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
What is the definition of a flail chest?
What are the signs of a flail chest?
A flail chest is defined as 2 or more ribs, fractured in 2 or more places resulting in paradoxical chest movements, respiratory distress and hypoxia (70% have an associated pneumothorax or haemothorax)
Link below shows paradoxical chest breathing
https://www.youtube.com/watch?v=mJ_FYwUqzsM&ab_channel=ReubenLamiakiKynta
Flail chest is associated with pulmonary contusions in 50% - also known as lung contusions - it is a bruise of the lung cause by chest trauma which can result in damage of the capillaries. Blood and other fluids can therefore accumulate in the lungs partially leading to gas exchange intereference.
What is the management of a flail chest?
Oxygen, analgesia, chest drain if penumo / haemothorax
Sometimes intubation and ventilation
What type of shock does a cardiac tamponade cause and how?
What are the clincial signs of cardiac tamponade?
Cardiac tamponade cause obstructive shock - a build up of blood in the pericardial sac causes pressure around the heart and failure to pump effectively
In the context of trauma, it is usually due to a penetrating wound
What is pulsus paradoxus?
it is seen in a variety of conditions - cardiac tamponade, chronic sleep apnea, croup, and obstructive lung disease (e.g. asthma, COPD)
Pulsus paradoxus is an abnormally large decrease in stroke volume, systolic blood pressure and pulse wave amplitude during inspiration. The normal fall in pressure is less than 10 mmHg. When the drop is more than 10 mmHg, it is referred to as pulsus paradoxus. Pulsus paradoxus is not related to pulse rate or heart rate, and it is not a paradoxical rise in systolic pressure. The normal variation of blood pressure during breathing/respiration is a decline in blood pressure during inhalation and an increase during exhalation.
Pulsus paradoxus is therefore an exaggeration or an increase in the fall of systolic BP beyond 10 mmHg during inspiration.
Why does pulsus paradoxus occur?
During normal inspiration, the negative intra-thoracic pressure results in an increased right venous return, filling the right atrium more than during an exhalation. The increased blood volume dilates the right atrium, reducing the compliance of the left atrium due to their shared septum. Lower left atrial compliance reduces the left atrium venous return and as a consequence causes a reduction in left ventricular preload. This results in a reduction in left ventricular stroke volume, and will be noted as a reduction in systolic blood pressure in inspiration.
In cardiac tamponade, there will be even less left atrium venous return meaning an even more reduced stroke volume and a bigger reduction in systolic blood pressure in inspiration
What is the management of a cardiac tamponade?
Periocardiocentesis is the usual treatment of choice to relieve pressure in a cardiac tamponade however in an emergency, resuscitative thoracatomy may be required to gain rapid access to the thoracic cavity and release the tamponade by opening the pericardium
The rational for doing this quickly in the Emergency Department is that it will be universally fatal if nothing is done
CIRCULATION
We have discussed what is assessed in circulation section of ABCDE in previous flashcard sets
Try and rename what is assessed in this area?
- Respiratory rate - technically part of breathing
- Pulse rate and volume
- Adequacy of peripheral criculation - can be assessed by noting capillary refill and laying a hand on the patient to assess how warm they are peripherally
- Blood pressure is used in assessment but be aware a drop in BP may only occur after significant blood loss (up to a third of their circulating volume)
Might also want to insert cannulas, take bloods and set up fluids (also maybe insert a catheter)
More subtle factors such as a change in their mental state can also be a diagnosis of shock
In this section we will be dicussing the most common causes of circulating compromise in trauma - namely haemorrhage (obvious or concealed) leading to hypovalameic shock
The module covers
- Abdominal trauma, blunt abdominal trauma
- Penetrating trauma, assessment and management of penetrating trauma,
- Pelvic trauma, assessment and management of pelvic trauma
What is the key to saving lives in abdominal trauma?
The key to saving lives in abdominal trauma is not to make an accurate diagnosis but rather to recognise that there is an abdominal injury
Abdominal injury is often not picked up in the primary survery and one in 10 deaths from trauma is due to abdominal injuries. Remembering that the possibility of occult haemorrhage is in the abdomen or pelvis is important
Blunt abdominal truma - mechanism of injury is important as it determines which organs are likely to be injured
What is the most commonly injured abdominal organ in blunt abdominal trauma?
The spleen is the organ most commonly injured in blunt abdominal trauma
The spleen (and the other ogans) can be injured by
- Direct blow
- Sheering injuries
- Deceleration injuries
- Lacerations
How do these terms cause injury to the spleen?
