Trauma pg 4 | Coconote

I'm asking you the procedure name. So, the procedure name, you may hear it called needle thoracentesis, which means needle into the thoracic cavity. You may hear it called pleural decompression. You may also hear it called needle decompression. Those are all interchangeable. For slang, we call it darting the chest. But the actual medical names of them are the thoracentesis, pleural decompression, or needle synthesis, or needle decompression. How do I know a simple or a traumatic is becoming attention? JVD. So if I said you have 27-year-old, tall, thin male, sun onset, short of breath, chest pain after sneezing. Spontaneous. Your patient is starting to develop JVD. It's now what? And it's time to do what? Neon decompress. The first thing that's going to happen when I go from a simple, which means it's not a tension yet, from a simple... to attention if you need a JVD. And the registry will want you to jump on that JVD and need to decompress it. What type of shock is attention pneumo? Obstructive. The three classic signs of attention pneumo. attention pneumo are JVD, absent breath sounds, and tracheal deviation. Which way does the trachea go in relation to the injury? Opposite. Opposite. So if my right lung has a hole in it and that pleural space is filled with air, it's going to start pushing the metastinum over, which is going to create tracheal deviation. All right? That's why it moves the opposite. That's the latest sign, though. You're probably not going to see that in the field. It's very rare to see it in the field because it takes so long to develop, but for testing purposes, if I said JVD and tracheal deviation, there's nothing else it can be but attention beam. That's why they like to put that tracheal tugging or tracheal deviation on the registry because there ain't nothing else that can go with it. Myocardial contusion. Whatever's bruised on the outside, we've got to consider what's bruised underneath. If they've got a bruise on the heart and it occurred between the R wave and the T wave, where the sodium potassium is moving in and out, they can go into V-fib. What is that Blount trunk? between the R and T wave column? Comotio cordis. And how do I get them out of comotio cordis? Shopping. Which the registry is going to call unsynchronized or asynchronous what? Cardioversion. Asynchronous or unsynchronized cardioversion. What antiarrhythmic would they get if they were myocardial contusion and went into V-fib or V-tach without a pulse? Lidocaine because it's traumatic is what caused it. It's not a 60 year old having a heart attack, it's blunt trauma, so they would get lidocaine instead of amiodarone first. Pulmonary contusion, once again, whatever's bruised on the outside, I've got to think about the organ. going to underneath. So if I have bruised ribs on the right, I've got to think about the lung. Is the lung involved? Do they have a tension? Do they have a hemo? And then I also got to understand that a bruised rib, which is what a pulmonary contusion is, it's a bruised rib and a bruised lung, is going to get much worse before it gets better. Because there's no way to splint your ribs. Your ribs and your lung are going to move 12 to 20 times a minute, every minute, every hour. hour, every day, as long as you're on this earth. It's not like your leg where we can put it in a cast and keep it from moving for six weeks. So this injury is going to get worse because it's going to continue to move and inflame itself before it gets better. That's why rib fractures and bruised ribs are so painful and take forever to heal if you've ever had them because there's no way to isolate and immobilize them like there is in the extremity. So expect them to get worse before they get better. Traumatic asphyxia. A lot of times what happens is these people will tear their aorta and they will have bilateral tension pneumos. Once again, if I take that deep breath, hyperinflate, hit that steering wheel, it's going to pop everything in there and tear it. As a result of that, a lot of times from the nipple line up, when the superior vena cava is torn loose, all the blood runs from the superior vena cava down into the abdomen. So they lose all the red. ...warm blood up here, which is why they look blue a lot of times from the nipple line up, from either tearing the superior vena cava or the ascending aorta. That's why they have that blue appearance from the nipple line up a lot of times. Most of these are dead. If we get there really quick, they may not be dead yet, but they are probably going to die from that. They're also prone, because of the tension pneumos, they're also prone to diaphragmatic ruptures. Now, how do I know a difference between a tension pneumo, a bronchial rupture, and a diaphragmatic rupture? Because that can appear on the test. Okay, so let me ask you this. Let's go back to my sack. Alright? We have, right now, we have attention pneumo, right? We tour the lung. If this person takes a breath... Am I moving air? Yeah, I was. I ain't moving air. Listen to it. Do I have rise and fall though? No. So because I don't have rise and fall of that, and based on the mechanism, you end up darting it. You end up darting it, they still have no rise and fall. They get decreased LFC, you intubate them. You intubate them, you get capnography back, you hear breath, but you have no rise and fall of the chest. And every time you bag them, their belly's getting bigger. So it didn't respond to darting, and the belly's getting bigger, and I hear breath sounds and I got capnography, but because there's a hole in the end of it, the air just goes straight through the lungs, straight through the diaphragm and into the belly. That's a diaphragmatic rupture. If it's a bronchial rupture, you'll hear breath sounds. You'll hear the air coming in, but you won't see the inflation. And they'll just keep swelling above the epigastric and swelling out this way. way because the diaphragm is still intact. That's a bronchial rupture. There's nothing we can do for that. That's literally the air sac has popped in bronchioles and the alveoli, so any air that goes in is just filling up that thoracic cavity. That's why any air leak beneath the skin gets trapped by the skin, whether it's a tension pneumo, a diaphragmatic rupture, or bronchial rupture, and what do they