Approach To The Injured Patient Flashcards
What are the five phases in the management of the severely injured patient
Pre Hospital
•Transportation
•Emergency Room
•Definitive care
•Rehabilitation.
What happens in pre hospital care
Pre Hospital Care
•Scene size up
•Call for appropriate support
•Secure area.
•In multiple trauma: triage
•Green—minor injuries
•Red—life threatening injuries
•Black—dead
triage
•Is patient awake, opening eyes and conversing?
•Is patient reacting to verbal stimuli?
•Is patient arousable only to painful or noxious stimuli?
•Is patient unresponsive?
RESUSCITATION
•ABCs
•Airway with cervical spine protection: scoop out contents, jaw thrust and chin tilt, hqnd ventilate.
•Breathing: cover open lesions on chest.
•Circulation: wide bore cannula, tourniquet.
What happens during transport
What are the characteristics of a trauma center
TRANSPORT.
•As a unit, ie strapped to long spine board.
•Inform receiving institution
•Transport appropriate patient to appropriate institution.
•Institutions categorized into 5 levels: level 5-1 based on quality of personnel, equipment to investigate, facility to treat and rehabilate.
• methods of transportation; ambulance, helicopter, trucks, pickups etc.
TRAUMA CENTRE
•CHARACTERISTICS;
•Surgeons with special skills to treat injured pt.
•Operating rooms, anaesthesia, blood bank, x-rays, CT scan etc.
•Emergency physicians
•Supportive staff working 24hrs.
What happens during primary survey in the emergency room(state the Traditional resuscitation as outlined by the Advanced Trauma Life Support guidelines)
Traditional resuscitation as outlined by the Advanced Trauma Life Support guidelines
i. Establishment of a functional airway
ii. Breathing assessed and established immediately if necessary
iii. Control major and life threatening haemorrhage
iv. Circulation supported by establishing reliable, large bore venous assess and fluid resuscitation. Avoid overzealous administration of crystalloids
v. Assess neurological disabilities
vi. Expose entire body to note significant deformities or penetrating injuries
vi. Baseline investigations; FBC, ABGs, GXM, etc
vii. Close co-operation with other surgical specialties
What injuries are treated during definitive care and rehabilitation
What are head injuries
State five causes
DEFINITIVE TREATMENT/REHABILITATION.
•Head injuries
•Chest injuries
•Spinal injuries.
•Abdominal injuries
•Genito urinary injuries
Head injury.
•Vast array of injuries to
• scalp
• skull
• brain +underlying tissues + blood vessels
•Brain injury
•Traumatic brain injury
•Oregon Healthcare ( 2006 )
Causes
•RTA/MVA
–Most serious injuries
–25% of all HI
–60% of deaths from HI
–50% die before reaching hosp
•Assault
•Injuries @ work
•Home ,sports
State the associated factors of head injury
How is head injury graded (mild moderate severe)
How do you assess a patient with head injury
Associated Factors
•Alcohol 35%
•Drugs 7%
•Suicide 10%
Grading severity acutely
•Mild
–GCS 14-15
•Moderate
–GCS 9-13
•Severe
–GCS 3-8
Assessment
•History
•Examination with resuscitation
•Investigation
•Stabilisation
•Transfer
What is important in the history of someone with head injury
History
•Mechanism of injury
–Severity/velocity
•Pedestrian/cyclist hit by car, ejection, rollover, other occupant death, fall>1m, high velocity
–Blunt (usual) - high or low velocity
–Penetrating (rare) – gun shot wound or other
PMH
–Brain surgery, clotting disorders, epilepsy
•Family history - epilepsy
•Medications – sedatives, AEDs,antidepressants,narcotics
•Allergies
•Suspicion of non accidental injury
What is important in the examination of someone with head injury
State five investigations done for people with head injury
Examination with resuscitation
•Focused neurological assessment
–GCS
–Pupils
–Lateralising signs
–Frequent re-evaluation
–Base skull fracture – csf rhinorrhoea, otorrhoea ,Racoon’s/Panda eyes, subconjunctival haemorrhage
–Lacerations and bruising
–Vital signs – pulse, BP,resp,temp.