- Direct blow - contact with a steering wheel causes a compression or crushing injury to the abdominal viscera - these forces deform solid or hollow organs and may cause rupture
- Sheering forces - form of crush injury that may result when a seatbelt is worn inappropriately
- Deceleration injuries - differential movement of fixed and non fixed body parts ie in RTC
- Liver and spleen lacerations at sites of supporting ligaments
When does blunt abdominal trauma become more worrying in pregnancy and why?
During the first trimester of pregnancy, the uterus is intrapelvic and thick walled and the foetus is well protected from any direct injury
After 12 weeks as the foetus grows, the uterus becomes exrapelvic displacing the maternal abdominal viscera and gradually putting more pressure on the IVC. The uterus is also thin walled and suceptible to direct trauma with risks of abruption placenta and uterine rupture
Blunt trauma causes the majority of abdominal injuries in children - most involve RTCs although a significant number happen during recreational activities.
- It is important however to consider Non Accidental injury
Why are children more suceptible to abdominal injuries?
- Children have thin abdominal walls which offer little protection
- The diaphragm is also more horizontal and therefore the liver and spleen lie lower
- The ribs are elastic and offer less protection to these organs
The spleen is the most commonly injured organ from blunt abdominal trauma
What is the most commonly injured organ from penetrating trauma to the abdomen?
The liver is the organ most commonly injured in penetrating trauma
- Most often caused by knives or guns
- Size of the external wound bears no relationship to the severity of the intra-abdominal injuries
Assessment of the abdomen should form part of the primary survery in a trauma patient - management should be as per ABCDE and focus on obtaining IV fluid and / or blood
If there is suspicion of intra-abdominal injury, who should be involved early?
What scan is gold standard in abdominal trauma?
If there is suspicion of intra-abdominal injruy, involve the surgeons early and the radiologists early
GOLD STANDARD imaging is CT scanning
The surgical team usually makes the decision to operate on the basis of the CT scan results and the current condition of the patient. What are indications for an emergency laparotomy in a trauma patient?
- Evisceration (Evisceration is a rare but severe surgical complication where the surgical incision opens (dehiscence) and the abdominal organs then protrude or come out of the incision)
- Gunshot wound
- Stab wound with peritoneum breached
- Haemodrynamic intability despite correction of estimated blood loss from extra-abdominal sites
- Frank peritonism
- Ruptured diaphragm / air under the diaphragm
Pelvic fracture is a disruption of the bony structures in the pelvis.
What is the most common cause of pelvic fractures in the elderly?
When are pelvic fractures associated with the greatest morbidity and mortality?
The most common cause of pelvic fractures in the elderly is a fall from a standing position
Pelvic fractures associated with the greatest morbidity and mortality involve significant forces such as that from a road traffic collision or a fall from a height
Pelvic fractures represents 3% to 6% of all fractures in adults and occur in up to 20% of all poly-trauma cases
What does the bony pelvis consist of and what does it connect to, to form an anastamotic ring?
What bones do the majority of the pelvic injuries result in damage to?
The bony pelvis consists of the ilium, ischium and pubis which form an anastamotic ring with the sacrum
The majority of pelvic injuries do not actually result in major disruption of the pelvic ring but rather involve fractures of the pubic ramus or acetabulum
Disruption of the pelvic ring requires a significant energy transfer, resulting in unstable fractures and the potential for significant blood loss due to the extensive blood supply within the region.
How much blood is often loss and where does the haemorrhage bleed into?
What is the most commonly injured artery in a pelvic fracture?
Up to 2 litres of blood can be lossed from a pelvic fracture disrupting the anastamotic ring and the bleeding is usually retroperitoneal
The superior gluteal artery is the most commonly injured arterial branch in a pelvic fracture (superior gluteal artery is the largest branch of the posterior division of the internal ilaic artery)
The Young-Burgess classification system is based on mechanism of injury for pelvic fractures
What are the different classifications?
Type A - Lateral compression fractures (closed boook fractures)
Type B - Anterior-posterior compression fractures (open book fractures)
Type C - Vertical shear fractures
There can also be a combination of forces
In patients with significant trauma and clinical concers regarding prelvic fracture, pelvic examination should be minimal to avoid possible disruption of clots
What is springing the pelvis and why should this be avoided in pelvic fracture?
