Causes & Effects of Accidents Flashcards
Statistics of Traffic Accidents:
According to WHO, what are the most common causes of death?
- 20,000 severely injured per year
- 4500 deaths per year
- Most common cause of death in under 40s
WHO
1) Dementia
2) Heart Disease
3) Accidents
Give 5 examples of road safety measures:
1) Seatbelts
2) Speed bumps
3) Speed limits
4) Speed cameras
5) Drink and drug driving regulations
Define MAJOR TRAUMA / POLYTRAUMA / MULTIPLE TRAUMA.
Give examples.
Severe injury to more than one organ system.
1) Pelvic fracture -> damaged pelvic floor (vascular structure) -> severe bleeding
2) Femoral shaft fracture -> fat embolism
- External fixation -> preferred
- Intramedullary nail -> marrow in bone distributed to lung -> small vessels in lung blocked -> problems with oxygenation
3) Tension pneumothorax AKA collapsed lung
- Air goes in but cant come out
- Heart shoved to the side of uncollapsed lung -> restricted venous return and blood out
- Patient is breathless (rapid and shallow breaths)
- Treatment: cannula in chest and chest drain
How is major trauma scored?
ISS - Injury Severity Score
1) Head and Neck
2) Face
3) Chest
4) Abdomen
5) Extremities (pelvis, skin, hands, feet, arm, leg)
6) External
- Top 3 scores are squared and added up -> higher than 15 = 10% mortality rate, thus considered as major trauma
How is major trauma managed?
How long do you have to live if airway is blocked?
ATLS - Advanced Trauma Life Support system by USA
Airway with cervical spine control
Breathing (with ventilation)
Control of haemorrhage -> stop bleeding
Disability brain protection -> maintain O2 supply to brain
Exposure -> careful w hypothermia in children and elderly
- 3 mins
What does pre-hospital care comprised of?
1) 100% oxygen to all injured patients -> prevents secondary damage to CVS and brain
- via breathing bag
2) Basic Life Support
3) Advanced Life Support (if BLS isn’t adequate)
- Endotracheal intubation / Nasotracheal intubation -> tube in trachea
- OR cricothyroidotomy -> incision in cricothyroid membrane -> tube
- OR tracheostomy -> needle in gap in 2nd tracheal ring (Seldinger technique safer than mini-tracheostomy) -> followed by cannula
4) Replace lost blood with whole blood
- crystalloid IV (Hartmans/saline solution) may worsen major trauma
What does the trimodal death distribution show? and where does it happen?
It shows when death is occurs following an accident - three peaks
1) 1st peak - seconds to minutes - at accident site
2) 2nd peak - minutes to hours - in hospital
3) 3rd peak - days to weeks - in ICU
What happens in the 1st peak of the trimodal death distribution?
1) laceration of brain
2) laceration of brainstem
3) laceration of spine
4) ruptured heart
5) ruptured major blood vessels
What happens in the 2nd peak of the trimodal death distribution? and possible management?
What happens during the golden hour?
1) Brain haemorrhages (extradural and subdural) -> remove blood ASAP
2) Tension pneumothorax (cannula and chest drain), open pneumothorax (dressing), hemathorax (drain blood, and transfusion)
3) pelvic fracture -> pelvic binders and pelvic plaster
4) Long bone fractures -> fixatures
5) abdominal injuries (ruptured liver and spleen)
GOLDEN HOUR (~20% preventable deaths) -> save life and prevent complications
1) Rapid assessment
2) Resus by ATLS
What is the physiological response to major trauma?
How is the inflammatory level, and thus the recovery state, marked?
1) Systemic inflammatory response -> releases cytokines -> makes blood vessels leaky -> can’t operate -> wait 4-5 days
2) Counter-regulatory anti-inflammatory response to balance
- IL6
What does the 2-hit theory of trauma show?
1) 1st hit - initial accident
- ARDS (acute respiratory distress syndrome)
- MODS (multiple organ dysfunction syndrome)
2) 2nd hit - surgical procedure
- ARDS
- MODS
- Recovery
SURGICAL PROCEDURE
- If fit (and no trauma triad) -> fixatures
- If unfit -> Damage Control Orthopaedics (DCO) to prolong life
What is the Trauma Triad composed of?
1) Acidosis
2) Hypothermia
3) Coagulopathy
Management of Damage Control Orthopaedics.
1) Control bleeding
- Chest -> CT scans & thoracotomy -> chest drain
- Abdomen -> CT scans, FAST scans & laparotomy
- Extremities -> long bone fractures and open wounds
- Pelvis -> pelvic binder -> angiography and embolisation -> pelvic plaster
2) Arterial repair, decompress tension pneumothorax, fasciotomy (for compartment syndrome)
3) External fixature for provisional fractures
Why can PELVIS FRACTURES be fatal?
How are they managed?
pelvis fractures -> damaged pelvic floor ->severe bleeding ->death
- bladder and bowel
- reproductive organ and prostate
- major arteries and veins
MANAGEMENT
1) Pelvic binder along greater trochanter
- bind legs
- pillow under knee to flex hips
2) Angiogram (to detect arterial bleed) -> embolisation
3) Pelvis packing
- apply double pelvic external fixators -> definitive fixation/treatment
- laparotomy
- pelvic packing
Define COMPARTMENT SYNDROME, and give an example.
How is it managed?
How is it measured?
