Approach to Acute Trauma and Traumatic Brain Injury Flashcards
Describe a structured approach to trauma
Primary survey = a rapid primary evaluation
Resuscitation = immediate intervention to restore vital functions
Secondary survey = a more detailed assessment of all systems from head to toe, after primary survey and all injuries are identified
Definitive care = initiation of other treatment or referral/transfer
What is the trimodal mortality distribution?
IMMEDIATE DEATH:
- Occurs within minutes of injury
- A person is said to have an immediate death when he/she is declared dead at the scene or dies shortly after arrival at the hospital
- Examples: Irreversible brain injury and Hemorrhage from injuries of the Heart, Aorta, Liver, Lungs, and Pelvic fracture
EARLY DEATH:
- Occurs within hours of arrival at the hospital
- Examples: Intracranial hemorrhage, Internal hemorrhage involving the respiratory system & abdominal organs, multiple injuries leading to massive blood loss, tension pneumothorax, and cardiac tamponade
LATE DEATH:
- Occurs days to weeks after injury
- Examples: the main causes are sepsis (the most common cause) and multiple organ failure
What is the golden hour of trauma?
The first 60 minutes following trauma is a critical period for getting patients to a trauma center and has been called the “golden hour”
This concept arouse from the treatment of the second peak of trauma mortality patients (early death) which occurs within minutes to hours after the injury
Describe how to manage “Airway”?
Check airway and immobilise C-spine
Initiate direct clearance and gentle suction
Position patient to achieve patent airway
Airway manoeuvres:
- Jaw thrust
- Chin lift
- Head tilt
Adjucts:
- OPA
- NPA
Definitive airway:
- ETT
Surgical airways:
- Needle cricothyroidectomy
- Surgical cricothyroidectomy
- Laryngectomy
Pitfals: struggling, paralysed, unknown laryngeal fracture or airway transection, avoid finger sweeps as you might push it further down
Describe how to manage “Breathing”?
Chest wall and abdominal inspection
Check for air shift
Palpation, percussion and auscultation
Oxygen at high flow
Bag and mask if need be
Needle decompression if tension pneumothorax suspected
Causes of fatal chest injuries?
“ATOM FC”
AIRWAY OBSTRUCTION:
TENSION PNEUMOTHORAX:
OPEN CHEST WOUND:
- Leads to pneumothorax
MASSIVE HAEMOTHORAX:
- Occurs when blood enters the pleural cavity, most commonly occurring following chest trauma
FLAIL CHEST:
- Occurs when three or more adjacent ribs are fractured in at least two places, causing paradoxical motions in the chest, limiting chest wall expansion and breathing
CARDIAC TAMPONADE:
- The accumulation of fluid, blood, pus, or air within the pericardial space that creates an increase in intra-pericardial pressure, restricting cardiac filling and decreasing cardiac output
Describe how to manage “Circulation”?
Check colour, pulses, CRT, HR, BP
Look for obvious sources of bleeding
Ensure IV access
Correlate with level of consciousness
Describe how to manage “Disability” and “Exposure”?
DISABILITY:
- GCS
- Blood glucose
- Temperature
- Pupils
EXPOSURE:
- Completely undress with minimal movement
- Keep patient warm and decent
- Caution with massive infusion of cold fluids in pre-existing hypothermia
What are the classes of haemorrhagic shock?
Indications for a CT head in persons aged 16 or above (NICE)?
FOR IMMEDIATE CT SCAN < 1 HOUR:
GCS < 14 at initial admission to ED
GCS < 15 at two hours post-injury
Suspected open or depressed skull fracture
Signs of basal skull fracture (eg: battle’s sign, raccoon’s eyes, CSF leak)
Post-traumatic seizure
Focal neurological deficit
Vomiting
On warfarin (could wait for 8 hours)
IF AMNESIC OR LOC, AND ONE OF THE FOLLOWING:
- Retrograde amnesia > 30 min
- Age > 65
- Coagulopathy
- Dangerous MOI (eg: ejected from vehicle in RTA, fall of > 1m or 5 stairs)
[NB: do a CT scan within 8 hours; or within 1 hour if presenting within 8 hours of injury]
Extradural hematoma
Subdural hematoma
Subarachnoid hematoma
Diffuse axonal injury
Traumatic spinal cord injury
Parameters for intracranial pressure?
What is the equation for cerebral perfusion pressure?
What is the normal value for cerebral blood flow?
PARAMETERS FOR INTRACRANIAL PRESSURE:
10mmHg = normal
> 20mmHg = abnormal
> 40mmHg = severely elevated
CEREBRAL PERFUSION PRESSURE:
Cerebral perfusion pressure (CPP) = Mean arterial pressure (MAP) - Intracranial pressure (ICP)
[NB: Poor prognosis if CPP < 70mmHg]
CEREBRAL BLOOD FLOW (CBF):
- 50mL/100g of brain tissue/minute
Monro-Kellie Doctrine?
The body compensates for a SOL in the skull by first draining an equal volume of CSF and venous blood in order to maintain a constant ICP
However, when this compensatory mechanism is exhausted, there is an exponential increase in ICP for even a small amount of increase in the haematoma
Classification of head injuries?
MECHANISM OF INJURY:
- Blunt
- Penetrating
SEVERITY (GCS):
- Severe = GCS 8 or less
- Moderate = GCS 9 to 13
- Mild = GCS 14 to 15
Classification of skull fractures?
CLASSIFICATION OF SKULL FRACTURES:
- Linear
- Stellate
- Depressed
