Day one

Question 1

Name the causes of airway obstruction?

Answer 1

CNS depression, foreign body (blood, vomit, secretions, food), trauma, blocked tracheostomy, swelling (infection etc), laryngospasm and bronchospasm.

Question 2

How does airway obstruction kill?

Answer 2

Cerebral oedema, pulmonary oedema, exhaustion, hypoxic brain injury and secondary apnoeas.

Question 3

Name some causes of breathing problems

Answer 3

CNS depression causing decreased/abolished respiratory drive, poor/diminished respiratory effect from muscle weakness or pain or restrictive abnormalities, disorders of lung function e.g. pneumonia, pneumothorax, haemothorax, asthma, COPD, PE, ARD, oedema.

Question 4

AIRWAY

Answer 4

Breath sounds- snoring/stridor/gurgling/hoarse voice/ obtundation (less that full alertness)/ cyanosis/ paradoxical movements/retractions/accessory muscles/ tracheal deviation/ laryngeal crepitus (passive movement of the larynx from side to side producing a grating sensation).
Facial fractures/burns/ neck wounds/ epistaxis or vomiting/ head injury with low GCS.

Question 5

BREATHING

Answer 5

Look, listen and feel for respiratory distress, count the RR, assess the quality of breathing, note any deformity, record sats and fi02 (how much oxygen they are on), listen near the face then palpate, percuss and auscultate the chest, trachea position and initiate treatment.

Question 6

What is a resuscitative thoracotomy?

Answer 6

This is for a victim of major thoracic or abdo trauma who has entered into cardiac arrest. The procedure allows immediate direct access to the thoracic cavity, permitting rescuers to control hemorrhage, relieve cardiac tamponade, repair or control major injuries to the heart, lungs or thoracic vasculature, and perform direct cardiac massage or defibrillation.

Question 7

CIRCULATION

Answer 7

Look at and feel the hands, assess the peripheral and central CRT, assess venous filling (can you get a cannula in??), count HR, palpate central and peripheral pulses, measure the blood pressure, listen to the heart and look for signs of poor cardiac output, look for haemorrhage.

Question 8

What is hypotension defined as?

Answer 8

SBP <90mmHg, MAP <60mmHg, a decrease greater than 40 systolic or 30% from the patients baseline MAP.

Question 9

What must you think about in a patient who is hypotensive?

Answer 9

HR, volume status, cardiac performance, systemic vascular resistance

Question 10

DISABILITY

Answer 10

Review and treat ABCs, check no hypoxia and hypotension. Check drug chart for reversible cause- drug induced low GCS, examine the pupils, assess GCS or AVPU, check lateralising signs, check capillary glucose and ensure airway protection. Look for spinal cord injury

Question 11

EXPOSURE

Answer 11

Expose and temp

Question 12

After E

Answer 12

Take a history, review the notes, review results, consider which level of care is required, reassess response, document everything and decide upon definitive treatment. Avoid hypothermia- give analgesia and splints etc. IV antibiotics and tetanus

Question 13

What is shock?

Answer 13

Clinical syndrome caused by inadequate tissue perfusion and oxygenation leading to abnormal metabolic function.

Question 14

What is ATOM FC for breathing?

Answer 14

Airway obstruction, tension pneumothorax, open chest wound, massive heamothorax, flail chest and cardiac tamponade.

Question 15

What is flail chest?

Answer 15

2 or more ribs broken in 2 or more places.

Question 16

What is HEPB for circulation?

Answer 16

Hands, end organ perfusion (kidneys with catheter and brain with GCS), pulse and blood pressure.
Also remember on the floor and 4 more- thorax, abdomen, pelvis and long bones. (splint, pelvic binder, if in abdomen- surgery).

Question 17

MANAGING INADEQUATE CIRCULATION

Answer 17

Optimise oxygenation. Splints, tourniquets/ direct pressure.
2 large bore cannulas
Fluid resus with warm crystalloid fluids and blood.
Consider IV transexamic acid if haemorrhaging, consider massive transfusion protocol.

Question 18

Signs of spinal injury (look for this under D)

Answer 18

Diaphragmatic breathing, evidence of neurogenic shock, responds to pain only above the clavicles, priapism, flexed posture of upper limbs or flaccid, areflexia, complaining of loss of sensation or function. Spinal tenderness, bruising or swelling on log roll

Question 19

What are the 4 types of hypoxia and how are they caused?

Answer 19

Hypoxic- reduced oxygen supply. Anaemic- reduced haemoglobin function. Stagnant- inadequate circulation. Histotoxic- impaired cellular oxygen metabolism.

Question 20

What is the cardiac output equation?

Answer 20

Stroke volume x HR

Question 21

Trauma triad of death

Answer 21

The trauma triad of death is a medical term describing the combination of hypothermia, acidosis and coagulopathy. This combination is commonly seen in patients who have sustained severe traumatic injuries and results in a significant rise in the mortality rate. Commonly when someone presents with these signs damage control surgery is employed to reverse the effects.

Question 22

What is a clinically significant hypothermia?

Answer 22

Body temperature of <36 for 4 hours or more.

Question 23

Hypothermia

Answer 23

Aggravated by heat loss from environmental factors (including the resus room) and/or surgical intervention. It may lead to cardia arrhythmias, decreased cardiac output, increase in systemic vascular resistance and LEFT shift of the oxygen haemoglobin dissociation curve.
This can induce coagulopathy by inhibition of the coagulation cascade and impair immunological function, this increasing the risk of subsequent sepsis. (left shift equals increase in pH)

Question 24

Why does clinical coagulopathy occur?

