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Guide to Essentials in Emergency Medicine > Chapter 10: Trauma > Flashcards

Chapter 10: Trauma Flashcards

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1
Q

What is the primary survery of a multi-trauma pt?

A

1) Airway-assume injury to C spine
- Ascertain patency: FB in oral cavity, Facial/mandibular fractures, Laryngeal/tracheal fractures
- Ascertain for obstruction: Stridor, Voice change, blood/mucus in oral cavity, subcut crepitus, swellings in neck
- Jaw-thrust
- Clear airway of FB and secretions with Yanker Suction
- insert OPA/NPA
- Definitive airway(RSI, Cricothyroidotomy etc)

2) Breathing and Vent
- Expose neck and chest
- Determine rate and depth of resp with rapid auscultation
- Attach pulse oximetry
- Give NRM 100% O2 first. Consider the need for BVM if SaO2

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2
Q

(Continue on from primary survey of multi trauma pt)

A
  • Attach ETCO2 if available
  • Needle thoracostomy for pts with tension PTX(deviated trachea, distended neck veins, shock)

3) Circulation:
- Assess 4 things:
* LOC
* Pulse(Carotid=60, radial=80)
* Skin colour and cap refill(1-2 seconds)
* BP
- Direct pressure on extern bleeding site
- 2 large bore IV cannula
- Draw blood for FBC, GXM, PT/PTT, U/E/Cr, ABG
- Vigorous IV Resus with 1-2 L of crystalloids or 1:1:1 Blood transx
- ECG
- Urinary and NG tube insertion if no CI

4) Disability
- GCS(E,V,M) 13-15 mild HI, 9-12 mod HI, 3-8 sev HI
- Pupillary rxn to light and equality of size

5) Envmnt
- Completely strip pt
- Bair Hugger
- Warm fluids if possible

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3
Q

What is the secondary survey in multi-trauma pat?

A

1) AMPLE Hx(Allergies, Medications currently on, Past-medical hx, Last meal, Events leading up to incident)
2) Head and face assessment
-Fractures
-Lacerations/contusions/thermal injury
-CN nerves
-Re-evaluate pupils
-Hemotympanum/nasal leakage of CSF
3) Neck
-Tenderness, deformity, tracheal deviation, distended neck veins, use of accessory muscles
-Can clear C-spine based on criteria
3) Chest
Inspect, palpate, percuss, auscultate(IPPA)
-blunt trauma, use of acc muscles, breath and H sounds, crepitus
-Emed room thoracotomy not indicated in blunt trauma
4) Abdo and pelvis
-Rebound tenderness
-Bowel sounds
5) Log-roll and PR Exam
-Bony tenderness/deformity
-Anal sphincter tone
-Peri-anal sensation
-Rectal bleeding
-Prostate position
-Bony frag from pelvis
6) Limbs
-Splint
-Pain relief
-Tetanus prophylaxis
-Apply pressure bandage

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4
Q

What is the definition of major burns requiring admn to burns centre?

A

1) Full thickness burns that >5% of BSA
2) Mixed partial and full thickness burns>20% in those aged 10-50
3) Burns invloving special areas such as eyes, face, ears, hands, perineum and feet
4) Inhalation injury
5) Circumferential burns of limbs/trunks
6) Electrical injury and chemical burns
7) Burns with co-existing Chronic med illness

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5
Q

What are risk factors suggestive of upper airway obstruction in burns?

A

1) Inspiratory stridor
2) Laryngeal edema on laryngoscopy
3) Swelling of buccal mucosa
4) Burns involving nose and mouth (sooty sputum)
5) Singed nasal hair and soot in nostrils
6) Burned tongue
7) Hoarse voice

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6
Q

What are 1st degree,2nd degree and 3rd degree burns?

A

1) Superficial burns are characterized by erythema, pain, absence of blisters
2) Partial thickness burns are painfully hypersensitive, weeping, wet,red,mottled appearance with blisters and swelling
3) Full degree burns are those that appear dark and leathery, translucent/waxy white. it appears red and does not blanch with pressure. Painless and gen dry.

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7
Q

What is the initial mgmnt of minor burns?

