EMERGENCY - Trauma Flashcards
What is polytrauma?
Polytrauma is when a patient has sustained multiple injuries across different body systems
What is primary polytrauma?
Primary polytrauma refer to injuries that occur at the time of the initial traumatic event
What is secondary polytrauma?
Secondary polytrauma refers to injuries that develop after the initial trauma as a result of various factors
Which three categories of trauma is death most commonly associated with?
Thoracic trauma
Central nervous system (CNS) trauma
Abdominal trauma
What are pulmonary contusions?
Pulmonary contusions are bruising of the lung parenchyma caused by leakage of blood and oedema into the alveoli caused by blunt trauma
How do pulmonary contusions affect gaseous exchange?
Gaseous exchange is impaired as oxygenated air cannot enter the fluid filled alveoli during inhalation resulting in a ventilation-perfusion mismatch and hypoxaemia
What can you use to diagnose pulmonary contusions?
Ultrasound
Radiography
Which two features on ultrasound can be indicative of pulmonary contusions?
B-lines
C-lines
What is the characteristic sign of pulmonary contusions on a radiograph?
Increased lung opacity/alveolar lung patterns
How do you manage pulmonary contusions?
For patients with pulmonary contusions you usually provide supportive management such as oxygen supplementation or even intubation in severe cases. It is also important to monitor patients with pulmonary contusions as they can progress in severity within the first 24 - 48 hours
Why is it important to avoid over-zealous fluid therapy in patients with pulmonary contusions?
In patients with pulmonary contusions, over-zealous fluid therapy can increase the risk of fluid overload and cause pulmonary oedema which could further impair gaseous exchange
(T/F) The extent and severity of pulmonary contusions is not always immediately apparent
TRUE. Pulmonary contusions are progressive and will generally worsen over the first 24 - 48 hours so it is important to reassess patients with thoracic trauma to ensure contusions haven’t developed or worsened
When should pulmonary contusions begin to improve?
Pulmonary contusions should begin to improve within 3 - 10 days
What is a pneumothorax?
A pneumothorax is an accumulation of free gas within the pleural space which puts positive pressure on the lungs resulting in lung collapse
What is an open pneumothorax?
An open pneumothorax is an accumulation of air in the pleural space resulting from a penetrating injury that permits the entry of air into the pleural space
What is a closed pneumothorax?
A closed pneumothorax is an accumulation of air originating from the respiratory system in the pleural space
What is a tension pneumothorax?
A tension pneumothorax is an accumulation of air into the pleural space where the site of air leakage acts as a one way valve resulting in the continuous entrance and entrapment of air into the pleural space
How can a pneumothorax cause cardiovascular collapse?
When a pneumothorax causes lung collapse, this causes an increase in intrathoracic pressure which can impede venous return to the heart (liquid will move from high pressure in the thoracic cavity to low pressure in the periphery), causing a decrease in cardiac output and rapidly progress to cardiovascular collapse. A pnuemothorax can also cause anatomical obstruction of the great vessels or the heart itself resulting in decreased venous return to the heart and decreased cardiac output
What are the four possible
clinical signs of a pneumothorax?
Dull dorsal lung sounds
Hyperesonance on percusion
Barrel-chest appearance (particularly in tension pneumothorax)
Paradoxical breathing
Which two diagnostic tools can be used to diagnose a pneumothorax?
Radiography
Ultrasound
What are the three characteristic signs of a pneumothorax on a radiograph?
- Heart elevated from the sternum
- Retraction of the lung lobes with free gas between the lung and the thoracic wall
- Increased lung opacity
What are the five characteristic signs of a tension pneumothorax on a radiograph?
- Heart always elevated from the sternum
- Retraction of the lung lobes with free gas between the lung and the thoracic wall
- Increased lung opacity
- Flat or concave diaphragm
- Increased size of intercostal spaces
What is one of the characteristic signs of a pneumothorax on ultrasound?
In a normal patient, you should see the pleural line glide slightly on ultrasound as the patient breathes. If the patient has a pneumothorax, this glide sign is lost
What are your main goals when treating a pneumothorax?
When treating a pneumothorax, your main goals are to allow for re-expansion of the lung and reduce intrathoracic pressure to improve venous return and cardiac output
Which two methods can be used to manage and treat a pneumothorax?
