General Trauma Flashcards
What is the definition of Strangulation
Asphyxia due to external pressure on the airway and vascular structures of the neck
In anterior neck trauma, pain on tongue movement can indicate?
Epiglotitis
Hyoid bone injury
Laryngeal cartilage injury
What does Horners syndrome suggest in neck injuries?
Ipsilateral carotid artery or ascending sympathetic trunk injury
What head injuries are particularly associated with neck neurovascular injuries
LeFort 2/3 fractures
Diffuse axonal injury
Base of skull fractures
What are the grades of BCVI in neck trauma?
1- intimal irregularity, <25% narrowing
2- dissection or intramural haematoma with >25% narrowing
3- Pseudoaneurysm
4- Occlusion
5- Transection with extravasation
What are the indications and contraindications for emergency cricothyroidotomy?
Indications
- CICO
Contraindications
- Other ways of intubating are still available
- Age <10 (needle cric preferred)
Central line insertion indications?
Volume resuscitation
CVP monitoring
Central venous blood sampling
Emergency vascular access
Infusion of irritant medications (vasoactives, chemo etc)
Central line contraindications?
Absolute
- Infection at site
- Burn >3days old at site
- Venous injury or other significant trauma downstream to the site
Relative
- Coagulopathy
- Distorted local anatomy
- Known thrombus in vessel
- Uncooperative patient
What is the maximum period of time suction should be applied to a chest drain?
24hrs
Beyond this suction can start to cause transudates and thus loss of plasma components, also suction itself is painful
What are the indications for suction on a chest tube in trauma?
Large haemothorax
Persistent air leak overwhelming the normal underwater seal mechanism
What are the indications for Escharotomy in a burns patient?
Limb hypoperfusion
- Reduction in flow with repeat doppler or absent peripheral pulses
- sats <95% in a circumferentially burned limb, normal sats elsewhere
- Compartment pressure >40mmHg
Ventilation restriction (chest wall and upper abdomen)
- elevated peak pressures
- Persistent arterial hypercapnia
- Prophylactic in paeds patients (diaphragm breathers)
Circumferential burns of the neck
- Prophylactic vs imminent airway compromise
- May also compromise blood flow
What are the indications for Retrieval Limb Amputation?
- Deteriorating patient trapped by limb
- Dangerous environment needing urgent extraction
- Non-survivable limb impeding extraction
- Patient is dead but their limbs are blocking access to living patients
- Limb extraction impossible despite all efforts
What is a blast injury?
A complex physical trauma related to direct or indirect exposure to an explosion
What are the 4 types of blast injury?
Primary- Direct effects of pressure from the blast wave, typically damages hollow air filled organs such as ears, lungs, bowel etc
Secondary- Projectile injuries (shrapnel)
Tertiary- Effects from being thrown by wind ie falling, hitting hard surfaces
Quaternary- All else, ie burns, inhalation, asphyxia etc
What strength of blast is typically considered lethal?
Pressure waves above 60-80psi
What is Boerhave syndrome?
Significant oesophageal rupture
- Usually due to forceful vomiting
- May also be secondary to chest/abdo blunt trauma, valsalva etc
What are the differentials for causes of pneumomediastinum?
Oesophageal perforation
Tracheobronchial perforation
Spreading infection
Vigorous exertion
Asthma
Barotrauma
Interstitial lung disease
Connective tissue disease
Idiopathic
Ideally how should a cervical collar fit?
It should brace both the mandible and occiput against the top of the shoulders
What is spinal shock?
Spinal shock is not a true form of shock. It refers to the flaccid areflexia that may occur after spinal cord injury, and may last hours to weeks. It may be thought of as ‘concussion’ of the spinal cord and resolves as soft tissue swelling improves. Priapism may be present.
Spinal shock if at a level above T6 can lead to neurogenic shock while it lasts
What is Neurogenic shock?
Neurogenic shock is classically characterised by hypotension, bradycardia and peripheral vasodilatation. Neurogenic shock is due to loss of sympathetic vascular tone and happens only after a significant proportion of the sympathetic nervous system has been damaged – as may occur with lesions at the T6 level or higher.
What is the Denver criteria in trauma used for?
A set of screening criteria used to detect blunt cerebrovascular injury (BCVI) and guide the need for CT angiography
What are the denver criteria signs/symptoms?
What are the Denver criteria risk factors?
Apart from external blood loss, what areas can life threatening bleeding occur?
Chest
Abdomen (+ retroperitoneum)
Pelvis
Thigh
Head (only in small babies/newborns)
What is the most common type of ICH in head trauma?
Subdural haemorrhage
When is thoracic surgery indicated for bleeding post insertion of a chest tube?
If more than 1500mls is evacuated post initial insertion
>200mls/hr for 3hrs consecutive
>100mls/hr for >6hrs consecutive
What are the pros and cons of taking an unstable trauma patient to the CT?