develop? Subcutaneous. Subcutaneous. Subcutaneous. Subcutaneous emphysema. Subcutaneous emphysema. Which subcutaneous emphysema is like that bubble wrap underneath the skin. Alright? Not much we can do for traumatic asphyxia. A couple things on that before we hit head injury one more time. Sucking chest wound, how should you immediately treat it? Gloved hand. Gloved hand. Because you should always have it seen safe. Tire it immediately with your gloved hand definitively. and they need an inclusive dressing. Three-sided with an open corner called a flutter valve. As y'all already said, they start getting difficult to bag, JVD, lift it, burp it, doesn't work, put it back down, dart it. All right, dart it. Pulmonary embolisms, you will see some risk factors here. They like to ask about females and pulmonary embolisms. Why are they telling me 42-year-old female on estrogen smokes with sudden onset, chest pain, shortness of breath, and coughing? PE. PE. Pregnant, or not pregnant, but birth control and smoking increases the risk of pulmonary embolisms, especially when they get in their mid to late 30s. The combination of the nicotine and the combination of the birth control puts them at high risk for pulmonary embolisms. Why are they telling me mom had a traumatic delivery three years ago? three days ago and developed sudden onset chest pain, shortness of breath. PE, clot. Why are they telling me patient broke their bone, femur fracture two days ago, sudden onset chest pain, shortness of breath. Hip reconstruction two days ago, sudden onset chest pain, shortness of breath. Those are all signs of a PE, clot. Now, if the clot is in the pulmonary arteries, Think about it, blood comes in, vena cava, right atrium, right ventricle, goes through the pulmonary arteries, the clot's there. No blood's going to move into the lungs, so where are the lungs going to be? Clear. Because no blood's moving in there. If it goes through the pulmonary circuit and it gets stuck on the pulmonary veins where I return to the heart, think about what's going to happen in that patient. Blood comes in, vena cava, right atrium, right ventricle, goes through the lungs, comes through Back to the left side, hits a roadblock. It's going to fill back up. So that's why you can have clear breath sounds, and that tells me that it's lodged on the right side. If it starts giving them pulmonary edema, it's lodged on the left side. Remember the... from yesterday the left side backs up the lungs so when you look at it it says maybe you create initially clear and progress the pulmonary edema and that's why it depends on which side it's caught on if you think they got the pulmonary embolism put him at 45 to 60 degrees and turn them on their left side. By turning them on their left side, if it is an air embolism, where air rises to the top of any container, if we look at Katie's bottle of water, where's the air at? Top. So if it is an air embolism and most of our blood is water, we're hoping that it will rise and not get sucked all the way through. If it gets sucked all the way through, they'll put a screen and put them on some sort of thrombolytics and heparin. So that's what we're looking at. How they definitively... test for a pulmonary embolism. It's called a VQ scan. So if you see on a test that says a VQ scan was positive, that means it's positive for a pulmonary embolism. All right, that's a VQ scan. Not much we can do for it. Pay attention to those risk factors. Pay attention to the risk factors. Closed head injury. Well, hang on, one more thing on pulmonary embolisms. They may ask you about arterial occlusion versus deep vein thrombosis. Alright? And they're going to ask you which one is most likely to cause a pulmonary embolism. So let's stop and think about this. I have my arteries. Carrying blood to the capillaries where we exchange oxygen and carbon dioxide because of ATP and acid production, correct? And so I go aorta, arteries, arterioles, capillaries, right? And then over here, I leave and I come back. So I got my venules to my veins. To my vena cava, correct? This side, when I leave the heart, the further away from the heart I get, the vessels get what? More. This way, the closer to the heart I get, the vessels get? Bigger. So if I have an arterial occlusion... it is not likely to cause a pulmonary embolism. And here's why. That clot would have to go all the way through the artery, through its smallest points, through the pre-capillary sphincter, which is a door that allows blood into the capillary. go through the microscopic capillaries, out the post-capillary sphincter, and all the way back to the heart. Chances are it's not what? Not going to happen. But what will happen in arterial occlusion is if it's occluded here, no red warm oxygen and sugar can get below that occlusion, okay? No blood can get below there. So below the injury would become what color? Blue? Sinai? Blue. Sinai? Cold. Mottled. Mottled. So it would be cool pale Tammy below the occlusion, and it would start becoming painful because there's no blood flow. Now compare that to a venous occlusion. If I have a venous occlusion, deep vein thrombosis, all the red-worn blood comes in the capillaries, picks up the trash, starts through the veins, and then the back of her knee, because of varicose veins or spider veins, it hits this occlusion. Red-worn blood keeps coming in. but it can't what? Can't leave. So below the knee, any blood that goes in there gets stuck. So what is the skin color and temp of the deep vein thrombosis going to be? Red, hot, and swollen. If they break this clot loose, it has a pathway, because it doesn't have to go through the sphincters, it has a direct pathway to the vena cava, to the right atrium, to the right ventricle. That's why I beat... frame thrombosis is more likely to cause a pulmonary embolism than arterial occlusion. They're both emergencies that both need to go to the hospital, but the deep vein thrombosis is more likely to cause a pulmonary embolism, where this is more likely to cause localized tissue damage and death because there's no blood flow to that. extremity. Not much we can do for either one of them. A lot of times varicose veins, spider veins, prolonged setting when that person with varicose or spider veins has prolonged setting and they're bent, because most commonly those veins are below