General Trauma Flashcards
1
Q
Define the grades of hypothermia
A
- Mild = 32-35
- Moderate = 28-32
- Severe = <28
2
Q
What are the CPR adjustments in hypothermia
A
- Defibrillation is ineffective until warm
- Use IV Bretylium
- Death cannot be confirmed until patient is warm
3
Q
Define heat stroke
A
Pyrexia >41 degrees associated with anhidrosis and neurological dysfunction
4
Q
Outline the monitored variables (HR, CVP, CO, SV, SVR) in hypovolaemia
A
- HR = up
- CVP = down
- CO = down
- SV = down
- SVR = up
5
Q
Outline the monitored variables (HR, CVP, CO, SV, SVR) in cardiogenic shock
A
- HR = up
- CVP = up
- CO = down
- SV = down
- SVR = up
6
Q
Outline the monitored variables (HR, CVP, CO, SV, SVR) in septic shock
A
- HR = up
- CVP = down
- CO = up
- SV = down
- SVR = down
7
Q
Outline the monitored variables (HR, CVP, CO, SV, SVR) in tamponade
A
- HR = up
- CVP = very up
- CO = down
- SV = down
- SVR = up
8
Q
Outline the monitored variables (HR, CVP, CO, SV, SVR) in neurogenic shock
A
- HR = down
- CO = down
- SVR = down
9
Q
What is normal CO
A
6L/min
10
Q
Describe class 1 hypovolaemic shock
A
- 0-750ml loss (0-15%)
- Pulse <100
- BP unchanged
- Pulse pressure unchanged
- Urine output >30
- RR 14-20
- Restless
11
Q
Describe class 2 hypovolaemic shock
A
- 750-1500ml loss (15-30%)
- Pulse 100-120
- BP unchanged
- Pulse pressure decreased
- Urine output 20-30
- RR 20-30
- Anxious
12
Q
Describe class 3 hypovolaemic shock
A
- 1500-2000ml loss (30-40%)
- Pulse 120-140
- BP decreased
- Pulse pressure decreased
- Urine output 5-15
- RR 30-40
- Anxious/confused
13
Q
Describe class 4 hypovolaemic shock
A
- > 2000ml loss (>40%)
- Pulse >140
- BP decreased
- Pulse pressure decreased
- Anuric
- RR >40
- Confused/lethargic
14
Q
What conditions can falsely raise CVP
A
- Tension pneumothorax
- Pericardial effusion
- Air embolus
- MI
15
Q
Define ‘massive transfusion’
A
Replacement of a patient’s total blood volume in <24 hours OR administration of over half the patient’s blood volume per hour
16
Q
What ratio of blood products should be transfused in haemostatic resuscitation
A
- 1:1:1
- Packed cells: platelets: FFP
17
Q
Normal urine outputs per hour for infant, child and adult
A
- Infant = 2ml/kg/hr
- Child = 1ml/kg/hr
- Adult = 0.5ml/kg/hr
18
Q
What hormones are increased in the stress response
A
- Growth hormone
- Cortisol
- Renin
- ACTH
- Aldosterone
- Prolactin
- ADH
- Glucagon
19
Q
What hormones are decreased in the stress response
A
- Insulin
- Testosterone
- Oestrogen
20
Q
What hormones remain unchanged in the stress response
A
- TSH
- LH
- FSH
21
Q
Result of neurogenic shock on preload
A
Reduces as loss of vasomotor tone causes pooling in the capacitance vessels
22
Q
List the 6 immediate life-threatening chest injuries (ATOMIC)
A
- Airway obstruction
- Tension pneumothorax
- Open (sucking) pneumothorax
- Massive haemothorax
- Intercostal disruption (flail chest)
- Cardiac tamponade
23
Q
What is the AMPLE history
A
- Allergies
- Medication
- Past medical history
- Last meal
- Events of the injury
24
Q
What autonomic symptoms are seen in diffuse axonal injury
A
- Fever
- HTN
- Sweating
25
Most common vessel to cause extradural haematoma
Middle meningeal artery
26
Why are children and young adults more susceptible to extradural haematoma
The dura becomes more adherent to the skull with age
27
What causes pupillary dilatation in extradural haematoma
Herniation of the uncus of the temporal lobe across the tentorial edge compresses the 3rd nerve
28
Describe the appearance of extradural haematoma on CT
- Bi-convex (lemon)
| - Limited by the dural attachments of the suture lines
29
Rupture of what vessels causes acute subdural haematoma
Bridging veins
30
Describe the classical presentation of extradural haematoma
Initial concussion followed by lucid interval
31
Describe the presentation of acute subdural haematoma
Rapid deterioration
32
Define the Monroe-Kelly Doctrine
Cranium is a rigid box, therefore total volume must remain constant if ICP is not to change
33
To what volume can the body compensate ICP for changes in intracranial volume
100ml
34
Outline the Cushing's response
- Respiratory rate falls (herniation of brainstem)
- Heart rate decreases
- SBP rises
- Pulse pressure rises
35
How is cerebral perfusion pressure calculated
MAP - ICP
36
What can break the cycle of exponentially rising ICP when autoregulation fails
- Ventilate to normocapnia 4.5kPa
- IV fluid to normovolaemia
- Mannitol bolus
- Thiopental infusion
37
Why does hyponatraemia develop in head injuries
SIADH
38
What is the minimal cerebral perfusion pressure in adults
70mmHg
39
List the causes of bilaterally constricted pupils
- Opiates
- Pontine lesions
- Metabolic encephalopathy
40
Criteria for immediate CT head within 1 hour
- GCS <13 on admission
- GCS <15 after 2 hours
- Suspected open/depressed skull fracture