Springing the pelvis involves compression or distraction of the fracture site - if pain is produced there is a likely pelvic fracture
This test is avoided however, as the current belief is that this is an unreliable test, which will only detect major pelvic disruption and is dangerous in dislodging clots and promoting further blood loss.
Management of a pelvic fracture will be as per ABCDE and should focus on haemorrhage control and fluid/blood resuscitation
If there are clinical concerns of a pelvic fracture, how can haemmorhage control be achieved?
Haemorrhage control can be achieved through mechanical stabilisation with a pelvic binder and this should be applied early if there is a concern
What is the choice of scanning in patients with low mechanism and high mechanism injury trauma?
In haemodynamically stable patients, with low mechanism of injur, or isolated pelvic/hip injury, plain films of the pelvis should be adequate in the first instance
In patients with significant mechanisms of injury or in those with a potential pelvic injury in the context of multisystem trauma, CT scanning is the GOLD standard
As stated, early application of the pelvic binder in cases of suspected pelvic fracture is paramount to reduce haemorrhaging
Treatment for the pelvic fracture is often a long and painful process as the fractures are foten complicatied and surgery is often rquired. What are the different methods of stabilisation of the fracture for treatment?
What is often the definitive management for patients with ongoing haemorrhaging related to pelvic fractures?
Many methods of pelvic stabilisation are used including external fixation or itnernal fixation and traction
Angiographic embolisation performed by Intervention Radiology Team is often the best option for definitive management of patients with ongoing haemorrhage related to pelvic fractures
In the case of likely femoral bone fractures, if it is an open fracture it is important to appply pressure or torunquet proximal to the fracture site (beware of ischaemic time).
If it is a closed femoral fracture, what we use to splint the fracture?
How does this help to manage the femoral long bone fracture?
We would use a Kendrick splint
Indicated in mid-shaft femur fractures, not for use in proximal (including #NOF) or for distal femur fractures. The benefits of traction & splinting are to reduce blood loss, pain and tissue damage. It can also be used in patients with pelvic fractures
Link shows how to properly apply a Kendrick splint - https://www.youtube.com/watch?v=QIxzroh2rhw&ab_channel=EM3FOAMed
DISABILITY
What is looked at in the disability section of the examination?
Measure glucose
Early neurological status examination - consciousness level (AVPU / GCS) and pupillary reactions, possibly a good initial history (AMPLE)
As stated, a good initial history is crucial to have a better idea of what may have potentially happen to the patient - if possible, an AMPLE history is key hear (Allergies, Medication, PMHx, Last ate or drink, Events leading to presentation)
A good neurological examination is key in disbaility
In the context of head trauma, what may a dilated pupil indicate?
What would indicate potential cervical spine injury?
In the context of head trauma, a dilated pupil may suggest an expanding intracranial lesion on the side of the abnormal pupil, leading to a significatn rise in ICP and resultant pressure on CN III
Presence of midline neck tenderness may indicate a potential cervical spine injury
What signs may indicate a base of skull fracture?
Skull X-rays play NO role in the investigation of a head injured patient - what is the scanning modality of choice and when would you carry this out?
Base of skull fracture indicators
- racoon (panda) eyes (aka peri-orbital ecchymosis)
- Battle’s sign - mastoid ecchymosis
- CSF rhinorrhoea
- Haemotympanum - blood in ear canal
Perform a CT head scan within one hour of a risk of skull fracture being identified - below is a link to a NICE algorithm for all risk factors indicating a scan
https://www.nice.org.uk/guidance/cg176/resources/imaging-algorithm-pdf-498950893
The majority of head injuries seen in the ED are minor and can be discharged home with a responsible adult if there are no concerning features on assessment
What should the advice given on patient who are discharged be?
Those discharged home should be advised to refrain from alcohol or driiving for 24 horus
They should be discharged with verbal and written head injury advice including what to look out for and when to return to the ED / seek medical attention
We have the ability to observe patients in whom assessment can be difficult due to alcohol/ drug intoxication on our Emergency Department Observation Unit. The same goes for patients who are showing signs of concussion and need a period of observation prior to discharge
What is the difference between primary and secondary head injury?
Which is preventable?
Primary head injury - happens at the time of the impact and is unpreventable
- Direct injury - blunt vs penetrating
- Indirect injury - acceleration / deceleration forces
Secondary head injury - happens as a result of hypoxia / hypotension and is preventable
What pressure-volume relationship makes up the Monro-Kellie hypothesis?
What does the Monro-Kellie hypothesis state?