the knee. So they prolong set, they stand up, and they walk, they break that pot loose. So, which fire department sees the most people with prolonged setting that get up and walk to exit? DFW. Cross-country flights, been on a plane six hours, little old lady, Barricos, Maine, sitting there for six hours, less gravity up there, less pressure, she exits the plane, breaks that clock loose. those of PE in the terminal. Cross-country bus rides, prolonged setting, airplanes, those people, they're more likely to develop a DVT that can lead to a pulmonary embolism. arterial occlusion and DBT on the test, and that's the difference in them. Last thing on this page, closed head injuries. Talked about it yesterday. A couple of things there. Remember they vomit? When they vomit, that stimulates the vagus nerve, which does what to the heart rate? Which does what to the pressure? Brings it down. So vomiting and a head injury, the more projection. projectile and further they vomit, they're actually trying to relieve ICP. The negative is anybody that's altered and vomiting is at high risk for aspiration and aspiration pneumonia. We talked yesterday about keeping the MAP at 90 to 110, which basically means prevent hypotension. We also talked about if it puts pressure on the brainstem, not only does it affect the chemoreceptors, but it also puts pressure on the spinal cord. So if I hear swelling and I'm pushing... pushing down at the for a magnum where the brain stem comes out and the spinal cord comes out, the more pressure that gets there, the more they're going to start to protect themselves, which is why they get a three on the cortic posture. As they get up into the cerebrum and midbrain, almost 50% of the brain is herniated. As I get midbrain pressure, I turn out and get the extension, which is the separate, which is why on the PCS is separate. posturing, got a two, it has a less chance of survival because more of the brain is herniated. Does that make sense? Just that this is herniated, necordic, I start getting 50% herniation up in the cerebrum, I go into separate posturing. And that's why they get a three and a two, and the separate posturing is more deadly than necordic. Ventilations on a head injury, if we have to ventilate them. The rules for ventilation at head injury. We talked yesterday about hyperoxemia, which is high oxygen, which is what occurred in panic attacks. If I hyperventilated or if I have a person hyperventilating, they got carpal-pedal spasms because oxygen level is too high and CO2 level is too low. Remember that from yesterday? If I hyperventilate a head injury, that will actually cause their CO2 level to go down, their oxygen level to go high, and it will cause more vasoconstriction. Vasoconstriction. Well, they've already had the alpha effects of epi. Their pressure's already high, so too much oxygen can actually make a head injury worse. Too little oxygen, if they become hypoxic, hypoxia leads to what we call hypercarbia, high CO2. Is too much CO2 good or bad? What do bad things do in your blood vessels? They cause vasodilation. So if I let their CO2 level get too high, they're going to vasodilate and bleed more in the brain. So I have to find that sweet spot. If you do not have capnography and you're having to ventilate a head injury, we want to ventilate them at 12 to 16 breaths per minute. If they herniate posture or seize, then I'm going to increase the 16 to 20 breaths per minute. Now, what is herniating or posture? How do I know that the brain is herniating? Pupils. Clenched jaw. So their pupil starts to blow, they start developing Cushing's, they get a clenched jaw, they're herniating. I need to increase my ventilation 16 to 20. If I got a head injury and they're just unresponsive, 12 to 16. Start seeing Cushing's. start seeing people, they maybe start posturing, increase to 16 to 20. Only if you have capnography can you go to a max of 24 breaths per minute to keep your entitled CO2 as close to 35 as possible. So let's say that I have a head injury, I innovate them and their CO2 is 60. In a head injury, I'm with your CO2 is... Close to 35 as I can get it. So let's say that I am bagging them 18 times a minute and they're capping those 60. What should I do with my ventilations? Speed up. The higher the CO2, the lower the oxygen. I need to speed up my ventilations. So I go from 18 to 22 and now they're at 50. Now what do I do? I go to a max of 24. Let's say I go to 24 breaths a minute and it takes your capnoe down to 45. I'm stuck. I cannot go faster than 24. Okay? That is what we call... mild hyperventilation. Normal is 12 to 20. 20 to 24 is mild hyperventilation, and I cannot go above 20 without Capno, and even with Capno, I can't go above 24. So let's say I had this person, let's go back here, they're 18 times a minute is what I'm bagging them, they're at 60, I speed up to 24 breaths per minute and their cap note is 28. Now what do I do? I slow down, so maybe I go from 24 to 22, and so I'm going to have to adjust my ventilations based on that cap note. But I can only go above 20 if I got cap note. Initial ventilations in a head injury, 12 to 16. Hernia and apostroces, 16 to 20. If I got catno, I can go to a max of 24 to try and get that catno down to 35. If it doesn't work, I can't go faster than 24. If the catno gets below 30, I need to what? Slow down. Slow down and give the body time to produce acid and carbon dioxide. That's what they're looking for on that. A couple of things about head injuries. They may ask you about subarachnoid, subdural, and epidural. Please. A subarachnoid typically has what associated with it? Come on. A clap, a thunder clap, a boom in their head. So if the person says, had the worst headache of my life and heard a loud thunder or a clap, that's a subarachnoid. An epidural head bleed is the most deadly. An epidural head bleed will hit their head. get knocked out, come back, and be completely normal for about 30 seconds. And then they die. So if I said you had a patient, blood trauma to the head, knocked out, witnesses say he was completely lucid, and now he's unresponsive, you suspect what? Epidural. Because they knock out, come back to like nothing happened, and then 30 seconds to a minute later they can end up dying. Because it's a massive arterial bleed. Subdural bleed is typically venous. Subdural bleed