4Cranial Injury Trauma must be extreme to fracture Basal Skull Linear DepressedOpenImpaled ObjectBasal SkullUnprotectedSpaces weaken structureRelatively easier to fracture
5Cranial Injury Basal Skull Fracture Signs Battle’s Signs Raccoon Eyes Retroauricular EcchymosisAssociated with fracture of auditory canal and lower areas of skullRaccoon EyesBilateral Periorbital EcchymosisAssociated with orbital fractures
6Cranial Injury Basilar Skull Fracture May tear dura Permit CSF to drain through an external passagewayMay mediate rise of ICPEvaluate for “Target” or “Halo” sign
7Brain Injury As defined by the National Head Injury Foundation “a traumatic insult to the brain capable of producing physical, intellectual, emotional, social and vocational changes.”ClassificationDirectPrimary injury caused by forces of traumaIndirectSecondary injury caused by factors resulting from the primary injury
8Direct Brain Injury Types CoupInjury at site of impactContrecoupInjury on opposite side from impact
9Direct Brain Injury Categories FocalOccur at a specific location in brainDifferentialsCerebral ContusionIntracranial HemorrhageEpidural hematomaSubdural hematomaIntracerebral HemorrhageDiffuseConcussionModerate Diffuse Axonal InjurySevere Diffuse Axonal Injury
10Focal Brain Injury Cerebral Contusion Blunt trauma to local brain tissueCapillary bleeding into brain tissueCommon with blunt head traumaConfusionNeurologic deficitPersonality changesVision changesSpeech changesResults fromCoup-contrecoup injury
11Focal Brain Injury Intracranial Hemorrhage Epidural HematomaBleeding between dura mater and skullInvolves arteriesMiddle meningeal artery most commonRapid bleeding & reduction of oxygen to tissuesHerniates brain toward foramen magnum
12Focal Brain Injury Intracranial Hemorrhage Subdural HematomaBleeding within meningesBeneath dura mater & within subarachnoid spaceAbove pia materSlow bleedingSuperior sagital sinusSigns progress over several daysSlow deterioration of mentation
13Focal Brain Injury Intracranial Hemorrhage Intracerebral HemorrhageRupture blood vessel within the brainPresentation similar to stroke symptomsSigns and symptoms worsen over time
14Diffuse Brain Injury Due to stretching forces placed on axons Pathology distributed throughout brainTypesConcussionModerate Diffuse Axonal InjurySevere Diffuse Axonal Injury
15Diffuse Brain Injury Concussion Mild to moderate form of Diffuse Axonal Injury (DAI)Nerve dysfunction without anatomic damageTransient episode ofConfusion, Disorientation, Event amnesiaSuspect if patient has a momentary loss of consciousnessManagementFrequent reassessment of mentationABC’s
16Diffuse Brain Injury Moderate Diffuse Axonal Injury “Classic Concussion”Same mechanism as concussionAdditional: Minute bruising of brain tissueUnconsciousnessIf cerebral cortex and RAS involvedMay exist with a basilar skull fractureSigns & SymptomsUnconsciousness or Persistent confusionLoss of concentration, disorientationRetrograde & Antegrade amnesiaVisual and sensory disturbancesMood or Personality changes
17Diffuse Brain Injury Severe Diffuse Axonal Injury Brainstem InjurySignificant mechanical disruption of axonsCerebral hemispheres and brainstemHigh mortality rateSigns & SymptomsProlonged unconsciousnessCushing’s reflexDecorticate or Decerebrate posturing
18Intracranial Perfusion ReviewCranial volume fixed80% = Cerebrum, cerebellum & brainstem12% = Blood vessels & blood8% = CSFIncrease in size of one component diminishes size of anotherInability to adjust = increased ICP
22Respiration and Ventilation Respiration is the exchange of gases between a living organism and its environment.Ventilation is the mechanical process that moves air into and out of the lungs.
23The Respiratory CyclePulmonary ventilation depends upon changes in pressure within the thoracic cavity.Coordinated interaction among the respiratory system, the central nervous system, and the musculoskeletal system.