Answer 24

Due to the combination of hypothermia, activation of the fibrinolytic system and haemodilution from fluid resuscitation.
Hypothermia causes imbalance between thromboxane and prostacyclin (thus causing platelet dysfunction) and inhibits coagulation enzymes function.
Haemodilution results after fluid and blood transfusion. ( blood can’t clot).

Question 25

Why does metabolic acidosis occur?

Answer 25

Tissue hypo perfusion with reduced oxygen delivery leads to anaerobic respiration and lactic acidosis.

Increasing acidosis will also occur in massive blood transfusions, aortic cross-clamping or compression (in resuscitative thoractomy or REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) or laparotomy), low cardiac output state and with the use of vasopressors.

Acidaemia causes reduced cardiac output (depresses myocardial contractility) so exacerbates shocked state, inhibits coagulation enzyme function and causes RIGHT shift of the oxygen dissociation curve. (remember right is acidotic and left is alkaline)

Question 26

How do you calculate the mean arterial pressure?

Answer 26

(2x Diastolic BP + systolic BP)/3

Question 27

How do you work out cerebral perfusion?

Answer 27

CPP= MAP - ICP

Mean arterial pressure - intracranial pressure

Question 28

What is the Monro-kellie Doctrine?

Answer 28

This describes the pressure-volume relationship between ICP, volume of CSF, blood and brain tissue and CPP.
It states that the cranium compartment is incompressible and the volume inside the cranium is fixed,
Thus the cranium and its constituents (blood, CSF and the brain) are in a state of volume equilibrium; meaning that an increase in volume of one of the cranial constituents must be compensated by a decrease in volume of another. (one in one out).
If there is an increase in volume requirement i.e. an extradural haematoma, there will be a downward displacement of CSF into the spinal canal, reduction int cerebral venous blood and slight stretch of the falx and tentorium.

Question 29

RECAP

Answer 29

The flax cerebri is in between the hemispheres and the tentorium is in between the hemispheres and the cerebellum.

Question 30

How much volume change of ICP can you compensate for?

Answer 30

Change of volume of less than approx 100-120ml

Question 31

What is cushing’s triad?

Answer 31

Cushing reflex (also referred to as the vasopressor response) is a physiological nervous system response to increased intracranial pressure (ICP) that results in Cushing’s triad of increased blood pressure, irregular breathing, and bradycardia. It is usually seen in the terminal stages of acute head injury and may indicate imminent brain herniation. It can also be seen after the intravenous administration of epinephrine and similar drugs.

Question 32

What are the clinical indications of a raised ICP?

Answer 32

Changes in LOC, headaches, papilloedema, pupillary changes, impaired eye movements, posturing (decerberate, decorticate, flaccid), speech changes, seizures, impaired sensory and motor function, vomiting.

Question 33

What is decerberate and decorticate posturing?

Answer 33

Corticate- the arms are FLEXED and ADDUCTED.
CerbErate- the arms are EXTENDED and PRONATED and the hands are FLEXED.
E for extended

Question 34

In children what are the clinical signs of a raised ICP?

Answer 34

Bulging fontanelle, cranial suture separation, increased head circumference and high pitched cry.

Question 35

NB

Answer 35

As ICP increases, CPP decreases
Then the response to fall in cerebral perfusion is to raise systemic blood pressure and to dilate cerebral blood vessels but this just accelerates intracranial haemorrhaging and increases ICP, lowering CPP further. Cushing response (hypertension, bradycardia and irregular respiration) is a pre-terminal sign.

Question 36

SO

Answer 36

Raised ICP induces cerebral ischaemia and consequent infarction….because as ICP raises CPP reduces. (CPP= MAP-ICP)

Question 37

If increased ICP is caused by a unilateral space-occupying lesion, what signs may develop?

Answer 37

Dilated pupil, sluggish then fixed (CN3 palsy), aphasia.

CN3= ptosis and down and out.

Question 38

What is the significance of the pupil response in a patient with a head injury?

Answer 38

Represents impending uncial (inner part of temporal lobe and can squish cranial nerve 3) herniation caused by raised ICP (likely due to unilateral haematoma).

Question 39

What is eFAST?

Answer 39

This is a bedside ultrasound scan undertaken on patients with trauma. Thoracis, abdo and pelvic cavities to look for pneumothorax, haemothorax, pericardial effusion, intraperitoneal haemorrhage (described as free fluid).

Question 40

What colour is free fluid on ultrasound?

Answer 40

Jet black

Question 41

Which organs does the FAST exam focus on visualising?

Answer 41

Peri-hepatic, peri-splenic, pelvic, pericardial and anterior thoracic.

Question 42

What position is the past in for the eFAST?

Answer 42

Lying supine

Question 43

Where is the probe placed for the peri-hepatic view?

Answer 43

Right mid- to posterior axillary line at the level of the 11th and 12th ribs.
The hepatorenal space is the most dependent part of the upper peritoneal cavity so small amounts of intra-peritoneal fluid may collect here first.

Question 44

Where is the probe placed for the peri-splenic view?

Answer 44

Left posterior axillary line at the level of the 10th and 11th ribs.

Question 45

Where is the probe placed for the pelvic view?

Answer 45

Posterior to the bladder in males and in the pouch of douglas in females.

Question 46

Where is the probe placed for the pericardial views?

Answer 46

Sub-xyphoid or transthoracic

Question 47

Where is the probe placed for the thoracic views?

Answer 47

Anterior chest wall, usually 2nd or 3rd rib spaces.