is very slow. In a subdural bleed, what typically happens is somebody has a mild head bleed or they hit their head, and when they lay flat in bed, they get a headache, maybe even a little bit of slurred speech. When they get up and move around, gravity pulls that blood out of the cranial vault, and their headache goes away. That's typically a subdural. It's slow. It can take a week to develop a subdural bleed can. It could be a week after a car wreck that they weren't checked out. that a subdural starts to give them severe problems, but they'll typically report when they lay flat they get a headache and it's because of blood pooling. And they'll ask you the three difference in those. Management's the same for them. While we're talking about head trauma, they're going to ask sometimes show, ask you about battle signs, raccoon eyes, and what different types of injuries those associated with. They also like to ask about the fort fractures. This is all going to be in that operations package. that you have. It's in the back of that. We'll get through a little bit later, but I just want you to be aware of those seven things of trauma. A Laforte fracture is one, two, and three. One is the mustache. Two is the tip of the nose. Three is the bridge of the nose out under the eye sockets. So one is tip, one is stache, two is tip, three is bridge. One, two, three. Obviously, the higher up, the more the face can fall down because it's a complete fracture across the maxilla. And that's it. The more of its fraction, the less stable the face is going to be, the higher chance of mortality that's going to happen. So if this said you have a patient struck in the face with a baseball bat, and you notice that their cheeks have completely fallen, Probably a three because when it breaks all the way across, basically the bone falls down within their skin. That's a Laforte three. One is stashed, just basically breaks right here. Two breaks across here, and three is basically at the bridge just below the eye sockets all the way through the maxilla. It'll fall down. One, two, and three. Laforte. L-E-F-O-R-T-E. All right? Last thing real quick. And we need a break. I know it's been a while. One trauma to the abdomen, whatever is on the inside, you need to be concerned with. So if I have what's called gray turners, which is bruising over the flank, what organ do you... need to be concerned with? Kidneys. If I have bruising over the right upper quadrant, what two organs you need to be concerned with? Gallbladder and liver. If I have bruising over the left upper quadrant, I need to be concerned with the and the pancreas. Alright? Now, one thing you need to know about blunt trauma to the abdomen or penetrating to the abdomen. Which is going to kill you first? A solid or hollow organ? Solid. Solid. A solid organ will have constant pain. Alright? A solid organ has what we call somatic pain which is constant because there's always blood in there. So if I have right upper quadrant pain radiating through the right shoulder and it's constant what organs involved? Liver because it's constant. The livers involved that's a solid organ so that person can bleed to death if they had a liver laceration etc. Hollow organs have what's called visceral pain all right and when you look at your hollow organs they're exactly what they say they have a opening in them. So this allows food, drink, bile, etc. to move through them. So it's only going to hurt when something is scraping the lining of that organ. So if I had crampy colically pain, comes and goes, works after fatty foods in my right upper quadrant, that's a what? Gallbladder. If it's constant pain radiating to the shoulder because because it's the spinal nerves, and the feedback, it would be somatic pain or liver. So let's relate that to a gunshot wound. Gunshot wound to the upper abdomen. What is my number one concern in the right upper abdomen? Liver or gallbladder then? Liver. Liver, because the liver is going to make them bleed to death and die today. If it ruptures the gallbladder, the gallbladder is going to dump all the toxins and enzymes and bacteria out. If that's not going to kill them today, that's going to kill them three to seven days from now because they're going to develop what? So my primary concern in abdominal trauma is the solid organs because of hemorrhagic shock. The secondary concern would be the hollow organs because they can develop sepsis down the road. You see the difference? Left upper quadrant, my primary concern in trauma would be the what then? Spleen. My secondary concern would be the pancreas. It's. If they have constant pain left upper quadrant, radiating to the left shoulder, it's probably their what? Spleen. If they have crampy colic pain, worse after alcohol and carbohydrate fatty food, comes and goes, do the pancreas. Solid organs, treat it like you would a hemorrhaging shock, surgical consultation, maintain a radial pulse because it's uncontrolled internal bleeding. Just like what we talked about yesterday. Any questions on that? We'll cover some more abdomen. and breaking out liver, gallbladder, pancreas, etc. when we get to medical. Last thing, and we need a break, injuries to the neck. If you have an open wound to the neck, it can suck air in and create a tension pneumo. So any wound, neck to navel, front, back, or side, we're going to use a gloved hand followed by a piece of dressing to prevent air from sucking down inside there. You can also use direct pressure on a neck wound. If I had a laceration to the right side, I could use direct pressure because if I pinch this carotid artery, the other one can still supply the brain because of the circle of Willis, which allows for collateral circulation. Remember yesterday on the drawing, the two carotid arteries coming up, I had the circle of Willis that allowed it. There's a blockage on one side. The other carotid artery can actually end up perfusing that brain. All right? So. So I can do direct pressure on the neck wound, but I don't want to do both sides. And you want to use an occlusive if it's sucking air in and out of it, all right? Because that can end up creating tension pneumo. All right, that's all I have for trauma. We'll cover burns a little bit later when we go through the ops packet and we do rule of nines. We were in here a while. Come back at 9.50.