- Suspected skull base fracture
- Focal neurology
- Vomiting >1 episode
- Post traumatic seizure
- Coagulopathy (or receiving an anticoagulant)
41
How often should a patient undergo observations following head injury
Half-hourly until GCS 15
42
What type of facial fracture does movement of the maxillary teeth suggest
Le Fort 1
43
What type of facial fracture does movement of the nasal bridge suggest
Le Fort 2 or 4
44
What must be excluded in septal fracture or dislocation
Septal haematoma
45
When do naso-ethmoidal fractures need to be referred to neurosurgery
If dural tear occurs at the cribriform plate
46
List the signs of longitudinal temporal bone fractures
- Swollen external auditory canal
- Tear of tympanic membrane
- Bleeding from the ear
- CSF otorrhoea
- Facial nerve palsy
47
List the signs of transverse temporal bone fractures
- Haemotympanum
- 50% have facial nerve palsy
- Sensorineural hearing loss
- Vertigo
- Nystagmus
- CN 9, 10, 11 palsies
48
How should temporal bone fractures be managed
- Hearing test
- EMG if facial nerve palsy
- Surgical decompression +/- facial nerve grafting
49
How may a TMJ dislocation be reduced
Downward and forward traction
50
Describe a Le Fort 1 fracture
Horizontal - Severs the tooth-bearing portion of the maxilla from the upper maxilla
51
Describe a Le Fort 2 fracture
Pyramidal - extends from nasal bridge (at or below nasofrontal suture) through the superior medial wall of the maxilla, inferolaterally through the lacrimal bones and inferior orbital floor
52
Describe a Le Fort 3 fracture
Transverse A.K.A. Craniofacial dissociation - involve zygomatic bone. Begin at nasofrontal and frontomaxillary sinus and extend posteriorly along the medial wall of the orbit, through the nasolacrimal groove and ethmoid air cells, continues through lateral orbital wall and zygomatic arch
53
Define flail chest
Two rib fractures in the same rib of two consecutive ribs
54
What is the effect on tidal volume in flail chest
Reduces due to paradoxical chest wall movement
55
How are tension pneumothoraces immediately decompressed
14G needle in 2nd intercostal space MCL
56
Define massive haemothorax
1500ml or more blood drained from the chest cavity on insertion of a chest drain
57
Describe the site of chest drain insertion
Mid-axillary line, 5th ICS
58
When is thoracotomy indicated in haemothorax
If immediate loss >2000ml or continuing losses of 200ml/hr
59
When should great vessel damage be suspected in haemothorax
If there are signs of penetrating injury medial to the nipples/scapula
60
List the CXR signs of mediastinal injury
- Subcutaneous emphysema
- Haemothoraces
- Pleural cap
- Widened mediastinum
- Free air in the mediastinum
61
What incision may be required to control pericardial tamponade or uncontrolled bleeding following blunt chest trauma
Left anterolateral thoracotomy
62
What size chest drain should be used in traumatic pneumothorax
32Fr
63
What sensory deficit arises in Le Fort 2 fractures
Infraorbital paraesthesia
64
How should traumatic pneumothoraces be managed
Insert chest drain for all
65
Describe Beck's Triad
1. Raised JVP
2. Muffled heart sounds
3. Low BP
66
Describe Kussmaul's sign
Raised JVP on inspiration (seen in cardiac tamponade)
67
How should traumatic cardiac tamponade be managed
Pericardiocentesis
68
Which Le Fort fracture is associated with CSF rhinorrhoea
Le Fort 3
69
How can CSF rhinorrhoea be confirmed
Beta-2 transferrin assay
70
Site of rupture in aortic disruption
Just distal to Ligamentum arteriosum
71
Which side is diaphragmatic rupture more likely to occur on
Left (right side is protected by the liver)
72
What percentage of blunt abdominal trauma require laparotomy
10%
73
What four areas does a FAST scan assess
1. Perihepatic and hepatorenal space
2. Perisplenic
3. Pelvic
4. Pericardium
74
Contraindications to diagnostic peritoneal lavage
- Absolute decision for laparotomy already made
| - Relative = previous abdominal surgery, obesity, pregnancy, coagulopathy, advanced cirrhosis
75
Indications for diagnostic peritoneal lavage
- Multiply injured patient with equivocal abdominal exam
- Suspicion of injury with difficult examination
- Refractory hypotension with no other sites of haemorrhage
76
List the indications for laparotomy following trauma
- Unexplained shock
- Peritonism
- Evisceration - bowel or omentum
- Radiological evidence of intraperitoneal gas
- Radiological evidence of ruptured diaphragm
- Gunshot wounds
- +ve DPL or CT
77
Define Kehr's sign
Shoulder tip pain secondary to blood in the peritoneal cavity - left sided Kehr's is classic of ruptured spleen
78
Outline the classification system used for splenic injury
```
1 = capsular tear
2 = tear and parenchymal injury
3 = tear up to the hilum
4 = complete fracture
```
79
When is splenic resection indicated post-trauma
- Hilar injuries
- Major haemorrhage.
