Emergency medicine and trauma Flashcards
Mandible injuries
- signs
- diagnosis
- management of TMJ dislocation
- management of mandibular fractures
Signs: tenderness and swelling, jaw malocclusion (misalignment of the teeth)
Tongue may make airway management difficult
Diagnosis: orthopantogram (OPG) X-rays
Management of TMJ dislocation: place thumbs over the back teeth and press downwards while at the same time levering the chin upwards with your fingers (may require midazolam sedation)
Management of mandibular fractures: ORIF with miniplates
What is the complication of a pterion fracture?
May rupture the middle meningeal artery and cause and extra-dural haemorrhage which could compress the brain and be life-threatening
Features of a basal skull fracture
Raccoon eyes Panda eye Ecchymosis CSF rhinorrhoea CSF otorrhoea Haemotympanum Battle sign
Management of drowning
Do not attempt CPR in water
Try to maintain C spine immobilisation throughout
Place the patient in prone position when lifted form water in order to exert pressure on venous return and prevent circulatory collapse
Intubation with high PEEP
Always suspect hypothermia
ALS protocol if cardiac arrest occurs (cardiac arrest secondary to hypoxaemia)
Key concerns in drowning
Cardiac arrest
Hypothermia
Pulmonary oedema
Do all drowning patients require admission?
Patients who have been in a drowning event need to be observe for 4 hours - monitor for haemoptysis, basal crackles, CXR changes, and hypoxia on room air
If asymptomatic 4 hours later then they can be discharged
Outpatient follow up with CXR 2 weeks later is advised
Prophylactic antibiotics not requires
Factors that increase the severity of electric shock injuries
- Types of current: alternating current (AC) is more dangerous than direct current (DC). DC causes one large muscular contraction and asystole. AC causes repeated muscle spasms making it impossible for the victim to let go of the source, and causes VF.
- Energy delivered
- Current pathway through the body: if it enters the head or chest (eg. through one arm and out of the other arm), fatal injury is more likely
- Resistance encountered: Bone is the most resistant tissue, and thick skin can limit the amount of current passing through. Heart and nerves conduct electricity well so often receive the most damage.
- Contact duration
Management of electric shock
Turn off the source of current
Long, aggressive resuscitation
More fluid replacement is required for electric shock burns than needed for thermal burns, as electrical burns penetrate deeper
Check for rhabdomyolysis
Treat arrhythmias conventionally
Compartment syndrome may occur - treat accordingly
Management of wounds
Tetanus prophylaxis is vital. Prophylactic abs often not needed.
- LOTS of irrigation with 0.9% saline
- Infiltrate with lidocaine 3mg/kg plain (or adrenaline if necessary)
- Remove debris, foreign bodies, and necrotic tissue, thorough scrubbing of abrasions, trim ragged skin edges
- Use absorbable subcutaneous sutures (vicryl) to bring skin edges together, avoiding skin tension. Then use interrupted monofilament (nylone) on the skin.
- Remove sutures at a correct time to minimise risk of unsightly permanent stitch marks (face = 5 days, UL/body = 7-10 days, LL = 14 days)
Primary survey in trauma
ABCDE
Airway and cervical spine (jaw thrust to protect C spine)
Breathing and oxygen: 100% O2
Circulation and haemorrhage control: local pressure, cross match
Disability and blood glucose
Exposure and temperature control: totally undress patient and do rewarming techniques, remembering dignity
Adjuncts to the primary survey
CT within 30 minutes
Urinary catheter to assess urinary output
NG tube, unless facial injury
ABG can assess oxygenation in cold patients where pulse oximeter fails
Airway adjuncts
Logrolling a patient to examine the back whilst immobilising the C spine
Indications to intubate in trauma
GCS <9 Sustained seizure activity Facial or airway trauma High aspiration risk Flail segments or respiratory failure
Life threatening chest injuries in trauma
ATOM FC
Airway obstruction Tension pneumothorax Open pneumothorax (sucking chest wound) Massive haemothorax Flail chest Traumatic cardiac tamponade
Types of primary head injuries
Focal: Contusions, haematomas
Diffuse: diffuse axonal injury
Haematomas may be extradural, subdural or intracerebral
Contusion may be adjacent to the site of impact (coup) or contralateral side (contracoup)
Diffuse axonal injury occurs as a result of mechanical shearing following deceleration, causing disruption and tearing of axons
Types of secondary brain injuries
Cerebral oedema, ischaemia, infection, tonsillar or tentorial herniation
Secondary injury exacerbates the primary injury
Cushings reflex
Hypertension, bradycardia, abnormal respiration
Due to brainstem compression and raised ICP causing dysfunction of the brains autoregulation
Usually a preterminal event
Management of head injuries
If there is a life threatening rise in ICP -> use IV mannitol/furosemide whilst waiting for theatre to prep
Diffuse cerebral oedema -> decompressive craniotomy
Depressed open skull fractures -> formal surgical reduction and debridement
GCS 3-8: ICP monitoring is acceptable if CT is normal but MANDATORY if CT is abnormal
Maintain minimum cerebral perfusion pressure of 70mmHg in adults and 40-70mmHg in children
Pupillary findings in head injuries
- CNIII compression secondary to tentorial herniation
- Bilateral CNIII palsy or poor CNS perfusion
- Optic nerve injury
- Opiates, pontine lesions, metabolic encephalopathy
- Sympathetic pathway disruption
- CNIII compression secondary to tentorial herniation: unilaterally dilated, sluggish or fixed in response to light
- Bilateral CNIII palsy or poor CNS perfusion: bilaterally dilated, sluggish or fixed in response to light
- Optic nerve injury: Marcus-Gunn pupil (RAPD) unilaterally dilated or equal, cross-reactive
- Opiates, pontine lesions, metabolic encephalopathy: bilaterally constricted, may be difficult to assess
- Sympathetic pathway disruption: unilaterally constricted, preserved reaction to light
Indications for immediate CT head following head injury
GCS<13 on initial assessment GCS<15 2hrs later Suspected open or depressed skull fracture Basal skull fracture Post-traumatic seizure Focal neurological deficit More than 1 episode of vomiting
Indications for CT within 8 hours of head injury
Adults who have experiences some loss of consciousness or amnesia since the injury, with one of the following risk factors:
- 65y+
- history of bleeding or clotting disorders
- dangerous mechanism of injury (ejection from motorvehicle, fall from >1m height)
- more than 30mins retrograde amnesia of events immediately before the head injury
Medical management of head injury
Keep systolic BP >90 Avoid hypoxia or hypercapnia Opiates Mannitol Seizure control (IV lorazepam/buccal midazolam) Raise head 30 degrees to improve jugular venous return Avoid hyperglycaemia and hyperpyrexia Urgent neurosurgical input
Equation for cerebral perfusion pressure, and how to enhance cerebral perfusion pressure
CPP = mean arterial pressure - ICP
Enhancing cerebral perfusion pressure: normalise the ICP (<20), and target mean arterial pressure to approx 90mmHg so that CPP remains >60mmHg, limiting the risk of ischaemia to the brain