I'm asking you the procedure name. So, the procedure name, you may hear it called needle thoracentesis, which means needle into the thoracic cavity. You may hear it called pleural decompression.

You may also hear it called needle decompression. Those are all interchangeable. For slang, we call it darting the chest.

But the actual medical names of them are the thoracentesis, pleural decompression, or needle synthesis, or needle decompression. How do I know a simple or a traumatic is becoming attention? JVD. So if I said you have 27-year-old, tall, thin male, sun onset, short of breath, chest pain after sneezing. Spontaneous.

Your patient is starting to develop JVD. It's now what? And it's time to do what? Neon decompress.

The first thing that's going to happen when I go from a simple, which means it's not a tension yet, from a simple... to attention if you need a JVD. And the registry will want you to jump on that JVD and need to decompress it. What type of shock is attention pneumo?

Obstructive. The three classic signs of attention pneumo. attention pneumo are JVD, absent breath sounds, and tracheal deviation. Which way does the trachea go in relation to the injury?

Opposite. Opposite. So if my right lung has a hole in it and that pleural space is filled with air, it's going to start pushing the metastinum over, which is going to create tracheal deviation.

All right? That's why it moves the opposite. That's the latest sign, though. You're probably not going to see that in the field. It's very rare to see it in the field because it takes so long to develop, but for testing purposes, if I said JVD and tracheal deviation, there's nothing else it can be but attention beam.

That's why they like to put that tracheal tugging or tracheal deviation on the registry because there ain't nothing else that can go with it. Myocardial contusion. Whatever's bruised on the outside, we've got to consider what's bruised underneath. If they've got a bruise on the heart and it occurred between the R wave and the T wave, where the sodium potassium is moving in and out, they can go into V-fib. What is that Blount trunk?

between the R and T wave column? Comotio cordis. And how do I get them out of comotio cordis? Shopping.

Which the registry is going to call unsynchronized or asynchronous what? Cardioversion. Asynchronous or unsynchronized cardioversion.

What antiarrhythmic would they get if they were myocardial contusion and went into V-fib or V-tach without a pulse? Lidocaine because it's traumatic is what caused it. It's not a 60 year old having a heart attack, it's blunt trauma, so they would get lidocaine instead of amiodarone first. Pulmonary contusion, once again, whatever's bruised on the outside, I've got to think about the organ. going to underneath.

So if I have bruised ribs on the right, I've got to think about the lung. Is the lung involved? Do they have a tension? Do they have a hemo?

And then I also got to understand that a bruised rib, which is what a pulmonary contusion is, it's a bruised rib and a bruised lung, is going to get much worse before it gets better. Because there's no way to splint your ribs. Your ribs and your lung are going to move 12 to 20 times a minute, every minute, every hour. hour, every day, as long as you're on this earth.

It's not like your leg where we can put it in a cast and keep it from moving for six weeks. So this injury is going to get worse because it's going to continue to move and inflame itself before it gets better. That's why rib fractures and bruised ribs are so painful and take forever to heal if you've ever had them because there's no way to isolate and immobilize them like there is in the extremity.

So expect them to get worse before they get better. Traumatic asphyxia. A lot of times what happens is these people will tear their aorta and they will have bilateral tension pneumos.

Once again, if I take that deep breath, hyperinflate, hit that steering wheel, it's going to pop everything in there and tear it. As a result of that, a lot of times from the nipple line up, when the superior vena cava is torn loose, all the blood runs from the superior vena cava down into the abdomen. So they lose all the red.

...warm blood up here, which is why they look blue a lot of times from the nipple line up, from either tearing the superior vena cava or the ascending aorta. That's why they have that blue appearance from the nipple line up a lot of times. Most of these are dead. If we get there really quick, they may not be dead yet, but they are probably going to die from that.

They're also prone, because of the tension pneumos, they're also prone to diaphragmatic ruptures. Now, how do I know a difference between a tension pneumo, a bronchial rupture, and a diaphragmatic rupture? Because that can appear on the test.

Okay, so let me ask you this. Let's go back to my sack. Alright? We have, right now, we have attention pneumo, right?

We tour the lung. If this person takes a breath... Am I moving air? Yeah, I was.

I ain't moving air. Listen to it. Do I have rise and fall though? No.

So because I don't have rise and fall of that, and based on the mechanism, you end up darting it. You end up darting it, they still have no rise and fall. They get decreased LFC, you intubate them. You intubate them, you get capnography back, you hear breath, but you have no rise and fall of the chest. And every time you bag them, their belly's getting bigger.

So it didn't respond to darting, and the belly's getting bigger, and I hear breath sounds and I got capnography, but because there's a hole in the end of it, the air just goes straight through the lungs, straight through the diaphragm and into the belly. That's a diaphragmatic rupture. If it's a bronchial rupture, you'll hear breath sounds. You'll hear the air coming in, but you won't see the inflation.

And they'll just keep swelling above the epigastric and swelling out this way. way because the diaphragm is still intact. That's a bronchial rupture. There's nothing we can do for that.

That's literally the air sac has popped in bronchioles and the alveoli, so any air that goes in is just filling up that thoracic cavity. That's why any air leak beneath the skin gets trapped by the skin, whether it's a tension pneumo, a diaphragmatic rupture, or bronchial rupture, and what do they develop? Subcutaneous. Subcutaneous. Subcutaneous.

Subcutaneous emphysema. Subcutaneous emphysema. Which subcutaneous emphysema is like that bubble wrap underneath the skin. Alright?