The pressure-volume relationship between the Intracranial Pressure, volume of CSF and brain tissue makes up the Monroe-Kellie hypothesis
The hypothesis states that any increase in one of the cranial constituents must be compensated by a decrease in the volume of another because the volume inside the cranium is fixed
Put simply, if there were eg a brain swelling or intracerebral haemorrhage - these cause a rise in the intracranial pressure (ICP) due to the brain being in a fixed vault
How can a rise in ICP be so dangerous as to cause cerebral ischaemia?
Cerebral perfusion pressure (CPP) = Mean Arterial Pressure (MAP) - Intracranial Pressure (ICP)
If the ICP increases, this will decrease the CPP resulting in cerebral ischaemia
How is MAP calculated?
Under normal circumstances, what MAP and ICP can be maintained with autoregulation?
How can ICP be measured directly?
MAP = DBP +1/3(SBP-DBP) = 2/3DBP + 1/3SBP
Under normal circumstances, MAP between 60 and 160mmHg and ICP about 10mmHg (giving a CPP of 50-150mmHg) can be maintained with autoregulation
ICP can be measuured directly using an invasive intracranial pressure monitor
Outside of the limitis of autoregulation, it is difficult to maintain the MAP and ICP
- What happens to cerebral blood flow if the BP goes down outside of autoregulation limits?
- What happens to cerebral blood flow if ICP goes up outside of autoregulation limits?
What is the recommended CPP by some in trauma patients?
Outside of the limits of autoregulation:
- If BP goes down, cerebral blood flow is reduced
- If ICP goes up, cerebral blood flow is reduced
In trauma, some recommend CPP to not go below 70mmHg
Cushing’s triad is the physiological response to a significant rise in intracranial pressure - what is the triad?
What does Cushing’s triad indicate?
Cushing’s response / triad is the phsyiological response to a significant rise in intracranial pressure
- Hypertension / bradycardia / respiratory depression
It is seen in the terminal phase of head injury and indicates impending brainstem herniation
What causes the different stages of Cushings Triad? (Hypertension followed by bradycardia followed by respiratory depression)
- Increased ICP activates the Cushing reflex, a nervous system response resulting in Cushing’s triad. As the ICP begins to increase, it eventually becomes greater than the MAP, which typically must be greater than the ICP in order for the brain tissue to be adequately oxygenated. This difference in pressure causes a decrease in the CPP therefore leading to the brain not receiving enough oxygen (cerebral ischemia).
- To compensate for the lack of oxygen, the sympathetic nervous system is activated, causing an increase in systemic blood pressure and an initial increase in heart rate. The increased blood pressure then signals the carotid and aortic baroreceptors to activate the parasympathetic nervous system, causing the heart rate to decrease.
- As the pressure in the brain continues to rise, the brain stem may start to dysfunction, resulting in irregular respirations followed by periods where breathing ceases completely.
- This progression is indicative of a worsening prognosis.
There are different types of brain injury
- Haematomas - extradural, subdural, subarachnoid
- Cerebral contusions
- Diffuse axonal injury
How does an extradural haematoma present? Which bone and artery is involved?
Arterial bleed secondary to direct trauma - usually at the pterion or temporal bone with involvement of middle meningeal artery
Usually younger patients presents after a head injury that initially produced no loss of consciousness (LOC) (or a transient LOC) or after initial drowsiness, followed by a period of lucency for hours (or days)
Clinical features then begin to show - increasingly severe headache, vomiting, confusion, potential siezures
What does an extradural haematoma look like on CT scan?
What is the treatment?
CT scan shows a lens shaped (biconvex) haematoma which is limited by skull sutures
Early neurosurgical itnervention is essential and early operation gives good prognosis - needs clot evacuation +/- ligation of bleeding vessel
How does an subdrual haemotoma present?
Which patients is it more common in?
What usually causes it?
Subdural haematomas are due to bleeding in the bridging veins between cortex and venous sinsues (vulnerable to deceleration injuries) - causes a haematoma between dura and arachnoid mater
More common in elderly patients and alcohoolics (falls) due to brain atrophy making bridging veins vulnerable
Symptoms include fluctuating levels of consciousness and insidious physical or intellectural slowing, headache, maybe seizures
What does a subdural haematoma look like on CT, how is it treated?
On CT scan, see a crescent shaped sickle of blood which is not limited by skull sutures
Rapid surgical evacuation of clot is recommended - especially if >5mm of midline shift
Address the cause of the trauma
Cerebral haemorrhagic contusions are a type of intracerebral haemorrhage and are common in the setting of significant head injury - it is essentially a bruise on the brain
Cerebral contusions can be either due to coup or contrceoup injuries, what is the difference?
