8 - Major Trauma Flashcards
What is ROCSM?
Restriction of Cervical Spine Motion
At what GCS score are patients unable to maintain their airway?
8 or below
What is important about a fracture to the first rib?
Requires such significant energy that it is v likely there are other injuries
What is shock?
Failure of the circulation to provide adequate perfusion to the tissues
What are the classes of shock?
Class I - <15% blood loss - normal vitals
Class II - 15-30% blood loss - tachycardia + narrowing of pulse pressure
Class III - 30-40% blood loss - low BP, reduced urine output, anxiety/mild confusion, tachypnoea
Class IV - >40% blood loss - reduced consciousness
What are the 5 places that blood can be sequestered in the body during major trauma? (On the floor and four more…)
External bleeding
Abdominal bleeding
Chest bleeding
Long bone bleeding (especially femoral)
Retroperitoneal bleeding
What is Poiseuille’s law
That flow through a tube is proportional to the radius to the power 4 and inversely proportional to the length (i.e. short and fat tubes better than long thin ones for resus)
What is the definition of a major transfusion?
Replacement of total blood volume in 24 hours (i.e. > 10 units of blood)
What are the common complications of major transfusion?
Metabolic alkalosis
Hypocalcaemia
Hypothermia
Hyperkalaemia
Why does major transfusion cause hypocalcemia?
There is addition of sodium citrate to blood products - the citrate binds to calcium in the patient and inactivates it.
Why does major transfusion cause metabolic alkalosis?
Citric acid and lactate from the stored blood are converted to bicarbonate in the liver.
Why does major transfusion cause hyperkalaemia?
Cell lysis in the stored blood = release of K+
Also K+ / H+ pump stops working as well - allows K+ to leak out of the cells.
What is the function of tranexamic acid? How does it do this?
It stops clots breaking down
It binds (reversibly) to plasminogen - reduces the conversion of plasminogen to plasmin (plasmin is used to break down fibrin in clots)
What is the window for tranexamic acid to be given as treatment to significant reduce death?
Within 3 hours
Deceleration injuries can do what to the aorta?
Cause a tear at the ligamentum arteriosum - is unsurvivable.
In deceleration injuries - at which point does the aorta tear?
At the ligamentum arteriosum (between aortic arch and pulmonary trunk).
What is Beck’s triad
Signs of cardiac tamponade
- Muffled heart sounds
- Low BP
- Distended neck veins
What is the most common cause of cardiac tamponade?
Blunt chest injury from hitting a steering wheel
What is the immediate management of a long bone fracture?
Splinting - can tamponade bleeding and reduce pressure on nerves or TVs
How much blood can be lost with a femoral fracture?
1-2L
Which three things are scored for GCS?
Eye Response
Speech Response
Motor Response
How is the eye scored on GCS?
4 - Spontaneous movement
3 - To Speech
2 - To Pain
1 - No response
How is speech scored on GCS?
5 - Orientated to time and place
4 - Confused
3 - Inappropriate words
2 - Incomprehensible sounds
1 - No response
(Orientated, confused, words, sounds, unresponsive)
How is motor control scored on GCS?
6 - Obeys command
5 - Moves to localised pain
4 - Flex to withdraw from pain
3 - Abnormal flexion
2 - Abnormal extension
1 - No response
What are the GCS thresholds for brain injury?
13-14 = mild brain injury
9-12 = moderate brain injury
8 or below = severe brain injury
Why is the airway at risk with a GCS less than 8
Risk of occlusion of the airway from the tongue
What is the difference between primary and secondary brain injury?
Primary = result of direct injury to the brain tissue
Secondary = failure to maintain adequate oxygenation and perfusion the brain tissue during assessment
What is the Monro-Kellie doctrine?
It says that the brain is in a fixed chamber - and that venous volume and CSF will be moved out first in the case of raised ICP (75ml of each)
What is the point of decompensation with raised ICP?
Is the point where the brain starts to herniate out of the foramen magnum.
What clinical sign can indicate the point of decompensation? What CN is effected to result in this?
Blown / dilated pupil
CN III which travels around the border of the foramen magnum
10% of Ps with a cervical spine fracture will have?
A second non-continuous vertebral column fracture elsewhere
What do you need to worry about if a patient has been lying on a hard board for > 2 hours?
Pressure ulcers
Why can trauma patients be at risk of hypothermia?
Pre-hospital exposure
Iatrogenic - removal of clothing, rapid infusion of cool fluids
How high does the diaphragm go in expiration?