Not much we can do for traumatic asphyxia. A couple things on that before we hit head injury one more time. Sucking chest wound, how should you immediately treat it? Gloved hand. Gloved hand.

Because you should always have it seen safe. Tire it immediately with your gloved hand definitively. and they need an inclusive dressing.

Three-sided with an open corner called a flutter valve. As y'all already said, they start getting difficult to bag, JVD, lift it, burp it, doesn't work, put it back down, dart it. All right, dart it.

Pulmonary embolisms, you will see some risk factors here. They like to ask about females and pulmonary embolisms. Why are they telling me 42-year-old female on estrogen smokes with sudden onset, chest pain, shortness of breath, and coughing?

PE. PE. Pregnant, or not pregnant, but birth control and smoking increases the risk of pulmonary embolisms, especially when they get in their mid to late 30s.

The combination of the nicotine and the combination of the birth control puts them at high risk for pulmonary embolisms. Why are they telling me mom had a traumatic delivery three years ago? three days ago and developed sudden onset chest pain, shortness of breath.

PE, clot. Why are they telling me patient broke their bone, femur fracture two days ago, sudden onset chest pain, shortness of breath. Hip reconstruction two days ago, sudden onset chest pain, shortness of breath. Those are all signs of a PE, clot.

Now, if the clot is in the pulmonary arteries, Think about it, blood comes in, vena cava, right atrium, right ventricle, goes through the pulmonary arteries, the clot's there. No blood's going to move into the lungs, so where are the lungs going to be? Clear. Because no blood's moving in there.

If it goes through the pulmonary circuit and it gets stuck on the pulmonary veins where I return to the heart, think about what's going to happen in that patient. Blood comes in, vena cava, right atrium, right ventricle, goes through the lungs, comes through Back to the left side, hits a roadblock. It's going to fill back up. So that's why you can have clear breath sounds, and that tells me that it's lodged on the right side.

If it starts giving them pulmonary edema, it's lodged on the left side. Remember the... from yesterday the left side backs up the lungs so when you look at it it says maybe you create initially clear and progress the pulmonary edema and that's why it depends on which side it's caught on if you think they got the pulmonary embolism put him at 45 to 60 degrees and turn them on their left side. By turning them on their left side, if it is an air embolism, where air rises to the top of any container, if we look at Katie's bottle of water, where's the air at? Top.

So if it is an air embolism and most of our blood is water, we're hoping that it will rise and not get sucked all the way through. If it gets sucked all the way through, they'll put a screen and put them on some sort of thrombolytics and heparin. So that's what we're looking at.

How they definitively... test for a pulmonary embolism. It's called a VQ scan.

So if you see on a test that says a VQ scan was positive, that means it's positive for a pulmonary embolism. All right, that's a VQ scan. Not much we can do for it.

Pay attention to those risk factors. Pay attention to the risk factors. Closed head injury.

Well, hang on, one more thing on pulmonary embolisms. They may ask you about arterial occlusion versus deep vein thrombosis. Alright?

And they're going to ask you which one is most likely to cause a pulmonary embolism. So let's stop and think about this. I have my arteries. Carrying blood to the capillaries where we exchange oxygen and carbon dioxide because of ATP and acid production, correct?

And so I go aorta, arteries, arterioles, capillaries, right? And then over here, I leave and I come back. So I got my venules to my veins. To my vena cava, correct? This side, when I leave the heart, the further away from the heart I get, the vessels get what?

More. This way, the closer to the heart I get, the vessels get? Bigger.

So if I have an arterial occlusion... it is not likely to cause a pulmonary embolism. And here's why. That clot would have to go all the way through the artery, through its smallest points, through the pre-capillary sphincter, which is a door that allows blood into the capillary. go through the microscopic capillaries, out the post-capillary sphincter, and all the way back to the heart.

Chances are it's not what? Not going to happen. But what will happen in arterial occlusion is if it's occluded here, no red warm oxygen and sugar can get below that occlusion, okay?

No blood can get below there. So below the injury would become what color? Blue?

Sinai? Blue. Sinai?

Cold. Mottled. Mottled.

So it would be cool pale Tammy below the occlusion, and it would start becoming painful because there's no blood flow. Now compare that to a venous occlusion. If I have a venous occlusion, deep vein thrombosis, all the red-worn blood comes in the capillaries, picks up the trash, starts through the veins, and then the back of her knee, because of varicose veins or spider veins, it hits this occlusion. Red-worn blood keeps coming in.

but it can't what? Can't leave. So below the knee, any blood that goes in there gets stuck. So what is the skin color and temp of the deep vein thrombosis going to be? Red, hot, and swollen.

If they break this clot loose, it has a pathway, because it doesn't have to go through the sphincters, it has a direct pathway to the vena cava, to the right atrium, to the right ventricle. That's why I beat... frame thrombosis is more likely to cause a pulmonary embolism than arterial occlusion.

They're both emergencies that both need to go to the hospital, but the deep vein thrombosis is more likely to cause a pulmonary embolism, where this is more likely to cause localized tissue damage and death because there's no blood flow to that. extremity. Not much we can do for either one of them. A lot of times varicose veins, spider veins, prolonged setting when that person with varicose or spider veins has prolonged setting and they're bent, because most commonly those veins are below the knee. So they prolong set, they stand up, and they walk, they break that pot loose.