A

1) ABC
2) Remove all burning objects and accessories like jewellery
3) Cool burns using the 10-15 rule
-Within 10-15 mins of incident, 10-15 degrees of cool water and immerse pt or run water for 10-15 mins
4) Document burn size
5) Burns dressing
-Inner layer: Non-adherent opsite
-Middle: Cotton wool
-Outer: Plastic wrap and bandage
OR Cling film
6) Analgesia(NSAIDs and paracet)
7) If there are large and tense blisters, can aspirate. Otherwise, leave it alone
8) Antibiotic cream(silver sulfadiazine) only used if its full-thickness burns
9) Tetanus Immunization if indicated

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8
Q

What is the follow-up care of minor burns pt?

A

1) See in 24-48 hours
2) Presence of exudate seepage
3) Signs of infxn
- Serosang/pus-like discharge
- Inflamed wound margins
- Wound tenderness
- Fever and chills
4) Dressing changes every 48 hours

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9
Q

How is severity of burns assessed?

A

1) Location
2) Depth (1st/2nd/3rd)
3) Extent(Rule of 9)

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10
Q

What is the fluid mgmnt of major burns pts?

A

Ant pt with BSA>20% need IV Fluids

1) Parkland Formula
- Total vol replacement in first 24hrs=2-4ml/kg/% BSA
- Give 1st half over 8hrs
- 2nd half over 16hrs
- Start time=time of actual burn injury
2) Daily fluid reqm in normal avg person

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11
Q

What other adjunct mgmnt in major burns pt?

A

1) Pain Relief
- Opioids(IV Fentanyl 2-3ug/kg)
2) Do not use cold water on pt with extensive burns as it will cause hypothermia
3) Escharotomy for full-thickness circumferential burns
- end point is till fat layer

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12
Q

What other adjuncts can be performed after primary survey in multi-trauma?

A

1) Trauma series X ray(AP CXR, AP/Lateral C-spine, AP Pelvis)
2) FAST(Focussed Assessment with Sonography in Trauma)
- Subxiphoid/epigastrium(Heart)
- Left Hypochondrium(Splenorenal angle)
- Right Hypochondrium (Morrison pouch)
- Hypogastrium(POD/Rectovesical area)

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13
Q

What is the diff between HI and TBI?

A

HI is injury that is clinically evident

TBI is injury of the brain itself and is not always clinically evident

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14
Q

What are the 5 ‘H’s that increase the chance of secondary brain injury due to cerebral perfusion pressure?

A

1) Hypotension
2) Hypoxia
3) Hypercarbia
4) Hypoglycemia
5) Hyperthermia

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15
Q

What is the relation between skull fractures and HI?

A

Skull fractures with disorientation means 1 in 4 chance of having Intra cranial hematoma

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16
Q

What are the indications of Skull XR?

A

1) Mild HI with large boggy hematoma preventing palpation of underlying skull vault
2) A suspected radio-opaque FB in scalp lacerations

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17
Q

What do you look out for in SXR?

A

1) Linear/depressed skull fractures
2) Mid-line position of calcified pineal gland>3mm to one side suggests large intra-cranial hematoma
3) Air-fluid levels in sinus(including sphenoid—>basal skull #)
4) Pneumocephalus
5) Facial fractures
6) Fb
7) Diastasis of sutures

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18
Q

What are the indications of a CT head according to CT head rule?

A

1) GCS 13-15 +LOC, confusion, amnesia inclusion
2) Age>65
3) Vomitting>1
4) BoS # signs
5) Suspected open or depressed skull

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19
Q

What is mgmnt of a pt with HI?

A

1)ABC
-Airway and spine control
-Beware of central causes of breathing problems
-Bloods: FBC, U/E/Cr, PT/PTT, GXM+-serum ethanol, CBG
Indications for intubation for HI:
-GCS

20
Q

What are the clinical features of herniation?

A 
Non-lateralizing signs 
-Decorticate positioning 
-Loss of brainstem reflex
-Sudden death
-Bilateral pin-point pupils
-Decreased LOC
Lateralizing signs:
-Dilatation of the pupil on the side of the lesion(due to compress of parasymp
-Hemiplegia
21
Q

How do you manage raised ICP?

A

1) Elevating the head by 30 degrees to increase outflow of CSF from skull base
2) Keep pat sedated and calm
3) Keep MAP at least 80 to maintain CPP
4) Hypervent
- EtCO2 of 35-40
- Check ABG and titrate accordingly
5) IV Mannitol
- make sure pt not hypotensive, ESRF and insert urinary catheter
6) Manage seizures

22
Q

How do you manage a pt with abdominal trauma?