24The Respiratory Cycle Inspiration Thoracic cavity is closed except for the tracheal openingRespiratory centers stimulate nerves which stimulate muscleChanges in pressure occur with diaphragmatic contraction and intercostals contract and air is drawn inwardActive process
25The Respiratory Cycle Expiration Receptors signal the respiratory center by way of the vagus nerve to inhibit inspiration.Expiration occursNormally passiveUse of accessory muscles
26Pulmonary Circulation Respiration also requires an intact circulatory system.Venous system carries deoxygenated blood to the right side of the heart, and the right ventricle pumps it into the pulmonary circulation.
27Pulmonary Circulation Diffusion occurs in the pulmonary capillaries.Blood returns to the left side of the heart for systemic circulation.
28DiffusionMovement of a gas from an area of higher concentration to an area of lower concentrationTransfers gases between the lungs and the blood and between the blood and peripheral tissues
29Measuring Oxygen and Carbon Dioxide Levels The partial pressure of a gas is its percentage of the mixture’s total pressure.Four major respiratory gases:Nitrogen (N2)Oxygen (O2)Carbon dioxide (CO2)Water (H2O)
31Factors Affecting Oxygen Concentration in the Blood Decreased hemoglobin concentrationInadequate alveolar ventilationDecreased diffusion across the pulmonary membraneVentilation/perfusion mismatch occurs when a portion of the alveoli collapses
32Factors Affecting Carbon Dioxide Concentrations in the Blood HyperventilationLowers CO2 levels due to increased respiratory rates or deeper respirationIncreased CO2 production include:Fever, muscle exertion, shivering, and metabolic processesDecreased CO2 elimination results from decreased alveolar ventilation
33Respiratory Rate Involuntary; however, can be voluntarily controlled Chemical and physical mechanisms provide involuntary impulses to correct any breathing irregularities
34Nervous Impulses from the Respiratory Center Main respiratory center is the medullaApneustic center assumes respiratory control if the medulla fails to initiate impulsesPneumotaxic center controls expirationStretch receptors prevent overexpansion of the lungsHering-Breuer reflex
35ChemoreceptorsLocated in carotid bodies, arch of the aorta, and medullaStimulated by decreased PaO2, increased PaCO2, and decreased pHCerebrospinal fluid (CSF) pH is primary control of respiratory center stimulation
36Hypoxic DriveHypoxemia is a profound stimulus of respiration in a normal individual.Hypoxic drive increases respiratory stimulation in people with chronic respiratory disease.
37Measures of Respiratory Function Respiratory rateFactors influencing rate include:Fever, emotion, pain, hypoxia, acidosis, stimulant drugs, depressant drugs, sleepAgeRate per MinuteAdult12–20Children18–24Infants40–60
38Measures of Respiratory Function Respiratory capacities and measurementsTotal lung capacityTotal volume of air at maximum inhalationAverage adult male TLC- 6 litersTidal VolumeAverage volume of gas inhaled or exhaled in one respiratory cycleApproximately 500 cc
39Measures of Respiratory Function Respiratory capacities and measurementsDead-spaceAmount of gases in tidal volume that remains in the airwayAlveolar volumeThe alveolar volume is the amount of gas in the tidal volume that reaches the alveoli for gas exchangeMinute volumeThe amount of gas moved in and out of the respiratory tract in 1 minute
40Measures of Respiratory Function Respiratory capacities and measurementsAlveolar minute volumeAmount of gas that reaches the alveoli for gas exchange in one minuteInspiratory reserve volumeThe amount of air that can be maximally inhaled after a normal inspirationExpiratory reserve volumeThe amount of air that can be maximally exhaled after a normal expiration
41Measures of Respiratory Function Respiratory capacities and measurementsResidual volumeThe amount of air remaining in the lungs at the end of maximal expirationFunctional residual volumeThe volume of gas that remains in the lungs at the end of normal expirationForced expiratory volumeThe amount of air that can be maximally expired after maximum inspiration
42Non-Invasive Respiratory Monitoring Devices will assist your measurement of the effectiveness of oxygenation and ventilation.Pulse oximetry, capnography, esophageal detection, and peak flow measurements
44SPO2 and waveform Plethysmograph Optically measures bloodflow to an organ
45Non-Invasive Respiratory Monitoring CapnographyRecordings or displays of exhaled CO2 measurements are called capnography.When perfusion decreases, as occurs in shock or cardiac arrest, ETCO2 levels reflect pulmonary blood flow and cardiac output, not ventilation.