So, which fire department sees the most people with prolonged setting that get up and walk to exit? DFW. Cross-country flights, been on a plane six hours, little old lady, Barricos, Maine, sitting there for six hours, less gravity up there, less pressure, she exits the plane, breaks that clock loose.

those of PE in the terminal. Cross-country bus rides, prolonged setting, airplanes, those people, they're more likely to develop a DVT that can lead to a pulmonary embolism. arterial occlusion and DBT on the test, and that's the difference in them.

Last thing on this page, closed head injuries. Talked about it yesterday. A couple of things there.

Remember they vomit? When they vomit, that stimulates the vagus nerve, which does what to the heart rate? Which does what to the pressure?

Brings it down. So vomiting and a head injury, the more projection. projectile and further they vomit, they're actually trying to relieve ICP. The negative is anybody that's altered and vomiting is at high risk for aspiration and aspiration pneumonia.

We talked yesterday about keeping the MAP at 90 to 110, which basically means prevent hypotension. We also talked about if it puts pressure on the brainstem, not only does it affect the chemoreceptors, but it also puts pressure on the spinal cord. So if I hear swelling and I'm pushing... pushing down at the for a magnum where the brain stem comes out and the spinal cord comes out, the more pressure that gets there, the more they're going to start to protect themselves, which is why they get a three on the cortic posture. As they get up into the cerebrum and midbrain, almost 50% of the brain is herniated.

As I get midbrain pressure, I turn out and get the extension, which is the separate, which is why on the PCS is separate. posturing, got a two, it has a less chance of survival because more of the brain is herniated. Does that make sense? Just that this is herniated, necordic, I start getting 50% herniation up in the cerebrum, I go into separate posturing.

And that's why they get a three and a two, and the separate posturing is more deadly than necordic. Ventilations on a head injury, if we have to ventilate them. The rules for ventilation at head injury.

We talked yesterday about hyperoxemia, which is high oxygen, which is what occurred in panic attacks. If I hyperventilated or if I have a person hyperventilating, they got carpal-pedal spasms because oxygen level is too high and CO2 level is too low. Remember that from yesterday?

If I hyperventilate a head injury, that will actually cause their CO2 level to go down, their oxygen level to go high, and it will cause more vasoconstriction. Vasoconstriction. Well, they've already had the alpha effects of epi. Their pressure's already high, so too much oxygen can actually make a head injury worse. Too little oxygen, if they become hypoxic, hypoxia leads to what we call hypercarbia, high CO2.

Is too much CO2 good or bad? What do bad things do in your blood vessels? They cause vasodilation.

So if I let their CO2 level get too high, they're going to vasodilate and bleed more in the brain. So I have to find that sweet spot. If you do not have capnography and you're having to ventilate a head injury, we want to ventilate them at 12 to 16 breaths per minute. If they herniate posture or seize, then I'm going to increase the 16 to 20 breaths per minute. Now, what is herniating or posture?

How do I know that the brain is herniating? Pupils. Clenched jaw.

So their pupil starts to blow, they start developing Cushing's, they get a clenched jaw, they're herniating. I need to increase my ventilation 16 to 20. If I got a head injury and they're just unresponsive, 12 to 16. Start seeing Cushing's. start seeing people, they maybe start posturing, increase to 16 to 20. Only if you have capnography can you go to a max of 24 breaths per minute to keep your entitled CO2 as close to 35 as possible.

So let's say that I have a head injury, I innovate them and their CO2 is 60. In a head injury, I'm with your CO2 is... Close to 35 as I can get it. So let's say that I am bagging them 18 times a minute and they're capping those 60. What should I do with my ventilations?

Speed up. The higher the CO2, the lower the oxygen. I need to speed up my ventilations. So I go from 18 to 22 and now they're at 50. Now what do I do? I go to a max of 24. Let's say I go to 24 breaths a minute and it takes your capnoe down to 45. I'm stuck.

I cannot go faster than 24. Okay? That is what we call... mild hyperventilation.

Normal is 12 to 20. 20 to 24 is mild hyperventilation, and I cannot go above 20 without Capno, and even with Capno, I can't go above 24. So let's say I had this person, let's go back here, they're 18 times a minute is what I'm bagging them, they're at 60, I speed up to 24 breaths per minute and their cap note is 28. Now what do I do? I slow down, so maybe I go from 24 to 22, and so I'm going to have to adjust my ventilations based on that cap note. But I can only go above 20 if I got cap note. Initial ventilations in a head injury, 12 to 16. Hernia and apostroces, 16 to 20. If I got catno, I can go to a max of 24 to try and get that catno down to 35. If it doesn't work, I can't go faster than 24. If the catno gets below 30, I need to what? Slow down.

Slow down and give the body time to produce acid and carbon dioxide. That's what they're looking for on that. A couple of things about head injuries.

They may ask you about subarachnoid, subdural, and epidural. Please. A subarachnoid typically has what associated with it?

Come on. A clap, a thunder clap, a boom in their head. So if the person says, had the worst headache of my life and heard a loud thunder or a clap, that's a subarachnoid.

An epidural head bleed is the most deadly. An epidural head bleed will hit their head. get knocked out, come back, and be completely normal for about 30 seconds.

And then they die. So if I said you had a patient, blood trauma to the head, knocked out, witnesses say he was completely lucid, and now he's unresponsive, you suspect what? Epidural.