A

All multi-trauma pts are assumed to have abdominal injury until proven otherwise
-ABC
-Targetted exam:
Abdominal: External injury, tenderness, guarding, peritonism, rebound and absent bowel sounds
-Insert NG tube and catheter unless CI
-Trauma series X ray
-Abdo stab wounds should not be removed until OT
-GS consult

23
Q

What are the indications for immediate laprotomy?

A

1) Evisceration/ stab wounds with implements in-situ
2) Any penetrating trauma with hemodyn instab
3) Signs of peritoneal irritation including rectal signs
4) PR fresh blood
5) Pneumoperitoneum/diaphragmatic rupture in CXR
6) Fresh blood aspirated in NG tube

24
Q

What is a positive DPL?

A

1) Frank blood/obvious bowel contents aspirated
2) Lavage fluid seen to exit from chest drain/urinary catheter
3) Effluent RBC count>100000, WBC>500, Gram stain +ve

25
Q

When is FAST useful and what are the apparent advn?

A

1) When DPL is contra and pt too unstable for CT scan

FAST is a portable instrument that can tell ED physcians about pericardial and pleural free fluid and hemoperitoneum within 5 mins and can be used for serial exams.

However does not image solid parenchymal damage and is operator dependant

26
Q

What are the life-threatening but potentially salvageable conditions you must watch out for in chest trauma?

A

1) Airway obstruction
2) Open pneumothorax
3) Tension pneumothorax
4) Flail chest
5) Pericardial tamponade
6) Massive hemothorax

27
Q

What are some indications for chest tube insertion?

A

1) Pneumothorax, hemothorax, open chest wound
2) Rib fractures
3) Selected pts with severe lung injury
4) Pts undergoing GA for rx of other injuries

28
Q

What is a flail chest and the clinical features?

A 
1) 2 or more contiguous ribs have been fractured in 2 or more places (radio features)
Clinical features:
-Paradoxical chest movements 
-Resp distress
-Pain on resp 
-External trauma on ribs
29
Q

What is pericardial tamponade and how do you manage the condition?

A

Clinical features:

  • Beck’s triad(hypotension, distended neck veins, muffled heart sounds)
  • Chest trauma with hypotension
  • PEA
  • Kussmaul’s sign(increased neck distension and pulsus paradoxus)

Mgmnt:

  • Ensure adequate O2
  • 2 large bore IV lines
  • GIve IV fluid bolus 500ml stat to ensure MAP>90
  • Pericardiocentesis(ECG/2D Echo guided)
  • CTVS consult
30
Q

What is the mgmnt of a massive hemothorax?

A

-blood loss>1500 in the chest
RX:
-Blood transfusion and correction of coagulopathy
-Tube thoracostomy of affected side
-Look out for blocked tube(sudden cessation of blood flow)

31
Q

What is the role of CXR in rib fractures?

A

Many clinically sig fractures not visible on cxr so main indication is to rule out pneumo/hemothorax as a cx of the rib fractures. Most common is middle rib #. Simple ones can be managed outpt. prophylatic chets tube should be done for all trauma pat with multiple rib # who are going to be intubated.

32
Q

What is the risk in pelvic #?

A

1) Most M&M due to a/w trauma involving adjacent BVs and nerves, genitourinary and distal GI tract. Cause of Mort is uncontrolled bleeding and common MOI are
- Fall from height/RTA
- Simple falls with muscle avulsion
- direct blows

33
Q

What is the mgmnt of pelvic #?

A

1) ABC and 2 large bore IV lines
2) Preop bloods including 4-6 units of GXM
3) Look for signs of pelvic #:
- swelling in supra pubic/groin area
- ecchymosis in ext genetalia/medial thigh
- Blood from urethra
- abrasions/contusiosns along bony prominences
- step-off instability
- crepitus with bimanual palpation of iliac wings
4) A/w injuries:
- Perineum for open wounds
- PR for blood and high riding prostate
5) Do not insert catheter
6) Do pelvic xray
7) Give analgesia and if open, give antibiotics
8) Support pelvis with sandbags
9) Consider angiography and embolization if hemorrhage control fails
10) Ortho activation to do external C-clamp fixators

34
Q

When should spinal injury be suspected in a pt?

A

1) Unconscious trauma pt
2) Survivors of high-velocity accidents
3) Presence of a/w injuries such as
- Face and head trauma
- Seat-belt injury
- scapula contusion
- injury to feet or ankle from Fall from Height

35
Q

What are signs of spinal cord injury?