Bleeding into the brain parenchyma from direct impact causes a coup injury
Injuries to the opposite side of the brain due to the brain movement within the skull causes what is known as contrecoup injuries
What is diffuse axonal injury? - it can occur from head trauma
Diffuse axonal injury (DAI) is a form of traumatic brain injury. It happens when the brain rapidly shifts inside the skull as an injury is occurring. The long connecting fibers in the brain called axons are sheared as the brain rapidly accelerates and decelerates inside the hard bone of the skull
Initial CT scan may be normal
Why is diffuse axonal injury particularly worrying?
It is one of the most devestating head injuries and a major cause of unconsciousness / persistent vegatative post head trauma
The primary goal of treatment for patients with suspected traumatic brain injury is the prevention of secondary brain injury
- We must establish diagnosis, ABC, optimise airway and oxygenation, normalise CO2
- What should we aim to maintain the systolic BP at?
- What angle should we have the patient at?
- Who should we involve early?
- What can be used to try and lower the ICP?
- Aim to maintain the systolic BP at >90mmHg
- Aim to have the patients at 30 degrees head up - use caution if spinal injuries suspected
- We should involve the neurosurgeons early
- Consider use of mannitol / hypertonic ssaline to lower ICP after discussion with neurosurgery - only a temporary measure and may need to be repeated
The main objective wehen assessing a major trauma patient with a suspected spinal injury is to prevent any further injury
Secondary injury can be avoided by using what different techniques?
- Manual in-line stabilisation (MILS)
- Three point fixation - hard collar, blocks, tape
- Log rolling - a total of five trained staff are required
When assessing patients with potential spinal injuries, it is imperative to remember that pain may be masked by other distracting injuries. In patients who are able to give a history, it is important ask about numbness, tingling, burning sensations and paraesthesisa
What is neurogenic shock?
What clinical signs may this result in?
Neurogenic shock is a form of distributive shock resulting from disruption to the sympathetic outflow autonomic pathways within the spinal cord as a result of spinal injury.
There is unopposed parasympathetic response driven by the vagus nerve - leading to bradycardia, hypotension and priaprim may also be seen and is the result of loss of sympathetic input into the pelvic vasculature
EXPOSURE
Full head to toe assessment of the truma patient must occur in this section - important to examine abdomen, back (eg for rash or penetrating injury), legs (eg for DVT), arms
It is important to reduce exposure time in a trauma patient is hypothermia can potentially cause death - the lethal triad
What is the lethal triad?
- Thermal
- Flame
- Scald
- Contact
- Electrical
- Chemical
- Radiation
- Mechanical
The coagulation system is a temperature- and pH-dependent series of complex enzymatic reactions that result in the formation of blood clots to stop both internal and external hemorrhage.
How does the lethal triad therefore occur? (and why is it a vicious cycle)
- Severe bleeding in trauma diminishes oxygen delivery, and may lead to hypothermia. This in turn can halt the coagulation cascade, preventing blood from clotting.
- In the absence of blood-bound oxygen and nutrients (hypoperfusion), the body’s cells burn glucose anaerobically for energy, causing the release of lactic acid, ketone bodies, and other acidic compounds into the blood stream, which lower the blood’s pH, leading to metabolic acidosis.
- Such an increase in acidity damages the tissues and organs of the body and can reduce myocardial performance, further reducing the oxygen delivery.
- The further reduced oxygen delivery continues the cycle of hypothermia, coagulopathy, lactic acidosis
EXPOSURE
Full head to toe assessment of the truma patient must occur in this section - important to examine abdomen, back (eg for rash or penetrating injury), legs (eg for DVT), arms
Burns may also be exposed in exposure
Name some different cause of burns?
- Thermal
- Flame
- Scald
- Contact
- Electrical
- Chemical
- Radiation
- Mechanical
When assessing a patient with burns it is very important to extract a good history
What are the key questions to ask?
- Time the burn was sustained
- Was the patient trapped
- Mechanism / what was burning
- Were they rescued or did they escape
- Was the patient in a confined space
- Was there an explosion
- Are there any other injuries
It is important to consider if the burn sustained could be the result of Non-accidental injury
Cooling the burn is important but you have to beware of hypothermia. When should attempts at cooling be made in reference to total body surface area (BSA)?
Attempts at cooling the burn should only be made if the burn is <10% total body surface area
Should you cover the burn? Why? And depending on answer, with what?