What does this mean for trauma?
5th intercostal space
That Lowe chest injuries can affect th abdomen
What do you need to be cautious of with pelvic injuries?
Pelvic injuries require massive force - therefore need to be concerned about soft tissue in the area - can have significant bleeding in this area.
Which is the most commonly injured abdominal organ?
The liver
Which imaging is good to detect liver trauma?
CT with contrast
How is liver injury managed?
Often conservatively
If severe - may need surgery for packing or resection (v rare).
Can do endovascular tx if available.
How is the spleen most commonly injured?
Blunt trauma
How is splenic injury treated?
If unstable with significant injury = splenectomy
Lesser injury & stable = splenic artery embolisation
Minor injury = conservative manage & close monitoring
What can result from splenic injury?
Catastrophic haemorrhage
How is the kidney most commonly injured?
Blunt trauma
If the kidney is injured from trauma - what should you also check for?
Other injuries - in up to 95% of cases there is another injury.
Kidney is seldom an isolated injury
What is the most common clinical sign that the kidney is injured?
How do you diagnose kidney injury?
Haematuria (visible or microscopic)
Diagnosed with CT
How are renal injuries often managed?
95% can be managed conservatively
Surgery or endovascular intervention if unstable
How does the pelvis commonly break?
In more than one place - like a polo mint
What is the commonest cause of pelvic injury?
High energy blunt injury
What is important to consider when dealing with a pelvic injury?
That blood loss can be significant in this area - the pelvis can hold the entire blood volume.
Is lots of pelvic vasculature that can bleed.
Damage can occur to abdomen or pelvic viscera
What is the cause of an unstable “open book” pelvic fracture?
Anterior-posterior compression
What are the signs of an unstable pelvic fracture?
Externally rotated legs
Bleeding / bruising (perineum, PR, PV)
How do we initially treat an unstable pelvic fracture? Why?
Pelvic binder - reduces the volume and therefore the potential blood loss.
What is the management of a pelvic fracture?
Diagnosis - CT, MRI, Retrograde urethrogram, angiography (+/- embolisation)
Control bleeding - pelvic binder (temporary), surgery (less common), radiological intervention (v common)
Fix bones - externally or internally
Which burns should be discussed with a specialist burns unit?
ALL facial, extensive or specialised area burns (i.e. hands, genitals)
What are the following all warning signs of? What should you do?
Soot in mouth/nose
Facial burns
Singed facial hair
Stridor / noisy breathing
Swelling of lips or tongue
Signs of possible impending airway obstruction
Secure an early definitive airway
If chest burns are substantial, what intervention can help with the patient’s breathing? Why?
Escharotomy
Burned skin = inelastic = restricts chest wall movement
Why do burns patients needs fluids?
To replace losses from capillary leaks due to inflammation (not bleeding)
What do we do for chemical burns?
Flush with large amounts of warm water for 20-30 minutes
Which chemical burn is worse - acid or alkali?
Alkali - penetrates more deeply and causes widespread tissue necrosis
What is the consequence of electrical burns that we need to be worried about?
Muscle breakdown –> rhabdomyolysis –> renal failure
Why can muscle breakdown cause kidney failure?
Breakdown release creatine kinase, lactic acid, myoglobin and potassium - some of these block the renal tubules –> tubular necrosis –> renal failure
What is a secondary survey of a patient in the trauma setting?
Top to toe exam of the P after completion of immediate treatment to ensure that nothing has been missed.
Why is tension pneumothorax an emergency?
Get severe respiratory distress
Reduces venous return / preload due to inc intrathroacic pressure
-> Shock (Can see distended neck veins due to sluggish venous return)
Need to decompress and drain
What is a flail segment defined as?
Frax of 2 or more adjacent ribs in more than one place -> paradoxical breathing + impaired ventilation
What is associated with intracellular ice crystal formation, microvascular occlusion and tissue hypoxia?
Frostbite
What is it termed when you have severe soft tissue injuries?
Degloving
What can crush injuries result in?
Traumatic rhabdomyolysis -> releases CK, lactic acid, myoglobin and K+ => renal tubular necrosis and renal failure
How are crush injuries managed?
IV fluids
Fasciotomies
Amputation
Bicarb therapy
What is the purpose of bicarbonate therapy?
Alkalises the urine - therefore decreases precipitation of myoglobin in the renal tubules in rhabdo.
What are common mechanisms of degloving injuries?
