Trauma Questions: Respiratory Obstruction - Essay Example

3 Trauma Questions 3 Trauma Questions Owing to the nature of the crash, respiratory obstruction may be imminent, and there is a need to establish intubation and ventilation, despite the fact that the airway is patent. The patient is time critical and may be at risk of significant delayed onset injuries, which may not be immediately symptomatic and pose a significant threat to patient health. Efforts should be directed at securing the airway, placing intravenous (IV) lines, and administering IV fluid (Ciraulo et al., 2006). It is also essential to utilize a cardiac monitor or other monitoring device as deemed appropriate since the patient can be considered as time critical. Despite the score of 15/15 Glasgow Coma Scale and PEARL, the patient health may rapidly worsen. Most common shock prevalent in trauma relate to haemorrhage included low volume/hypovolemic shock (absolute hypovolemia) emanating from hemorrhage or other significant body fluid loss; high-space or neurogenic shock (relative hypovolemia) emanating from spinal injury, sepsis, or certain drug overdoses, and mechanical/obstructive shock emanating from pericardial tamponade or myocardial contusion. The patient may be experiencing circulatory problems as a result of shock. The patient may not be having enough blood (hypovolaemia) due to the extensive external bleeding (O’Neill, 2005). Increased blood pressure can accelerate bleeding, dislodging soft early clots. Class II shock represents a significant volume loss of about 15% to 30%. This is evidenced by a delay in capillary refill, as well as an increase in heart rate and respiratory rate. The extensive blood loss may have led to profound shock and may easily transit into Class III shock (Americal Academy of Orthopedic Surgeons, 2011). The paramedic should run wide-open employing regular, macro-drip, or blood tubing. There is a need to decrease fluid rate by SPB>100. The unstable nature of the trauma patient requires an early active treatment. Two peripheral IV catheters should be established. The standard early treatment is a 2L bolus with normal saline (NS) as well as IV fluid resuscitation with saline or colloid (500ml 15 minutes). Normal saline is mainly less expensive and compatible with most medications/fluids. The goal of initial fluid resuscitation should be to restore circulating volume to maintain vital organ perfusion (Soreide & Grande, 2001). However, there is evidence that normalizing the blood pressure in the setting of an uncontrolled haemorrhage may worsen the outcome. If the patient is still hypotensive, PRBC’s should be launched if the patient is in profound shock and needing more aggressive resuscitation. Blood type O positive should be made available to the patient (>age 50). En route, the paramedic should administer normal saline solution to the patient as evidence of shock manifest. The paramedic should administer IV fluid therapy in line with the patient’s clinical response since overaggressive volume resuscitation may lead to recurrent or enhanced haemorrhage. This practice avails the mean blood pressure critical to maintaining perfusion of the vital organs (Lennquist, 2012). Pain medication should be administered through IV flasks with either pethidine/saline or tramadol infused and titrating against the pain according to pain levels. However, Morphine should be employed with caution since it may cause respiratory depression. # 2 The establishment of hand-held ultrasound equipments facilitated the inception of FAST into pre-hospital trauma management. Overtime, FAST has been established as a gold standard initial screening method for blunt abdominal trauma, especially when undertaking trauma management within a Pre-hospital setting or in the emergency department (ED) as outlined by the Advanced Trauma Support algorithm. FAST is an easy to learn diagnostic tool applicable to patients who are haemodynamically unstable (Ruesseler et al, 2009). Early detection of abdominal trauma may have a significant impact on the patient outcome as intra-abdominal trauma is a significant cause of preventable traumatic deaths. As a result, it is essential to recognize, address, and document blunt abdominal trauma immediately. Computer tomography is prominently employed due to its sensitivity and specificity to blunt abdominal trauma. Nevertheless, the procedure is time consuming and hence contraindicated in hemodynamically unstable patients. Focussed Assessment with Sonography for Trauma (FAST) avails a fast and readily applicable screening method in spotlighting patients for urgent laparotomy devoid of any further diagnostics (Jorgensen, Jensen & Dirks, 2010). FAST detects, with an enhanced sensitivity, intraperitoneal fluid, which usually accumulates in dependent areas simulating blunt abdominal trauma. FAST is an essential tool for prehospital management of blunt abdominal trauma. FAST functions as the initial diagnostic tool for abdominal trauma, especially in detecting intra-abdominal fluid. FAST is applicable in pre-hospital care since it can be done during resuscitation. One of the most prominent advantages of employing FAST in prehospital care lies in its high sensitivity in detecting intra- peritoneal fluid that accumulates in dependent areas such as around the liver, spleen, and pouch of Douglas (Hoff et al, 2002). Ultrasonography is usually correct in detecting intra- peritoneal fluid, although it fails in differentiating between blood, urine, bile, or ascites. This necessitates the need for correlating sonographic findings with the clinical findings so as to make critical decisions. The presence of free intra- peritoneal fluid in a hypotensive patient may alert the paramedic/physician that the patient is in an urgent need of laparotomy. Ultrasound is inaccurate in obese patients owing to the lack of penetration of sonographic waves; besides, it