Exam course Flashcards
Discuss the sensitivity and specificity of eFAST in the context of multi-trauma?
Ultrasound can detect as little as 20ml in the pleural space
96% sensitive for pneumothorax
XR requires at least 200ml of fluid in pleural space
Ultrasound 98.1% sensitive for intra-abdominal fluid
Pericardial ultrasound 100% sensitive, 96.9% specific and 97.3% accurate
What are advantages of ultrasound?
Faster than CT or X-ray
Radiation free
Performed at bedside simultaneously with other medical care
A superior test in many cases (haemothorax, pneumothorax)
What are the limitations of eFAST in the context of multrauma?
Not reliable for detecting solid organ injuries
Obesity
-Fat obscures ultrasound and reduces sensitivity
Subcutaneous air can distort ultrasound images - subcutaneous emphysema
Retroperitoneum not able to be visualised
Cannot detect < 200ml of peritoneal free fluid
Pancreas not well visualized
What can increase sensitivity of eFAST?
Repeat scanning if clinical suspicion remains high
Trendelenburg positioning can make upper quadrant views more sensitive
Reverse trendelenburg can make pelvic views more sensitive
What are 5 false positives with eFAST?
Pericardial fat pads
Perirenal fat
Seminal vesicles with fluid
Fluid - lungs - ascitic abdomen
POD fluid
Explain your airway management algorithm in a patient with multiple traumatic injuries?
Assess airway is protected
-GCS > 8
-No vomiting
-No significant oropharyngeal bleeding
-Sufficient respiratory effort
If airway protected - supplemental oxygen, assess breathing
If airway not protected
-Assess for obstruction - suction etc.
If airway not protected then proceed to intubation
-PPV with BVM
-1st option RSI with video laryngoscope
-If unable to intubate then place LMA and repeat attempt with video laryngoscope + bougie or fiberoptic airway
-If unable to place LMA proceed to surgical airway
A patient with multi trauma arrives in ED with shock. State the priorities you will focus on in assessment. State your initial management.
Assess for cause of shock
Hypovolaemic - secondary to haemorrhage
-Primary survey including eFAST
-CXR, pelvis XR, CT scan
Resuscitation
-RBC, platelets, FFP in 1:1:1 ratio
-Prevent hypothermia
-TXA 1g IV followed by 1g over 8 hours
Targeted interventions
-e.g. pelvic binder, splint and reduce fractures, torniquet, laparotomy, thoracotomy
Non haemorrhagic
-Tension pneumothorax
-Cardiac tamponade
-Cardiogenic - myocardial contusion
-Neurogenic
-Septic
Treat etiology: ICC, thoracotomy, noradrenaline
State the criteria for a surgeon to attend a patient with trauma in ED?
Hypotension SBP < 90mmHg
Gunshot wounds to neck, chest or abdomen, proximal extremities
Respiratory compromise requiring urgent airway
Penetrating wound to neck/ chest/ abdomen/ pelvis
GCS < 8 attributed to trauma
What are the goals of a resuscitative thoracotomy?
Relieve cardiac tamponade
Perform open cardiac massage
Occlude descending aorta to increase blood flow to heart and brain
Control life threatening thoracic bleeding - hilar twist
Control broncho venous air embolism - hilar twist, trendelenburg position
How do you resuscitate a patient following a traumatic arrest?
Intubate
Insert bilateral chest drains (or thoracostomies)
Resuscitative thoracotomy
Limit fluid as this will worsen outcome unless hemorrhage controlled
Limit inotropes and pressors until circulation restored
Describe the AAST grading of liver injuries?
Most important to know grade III - V
Where is free fluid seen in the abdomen on an eFAST?
Morrisons pouch - hepatorenal space
Between liver and diaphragm
Right paracolic gutter
Splenorenal space
Rectovesical space
What is the AAST grading of splenic injuries?
What abdominal injuries are associated with a chance fracture?
Injuries
Duodenal
-First part intraperitoneal, remainder retroperitoneal
-Abdominal compression by seatbelt causes high intraduodenal pressures
-Penetrating injuries
-Shearing forces at duodenojejunal flexure or ampulla (points of fixation) lead to submucosal hematoma
-Diagnoses made by oral/ NG contrast study (XR/CT)
-Lower sensitivity on CT and AXR
Pancreatic injury
-Penetrating injury
-Rare following blunt injury - usually a blow to epigastrium
-Associated with duodenal rupture or severe multiple organ injury
-Seen in lap belt injuries, chance fractures
-CT scan 50% sensitive on initial scan, increases to > 80% with repeat CT at 8-12 hours
-Negative amylase and lipase is reassuring (95% sensitive)
Mesenteric injury
-Haematoma, vessel laceration
-CT 95% sensitive
Small bowel injury
-Jejunal or ileum tear
-Peritonism in 85%
-Erect CXR 25% sensitive
-CT: free intra-abdominal gas in 40% cases, free fluid without solid organ injury, free fluid in 80% of cases
-Mesenteric fat stranding
-Extravasation of oral contrast
-Can be normal in 5% of cases
-DPL > 95% sensitivity and specificity
-Laparoscopy highly sensitive and specific
Colonic injury
-Mortality 10%
-Operative repair for grade II-V injuries
Define abdominal compartment syndrome?
