Emergency medicine and trauma

Question 1

Mandible injuries

• signs
• diagnosis
• management of TMJ dislocation
• management of mandibular fractures

Answer 1

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

Question 2

What is the complication of a pterion fracture?

Answer 2

May rupture the middle meningeal artery and cause and extra-dural haemorrhage which could compress the brain and be life-threatening

Question 3

Features of a basal skull fracture

Answer 3

Raccoon eyes
Panda eye
Ecchymosis
CSF rhinorrhoea
CSF otorrhoea
Haemotympanum
Battle sign

Question 4

Management of drowning

Answer 4

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)

Question 5

Key concerns in drowning

Answer 5

Cardiac arrest
Hypothermia
Pulmonary oedema

Question 6

Do all drowning patients require admission?

Answer 6

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

Question 7

Factors that increase the severity of electric shock injuries

Answer 7

• 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

Question 8

Management of electric shock

Answer 8

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

Question 9

Management of wounds

Answer 9

Tetanus prophylaxis is vital. Prophylactic abs often not needed.

1. LOTS of irrigation with 0.9% saline
2. Infiltrate with lidocaine 3mg/kg plain (or adrenaline if necessary)
3. Remove debris, foreign bodies, and necrotic tissue, thorough scrubbing of abrasions, trim ragged skin edges
4. Use absorbable subcutaneous sutures (vicryl) to bring skin edges together, avoiding skin tension. Then use interrupted monofilament (nylone) on the skin.
5. 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)

Question 10

Primary survey in trauma

Answer 10

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

Question 11

Adjuncts to the primary survey

Answer 11

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

Question 12

Indications to intubate in trauma

Answer 12

GCS <9
Sustained seizure activity
Facial or airway trauma
High aspiration risk
Flail segments or respiratory failure

Question 13

Life threatening chest injuries in trauma

Answer 13

ATOM FC

Airway obstruction
Tension pneumothorax
Open pneumothorax (sucking chest wound)
Massive haemothorax
Flail chest
Traumatic cardiac tamponade

Question 14

Types of primary head injuries

Answer 14

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

Question 15

Types of secondary brain injuries

Answer 15

Cerebral oedema, ischaemia, infection, tonsillar or tentorial herniation

Secondary injury exacerbates the primary injury

Question 16

Cushings reflex

Answer 16

Hypertension, bradycardia, abnormal respiration

Due to brainstem compression and raised ICP causing dysfunction of the brains autoregulation
Usually a preterminal event

Question 17

Management of head injuries

Answer 17

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

Question 18

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

Answer 18

• 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

Question 19

Indications for immediate CT head following head injury

Answer 19

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

Question 20

Indications for CT within 8 hours of head injury

Answer 20

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

Question 21

Medical management of head injury

Answer 21

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

Question 22

Equation for cerebral perfusion pressure, and how to enhance cerebral perfusion pressure

Answer 22

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