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Trauma (main)

2016-08-25T22:00:23Z

Robertgranata: /* Evaluation */

''This page lists the major trauma types. See [[fractures]] for ortho related injuries.''
==Background==
===Initial evaluation objectives===
#Rapidly identify life-threatening injuries
#Initiate supportive therapy
#Organize definitive therapy

{{Locations of Possible Life-Threatening Bleeding}}

===Lethal Triad of Major Trauma===
#[[Hypothermia]]
#[[Coagulopathy]]
#[[Acidosis]]

==Clinical Features==
{{Hemorrhagic shock classes}}

==Differential Diagnosis==
*[[Head trauma]]
*[[Maxillofacial trauma]]
*[[Neck trauma]]
**[[Spinal cord trauma]]
**[[Blunt neck trauma]]
*[[Thoracic trauma]]
**[[Cardiac trauma]]
**[[Thoracic and lumbar spine trauma]]
*[[Abdominal trauma]]
*[[Genitourinary trauma]]
*[[Penile trauma]]
*[[Extremity trauma]]
**[[Fractures (main)]]
*[[Trauma (Peds)|Pediatric trauma]]
**[[Pediatric head trauma]]

==Evaluation==
At times the cause of shock is not obvious and therefore we use imaging that are present at the trauma bay to assist us. This includes an ultrasound, or FAST (Focused Assessment with Sonography for Trauma), which is used to evaluate for hemopericardium (cardiac tamponade), pneumothorax, intraabdominal bleeding, bladder damage. X-ray imaging is initially include the chest (portable is commonly used), pelvis, and lateral cervical spine, and at times they patient will go straight for CT (computed tomography).

==Management==

2 L of isotonic saline is the choice of fluid resuscitation in hemorrhagic shock through short and large gauge, preferably 16 or larger peripheral IVs. Occasionally it is impossible to obtain peripheral IV access and therefore you must place a central venous catheter.
Very commonly blood products are immediately available in severe hemorrhagic emergency cases and physicians forego normal saline for blood products. Please note that infusing large volumes of NS can lead to development of a nonunion gap hyperchloremic metabolic acidosis, or metabolic alkalosis if one uses large amount of lactated ringers.
It is critical to keep monitoring the patient and their vitals, including the MAP (mean arterial pressure), which ideally you want to keep around 65 mmHg or their systolic blood pressure at around 90 mmHg.
When a traumatic patient presents with severe hemorrhage, there is a fine line between overloading the patient with fluids, which can actually cause the patient to bleed out faster while diluting the blood products of the patient, therefore leading to catastrophic result. The patients with severe and ongoing hemorrhage that can’t be controlled adequately or in timely manner, it is imperative to start immediate transfusion of blood products in a 1:1:1 ration of PRBCs (packed red blood cells), FFP (fresh frozen plasma) and platelets.

Complications: during resuscitation of severe traumatic patients, the development of hypothermia (core temperature under 35 degrees Celsius) , acidosis, and coagulopathy, known as the lethal triad can have devastating and lethal consequences.
The coagulation system consists of complex enzymatic reactions that are temperature and pH dependent that result in the formation of blood clots to stop both the internal and the external hemorrhage.
A healthy individual maintains a physiologically normal pH of 7.35 to 3.45 through a complex and intricate balance of hydrogen ions and buffers that are predominately controlled by the pulmonary and renal systems. Acidosis is defined as arterial pH under 7.35. As a trauma patient’s perfusion worsens, they have a rapid accumulation of lactic acid in the tissues, therefore resulting in severe metabolic acidosis. With severe academia (pH under 7.20), the consequences are detrimental and for the trauma patient, one of the most harmful effects is that their coagulation system can become severely impaired therefore leading to death.
Dilutional coagulopathy occurs when resuscitation of a bleeding trauma patient is with fluid (NS or PRBCS) or blood products that do not contain the same clotting factors lost in the acutely hemorrhaged whole blood. Furthermore, in the critically injured patient, via complex series of enzymatic reactions, the clotting cascade can also become abnormally activated, therefore causing excessive clot formation and subsequent fibrinolysis out of proportion to the injury. This excessive and abnormal activated of the coagulation system rapidly consumes the body’s remaining clotting factors, resulting in a further deficiency of the essential factors required to achieve hemorrhage control.