Thoracocentesis
Thoracostomy tube placement
Intubation and IPPV if indicated
What treatment plan should you consider for a patient with an ongoing/unresolved pneumothorax?
Exploratory thoracotomy
What are the three main clinical signs of a diaphragmatic rupture?
Dull ventral lung sounds
Borborygmi on thoracic auscultation
Paradoxical breathing
Which diagnostic tools can you use to diagnose a diaphragmatic rupture?
Radiography
Ultrasound
What are two characteristic features of a diaphragmatic rupture on a radiograph?
Presence of abdominal structures in the thorax
Loss of visualisation of the diaphragm
What are two characteristic features of a diaphragmatic rupture on ultrasound?
Presence of abdominal structures in the thorax
Loss of diaphragmatic line
How do you treat a diaphragmatic rupture?
Surgical intervention
What are the two causes of paradoxical breathing?
Pleural disease
Diaphragmatic disease
How do you manage a patient with fractured rib(s)?
Treat pain associated hypoventilation with systemic analgesics or local analgesic blocks
What is flail chest?
Flail chest is when multiple consecutive ribs are fractured in two or more places. This results in a paradoxical chest motion where the injured section of the chest wall moves in an opposite direction to the uninjured side of the chest wall
What is a primary head trauma/traumatic brain injury (TBI)?
A primary head trauma/traumatic brain injury (TBI) refers to injuries that occur at the time of the initial traumatic event
What is a secondary head trauma/traumatic brain injury (TBI)?
A secondary head trauma/traumatic brain injury (TBI) refers to injuries that develop after the initial trauma as a result of various factors
List two examples of primary head traumas/traumatic brain injuries (TBI)?
Concussion
Brain contusion
What is a concussion?
A concussion is characterised by a brief loss of consiousness and is not associated with an underlying histopathological lesion
What is a brain contusion?
Brain contusions are bruising of the brain parenchyma caused by leakage of blood and oedema into the brain parenchyma
What are coup brain lesions?
Coup brain lesions occur in the brain directly under the site of injury
What are contrecoup brain lesions?
Contrecoup brain lesions occur on the opposite brain hemisphere from the site of injury
What are axial brain lesions?
Axial brain lesions is a descriptive term used to describe brain lesions that are within the brain parenchyma
What are extra-axial brain lesions?
Extra-axial brain lesions is a descriptive term used to describe brain lesions that are external to the brain parenchyma
What are the main clinical signs of increased intracranial pressure (ICP)?
Deterioration in mentation
Signs of brainstem dysfunction
Postural changes
Abnormal respiratory patterns
Development of the cushings reflex
Give an example of a postural change that can occur due to increased intracranial pressure (ICP)
Decerebrate rigidity
What is the cushing’s reflex?
The cushing’s reflex is a physiological response to increased intracranial pressure characterised by hypertension and bradycardia
What are your three main goals when treating a patient with head trauma/traumatic brain injury (TBI)?
- Ensure adequate oxygenation of the brain
- Avoid and/or correct factors that predispose the patient to secondary brain injury
- Address increased intracranial pressure (ICP)
At what level should you maintain the PaO2 to maintain adequate oxygenation of the brain?
PaO2 more than 80mmHg
Why is it important to treat any factors that can increase intrathoracic pressure in patients that have sufferered a head trauma/traumatic brain injury (TBI)?
Increased intrathoracic pressure can impede venous return to the heart, causing a decrease in cardiac output and thus blood flow to and oxygenation of the brain
What else can you do to ensure normal blood flow to the brain?
Elevate the head to 30° to prevent jugular compression as jugular compression can lead to a backup of blood to the brain - worsening the intracranial pressure and affecting cerebral perfusion
Why is it important to prevent hypercapnia in patients at risk of increased intracranial pressure (ICP)?
Hypercapnia triggers cerebral vasodilation to increase blood flow to flush out the excess CO2 which can further increase intracranial pressure (ICP)
What PCO2 level should you maintain in patients at risk of increased intracranial pressure (ICP)?
Maintain the PCO2 levels between 30 - 35mmHg using IPPV
What should you do if there is clinical evidence of increased intracranial pressure (ICP)?