A

1) Neurogenic shock(hypotension+brady)
2) Diaphragmatic breathing
3) Flexed posture of upper limbs
4) Spontaneous muscle fasciculations
5) Priapism
6) Myotomic/dermatomic loss of muscle/sensory loss
7) Sacral sparing?(intact anal tone, sensation and flexor toe movement

36
Q

What is spinal shock?

A

Transient spinal concussion with loss of all motor and sensory function below cord lesion and lasts 24-48 hrs. Return of bulbocavernosus reflex signifies end of spinal shock. This reflex is not a sign of sacral sparin and continued loss implies damage to sacral reflex arc (conus medullaris/cauda equina)

37
Q

What are some cord syndromes to take note of?

A

1) Central cord: Disproportionately greater loss of motor power in UL than LL. Sensory loss +-. Bladder bowel often affected. Hyper-extension injury
2) Ant cord: Paraplegia with dissociated sensory loss (loss of pain and temp but with vibration/propioception) MOI is cervical flexion injury causing disruption of ant spinal artery
3) Brown-sequard: Ipsilateral motor, ipsi position and vibration, contra pain and temp)

38
Q

How do you manage a spinal trauma pt?

A

1) ABC
- IV fluids avoid overzealous as it may cause APO
- Vasopressors for neuro shock
2) Immobilize spine in neutral position
3) Document neuro deficits
4) Radio invg:
- AP and Lateral/open mouth C spine X ray
- Swimmers view if C7/T1 not seen
- Thoracic/lumbar spine X ray AP/lat
- CT scan
5) IV methylprednisolone
- If within 8hrs
- Non-penetrating spinal cord injury

39
Q

What is the NEXUS C-spine clearance criteria?

A

For pts who are alert and stable,(NSAID)

Neurological deficit absent
Spinal tenderness absent
Alert and oriented 
Intoxication not seen
Distracting injury
40
Q

How do you manage a fingertip amputation?

A

1) Analgesia parenteral
2) IV Cefazolin
3) X-ray amputated part
4) Digital photography for documentation
5) Wrap amputated part with saline soaked guaze and then insert into waterproof plastic bag and eventually into ice water
6) Apply sterile dry dressing
7) Keep patient NBM and preop invg FBC, U/E/Cr, GXM
8) Admit to hand surgery

41
Q

What is paronychia vs felon and what is the difference in mgmnt?

A

1) Paronychia is a subungal/lateral nail fold infection
- Screen for DM
- Oral antibiotics and warm compress if early, or I&D under digital block
2) Felon is an infection of distal pulp
- X-ray to exclude FB and bony involvement
- I&D under digital block
- Cloxacillin antibiotics
- Look for cx such as OM, Septic arthritis of DIP, flexor tenosynovitis

42
Q

What is suppurative flexor tenosynovitis?

A

Infection in the flexor tendon sheath that usually follows a penetrating injury. The Kanavel’s 4 cardinal signs are;

  • Fusiform swelling of the digit
  • Semi-flexed position of the hand in rest
  • Tenderness upon palpation of the whole sheath
  • Marked pain upon passive extension of the digit
43
Q

What is the rx and cx of flexor tenosynovitis?

A
  • Emergent hand consult
  • IV antibiotics
  • Elevate and splint hand in position of function
  • Admit to Hand surgery

Cx: Tendon ischemia, necrosis and rupture

44
Q

What are 3 important lower extremity injuries to look out for?

A
  • Knee dislocation
  • Hip Dislocation
  • Ankle dislocation
45
Q

What are the clinical features of hip dislocations?

A

1) Ant: Hip is abducted, flexed and ext rotated
2) Post: Hip is adducted, flexed and int rotated

Cx: Foot drop from sciatic nerve in post discloca, Femoral nerve, artery and vein in ant dislocation and AVN for both types

46
Q

What is the rx of hip dislocations?

A

1) Pain relief with IV Narcotics before X ray
2) Reduction with conscious sedation
3) Check X ray after reduction and admit to ortho

47
Q

What is the rx of femoral shaft #?

A

1) X ray Ap and Lat of femur
2) IV Drip + GXM as there is close to 1L of blood
3) give pain relief
4) Immobilize fractured limb and check distal pulses
Cx: Hemorrhagic shock and fat embolism

Guide to Essentials in Emergency Medicine (10 decks)

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