A rise in pressure within a closed space resulting in ischaemia of components
EXAMPLE Tibia -> 4 compartments - Anterior - Deep posterior - Lateral - Superficial
Tibial fracture -> severe bleeding -> rise in pressure within compartment -> compresses and shuts down…
1) lymphatic - no clinical signs
2) small vessels to muscle - severe unremitting ischaemic pain & pain when passively stretching/ moving foot or toes
3) Nerve -> paraesthesia, numbness, paralysis
4) Major arteries -> by this time, limb is dead
MANAGEMENT
Urgent fasciotomy
MEASURED
1) intermittently - pressure meter
2) continuously - cannula inserted in compartment
What is ARDS?
What are some possible causes, and how can it be avoided?
ARDS - Acute Respiratory Distress Syndrome
Fat embolism -> fat globules block small vessels in lung -> local inflammation -> impairs gas exchange -> hypoxia -> multiple organ failure
POSSIBLE CAUSE
- Intramedullary nail -> distributes marrow fat from bone
PREVENTED BY
- long bone fracture -> intramedullary nail
- long bone fracture with chest injury -> external fixature
What are the advantages of early long bone stabilisation?
Reduced
1) ARDS
2) Pneumonia
3) Systemic infections
4) Hospital, ITU, and ventilation days
Management of OPEN FRACTURES.
- Operation within 6hrs
1) Photograph
2) Antiseptic dressing & Antibiotics
3) External fixature / splint
4) Debridement
5) Stabilisation
What is associated with moderate to severe head injury?
High mortality rate
- leading cause in young people
Advantages of early spinal fracture fixation.
1) Less pulmonary complications
2) Shorter hospital and ITU stay
Trauma in elderly facts
1) 5th cause of death
2) x5 more likely to die than a young person with MODS and sepsis
What are the clinical parameters associated with poor prognosis in major trauma patients?
1) Acidosis
2) Hypothermia (less than 32)
3) Coagulopathy (platelet < 90,000)
4) Operation < 6 hrs
5) Shock and 25 units of blood transfusion
6) excessive inflammatory response IL6 > 800 pg/ml
7) multiple long bone and truncal injury
8) bilateral lung contusions on first CXR
9) arterial injury & haemodynamic instability BP < 90 mmHg
What happens in the 3rd peak of the trimodal death distribution?
1) Sepsis
2) MODS
3) ARDS
4) Pneumonia
5) Renal failure
What are the principles of management of SEVERLY INJURED?
1) Save life
2) Save limb
3) Save joint
As an orthopaedic, what do you do as soon as someone comes in with a major trauma?
1) AMPLE
2) Examination of both legs
3) Look for skin lacerations
4) Feel for pulses (femoral, popliteal, and foot)
5) Feel for nerves (sensation and motor power)
6) Check splint is satisfactory
What are the processes of saving a limb?
1) Photograph wound
2) Painkiller
- Nitrous Oxide
- Diamorphine hydrochloride
3) Broad spectrum IV antibiotics
- Augmentin (co-amoxiclav) -> 1.2g, 12hourly
=Amoxicillin x Clavulanic acid -> B-lactamase
- Clindamycin if allergic to penicillin -> 600g
- + Gentamicin or Metronidazole if farmyard contamination
4) Debride wound
5) Dress wound
- cover with sterile moist saline dressing and adhesive film dressing
6) Check splint
7) Repeat neurovascular examination
8) Check tetanus status and prophylaxis if required
9) Immediate referral to orthopaedic and plastic surgeon
Before surgery, what must you obtain?
1) Patient consent, mark, and remember
- Voluntary
- Valid
2) Patient capacity
3) Involve family and next of kin if available
What are the 4R principle of FRACTURE MANAGEMENT?
1) Reduction
- Closed
= Traction
= Splint
= manipulation
- Open
2) Retain
- Closed
= traction
= splint
= plaster
= gravity in humeral fractures
- Open
= screw fixation
= K wire
= plate
- Open/Closed
= internal fixature (DHS in pelvis, intramedullary nail in long bone)
= external fixature
3) Rehabilitation
4) Respect soft tissue
What are the two types of fracture healing?
1) Indirect fracture healing with callus
2) Direct fracture healing without callus
Describe the process of indirect fracture healing aka endochondral pathway.
1) Fracture
2) Haematoma
3) Mesenchymal cells (under periosteum) activated by hormones (e.g. BMP2) -> migrate into haematoma
4) Mesenchymal cells -> differentiate into soft callus (i.e. cartilage) via chondrogenesis
5) Soft callus -> endochondral ossification -> hard callus (i.e. lamellar/woven immature bone)
- AVOID NSAIDs -> prevent inflammation -> may delay bone healing
6) Hard callus -> osteogenesis -> new bone
7) Remodelling bone
Describe the process of direct bone healing.
1) Fracture
2) Cutter zones -> osteoclast followed by osteoblasts
- No callus
- Fracture line ignored
Give examples of GROWTH and DIFFERENTIATION signalling factors.
1) BMP - Bone Morphogenetic Protein (2)
2) FGF - Fibroblast Growth Factor (1, 2)
3) IGF - Insulin-like Growth Factor (1)
4) TGF - Transforming Growth Factor (B)
5) PDGF - Platelet Derived Growth Factor
How do signalling factors influence bone development?
1) Stem cells
2) Proliferation and migration
- FGF
- IGF
- TGF (B)
- PDGF
3) Differentiation
- BMP
4) Matrix formation and vascularisation
- BMP
- TGF (B)
- FGF