Hyperosmolar therapy
Reduce the cerebral metabolic rate
How can hyperosmolar therapy be used to treat increased intracranial pressure (ICP)?
Hyperosmolar therapy involves the administration of intravenous mannitol or hypertonic saline to create an osmotic gradient which moves fluid from the intracranial space into the intravascular space to reduce the intracranial pressure
What volume of mannitol should you administer in hyperosmolar therapy?
0.5 - 1ml/kg intravenous mannitol over 20 mins
What volume of hypertonic saline should you administer in hyperosmolar therapy?
2 - 4ml/kg intravenous hypertonic saline over 10 mins
What can be done to reduce the cerebral metabolic rate?
Anaesthesia
Barbituate therapy
Induce hypothermia
What can happen if raised intracranial pressure (ICP) is not identified and treated?
Brain herniation
What is transtentorial brain herniation?
Transtentorial brain herniation is the herniation of the cerebrum caudally
What is transforaminal brain herniation?
Transforaminal brain herniation is the herniation of the cerebellum through the foramen magnum
What is a common skeletal trauma seen in cats following a road traffic accident?
Mandibular symphyseal fracture
What is important to consider when treating a mandibular symphyseal fracture?
It is important to consider the nutritional managment of a patient with a mandibular symphyseal fracture and consider placing an oesophagostomy tube
What is the difference between abdominal trauma and acute abdomen?
Abdominal trauma is an injury to the abdomen, whereas acute abdomen is a per-acute, rapidly deteriorating condition (often caused by abdominal trauma) that prompts emergency treatment
What is a fluid wave test?
A fluid wave test is a physical exam technique used to test if there is fluid accumulation in the abdomen. The clinician places their hand on one side of the abdomen and taps the opposite side. If a fluid wave is felt, it indicates the presence of fluid
How many millilitres of fluid does their have to be in the abdomen for a positive fluid wave test?
At least 40ml/kg of fluid in the abdomen
Why is it important to do a series of ultrasounds in a patient that has undergone abdominal trauma?
It is important to do a series of ultrasounds to assess for any delayed or progressive fluid accumulation
What are the three main classifications of effusions?
Transudate
Modified transudate
Exudate
What is transudate?
Transudate is a fluid with a low protein count and specific gravity with the primary cell types found in this fluid being mononuclear and mesothelial cells
What is modified transudate?
Modified transudate is a fluid with a moderate protein count and specific gravity with the primary cell types found in this fluid being mononuclear cells, mesothelial cells, neutrophils and erythrocytes
What is exudate?
Exudate is a fluid with a high protein count and specific gravity with the primary cell types found in this fluid being mononuclear cells, neutrophils and erythrocytes
What is a haemoabdomen?
A haemoabdomen is the presence of haemorrhagic fluid in the peritoneal cavity
What are the five main clinical signs of a haemoabdomen?
Shock (specifically haemorrhagic shock)
Collapsed
Arrhythmias
Anaemia
Pulse deficits
Which seven diagnostic tools can be used to help diagnose a haemoabdomen?
Ultrasound
Radiography
PCV/TS
Haematology
Biochemistry
Coagulation profile
Abdominocentesis
Why should you carry out a coagulation profile if you suspect a haemoabdomen?
You should carry out a coagulation profile to see if the haemoadbomen may be secondary to a coagulation disorder
How can you confirm that the fluid collected from an abdominocentesis is a haemoabdomen?
To confirm the fluid collected from the abdominocentesis is a haemoabdomen, you should compare the PCV of the effusion to the patient’s peripheral PCV (take a blood sample). If the effusion PCV is within 10-25% of the peripheral PCV, then it is a haemoabdomen
What if your goal when treating a haemoabdomen?
When treating a haemoabdomen, your goal is to manage the shock and control the source of the bleeding
What can you do to manage shock when treating a haemoabdomen?
Goal directed fluid therapy
Hypotensive resuscitation
Whole blood transfusion
Oxygen supplementation
Why would you choose hypotension resuscitation over goal directed fluid therapy for shock management in a patient with a haemoabdomen?
