Created by: Sanford Health - Fargo, ND Trauma Services - May 2014

Vital Signs mean what? HR >140 (adult) Systolic BP <90 GCS < 8 HR in 40’s & 50’s SBP of at least 80 Palpable Radial Pulse Intubate!Intubate! Loss of 40% of pt’s blood Potential for high mortality! Well trained athletes, beta blockers ?

TRUE or FALSE? An “obese” trauma patient needs intraosseous IV access. You are using the EZ IO for insertion. Would you use a blue needle? Pink 3-39kg Blue > 39 kg Yellow >39 kg, excessive tissue: edema, large musculature, obesity

What “criteria” must be met to clear the Adult Cervical Spine without imaging? Not Intoxicated Not Intoxicated Normal Mentation Normal Mentation No Neurologic Deficit No Neurologic Deficit No Midline Neck Pain No Midline Neck Pain No Distracting Injuries No Distracting Injuries

A significant cause of death- the combination of three common complications in patients with traumatic injuries and when they occur together is called: HypothermiaAcidosisCoagulopathy

TRUE or FALSE? Care done in the field and ED may contribute to this problem. Consider: Consider: ­ Prevention ­ Identification ­ Treatment

When does this start? - immediately after injury - immediately after injury

Control hemorrhage !! Warm: room; patient; fluids… Oxygenation & Ventilation  Perfusion Limit crystaloids Blood products / MTP Consider TXA (if < 3hrs from time of injury)

Fluid resuscitation – limit to 1-2 liters of crystaloids (NS/LR) Crystalloids are not benign Crystalloids are not benign Associated with prolonged mechanical ventilation Associated with prolonged mechanical ventilation Normal saline causes metabolic acidosis Normal saline causes metabolic acidosis Associated with multiple organ failure and systematic inflammatory response syndrome (SIRS) Associated with multiple organ failure and systematic inflammatory response syndrome (SIRS)

Logroll 4-6 inches to left side and support with “something” (? pillows, bath blankets, etc.), thus maintaining spinal precautions and decompressing the vena cava. What side should a pregnant patient lie when immobilized supine on a spine board?

What drug has shown significantly reduced mortality rates from bleeding in trauma patients? Binds to a receptor on fibrin and plasmin, thus blocking the binding of plasmin to fibrin. Net effect is fibrin is not broken down. Clots are stabilized. No effect on platelets, coagulation factors.

TXA should be given as early as possible to bleeding trauma patients, but should not be given if > 3 hours from time of injury! Contraindications (in FDA labeled population) –Hypersensitivity to TXA –Active intravascular clotting –Active thromboembolic disease –Subarachnoid hemorrhage

What % of Spinal Injuries occur in each region? Approximately 10% of patients with a cervical spine fracture have a second, noncontiguous vertebral column fracture.

C-spine injury in what pediatric age group is extremely rare, occurring in < 1% of injuries in this age group? Nearly all injuries in this age group occur above C3 Nearly all injuries in this age group occur above C3 Factors associated with c-spine injuries in children < 3 yrs of age: Factors associated with c-spine injuries in children < 3 yrs of age: – GCS < 14 – GCS Eye Score = 1 – MVC mechanism of injury – May be higher incident of injury between 2 & 3 years of age

Factors associated with c-spine injuries in children < 3 yrs of age: Factors associated with c-spine injuries in children < 3 yrs of age: – GCS < 14 – GCS Eye Score = 1 15

TRUE or FALSE? Secondary brain injury is caused by hypotension & hypoxia A ABCDE dminister oxygen M Maintain adequate ventilation aintain blood pressure (systolic > 90 mm Hg) D Do not resuscitation with multiple liters of crystaloids

What is a quick, simple way to assess a patient in 10 seconds? A quick assessment of the A, B, C, & D in a trauma patient can be conducted by identifying oneself, asking the patient for his or her name, and asking what happened.

An intoxicated person lay sprawled across three seats in a fancy Theater. When the usher noticed this, he whispered to the person, "Sorry, sir, but you're only allowed one seat.” The person groaned but didn't budge. The usher became more impatient: "Sir, if you don't get up from there I'm going to have to call the manager.“ Once again, the person just groaned. The usher marched back up the aisle, and he returned with the manager. Together the two of them tried repeatedly to move the person, but with no success. Finally, they summoned the police. The police officer surveyed the situation briefly, then asked, "All right buddy, what's your name?" "Fred," the person moaned. "Where ya from, Fred? asked the police officer. With terrible pain in his voice, and without moving a muscle, Fred replied,......

TRUE or FALSE? Children often sustain significant injury to the intra-thoracic structures without evidence of thoracic skeletal trauma High index of suspicion is necessary! High index of suspicion is necessary! Consider mechanism of injury Consider mechanism of injury Identification of skull or rib fractures in a child suggests the transfer of a massive amount of energy…… Identification of skull or rib fractures in a child suggests the transfer of a massive amount of energy…… Rib fractures in children are uncommon, but pulmonary contusion is not. Rib fractures in children are uncommon, but pulmonary contusion is not.

A patient presents to your ED after a bar fight. Family members report the patient “passed out” earlier, after the fight. He then went home, where they had a hard time waking him up. The family now brings the patient to your ED, and you determine his GCS is 11. Based on the report, what might you suspect your patient’s injury may be? A lucid (awake) interval between time of injury and neurologic deterioration is the classic presentation of an epidural hematoma.

Choosing the correct size of a King LT airway is based on what? Yellow (#3) 4-5 feet tall Yellow (#3) 4-5 feet tall Red (#4) 5-6 feet tall Red (#4) 5-6 feet tall Purple (#5) >6 feet tall Purple (#5) >6 feet tall

Frostbite Management Treat hypothermia first (LIFE OVER LIMB) Treat hypothermia first (LIFE OVER LIMB) Lightly wrap frostbit areas with Kerlex / gauze and protect from mechanical trauma Lightly wrap frostbit areas with Kerlex / gauze and protect from mechanical trauma Allow passive re-warming of frostbite during transport Allow passive re-warming of frostbite during transport Administer pain medications Administer pain medications Massage or manipulate the tissue Massage or manipulate the tissue

What is the most common type of Pelvic Fracture ? 4. Vertical Shear 1. Anterior - Posterior “Open Book” 2. Acetabulum 3. Lateral Compression “Closed” “”Open Book”

When safety belts are worn incorrectly, they can cause what types of injuries?

Using the “Rule of Nines”, estimate the BSA burned of a 2 y/o old who pulled a pan of boiling liquid off from the stove and burned his entire head (front and back) and the anterior portion of his chest: 28% 27% 64% 36% The child’s palm represents 1% of his or her body.

What do “raccoon eyes” & “battle signs” indicate in a trauma patient? Picture below : base of skull – depicting where the blood would “pool” and cause ecchymosis of the mastoid process area by the temporal bone, and the periorbital ecchymosis.

What oral anticoagulant, which is marketed as a Coumadin replacement, has come under great scrutiny over reports of irreversible bleeding and other serious side effects? Irreversible GI bleed Irreversible GI bleed Cerebral bleed Cerebral bleed Other Oral Anticoagulants….. Eliquis (apixaban) Xarelto (rivaroxaban)