may be difficult to visualize intra-abdominal structures in instances where there is surgical emphysema under the skin. One of the drawbacks of FAST is that a positive examination depends on the presence of free intra- peritoneal fluid, which makes it difficult to detect injuries not associated with hemoperitoneum. In addition, FAST examination cannot be employed to reliably grade solid organ injuries and requires at least 200cc of fluid in order to detect (Smith, 2010). FAST has effectively demonstrated the utility in hemodynamically stable patients suffering from blunt abdominal trauma. FAST is also ideal for use in Prehospital care of a patient with blunt abdominal trauma since it is noninvasive, highly specific in detecting free fluid, easily performed, and can be performed concurrently with resuscitation, and takes a shorter period (3-4 minutes). Furthermore, the technology is portable and can be easily replicated, if need be (Brooks, Connolly & Chan, 2004). There is no doubt that prehospital FAST (p-FAST) can be undertaken with high sensitivity (accuracy) and specificity and can deliver significant changes in prehospital trauma therapy and management. # 3 A bomb blast often inflicts bodily damage in four ways. The first way includes blast wave pressure that may rupture internal organs such as lungs, eardrums, or bowels. Secondly, the heat can burn lungs, as well as the skin; thirdly, shrapnel can cause cuts, amputations, and penetrating wounds. Fourthly, crush injuries emanating from collapse of buildings. The conventional burns treatment features fluid replacement that is essential as fluid loss is uncontrolled in patients with severe burns. Upper and lower airway injuries can occur due to thermal or chemical insults. Airway oedema may occur within a short period from exposure to heat and may advance quickly to airway obstruction (Southwick et al., 2002). The fluid losses from a burnt skin mainly lead to a fall in blood pressure and may cause organs such as the kidney to fail. Burns may also lead to swelling and adding fluids can heighten the swelling, which may constrain blood flow. Thus, fluids must be administered carefully as too much fluid may orchestrate swelling, or even cell death (Alvarado et al., 2009). However, too little fluid may lead to multiorgan failure. The amount of fluid to be administered is directed by the percentage of burns whereby more burns will require more fluid, as outlined by the Parkland formula. All patients in Bali with burns were examined to determine the estimates of burn area and the intravenous fluid requirements. The victims with significant burns (20%-30%) were mainly managed with moist burn dressings, intravenous analgesia, and intravenous fluid therapy (Hampson, Cook & Frederiksen, 2002). Fluids are administered for maintenance and replacement of the lost fluids from the evaporation. The evaporative losses in this case are calculated based on the burn size and body surface area whereby evaporative losses = (25ml + TBSA% burn). Inadequate fluid replacement may lead to hypotension and renal failure, while the administration of excessive fluid replacement may orchestrate to tissue oedema and upgrading of burn depth. Thermal injury emanating from smoke inhalation contributes to inability to ventilate or intubate due to the direct heat injury caused by direct heat injury from the hot air, gases, and vapours to the upper airway and the oropharynx. The thermal damage to the airway hinges on the heat capacity characteristics of the vapour or gas inhaled during the exposure. Dry gases often inflict less injury compared to saturated vapours at a comparable temperature. The thermal injury sustained may produce immediate injury to the mucosa, leading to oedema, erythaema and ulceration. Oedema may form rapidly due to a combination of altered hydrostatic pressures, enhanced vascular permeability, and cytokine. Although oedema will form spontaneously, the condition may be accelerated by fluid resuscitation, especially from over aggressive fluid resuscitation (Minh et al, 2003). Anecdotal evidence derived from unintubated patients cared at the Royal Darwin Hospital, more than 24 hours after the Bali bombings, indicated that suboptimal fluid resuscitation may have been fortuitous in sustaining the airway patency in a number of patients with airway burns. The moment aggressive fluid resuscitation was implemented; there was a marked increase in airway oedema, which necessitated expert airway skills in urgently securing the airways (Shaw, Kumar & Dodds, 2010). Nevertheless, fluid should not be withheld since a delayed resuscitation of fluid (greater than 2 hours) may yield the rates of sepsis. References Alvarado, R., Chung, K., Cancio, L. & Wolf, S. (2009). Burn resuscitation. Burns 35, 4-14. Americal Academy of Orthopedic Surgeons. (2011). 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Garner, I., Morrison, P., Sharley, W., & Colin, X. (2003). The Bali bombing: Civilian aeromedical evacuation. Medical Journal of Australia 179 (7), 353-356. O’Neill, P. (2005). The ABC’s of disaster response. Scandinavian Journal of Surgery 94, 259-266. Ruesseler, M., Kirschning, T., Breitkreutz, R., Marzi, I. & Walcher, F. (2009). Prehospital and emergency department ultrasound in blunt abdominal trauma. European Journal of Trauma and Emergency Surgery 35 (4), 341-346. Shaw, I., Kumar, C. & Dodds, C. (2010). Oxford textbook of anaesthesia for oral and maxillofacial surgery. Oxford, UK: Oxford University Press. Smith, J. (2010). Focused assessment with sonography in trauma (FAST): Should its role be reconsidered? Post Graduate Medical Journal 86, 285-291. Soreide, E. & Grande, C. (2001). Prehospital trauma care. New York, NY: Marcel Dekker, Inc. Southwick, G., et al. (2002). Australian doctors in Bali: the initial medical response to the Bali bombing. 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