JC Block C - Emergency Medicine (II) Flashcards
4S for resuscitation preparation
Goals of initial trauma assessment
o To rapidly identify and treat life-threatening injuries
o To prevent secondary injury from hypoxia and decreased tissue perfusion (shock)
o To control pain (give morphine)
o To plan definitive care and patient transfer to appropriate facilities
General ED approach to all trauma patients**
1) Triage
2) Primary survey (in 5 mins) - identify and resuscitate life-threatening injuries one at a time
- ABCDE
- Adjunctive tests and investigations
3) Secondary survery
- Head to toe exam
4) Definitive care - on-site treatment or transfer
Emergency Assessment of airway patency
Assess quickly by talking to him:
Ask the patient his/her name (confirm identity)
Ask the patient what happened
A right answer confirms:
- Patent airway
- Adequate ventilation to permit speech
- Sufficient perfusion (adequate circulation to brain)
- Clear sensorium (at least not comatose)
Why is C-spine damage rapidly fatal
High C-spine injury (C3-5) impairs respiratory drive
Rapidly progress into respiratory arrest
Management of the following airway complications:
Blood / secretions in airway
Vomitus aspiration
Foreign objects in airway
Blood / secretions in airway - Suction with a Yankauer suction catheter
Vomitus
Log roll to lateral position
Suction with a Yankauer suction catheter
Foreign objects in airway - Removal with MaGill forceps/ suction
First line airway protection measures for comatose patient
OPA – watch out for gag reflex which may induce vomiting
NPA – avoid if basal skull fracture suspected (to avoid injuring the brain)
Endotracheal tube (ETT) if GCS <8
First-line measure for thermal airway injury
Thermal airway injury signs
Prophylactic intubation (subsequent airway obstruction due to swelling (oedema) would make intubation impossible)
Thermal airway injury: Burnt nasal hairs Carbonaceous sputum Facial burns Stridor
First-line measure for Maxillofacial trauma patient
Surgical airway – cricothyrotomy (anticipate difficult airway because of bleeding, swelling, distorted anatomy)
Criteria for C-spine imaging
cervical spine imaging (prefer CT initially) if fail to meet any one of the
National Emergency X-Radiography Utilization Study (NEXUS) Criteria:
No posterior midline cervical spine tenderness No evidence of intoxication Alert mental status No focal neurological deficits No painful distracting injuries
Breathing protection measure in a trauma patient
Give O2 15L/min via a non-rebreathing mask
Circulation assessment in emergency
Signs of poor circulation
Any source of bleeding:
1) Thoracic cavity, abdominal cavity, retroperitoneal cavity, pelvic cavity
2) Thigh bone fracture
3) External bleeding
Altered mental status (a lack of cerebral perfusion)
Tachycardia (1st sign) and hypotension
Skin colour and pale extremities
Auscultate: Muffled heart sounds, Unequal breath sounds
Palpate: Pulse volume and rate Cold extremities Capillary refill >3s Tracheal deviation
Monitor: BP/P, pulse pressure, urine output
Causes of acute hypotension/ shock
Haemorrhage (must be the cause in trauma until proven otherwise)
Obstructive shock (tension pneumothorax, cardiac tamponade)
Neurogenic shock: Due to cervical spinal cord injury above T6 level
Pathophysiology of neurogenic shock
Due to cervical spinal cord injury above T6 level
Loss of sympathetic arterial tone vasodilatation (warm skin, non- sweaty), low BP
Loss of sympathetic innervation to the heart unopposed vagal parasympathetic innervation slow pulse
Slow respiratory rate
How to estimate blood pressure on P/E
Measures to control acute external bleeding in a trauma patient
Control haemorrhage (stop the bleeding):
Direct pressure for external bleeding, elevate
Apply tourniquet for exsanguinating limb bleeding not controlled by direct pressure (tighten till no radial pulse – maximum 4h)
Pelvic binder for pelvic fracture (tamponade effect)
Reduction and traction of thigh bone fracture
Definitive surgery based on the underlying injury
Measures to preserve circulation in a trauma patient
Stop bleeding first
1) Set 2 large-bore IV catheters in the antecubital fossae (14 or 16 G) or intraosseous route in case of difficult venous access
Crystalloid: normal saline 0.9% or Ringer Lactate solution 2L IV bolus
When internal bleeding is not controlled, maintain ‘permissive hypotension’ with systolic BP ~90 mm Hg
2) Draw blood for T&S, prepare for blood transfusion
- still unstable after 2 L of fluid or having on-going blood loss, transfuse unmatched type O blood:
- If transfuse >10 units of packed red cells within 24 hours of trauma, transfuse at an 1:1:1 ratio of packed red cells, platelet, and fresh frozen plasma to minimize coagulopathy