Other than abdominal trauma list 4 other groups of patients at risk of abdominal compartment syndrome?
Discuss the diagnosis of abdominal compartment syndrome?
State 5 key principles involved in the management of ACS?
Organ dysfunction caused by intra-abdominal hypertension
Intra abdominal pressure usually 5mmHg
APP = MAP - IAP
APP target is 60mmHg
Abdominal compartment syndrome is intra abdominal pressure > 20mmHg associated with organ dysfunction (raised lactate/ creatinine)
Risks
-Trauma and aggressive fluid resuscitation
-Burns > 30% TBSA
-Liver transplantation
-Massive ascites
-Retroperitoneal conditions: AAA, pelvic fracture, pancreatitis
-Sepsis with third spacing
Systemic effects
-Raised ICP, decreased CCP
-Hypotension, decreased venous return, decreased CO, increased SVR
-Decreased UO, renal blood flow, GFR
-Decreased coeliac blood flow/ SMA blood flow
-Decreased hepatic flow/ mitochondrial function/ lactate clearance
-Increased intrathoracic pressure, increased PIP, reduced compliance
Diagnosis
-CT may demonstrate extrinsic compression of IVC, massive abdominal distension, bilateral inguinal hernia
Measurement of intra-abdominal pressure
-Using intravesical catheter and pressure transducer
Management
-Surgical decompression of abdominal cavity if pressure > 25mmHg - delayed abdominal wall closure
-Escharotomy if abdominal burn
-Percutaneous catheter to decompress massive ascites
-Supine position
-Improve abdominal wall compliance: Pain control, sedation, paralysis, mechanical ventilation, permissive hypercapnia
What does damage control surgery/ resuscitation mean, what are its goals and what are its indications?
Pre op
-Prevent hypothermia / acidosis/ coagulopathy
In theatre / pre op indications for damage control resuscitation rather than definitive repair
-Severe physiological insult - hypothermia, coagulopathy (INR > 1.5), pH < 7.2, lactate > 5, dysrhythmia
-Inability to control bleeding using conventional methods
-Large volume resuscitation required (> 10U RBC)
Goals
-Arrest bleeding
-Prevent worsening hypothermia, acidosis, coagulopathy
List 6 CT findings that indicate need for surgery/ laparotomy in a haemodynamically stable patient with blunt abdominal trauma?
Diaphragmatic herniation
Sold organ injury - e.g. bowel, bladder
Vascular injury requiring repair if angiography not available
End organ devascularisation
Traumatic herniation of bowel or solid organs with ischaemia or infarction
Internal herniation of mesentery
List 5 indications for intercostal catheter with pneumothorax?
Traumatic pneumothorax
Moderate to large pneumothorax
Increasing size of pneumothorax after conservative management
Patient has a pneumothorax and requires ventilatory support or general anaesthesia
Pneumothorax with associated haemorrhage
Tension pneumothorax
What are risks of intercostal catheter?
Intercostal artery tear
Haemothorax
Cardiac contusion
Empyema/ pneumonia
Parenchymal injury
Pulmonary oedema
Bronchopleural fistula
What are options for managing VT?
DC synchronised cardioversion
-Use as first option if underlying comorbidity such as heart failure or unstable
Procainamide
-25mg/min IV
-Use as first option if patient stable as will also treat SVT with aberrancy, AVRT WPW and monomorphic VT with safety and efficacy
-Avoid if unstable or patient has heart failure
Amiodarone
-300mg IV over 30 mins
-Treatment of choice in unstable patient or in setting of cardiac arrest.
-Avoid if prolonged QT or WPW suspected
Lignocaine 1mg/kg IV
-Third line agent in VT which is stable
-Agent of choice in patients with suspected toxicological cause of VT
What are structural causes of VT?
What are causes of VT in a structurally normal heart?
Structural heart disease
-Ischaemic cardiomyopathy
-Non ischaemic cardiomyopathy: HCM, cardiac sarcoid, arrhythmogenic right ventricular cardiomyopathy
Structurally normal heart
-Idiopathic VT - RVOT VT, fascicular VT
-Primary arrhythmic syndromes: brugada, long QT, short QT, catecholamine polymorphic VT
What are causes of grey turners and cullens sign?
Periumbilical ecchymoses
Causes
-Pancreatitis
-Retroperitoneal bleeding
-Anticoagulation complication
-Rectus sheath haematoma
-Ectopic pregnancy
-Ishcaemic bowel
-Ruptured AAA
-Peforated duodenal ulcer
