Acute Care Block - Trauma Module cABCDE COPY Flashcards
We have discussed on a previous flashcard set how securing the airway and immbolising the C-spine is vital to trauma patients
State again how a cervical spine should be immobolised intitially before trying to secure the airway?
Cervical spine should be immbolised with manual in-line immbolisation (MILS) and later with semi-regidi collar, blocks and tape
How is airway patency assessed?
What would indicate a clear, partially obstructed or completely obstructed airway?
- Patients who vocalise normally have a clear airway
- Noisy breathing may indicate a partially obstructed airway
- No airway movement at all may indicate a completely obstructed airway
What is the most common cause of airway obstruction in trauma? - name other causes as well
The commonest cause of airway obstruction is the loss of pharyngeal tone with posterior tongue displacement
Other causes include:
- Displaced facial fractures
- Vomitus/blood/secretions
- Soft tissue swelling / oedema / inhalation burns
- Direct laryngeal trauma
What sounds are heard if the patient has an obstructed airway?
What movements of the chest would indicate an obstructed airway?
See saw movements of the abdomen and snoring sounds indicate an obstructed airway.
See saw breathing - A pattern of breathing seen in complete (or almost) complete) airway obstruction. As the patient attempts to breathe, the diaphragm descends, causing the abdomen to lift and the chest to sink (link below)
https://www.youtube.com/watch?v=tSIqE9E2S5c&ab_channel=DavidLDaltonProductions

There are simple airway interventions, followed by manoeuvures, followed by airway adjuncts to try and secure and airway - and then after whichever is successful we want to do a definitive airway
What are the simple airway interventions / manoeuvres?
- Airway intervention - Yankeur suction catheter - suction what you can see
- Airway manoevure - jaw thrust (to pull manidble and tongue forward)
- Airway adjuncts - nasopharyngeal airway insertion and oropharyngeal insertion (guedel)
What is a relative and what is an absolute contraindication to nasopharyngeal airway insertion?
Relative contraindication to nasopharyngeal airway insertion - base of skull fracture
Absolute contraindication to nasopharyngeal airway insertion - midface instability
A defintive airway is defined as the presence of a cuffed endotracheal tube in the trachea
What are indications for intubation in major trauma?

- To facilitaste oxygenation and ventilation
- Airway protection
- Prevent / overcome impending airway obstruction
- Neuroprotection - paCO2
- Safe transfer
- Humanitarian reasons - analgesia / anaesthesia for procedures
A number of issues can make advanced airway management in critically injured trauma patients more challenging. These include
- Aspiration risk
- MILS - restricted neck movement
- Facial trauma
- Time critical - due to hypoxia / obstruction
- Difficult oxygenation / ventilation - poor mask fit, poor chest compliance
- Local airway swelling / oedema
In times of failed intubation, a surgical airway may have to be created. What is the emergency surgical airway that is created?
An emergency cricothyroidotomy involves the creation of an incision through the skin just inferior to the thyroid prominence and through the cricothyroid membrane

What age group is an emergency cricothyroidotomy done in and what are the four steps?
Cricothyroidotomy is done in patients aged 8 and above and in four steps – if possible patient is supine and neck is extended – creates an emergency airway when masked ventilation and endotracheal intubation attempts have failed – will also need a 10ml syringe for inflation of the cuff tape to hold it down
- Identify cricothyroid membrane
- Stab incision with number 10 scalpel
- Caudal traction with a tracheal hook
- Intubation of trachea with a 6-7mm endoctracheal tube