Covering the burn is important as this helps with pain control. It keeps the affected area clean and prevents heat loss and fluid loss
Cling film should be placed directly onto the skin, but should not be circumfrential due to the risks of associated swelling and compartment syndrome
There is a low threshold for definitive airway protection in patients who have sustained facial burns.
What are indicators of potential significant airway involvement?
Indicators of potential significant airway involvment
- Loss of facial hair / nasal hair
- Intraoral burns / blisters
- Hoarse voice
- Carbonaceous sputum (burnt sputum) / soot in mouth
- Stridor / wheeze
We have disussed indicators of potential significant airway involvement -
- loss of facial hair / nasal hair,
- intraoral burns / blisters,
- hoarse voice,
- carbonaceous sputum / soot in mouth,
- stridor / wheeze
What are the indications for intubation in patients who have sustained significant facial burns?
- Persistent hypoxia despite high flow oxygen
- Actual or anticipated airway comproomise
- Extensive burns - marked fluid loss / oxygen delivery issue
Any of these should prompt early involvement of the anaesthetics team
A difficult airway should be prepared for in a burns patient.
What are anticipated issues here?
What may end up being necessary to secure the airway?
Anticipated issues include
- Limited jaw movement
- Swelling - no view, unable to pass the tube
A surgical airway may be necessary to secure the airway if a tube cannot be passed into the trachea
Full thickness circumfrential burns can result in the formation of tough, inelastic burnt tissue. What is this known as?
What can this tough, inelastic burn tissue cause?
- Full thickness, circumfrential burns can result in the formation of tough, inelastic burnt tissue known as ESCHAR
Formation of ESCHAR can lead to significant airway compromise in chest wall excursion and impair ventilation
What may be necessary to perform in patients who have the thick circumfriential eschar formation?
ESCHAROTOMY may be necessary to perform where incisions are made through the formed eschar to expose the underlying fatty tissue and improve chest wall compliance
Significant fluid loss can occur as a result of burns. It is important that the severity and the size of the burn are assessed to allow accurate calculation of required fluid replacement. IV access should be established early to allow the provision of analgesia and commencement of fluid replacement
What are the methods for assessing the size of the burns? - what is the most accurate?
- Palm of the hand approximately equates to 1% BSA
- Rule of Nines - allows BSA to be estimated on an adult using multiples of nines
- LUND BOWDER CHART is probabaly the most accurate and allows for varuation in body shape with age (can therefore be used also in children)
Pic shows Lund Bowder Chart alongside rule of Nines
It is important to understand the formula used to give an estimate of the amount of fluid resuscitation required - actual requirements should be guided by patients circulatory status and urine output which should be closely monitored
What is the Parkland formula for calculating the amount of fluid resucitation required?
When should the fluids be given?
Parkland formula
Fluid resuscitation required = 4ml x %burn x Weight (kg)
This calculates the total volume of fluid over a 24 hour period. 50% of this total should be administered over the first 8 hours of treatment from the time of the thermal insult. The remaining 50% should be administered over the next 16 hours.
It is also important to understant the difference in severity of burns
What depth of skin is affected in each depth of burn?
Erythema - epidermis only
Superficial partial thickness - epidermis and upper dermis
Deep partial thickness - epidermis, upper and deeper layers of dermis
Full thickness - burns extends through layers of skin to the subcutaneous tissue
It is also important to understant the difference in severity of burns
What signs are seen for each of the burn depths?
- Erythema
- Superficical partial thickness
- Deep partial thickness
- Full thickness
Superficial partial thickness - redness of skin with blister formation
Deep partial thickness - skin discolouration and blister formation, produces moist and mottled skin
Full thickness - produces white leathery, charred and dry skin. Destroys hair follicles, blood vessels and nerve endings. Causes tissue coagulation with little or no pain.
In the past, patients presenting with mutlisystem trauma would get a trauma series of X-rays, consisting of C-spine, chest and pelvic plain filsm
In modern trauma care, there is almost no role for x-rays in the immediate investigsation of the seriously injured trauma patients
What is the modality of choice?
When may X-rays precede this mordality of choice?
Modality of choice is CT scan - will include imaging of the head to pelvis/thigh (known as Whole Body CT or Pan-Scan)
A CXR may precede transfer to CT scan in patients where there is concern about life threatening chest injjuries and who may require immediate intervention as part of their primary survey management
What is FAST Scanning and why is not performed in NHS Tayside?