Investigation
• Xrays
–Skull
–C spine
•CT scan
–Brain
–Bone windows
–C1 to T1
(There are pics of CTs with a brain having subdural hematoma and all in the slides)
How is head injury managed
What can happen to a patient with head injury within several hours and within several days to weeks?
management
•Mannitol
–0.25-0.5 g/kg
•Antibiotics
•Steroids
•Anticonvulsants
•surgery
Time is of essence-1st 20min most vital
•Nutrition – high requirements 2000-3000 cal/day 1st week
•Take care of problems associated with the unconcious state
Distribution of death
Trimodal
•1st peak – seconds to mins after HI
•2nd peak- within several hrs = Golden hour
•Expanding haematomas
•Pneumothorax
•Abdominal injuries
•Pelvic fractures
•Others – hypotension ,hypovolaemia
•3rd peak –several days to weeks
•Sepsis
•Multiple organ failure
Why is the Age of the patient important in the severity of injury in chest injury
Age of the patient important in the severity of injury
•Children:- immature chest wall is elastic and flexible
•Fractures are uncommon but visceral injuries are more significant
•Elderly patients:-fragile bony thorax susceptible to low-impact forces
•Offers poor protection for underlying viscera, high mortality with even minor injuries
State six causes of blunt chest injuries and six causes of penetrating chest injuries
RTA 70-80%
•Fall from heights
•Crush injuries
•Blasts
•Industrial accidents
•Blunt injuries are usually associated with other injuries, e.g. head injury, long bone fractures, abdominal injuries
Penetrating:
Civilian practice
•Stabs
•Impalement injuries
•Arrows and spears
•Gunshots
Wars and Conflicts
•Bullets
•Shrapnel
In war, chest injuries account for about 10% of all injuries.
•85% - 90% of chest injuries can be managed non operatively
–only 10% - 15% require thoracotomy or sternotomy.
True or false
Explain the pathophysiology of chest trauma
Major derangements include:
-Respiratory insufficiency
-Circulatory insufficiency
-Sepsis due to leakage of alimentary tract contents as in oesophageal perforations
Pain from chest injuries can make breathing difficult
•Restriction of chest movement, atelectasis, diminished cough, retention of secretions, superimposed infection
•Direct lung injuries, e.g. pulmonary contusions, shunting, also impair oxygenation
State the deadly dozen in chest injuries (lethal 6 and hidden6)
AIRWAY OBSTRUCTION
•TENSION PNEUMOTHORAX
•OPEN PNEUMOTHORAX
•FLAIL CHEST
•MASSIVE HAEMOTHORAX
•CARDIAC TAMPONADE
HIDDEN SIX
PULMONARY CONTUSION
• MYOCARDIAL CONTUSION
•TRACHEOBRONCHIAL DISRUPTION
•DIAPHRAGMATIC RUPTURE
•OESOPHAGEAL INJURY
•TRAUMATIC AORTIC RUPTURE
What is the commonest blunt thoracic injury and what does it represent?
Fractures of which rubs in chest injury are associated with the lungs,heart,pleura and bronchus
Fracture of which rib is indicative of spleen,hepatic and renal injury?
Why are first rib fractures of particular importance?
Rib fractures The commonest blunt thoracic injury
•Represent an important indicator of trauma severity, the greater the number of ribs fractured the greater the morbidity and mortality
•81% of rib fractures are associated with haemo or pneumothorax
Fractures of the fourth through the ninth ribs are associated with injuries to the lung, bronchus , pleura, and heart
•Fractures below the ninth rib are indicative of spleen, hepatic, or renal injuries
•First rib fractures are of particular significance because of the great force required for it to occur and the likelihood of intrathoracic visceral injury as well as injury to the brachial plexus and the subclavian vessels
What are the symptoms of rib fractures
What are the objectives in treatment of rib fractures
Symptoms include pain, exquisite tenderness, and crepitus
•CXR usually confirms the ribs that are fractured and any associated pathology
TREATMENT OF RIB FRACTURES
Pain relief:
-intravenous opiates
-NSAIDs
-Intercostal nerve blocks
-thoracic epidural
-intrapleural instillation of local anaesthetic agents
-transdermal patches
Prevention of atelectasis and optimization of pulmonary toilet by deep breathing exercises, coughing, incentive spirometry, ambulation
•Patients should be counseled that the pain my go on for weeks