Another complication can occur after resuscitating trauma patients with blood products, which is hypocalcemia. Hypocalcemia occurs because of the anticoagulant citrate. Citrate binds with free calcium, therefore decreasing active calcium levels in the serum, leading to hypocalcemia.

==Disposition==

==See Also==
*[[Trauma Sedation]]
*[[Trauma in pregnancy]]
*[[Trauma center levels]]
*[[Hemorrhagic shock]]

==External Links==

==References==
<references/>

[[Category:Trauma]]

Acute cerebrovascular event

2016-08-01T13:50:57Z

Robertgranata: Adding a redirect

#REDIRECT[[Stroke_(main)]]

Dialysis disequilibrium syndrome

2016-08-01T01:53:00Z

Robertgranata: Expanded differential, workup and management sections, minor additions and formatting changes to background and clinical features, added references

==Background==
*Dialysis Disequilibrium Syndrome (DDS) is a rare clinical syndrome occurring at end of dialysis or the beginning of continuous renal replacement therapy
**Occurs most commonly during initial hemodialysis or during hypercatabolic states
*Large and rapid solute clearance creates an osmotic gradient which can precipitate cerebral edema <ref>Silver SM. et al. Dialysis disequilibrium syndrome (DDS) in the rat: role of the "reverse urea effect". Kidney Int. 1992;42(1):161-6. [http://www.ncbi.nlm.nih.gov/pubmed?term=1635345 Pubmed]</ref>

==Clinical Features==
*Headache
*Disorientation
*Nausea and vomiting
*Restlessness
*Can progress to seizure, coma & death <ref name="DDS">Zepeda-orozco D. et al. Dialysis disequilibrium syndrome. Pediatr Nephrol. 2012;27(12):2205-11.[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3491204/ Pubmed]</ref>

==Differential Diagnosis==
*[[Subdural hematoma]]
*[[Uremia]]
*Nonketotic hyperosmolar [[coma]]
*[[Acute cerebrovascular event]]
*Dialysis dementia
*Excessive ultrafiltration and seizure
*Metabolic disturbances
**[[Hypoglycemia]]
**[[Hyponatremia]]
*[[Meningitis]]
*[[Malignant hypertension]]<ref name="DDS"></ref><ref>Mahoney CA. et al. Uremic encephalopathies: clinical, biochemical, and experimental features. Am J Kidney Dis. 1982;2(3):324-36. [http://www.ncbi.nlm.nih.gov/pubmed/6756130 Pubmed]</ref>
{{Dialysis complications DDX}}

==Workup==
*Diagnosis suggested by development of neurologic symptoms associated with dialysis, however DDS is a diagnosis of exclusion (rule out [[SDH]], [[CVA]]).

==Management==
===Prevention===
*Response to treatment is typically poor, so preventive measures are important<ref name="DDS"></ref>
*Add an osmotic agent to mitigate the osmotic gradient
**Elevate the sodium concentration in the diasylate<ref> Port FK. et al. Prevention of dialysis disequilibrium syndrome by use of high sodium concentration in the dialysate. Kidney Int. 1973;3(5):327-33.[http://www.ncbi.nlm.nih.gov/pubmed/4792047/ Pubmed]</ref>
**Elevate the glucose concentration in the diasylate (717 mg/dl) or add IV mannitol (1g/kg)<ref>Rodrigo F. et al. Osmolality changes during hemodialysis. Natural history, clinical correlations, and influence of dialysate glucose and intravenous mannitol. Ann Intern Med. 1977;86(5):554-61. [http://www.ncbi.nlm.nih.gov/pubmed/851303/ Pubmed]</ref>
*Consider hemofiltration rather than hemodialysis<ref>Kishimoto T. et al. Superiority of hemofiltration to hemodialysis for treatment of chronic renal failure: comparative studies between hemofiltration and hemodialysis on dialysis disequilibrium syndrome. Artif Organs. 1980;4(2):86-93. [http://www.ncbi.nlm.nih.gov/pubmed/7396769/ Pubmed]</ref>

===Treatment===
*The mainstay of treatment is ICP reduction<ref name="DDS"></ref>
**Can give mannitol or hypertonic saline IV
**Can hyperventilate patient
*Symptomatic management for mild symptoms (nausea, headache, restlessness)
*Symptoms are self-limiting and typically resolve within several hours

==See Also==
*[[Dialysis complications]]

==References==
<references/>

[[Category:Renal]]