- Major associated injuries
80
What structures are at risk during splenectomy
Tail of the pancreas
81
What infections may complicate splenectomy
- Strep pneumoniae
- Haemophilus influenzae
- Neisseria meningitidis
82
How should those with grades 1-3 splenic injury be managed
Observation in HDU
83
Outline the management of liver trauma
- Conservative if capsule intact
- Suture laceration
- Partial hepatectomy
- Packing
84
Outline how pancreatic trauma is classified
- Major = proximal gland damage involving the head with duct disruption
- Intermediate = distal gland damage with duct disruption
- Minor = contusion or laceration that does not include damage to the main ducts
85
What x-ray signs suggest renal damage following trauma
- Loss of psoas shadow
- Enlarged kidney
- Fracture of overlying ribs/transverse processes
- Scoliosis from muscle spasm
86
Imaging of choice in suspected renal injury
CT with contrast
87
Outline the classification system used for renal trauma
```
1 = contusion, subscapular haematoma but intact renal capsule
2 = minor laceration of the cortex not involving the medulla or collecting system
3 = major laceration extending through the cortex and medulla but not involving the collecting system
4 = a major laceration extending into the collecting system
5 = completely shattered kidney or renal pedicle avulsion
```
88
List the absolute indications for renal exploration
- Persistent hypotension despite resus
- Expanding haematoma
- Disruption of the renal pelvis with leakage of urine
89
Most common cause of ureteric trauma
Iatrogenic in gynaecological surgery
90
Investigation of choice in suspected ureteric trauma
IV urogram
91
How is ureteric damage managed if immediately recognised
- Ligation of ureter
- Direct-end-to-end repair
- Bladder mobilised up to ureter
92
How is ureteric damage managed if delayed recognition
- Retrograde stent via bladder
- Nephrostomy to relieve obstruction
- Subsequent repair at 6 weeks
93
Where do tears of the bladder typically occur
Dome
94
How is bladder trauma assessed
Retrograde cystoscopy
95
When is retrograde urethrogram indicated
If there is any doubt regarding urethral trauma
96
How is urethral trauma classified
- Anterior = affects the penile and bulbar parts of the urethra
- Posterior = usually affects the membranous urethra
97
How does urethral trauma present
- Blood at urethral meatus
- Inability to void
- Palpably full bladder
- (Butterfly bruising of perineum in anterior injury)
98
Describe the 3 layers of a peripheral nerve
1. Endoneurium = connective tissue around individual axons
2. Perineurium = dense connective tissue surrounding fascicle
3. Epineurium = outermost layer of connective tissue
99
C5 motor test
Elbow flexion
100
C6 motor test
Wrist extension
101
C7 motor test
Elbow extension
102
C8 motor test
Flexes fingers
103
T1 motor test
Spreads fingers
104
L2 motor test
Flexes hip
105
L3 motor test
Extends knee
106
L4 motor test
Dorsiflexes foot
107
L5 motor test
Wiggles toes
108
S1 motor test
Plantarflexes toes
109
Corticospinal tract function
Fine limb control
110
Spinothalamic tract function
Light touch, temperature, pain, pressure
111
Spinoretucular tract function
Pain sensation from tissue injury
112
Spinocerebellar tract function
Proprioceptive feedback from muscles
113
Gracile fasciculus (Dorsal column) function
Gross touch, visceral pain, vibration
114
Consequence of dorsal column lesion
- Loss of vibration and proprioception
| - Tabes dorsalis, SACD
115
Consequence of spinothalamic tract lesion
Loss of pain, sensation and temperature
116
Consequence of Brown-Sequard syndrome
- Hemisection of the spinal cord
- Ipsilateral paralysis
- Ipsilateral loss of proprioception and fine discrimination
- Contralateral loss of pain and temperature
117
Describe a Jefferson fracture
- Blow-out fracture of C1
| - Best viewed on open-mouth view
118
Outline the 3 types of odontoid fractures
- Type 1 = above the base
- Type 2 = across the base
- Type 3 = fracture extends into vertebral body
