Cortex - general trauma 1 (this part is more 4th year stuff so if you do just glance at it)

Question 1

Trauma can involve many many many different specialities depending on the type of trauma and structures affected, what sort of trauma injuries is orthopaedics mainly involved in ?

Answer 1

Orthopaedics is involved in the management of fractures, dislocations, lacerations and penetrating injuries involving the upper and lower limbs

Question 2

In terms of orthopaedic trauma what specialities often work closely with orthopaedics and why ?

Answer 2

• Plastic surgeons and vascular surgery
• Vascular injury can often occur and may require vascular surgery or help from plastics
• If there is concerns regarding skin/soft tissue of a wound or peripheral nerve division - plastics often involved

Question 3

Following any high energy injury what is the priority of the physician ?

Answer 3

To save life and prevent serious systemic complications ahead of preventing pain and loss of function from fractures or dislocations.

Question 4

During the golden hour following major trauma what are you worried about killing the patient ?

Answer 4

Airway compromise, severe head injuries, severe chest injuries, internal organ rupture and fractures associated with substantial blood loss (pelvis, femur) can be avoided with rapid resuscitation and prompt, appropriate medical and surgical care

Question 5

To help prevent dearth following major trauma there is the Advanced trauma life support ATLS (guidelines) what is this mainly made up of ?

Answer 5

An initial and secondary survey - two key times you should check the patient

Initial primary survey - a quick assessment of vital functions is made and appropriate management instigated

Secondary survey - a head to toe survey to detect other injuries of the head, face, chest, abdomen, pelvis, genitourinary system, perineum, spine, neurological system and appendicular skeleton.

Question 6

The initial primary survey consists of what evaluation ?

Answer 6

ABCDE

• A - Airway management with cervical spine control
• B - Breathing and ventilation
• C - circulation and bleeding control
• D - disability (neurological evaluation)
• E - exposure and environmental control

Question 7

What are some of the signs of airway obstruction?

Answer 7

• Noisy breathing
• Gurgling
• Stridor
• Agitation from hypoxia and hypercapnoea.

Question 8

What are the different procedures done in the management of a patient with loss of airway control?

Answer 8

• First aid manoevre of chin‐lift, jaw thrust
• A definitive airway (cuffed endotracheal tube) is required after this
• An oropharyngeal (Guedel) airway or nasopharyngeal airway can provide temporary control.

Question 9

What must be done for any airway obstruction ?

Answer 9

• If it can be them remove it
• If not then emergency cricothyroidotomy can be done which you can then give oxygenation and ventilation through

Question 10

When assessing and managing airway problems what should be done to the C-spine ?

Answer 10

It should be immobilised

Question 11

What is the management of B - breathing and ventilation ?

Answer 11

All major trauma patients should receive high flow O2

• If tension pneumothorax - needle decompression with large bore needle in the 2nd intercostal space, midclavicular line. Chest drain then inserted
• If open penumothorax - chest drain distant from the wound inserted
• Massive haemothorax - again chest drain

Question 12

What is done to assess C - circulation and haemorrhage control?

Answer 12

• Assess the patients pulse rate and volume
• BP
• Cardiac monitor
• Bilateral IV access
• Urinary catheterisation and urine output monitoring
• Capillary refil

Question 13

Pelvic fractures can result in substantial blood loss from arterial bleeding (internal iliac artery & branches), venous bleeding (pelvic venous plexus) and from fractured bone ends.

In particular what type of pelvic fracture has a risk of life-threatening hearmorrhage ?

Answer 13

An open book pelvic fracture where the two hemi‐pelvises are sprung apart

Question 14

What is the treatment of an open book pelvic fracture ?

Answer 14

An open book pelvic fracture should be reduced as an emergency with a pelvic binder or emergency external fixator to reduce the potential pelvic volume and allow tamponade of bleeding to occur sooner.

Question 15

What should be assessed in D - disability ?

Answer 15

• Establish the level of consciousness (determined by glasgow coma scale)
• Identify signs of severely raised intracranial pressure from intracranial haemorrrhage (pupil fixed, dilated)

(would have blood glucose here but remember these ones are in relation to trauma not a collapse etc)

Question 16

Appreciate the glasgow coma scale

Answer 16

Question 17

What does a GCS of less than 8 imply ?

Answer 17

Implies severe head injury and loss of airway control - requires placement of a definite airway

Question 18

What is done in E - exposure ?

Answer 18

As it says - expose the patient to make sure no injuries are missed

Question 19

When is the secondary survey of a patient following major trauma done ?

Answer 19

Only if primary survey is complete and patient is stable

Question 20

What does the secondary survey involve ?

Answer 20

Head to toe examination to detect other injuries (facial injuries, lacerations, fractures, dislocations etc.).

Question 21

What is polytrauma ?

Answer 21

Is where more than one major long bone is injured or where a major fracture is associated with significant chest or abdominal trauma.

Question 22

What does polytrauma have a risk of leading to ?

Answer 22

Systemic Inflammatory Response Syndrome (SIRS) and Acute Respiratory Distress Syndrome (ARDS) both of which can cause Multi‐Organ Dysfunction Syndrome (MODS) and death.

Question 23

What is the management of polytrauma ?

Answer 23

Rapid skeletal stabilization is required to limit the biological load of trauma and to limit blood loss.

Question 24

What should be done following the end of the primary survey?

Answer 24

• A trauma series of X‐rays (lateral C‐spine, chest and pelvis xrays) may be performed depending on the clinical condition along with X‐rays of any other significant MSK injuries (major long bone fractures).
• The patient should be log rolled and signs of spinal fracture (tenderness, swelling) should be looked for and a PR examination performed (to detect PR bleeding and assess anal tone & perianal sensation).
• The cervical spine may be “cleared” at this stage if the patient is conscious, co‐operative, not confused and has no clinical signs of c‐spine injury (no tenderness, no pain on neck movements and no peripheral neurological deficit).
• A urinary catheter should be passed (unless suspicion of urethral injury from pelvic injury –call urologist if blood at urethral meatus) and a nasogastric tube is usually passed to prevent aspiration in the event of gastric dilatation which can occur in major trauma.
• Formal ABGs give data regarding oxygenation, adequacy of ventilation and adequacy of perfusion (acidosis).
• FBC, U&Es and Group & Save or Cross Match are sent. CT scans, Ultrasound or DPL may be performed at this stage.