Acute trauma Flashcards
taken from LITFL
What are the 5 key components of the primary survey in major trauma?
Airway maintenance with cervical spine protection
Breathing and ventilation
Circulation with hemorrhage control
Disability (neurological status)
Exposure and environmental control (completely undress the patient but avoid hypothermia)
taken from LITFL
What does airway maintenance with cervical spine control involve?
- ensure the airway is patent
- escalate from simple to advances techniques
- make sure suction is available and forceps
- use airway maneuvers - jaw thrust (head tilt is not appropriate here)
- use airwary adjuncts - oropharyngeal airway. (nasopharyngeal = not appropriate in head and facial trauma due to risk of intracranial passage)
consider a definitive airway
control cervical spine with a hard collar, sandbags and tape
taken from LITFL
Why may a major trauma pt need a definitive airway?
think of reasons based on what you might find in A-E assessment
A = impending airway obstruction (burns, penetrating or blunt neck injury) or an injury that can distort the airway anatomy (neck hematoma)
B = respiratory insufficiency due to a large pulmonary contusion, flail chest or other thoracic injury
C = mutisystem trauma with shock
D = reduced GCS (below 8), penetrating cranial vault injury (causes skull to bend inwards)
Taken from LITFL
In major trauma, what is important to assess and manage in B (breathing and ventilation)?
1. what would you assess? 2. what management would you do?
Assess:
* RR and SpO2
* Exposure and inspection = look for external signs of trauma, asymmetrical chest movements
* Palpate over chest wall = may find crepitus/surgical emphysema
* Percuss
* Auscultation = listen for air entry bilaterally, gauge adequacy, assess any added sounds
* Trachea = palpate for deviation - potential tension pneumothorax
* Back of chest - for posterior chest injury
Manage:
* high flow O2 15L/min via NRB mask
* intubate and mechanically ventilate if need resp support
* needle thoractomy, finger thoracotomy or intercostal catheter insertion may be needed
taken from LITFL
What does assessment and management of haemorrhage involve? (think of C in a-e)
Assess:
* hr, bp, cap refill, warm peripheries
* look for evidence of bleeding
* remove any pre-hospital bandaging
Manage:
* 2 x large bore cannula
* send off trauma bloods - these include Crossmatch blood alongside other bloods and glucose.
* do VBG to check Hb levels and lactate
* if not stable - initiate fluids.
* manage bleed - direct pressure, tourniquets, tie off vessels.
taken from LITFL
How would you manage major trauma signs that show in D of a-e?
e.g. what would you do for low GCS/seizure etc
- ensure airway is protected
- seizure control - midazolam 5-10mg IV, followed by pheyntoin 18mg/kg IV over 30 mins
- treat hypoglycaemia
- pain and shock can present as anxiety and agitation - manage with analgesia/treat shock
- treat raised ICP - 30degree head raise, analgesia, sedation, NMJ blockade, manitol/hypertonic saline, arrange urgent surgical decompression
In major trauma, which parts of body must you check for life threatening injuries?
- back of head
- back
- buttocks
- perineum
- axillae
- skin folds
taken from LITFL
In a trauma pt, what should you examine for in the neck?
- tracheal deviation
- wounds
- external markings
- laryngeal disruption
- venous distenion - jvp
- surgical empyhsema - in pic below
taken from LITFL
What does secondary survey involve?
It involves a systematic ‘top-to-toe’ examination, including:
- Head, face, eyes, ears, nose and throat — carefully check the scalp and the oral cavity
- Neck
- Chest
- Abdomen
- Pelvis
- The back
- Extremities
- All wounds
taken from LITFL
What is key to ask in Hx of trauma pt?
Use mnemonic AMPLE
- Allergies and ADR status
- Medications
- PMH
- Last ate and drank +/- last menstrual period in females
- Events/environemnt related to injury i.e mechanism of injury
In trauma, what is permissive hypotension?
This is low volume resuscitation.
* allow systolic BP to drop low enough to avoid severe loss of blood but high enough to maintain perfusion
* a low BP is not good - but it is a compromise for pending emergency surgical intervention.
* the goal = avoid disruption of an unstable clot by higher pressures and worsening of bleeding (‘don’t pop the clot’). We want to control the haemorrhage - once we do this, we can normalise haemodynamics.
In a suspected major haemorrhage, what drug is given (usually within 3hrs of injury)?
- tranexamic acid - usually 1g IV over 10 mins (check if paramedic has given this already before reaching A+E)
- Follow this wiht infusion of tranexamic acid 1g IVI over 8hrs.
Tranexamic acid:
1. what is drug action?
2. name three indications for use of tranexamic acid
- antifibrinolytic - prevents or reduces bleeding by impairing fibrin dissolution.
- menorrhagia, preventina and treatment of significant haemorrhage following trauma, epistaxis, hereditary angiodema, local or general fibrinolysis.
For all trauma, describe the phases of ATLS.
(in trauma resuscitation)
- Primary survey.
- Resuscitation phase.
- Secondary survey.
- Definitive care phase.
What inv do most trauma pts require?
- group and save/cross-match (and baseline clotting screen if major haemorrhage)
- FBC
- U&E
- CT and/or X-rays
- ABG or VBG (including lactate and glucose levels).
Also mentioned in oxford handbook =
* urine sample if abdo injury (may show microscopic haematuria)
* ECG - to monitor pts and required if over 50 or have significant chest trauma
* Angiography if have major pelvic fracture or aortic injury.
* Echo can be ordered based on context.
What scoring tools are used in major trauma?
Injury severity score:
* used to score anatomical injuries of pt.
Revised trauma score:
* used to assess physiological disturbance of the trauma pt.
* calculate from RR, systolic BP and GCS.
What are some causes of major trauma?
(won’t go into depth of all as they are covered in other decks)
- head injury
- airway obstruction - e.g foreign body
- tension pneumothorax or traumatic pneumothorax, haemothorax
- rib fractures - can get flail chest
- ruptured diaphragm
- oesophageal rupture
- traumatic cardiac arrest
- chest injury e.g. stab wound or blunt abdominal trauma
- aortic injury e.g. dissection, AAA
- kidney, bladder, testicular trauma
- open wounds
- maxillofacial injuries
- spinal cord injuries
- burns
Label the following
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What are common sites of mandible fracture?
neck, ramus, angle, body.
Label this mandible
A pt attends via ambulance after a traumatic accident. What does this XR show?
Diaphragmatic rupture
- can see R sided rib fractures
- there is abnormal density in L lower zone.
- Gas bubble is above normal position
- there is mild shift of mediastinum to the R
A man playing football has attended after trauma to his right leg. What is shown?
Spiral fracture to the right tibia
A 17 year old attends A+E after falling whilst at a ball. Her left foot is swollen and she has reduced ROM. What does her XR show?
Dislocation of the talus out the mortise.
Fracture of the fibula.
A man gets into an altercation whilst out on Friday night. He has a deformity of his R shoulder. What can you see?
Anterior shoulder dislocation
A man falls from a height and lands on his R shoulder. What does XR show?
Posterior shoulder dislocation - see lightbulb sign!
Label this normal chest XR