- CT can define the injuries and allow for easier/targeted operative management
- CT can identify missed injuries ie occult head injury or contained aortic transection
- CT of the pelvis can determine if IR is the better choice for management
- Patient may die in CT
What is the importance of TXA? What are the contraindications? What are the adverse effects?
- CRASH-2 trial showed a reduction of 1.5% in all cause mortality for major trauma with no increased rate of thromboembolic disease
- Antifibrinolytic agent
- 1gm initially then 1gm over 8hrs
- Should be given within 3hrs of trauma
Contraindications
- Known TXA allergy (absolute)
- Known pro-coagulant disorder (relative)
- >3hrs since the trauma (relative)
Adverse effects
- Seizures
- VTE
- Visual disturbance
- GI upset
How can spinal shock be differentiated from a complete cord transection?
Both have flaccid paralysis and areflexia
However the bulbocavernosus reflex is still present in a cord transection (loss of supraspinal inhibition) whereas it is absent in spinal shock
How does a central cord syndrome present?
Weakness to the upper limbs proportionally greater than the lower limbs
Altered sensation below level of cord injury
Caused by the upper limb fibres being closer to the centre of the cord than the lower limb fibres, thus damaged first
Usually in older people post minor trauma who have cervical spondylosis
How does an anterior cord syndrome present?
Usually reflects an injury to the anterior spinal artery or direct injury from a retropulsed fragment/disc
Weakness/pralaysis and loss of pain + temperature sensation
Proprioception and vibratory sensation remain intact
How does Brown-Sequard (hemisection) syndrome present?
Loss of pain on temperature on the opposite side
Loss of proprioception, vibration and paralysis on the ipsilateral side
Most common cause is acute trauma such as bullets and stabbing
How does cauda equina syndrome usually present?
- Low back pain usually with pain radiating into both legs, if this is present alone can be difficult to distinguish from sciatica
- S1/2 roots loss of ankle jerks and weakness of plantar flexion
- S3-5 give bladder and rectal sphincter dysfunction
- Loss of sensation in dermatome of affected levels, ie saddle anaesthesia with S3-5
What are some of the immediate complications of spinal cord injury that need managment in the ED?
- Neurogenic shock
- Respiratory failure
- Expanding haematoma in the neck
- Urinary retention
- Aspiration
- Hypothermia from reduced autonomic regulation
- Pressure areas (if delay to transfer)
What are the typical ECG changes in blunt cardiac injury (BCI)?
- Persistent sinus tachycardia (most common)
- Atrial fibrillation
- PVT post commotio cordis
- SVT’s
- New STE/STD
- Non-specific TWI
- New bundle branch blocks
What are the complications of chest drain insertion?
What are the indications for emergent surgery in abdominal trauma?
Gun shot wound
Evisceration
Peritonism
FAST+ve and hypotensive
Penetrating wound and hypotensive
Ruptured diaphragm
Free gas in abdomen on scans
What is the difference between and emergency thoracomtomy and a resuscitative thoracotomy?
Resuscitative- performed in ED or pre-hospital, peri/actual arrest
Emergency- Performed in theatre, not immediately peri-arrest or arrested but likely unstable
What are the indications for an emergency thoracotomy?
Cardiac tamponade
traumatic loss of chest wall
Massive air leak from chest tube
Massiv continuous haemothorax
Vascular injury causing continuopus haemorrhage at thoracic outlet
What are the indications for resuscitative thoracotomy
- SBP <70 with penetrating thoracic trauma despite resuscitation (blood and pleural decompression)
Or - Penetrating thoracic trauma with cardiac arrest but signs of life <15mins ago
Or - Blunt thoracic trauma with cardiac arrest and tamponade on EFAST
What are the contraindications to Resuscitative thoracomtomy?
- Unsurvivable injuries
- Staff not trained
- Advanced age/co-morbidities
- ACF or GOC in place not for heroic treatments
- Non-thoracic trauma with cardiac arrest
What are the therapeutic interventions that can be performed once a resuscitative thoracotomy is done?
- Pericardotomy (tamponade)
- Close cardiac lacerations
- Compression or cross clamping of descending thoracic aorta
- Internal cardiac compressions
- Stop pulmonary haemorrhage ie hilar twist
- R) atrial cath to give fluids, drugs and blood products
- Control of bronchovenous air embolism
What are the differences between the anterolateral and clamshell approaches to thoracotomy?
Anterolateral
- Less morbidity
- Easier to close
- Fast access to the heart
- Limited overall access (ie the right side)
- Limited interventions
- Anatomy can be obscure
Clamshell
- Greater exposure
- Simultaneous interventions
- More easily identifieable anatomy
- access both pleural cavities
- Easier for non-surgeons to perform
- More difficult to close
- Greater morbidity
What are the main blocks used for rib fracture pain control?
- Serratus anterior
- Erector spinae
- Paravertebral
- Intercostal
- Can also use thoracic epidural in severe cases but needs close monitoring