The animal could be actively bleeding into their abdomen so fully overzealous fluid therapy could result in fluid overload and exacerbate the bleeding. Hypotensive resuscitation uses minimal fluids and blood products to improve the patients condition and deliberately allows the patient’s mean arterial pressure (MAP) to remain lower than normal physiological levels to prevent exacerbating the bleeding
Careful goal directed fluid therapy is generally fine
If you don’t have blood products available in your clinic, what other method can you use to transfuse blood into a patient with a haemoabdomen?
Autotransfusion - a process where a patient receives their own blood for a transfusion
What can be used to control the bleeding in a mild haemoabdomen?
A pressure banadage around the abdomen can be used to control the bleeding in a mild haemoabdomen
Why is it so important to frequently change a pressure banadage being used to treat a mild haemoabdomen?
It is important to frequently change the pressure bandage being used to treat a mild haemoabdomen to prevent pressure necrosis of the abdominal organs
Which surgery is often required following stabilisation of the patient to definitively treat a haemoabdomen?
Exploratory laparotomy to identify and repair the source of the bleeding
What is a uroabdomen?
A uroabdomen is the leakage of urine into the peritoneal or retroperitoneal cavities caused by a loss of integrity of the urinary system
What is the most common cause of a uroabdomen?
Blunt trauma - so every patient with abdominal trauma should be assessed for uroabdomen
What is the term used to describe a leakage of urine into the peritoneum?
Uroperitoneum
The loss of integrity of which three structures can cause a uroperitoneum?
Distal ureters
Bladder
Abdominal urethra
What is the term used to describe a leakage of urine into the retroperitoneum?
Uroretroperitoneum
The loss of integrity of which two structures can cause a retrouroperitoneum?
Kidneys
Proximal ureters
What are the clinical signs of a uroabdomen?
There are often non-specific clinical signs. The bladder may or may not be palpable however this does not rule anything out as a uroabdomen can be due to a loss of integrity of any portion of the urinary system
Describe how the pathophysiology of a uroabdomen results in several electrolyte imbalances
Urine is rich in potassium, urea and creatinine. When urine accumulates in the abdomen, the potassium and urea move from high to low concentration from the abdomen into the bloodstream via the peritoneum, causing hyperkalaemia and azotaemia, the azotaemia can progress to metabolic acidosis. Creatinine is too big of a molecule to pass into the bloodstream so it will remain in the abdomen, creating a driving force which will move water, sodium and chloride out of the intravascular space into the abdomen, causing hyponatraemia and hypochloraemia
Describe how the pathophysiology of a uroabdomen affects the kidneys
Hyperkalaemia is detected by the kidneys which will increase their glomerular filtration rate (GFR) to process more of the potassium rich plasma and excrete this excess in the form of urine. Hyperkalaemia will also trigger the release of aldosterone which will trigger sodium reabsorption into the bloodstream and potassium excretion into the urine by the kidneys. However, this potassium rich urine that is being produced will just end up back in the abdomen due to the leakage from the urinary system - worsening the uroabdomen
How does the pathophysiology of a uroabdomen result in dehydration and hypovolaemia?
The increased glomerular filtration rate and aldosterone release both trigger increased urine production which can contribute to dehydration. Furthermore, the persistence of urine (which has high levels of potassium, urea and creatinine) in the abdomen exerts an osmolar drive moving water from the extracellular compartment (intravascular and interstitial) and even from the intracellular compartment. This can lead to dehydration and hypovolemia
How does the pathophysiology of a uroabdomen affect the heart?
Hyperkalaemia results in bradyarrythmia’s
Which four diagnostic tools can be used to help diagnose a uroabdomen?
Ultrasound
Positive contrast radiography
Biochemistry
Abdominocentesis
How can you confirm that the fluid collected from an abdominocentesis is a uroabdomen?
To confirm the fluid collected from the abdominocentesis is a uroabdomen, you should compare the ratios between the effusion creatinine and potassium to the blood creatinine and potassium levels
What ratio between effusion creatinine and blood creatinine is indicative of uroabdomen?
A ratio of more than 2:1 (effusion creatinine: blood creatinine)
What ratio between effusion potassium and blood potassium is indicative of uroabdomen in dogs?
A ratio of more than 1.4:1 (effusion potassium: blood potassium) in dogs
What ratio between effusion potassium and blood potassium is indicative of uroabdomen in cats?
