on three sides

Progressive airway management if indicated

173 Management of Tension PneumothoraxEnsure airway, oxygenation, and ______________________________________Confirmation:

– Auscultaton & ______________________________________– ______________________________________ shift

174 Management of Tension PneumothoraxPleural Decompression: ___________ intercostal space in mid-clavicular line ______________________________________ OF RIBConsider multiple decompression sites if patient remains symptomaticLarge over the needle catheter: _________gaCreate a one-way-valve: Glove tip or Heimlich valve if required

175 Management of Tension Pneumothorax

176 Management of HemothoraxHigh flow O2

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2 large bore IV’s– Maintain SBP of ____________-____________– EVALUATE BREATH SOUNDS for fluid

______________________________________

177 Management of Pericardial TamponadeHigh flow O2 IV therapyConsider ______________________________________ if within scope and skill

178 Management of Traumatic Asphyxia Support airway

-Provide O2-PPV with BVM to assure adequate ______________________________________-Intubate as needed

2 large bore IV’sEvaluate and treat for ______________________________________ injuries If entrapment > 20 min with chest ______________________________________,

consider 1mEq/kg of Sodium Bicarbonate

179 Abdominal Trauma

180 Injury to the Hollow OrgansMay rupture with compression from ______________________________________

forcesMay tear due to penetrating trauma ______________________________________ of contents into:

-Peritoneal space- ______________________________________ space

Intestines have a large amount of ______________________________________-Leakage can result in sepsis

181 Injury to the Hollow OrgansManifestations of Blood Loss: ______________________________________ : Bright red blood in stoolMelena: Dark tarry stool indicative of partially digested bloodHematemesis: Blood in emesis ______________________________________ : Blood in the urine

182 Injury to the Solid OrgansDense and less strongly held together Prone to contusion

– ______________________________________– Fracture (rupture)

Unrestricted ______________________________________ if organ capsule is ruptured

183 Injury to the Solid OrgansSpecific Organs:

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Spleen: pain referred to left ______________________________________ Pancreas: pain radiate to backKidneys: pain radiate from ______________________________________ to groin &

hematuria ______________________________________ : pain referred to the right shoulder

184 Injury to the Vascular StructuresAbdominal Aorta & Vena Cava: Prone to direct blunt or penetrating traumaMay be injured in ______________________________________ injuriesBlood accumulates beneath diaphragm Produces ______________________________________ pain in the shoulder regionGreater volume of blood can be lost Presence of blood in abdomen, stimulates ______________________________________

nerve resulting in slowing of heart rateBlood can ______________________________________ in any of the abdominal spaces

185 Injury to the Mesentery and Bowel ______________________________________ : double fold of tissue in the peritoneum

that supports the major portion of the small bowel, suspending it from the posterior abdominal wall

Provides bowel with circulation and attachmentBlood loss ______________________________________Tear of mesentery may ______________________________________ bowel Penetrating trauma to the lateral abdomen likely to injure large bowel

186 Injury to the PeritoneumDelicate & sensitive lining of ______________________________________ abdomen ______________________________________ : inflammation of the peritoneum due to:

-Bacterial irritation: due to torn bowel or open wound-Chemical irritation

- ______________________________________ nature of digestive enzymes-Urine initiates inflammatory response

187 Injury to the Peritoneum ______________________________________ does not induce peritonitis Progression

-Slight tenderness at location of injury- ______________________________________ tenderness-Guarding-Rigid, ______________________________________ -like feel

188 Management of Abdominal Injuries Position Patient

– Position of comfort unless spinal injury– ______________________________________ knees or left lateral recumbent

General shock care

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______________________________________ application Specific injury care

– Impaled Objects or ______________________________________

189 Management of Abdominal Injuries ______________________________________ resuscitation

-Large bore IV with isotonic solution-Fluid challenge 250-500ml

-Limit to ____________ L-Titrate to SBP of ____________ mmHg

190 Keys to Trauma ManagementDon’t get ______________________________________ vision

– Often, the less obvious injuries are the life threatening injuriesLimit IV fluids to maintain ______________________________________ BP at or

around 90-100mmHg systolicMost treatments should be performed en route

– IV, ECG, Intubation?Don’t forget ______________________________________

191 Keys to Trauma ManagementObserve AND report ______________________________________ Consider ______________________________________ evacuation early

– Ask “will this patient get there quicker?”– Ask “can the helicopter crew do something that will aid this patient that I cannot do?”

Consider proper receiving facility ______________________________________ the patient oftenDOCUMENT!