46Non-Invasive Respiratory Monitoring Capnography (cont.)A normal partial pressure of end-tidal CO2 (PETCO2) is approximately mmHg.Increased ETCO2 levels are found with hypoventilation, respiratory depression, and hyperthermia.Decreased ETCO2 levels can be found in shock, cardiac arrest, pulmonary embolism, bronchospasm, and with incomplete airway obstruction.
52ComponentsIv lockSalineHeparinIv tubingMedication bag
53Fluid Administration Administer up to 250ml of saline. Medical control option for 250ml or moreIndicatorsExcessive bleedingBlood pressure below 100mm HGSuspected dehydrationSuspected internal bleeding
55Priority Determination Once the initial assessment is completed, determine the patient’s priority.If serious injury or illness is indicated by the initial assessment, conduct rapid head-to-toe assessment for other potential life-threats and initiate transport.
56Top Priority Patients Poor general impression Complicated childbirth UnresponsiveConscious but cannot follow commandsDifficulty breathingHypoperfusionComplicated childbirthChest pain and BP below 100 systolicUncontrolled bleedingSevere painMultiple injuries
62Predictors of Serious Internal Injury Ejection from vehicleDeath in same passenger compartmentFall from higher than 20 feetRollover of vehicleHigh-speed motor vehicle collisionVehicle-passenger collisionMotorcycle crashPenetration of the head, chest, or abdomen
63MOI Considerations for Infants and Children Fall from higher than ten feetBicycle collisionMedium-speed vehicle collision with resulting severe vehicle deformity
64A bent steering wheel indicates potentially serious injuries. Courtesy of Edward T. Dickinson, MD
65Rapid Trauma Assessment Not a detailed physical examFast, systematic assessment for other life-threatening injuriesFindings may influence transport decision
77Hemorrhage Assessment Primary AssessmentGeneral ImpressionObvious BleedingMental StatusABCInterventionsManage as you goO2Bleeding controlShockBLS before ALS!
78Hemorrhage Assessment Secondary AssessmentRapid Trauma AssessmentFull head to toeConsider air medical if stage 2+ blood lossFocused Physical ExamGuided by c/cVitals, SAMPLE, and OPQRSTAdditional AssessmentSearch for signs of internal bleedingBleeding from body orifice, melena, hematocheziaOrthostatic hypotension
79Hemorrhage Assessment Ongoing AssessmentReassess vitals and mental status:Q 5 min: UNSTABLE patientsQ 15 min: STABLE patientsReassess interventions:OxygenETIVMedication actionsTrending: improvement vs. deteriorationPulse oximetryEnd-tidal CO2 levels
80Hemorrhage Management Assure that the airway is patent and breathing is adequate.Maintain the airway and provide the necessary ventilatory support.Administer high-flow oxygen.Carotid pulse.CaAssure that the patient has a palpable re for serious (arterial and heavy venous) hemorrhage, immediately after you correct airway and breathing problems.
81Hemorrhage Management Direct PressureControls all but the most persistent hemorrhageIf bleeding saturates the dressing, cover it with another dressingIf ineffective, may be necessary to visualize wound to apply pressure directly to site
82Hemorrhage Management TourniquetConsider using a tourniquet only as a last resort when hemorrhage is prolonged and persistent.Apply a blood pressure cuff just proximal to the hemorrhage site.Inflate to apply pressure 20-30mmHg greater than the systolic blood pressure