Because they knock out, come back to like nothing happened, and then 30 seconds to a minute later they can end up dying. Because it's a massive arterial bleed. Subdural bleed is typically venous.

Subdural bleed is very slow. In a subdural bleed, what typically happens is somebody has a mild head bleed or they hit their head, and when they lay flat in bed, they get a headache, maybe even a little bit of slurred speech. When they get up and move around, gravity pulls that blood out of the cranial vault, and their headache goes away. That's typically a subdural. It's slow.

It can take a week to develop a subdural bleed can. It could be a week after a car wreck that they weren't checked out. that a subdural starts to give them severe problems, but they'll typically report when they lay flat they get a headache and it's because of blood pooling. And they'll ask you the three difference in those. Management's the same for them.

While we're talking about head trauma, they're going to ask sometimes show, ask you about battle signs, raccoon eyes, and what different types of injuries those associated with. They also like to ask about the fort fractures. This is all going to be in that operations package. that you have. It's in the back of that.

We'll get through a little bit later, but I just want you to be aware of those seven things of trauma. A Laforte fracture is one, two, and three. One is the mustache.

Two is the tip of the nose. Three is the bridge of the nose out under the eye sockets. So one is tip, one is stache, two is tip, three is bridge. One, two, three.

Obviously, the higher up, the more the face can fall down because it's a complete fracture across the maxilla. And that's it. The more of its fraction, the less stable the face is going to be, the higher chance of mortality that's going to happen. So if this said you have a patient struck in the face with a baseball bat, and you notice that their cheeks have completely fallen, Probably a three because when it breaks all the way across, basically the bone falls down within their skin. That's a Laforte three.

One is stashed, just basically breaks right here. Two breaks across here, and three is basically at the bridge just below the eye sockets all the way through the maxilla. It'll fall down. One, two, and three. Laforte.

L-E-F-O-R-T-E. All right? Last thing real quick.

And we need a break. I know it's been a while. One trauma to the abdomen, whatever is on the inside, you need to be concerned with.

So if I have what's called gray turners, which is bruising over the flank, what organ do you... need to be concerned with? Kidneys.

If I have bruising over the right upper quadrant, what two organs you need to be concerned with? Gallbladder and liver. If I have bruising over the left upper quadrant, I need to be concerned with the and the pancreas.

Alright? Now, one thing you need to know about blunt trauma to the abdomen or penetrating to the abdomen. Which is going to kill you first?

A solid or hollow organ? Solid. Solid. A solid organ will have constant pain. Alright?

A solid organ has what we call somatic pain which is constant because there's always blood in there. So if I have right upper quadrant pain radiating through the right shoulder and it's constant what organs involved? Liver because it's constant.

The livers involved that's a solid organ so that person can bleed to death if they had a liver laceration etc. Hollow organs have what's called visceral pain all right and when you look at your hollow organs they're exactly what they say they have a opening in them. So this allows food, drink, bile, etc. to move through them.

So it's only going to hurt when something is scraping the lining of that organ. So if I had crampy colically pain, comes and goes, works after fatty foods in my right upper quadrant, that's a what? Gallbladder. If it's constant pain radiating to the shoulder because because it's the spinal nerves, and the feedback, it would be somatic pain or liver.

So let's relate that to a gunshot wound. Gunshot wound to the upper abdomen. What is my number one concern in the right upper abdomen? Liver or gallbladder then? Liver.

Liver, because the liver is going to make them bleed to death and die today. If it ruptures the gallbladder, the gallbladder is going to dump all the toxins and enzymes and bacteria out. If that's not going to kill them today, that's going to kill them three to seven days from now because they're going to develop what? So my primary concern in abdominal trauma is the solid organs because of hemorrhagic shock.

The secondary concern would be the hollow organs because they can develop sepsis down the road. You see the difference? Left upper quadrant, my primary concern in trauma would be the what then? Spleen.

My secondary concern would be the pancreas. It's. If they have constant pain left upper quadrant, radiating to the left shoulder, it's probably their what?

Spleen. If they have crampy colic pain, worse after alcohol and carbohydrate fatty food, comes and goes, do the pancreas. Solid organs, treat it like you would a hemorrhaging shock, surgical consultation, maintain a radial pulse because it's uncontrolled internal bleeding.

Just like what we talked about yesterday. Any questions on that? We'll cover some more abdomen. and breaking out liver, gallbladder, pancreas, etc. when we get to medical. Last thing, and we need a break, injuries to the neck.

If you have an open wound to the neck, it can suck air in and create a tension pneumo. So any wound, neck to navel, front, back, or side, we're going to use a gloved hand followed by a piece of dressing to prevent air from sucking down inside there. You can also use direct pressure on a neck wound. If I had a laceration to the right side, I could use direct pressure because if I pinch this carotid artery, the other one can still supply the brain because of the circle of Willis, which allows for collateral circulation.

Remember yesterday on the drawing, the two carotid arteries coming up, I had the circle of Willis that allowed it. There's a blockage on one side. The other carotid artery can actually end up perfusing that brain. All right?

So. So I can do direct pressure on the neck wound, but I don't want to do both sides. And you want to use an occlusive if it's sucking air in and out of it, all right? Because that can end up creating tension pneumo.

All right, that's all I have for trauma. We'll cover burns a little bit later when we go through the ops packet and we do rule of nines. We were in here a while. Come back at 9.50.

Transcript for:Trauma pg 4

Transcript for:
Trauma pg 4