BREATHING
There are over 17,000 trauma deaths in the UK per year with almost 25% of these directly attributable to thoracic injuries. Many of these patients will die at the scene of injury.
What are the investigations usulally done in the emergency department for thoracic trauma and which investigation is gold standard?
- Investigations done in the emergency department will include CXR - especially in the presence of isolated penetrating trauma.
- In patients with blunt chest trauma often in the context of multisystem injuries, a CXR will often be done to pick up life threatening abnormalities, or to confirm tube positioning post intubation.
GOLD STANDARD investigation for these patients will be CT scanning
What are the immediate life threatening chest injuries which may be detected in the primary survery again? (try and remember the acronym)
- Airway obstruction
- Tension pneumothorax
- Open (sucking) pneumothorax
- Massive haemothorax
- Flail chest
- Cardiac tamponade
Children have more pliable chests than adults
What does this mean for rib fractures when sustaining lung trauma?
How are hypoxia and chest injuries tolerate by children?
- As children have more pliable chest walls, they can sustain signficiant lung trauma in the absence of rib fractures
- Conversely, the prsence of rib fractures indicates high energy transfer
Hypoxia and chest injuries are often poorly tolerated by children due to their little respiratory reserve
In the breathing part of the assessment, it is important to look listen and feel
What is carried out in this section of the ABCDE review?
Look for the general signs of respiratory distress - sweating, central cyanosis, use of accessory muscles of respiration, paradoxical breathing (see-saw) and flail chest
Feel - feel for surgical emphysema or crepitus, and for normal chest expansions, percuss the chest
Listen - auscultate the chest
Take patients breathing rate and pulse oximetry
What do you suspect if the patients chest is full on percussion?
What do you suspect if the percussion is hyperesonant on percussion?
What does hearing a stridor or wheeze mean?
Why should you check the position of the trachea here?
- Dull to percuss - consolidation or pleural fluid
- Hyperresonant on percussion - pneumothorax most likely
- Stridor- harsh inspiratory breathing suggesting an airway obstruction
- Wheeze - high pitched expiratory noise indicate partial airway narrowing / obstruction
- Check the position of the trachea to rule out deviation suggestive of a tension pneumothorax
What O2 sats do we want and what do we do if they are low?
What is the normal resp rate?
Aim for O2 sats 94-98% (and 88-92% of underlying respiratory condition)
Provide high flow oxygen through a non-rebreather mask (15l/min)
Normal resp rate range is 12-20 breaths per minute
We have discussed how to manage airway obstruction during the airway section of cards
We will now discuss how to treat the rest of ATOM FC immediate life threatening chest injuries
What type of shock is a tension pneumothorax a cause of?
What are different causes of a tension pneumothorax?
A tension penumothorax is a cause of ‘obstructive shock’ and by definition the patient will be tachycardic / hypotensive / in a certain degree of respiratory distress
Can be caused by penetrating or blunt trauma, mechanical ventilation, rupture of a pleural bleb etc
What are the different signs found in a tension pneumothorax?
Image shows a left sided tension pneumothorax

- Hyper-resonance on percussion / reduced breath sounds on the side of injury
- Bony crepitus - rib fractures
- Flail chest
- Hypotension
- Narrow pulse pressure
- Tracheal deviation - typically a very late sign
- Distended neck veins - not if the patient is hypovalaemia
- Cyanosis - this is pre-terminal hypoxia due to the tension pneumothorax pressing on the large vessels
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What is the immediate management of a tension pneumothorax?
What is then performed as the proper treatment for this condition?
Immediate management is emergency needle decompression in to the second intercostal space, mid-clavicular line with a large bore cannula
Needle thoracentesis is a temporary measure until a formal chest drain can be sited into the 5th intercostal space, just anterior to the mid-axillary line int he safe triangle

What are the borders of the safe triangle where the intercostal drain is inserted?
Image shows a chest drain in-situ

Triangle of safety
- Anteriorly - lateral edge of pectoralis major
- Posteriorly - lateral edge of latissimus dorsi
- Inferiorly - 6th rib

What is the difference between a chest drain and a simple thoracostomy?
A simple thoracosotmy uses the same anatomy and procedure as the intercostal drain insertion but just doesnt use the drain
Link below shows a tube thoracostomy insertion
https://www.youtube.com/watch?v=U618Jte_1Uk&ab_channel=umemergencymed
In special circumstances, the chest drain is not placed in the 5th intercostal space - eg pregnant women - where is it placed in these circumstances?
Why may extra care have to be taken in patients requiring a chest drain who have had associated severe abdominal trauma?
In heavily pregnant patients, chest drain insertion should be 3rd or 4th intercostal space to avoid intra-abdominal placement
Care should also be taken in those patients with associated severe abdominal trauma. Diaphragmatic rupture may mean abdominal contents within the chest wall
Some patients with a traumatic pneumothorax have an unsealed opening in the chest wall ie a stab wound.
How can this defect lead to a shortness of breath?
When patients with an open pneumothorax inhale, negative intrathoracic pressure with inspiration causes air flow into the lungs through the trachea and simultaneously into the pleural space through the chest wall defect.
If the chest wall defect is large enough, more air can pass through here than into the lungs causing the intrapleural pressure to decrease the size of the lung making the patient enter respiratory distress and failure
How is an open pneumothorax treated?
Immediate management is to cover the wound with a rectangular sterile occlusive dressing secured with a tape on 3 side. The dressing prevents air entering the chest on inspiration but allows any intrpleural air out during expiration.
Following this a chest drain should be inserted at a site away from the defect

How is a massive haemothorax managed?
What would indicate the need for a surgical thoracatomy?
Chest drain insertion to treat and ensure patient is cross matched and blood available prior to drain insertion
Immediate drainage of >1500ml or continued drainage >200ml/hr are indications for surgical thoracatomy - interventional radiology may be an alternative option and the radiologist should be involved





