A ratio of more than 1.9:1 (effusion potassium: blood potassium) in cats
Why is it important to do a smear of the fluid that you collect from a patient with a uroabdomen?
Do a smear of the fluid collected to assess for an infection
How do you treat a uroabdomen?
A uroabdomen often required surgical intervention but it is important to stabilise the patient before surgery
How do you stabilise a patient with a uroabdomen?
Goal directed fluid therapy
Urinary catheterisation
Correct the electrolyte balance
Abdominal drainage
Antibiotics if indicated
Why is it important to place a urinary catheter and abdominal drain in a patient with a uroabdomen?
It is important to place a urinary catheter and abdominal drain in a patient with a uroabdomen because it helps to drain the urine being produced and aids in stabilisation as it prevents worsening hyperkalaemia etc.
What is septic peritonitis?
Septic peritonitis is a peritonitis as a result of an identifiable source of intraperitoneal infection that is typically bacterial in origin
What is a primary septic peritonitis?
Septic peritonitis caused by a spontaneous source of infection
What is a secondary septic peritonitis?
Septic peritonitis caused by a leakage of bacteria into the peritoneum
What is a tertiary septic peritonitis?
A recurrent septic peritonitis
Which diagnostic tools can be used to help diagnose a septic peritonitis?
Ultrasound
Radiography
Haematology
Biochemistry
Blood lactate
Abdominocentesis
Cytology
How can you confirm that the fluid collected from an abdominocentesis is a septic peritonitis?
- Do a cytology to identify intracellular bacteria and degenerate neutrophils most diagnostic method
- If the effusion glucose levels are 2.1mmol/L than the peripheral blood this is indicative of septic peritonitis
- If the effusion lactate levels are 2.5 mmol/L than the peripheral blood this is indicative of septic peritonitis
Remember bacteria utilise glucose and produce lactate
What are your goals when treating septic peritonitis?
When treating septic peritonitis, your aim is to manage the septic shock and control the source of infection
What can you do to manage the septic shock as a result of septic peritonitis?
Administer broad spectrum antibiotics
Goal directed fluid therapy
Vasopressors
Why might you need to administer vasopressors to manage septic shock?
Sepsis causes vasodilation and hypotension due to the systemic inflammatory response so vasopressors should be administered to trigger vasocontriction to improve the blood pressure
Which four methods can be used to control the source of infection when treating septic peritonitis?
Administer broad spectrum antibiotics
Exploratory laparotomy
Peritoneal lavage
Abdominal drainage
What is bile peritonitis?
Bile peritonitis is the leakage of bile into the peritoneal cavity
List three possible causes of bile peritonitis
Traumatic gall bladder rupture
Post hepatic biliary obstruction
Chemical erosion of the gall bladder
What is one of the main clinical signs of bile peritonitis?
Icterus
Which diagnostic tools can be used to help diagnose a bile peritonitis?
Biochemistry
Abdominocentesis
Radiography
Ultrasound
How can you confirm that the fluid collected from an abdominocentesis is a bile peritonitis?
To confirm the fluid collected from the abdominocentesis is a bile peritonitis, you should compare the ratios between the effusion bilirubin and the blood bilirubin levels
What ratio between effusion bilirubin and blood bilirubin levels is indicative of bile peritonitis?
A ratio of more than 2:1 (effusion bilirubin: blood bilirubin)
How do you treat a bile peritonitis?
A bile peritonitis often required surgical intervention but it is important to stabilise the patient before surgery
How do you stabilise a patient with a bile peritonitis?
Goal directed fluid therapy
Supplement with fresh frozen plasma or vitamin K
Why should you supplement a patient with bile peritonitis with fresh frozen plasma or vitamin K?
Bile peritonitis can cause coagulopathies
Which three surgical methods can be used to treat a bile peritonitis?
Exploratory laparotomy
Peritoneal lavage
Abdominal drainage
What is traumatic pancreatitis?
Traumatic pancreatitis is inflammation of the pancreas which can be caused by direct or indirect trauma
What can occur when there is direct trauma to the pancreas?
Direct trauma to the pancreas can cause leakage of pancreatic enzymes which can cause autodigestion of the pancreas
In which species is traumatic pancreatitis very common?
Cats