3) If presented within 3 hours, give IV tranexamic acid 1 g IV bolus followed by 1g over 10 min, followed by 1 g IV over 8 hours
Emergency treatment of cardiac tamponade
Subxyphoid pericardiocentesis (aspirating 15-20 ml of blood may improve the condition)
IV fluid bolus
Definite care – surgery
How to assess disability in a trauma patient
Emergency management of disability (e.g. low GCS, Low blood glucose…)
Disability management:
If GCS <8, intubate for airway protection to prevent asphyxia and aspiration
Assume C-spine injury for patient with altered mental status
Maintain oxygenation and perfusion
Correct hypoglycaemia and maintain euglycaemia
CT brain after stabilization of the patient
Definitive care based on the CT findings
Measures for adequate exposure in a trauma patient
o Remove/ cut all clothing - examine the entire body for evidence of injury (including axillae, groin)
o Perform log-roll maneuver - examine the patient’s back (perform per rectal examination for anal tone)
o Cover patient with warm blankets to:
Prevent heat loss/ maintain normal temperature (hypothermia can lead to coagulopathy)
Protect patient’s privacy
Primary survey adjunctive tests
Primary survey adjuncts:
1) Trauma series: CXR, X-ray pelvis (AP) +/- X-ray C-spine (lateral)
2) Blood for CBC, L/RFT, clotting profile, T&S, ABG
3) E-FAST (focused assessment with sonography for trauma) scan
4) ECG if indicated
5) Foley catheter for urine output monitoring (avoid in urethral injury)
6) Nasogastric tube to empty the stomach (orogastric tube if basal skull fracture)
7) Urine for pregnancy test if indicated
E-FAST (focused assessment with sonography for trauma) scan
Views?
Any fluid is blood until proven otherwise
- The pericardial view - for cardiac tamponade
- The right upper quadrant view (including interfaces of the diaphragm, liver, right kidney, Morrison’s pouch)
- For diaphragm, liver and kidney, as well as the entire hepatorenal fossa or Morrison’s pouch, looking for fluid.
- presence of fluid between the diaphragm and liver or liver and kidney is blood until proven otherwise - The left upper quadrant view (including the diaphragm-spleen interface, spleen-kidney interface)
- Suprapubic view (bladder, bowel)
- obtain prior to placement of a Foley catheter.
Head exam for acute trauma
Scalp wound bleeding/ haematoma
Evidence of skull base fracture (e.g. haemotympanum)
Epistaxis/ septal haematoma
Facial wounds and instability
o Airway protection for significant mid-face trauma
Teeth fracture, avulsion
Surgical emphysema/ haematoma over the neck
Trunk exam for acute trauma
Full CVS
Full Abdominal exam
Pelvis stability
Perineum and genital:
Blood in urethral meatus (urethral injury)
Per-rectal exam:
o For anal tone, blood, high-riding prostate (for man)
o Not performed in alert patients without evidence of pelvic/ spinal injury
Back Log roll for wounds
Limb exams for acute trauma
Extremities deformity, fractures, wounds
Peripheral pulse for vascular compromise
Complete neurological examination
Outline SAMPLE history in trauma
Pain management options for acute trauma
Open pneumothorax **
- Key features
- Treatment option
Key features: Respiratory distress Tachypnea Sucking chest wound**** Tachycardia only (no hypotension) ***** Decreased breath sound on affected side
Treatment:
1) Three-sided occlusive dressing over the sucking chest wound (use impermeable material, e.g. plastic gauze package, to create a one-way valve)
2) Followed by chest drain insertion
Tension Pneumothorax **
- Key features
- Treatment options
Key features: Respiratory distress Tachypnea Distended neck veins **** Shock: Tachycardia, hypotension **** Tracheal deviation to opposite side **** Hyper-resonance on the affected side ****
Treatment:
1) clinical diagnosis (no time for X-ray)
- Needle decompression: 14 or 16 G needle at 2nd ICS, mid-clavicular line
- Diagnosis confirmed by gust of air, return of breathing
2) Followed by chest drain insertion (at safety triangle)
Massive hemothorax
- Key features
- Treatment options
Key features: 1.5L blood in thoracic cavity Tachycardia, hypotension obtundation Percussion Dull on the affected side
Treatment:
1) Replace loss, stop bleeding
2) IV fluid resuscitation (large bore: 14 or 16 G)
3) Blood transfusion
4) Chest drain insertion
5) Definitive surgery – thoracotomy/ video- assisted thoracic surgery
Flail chest
- Key features
- Treatment options
Key features:
- > 2 rib fractures in >2 places
- Associated with underlying pulmonary contusion
- Paradoxical chest movement (segment is disconnected with the rest of ribcage)
- Decreased breath sound on the affected side
Treatment:
1) Supplemental O2
2) Judicial use of IV fluid (overzealous fluid replacement can lead to pulmonary oedema (ARDS))
3) Pain control (IV morphine)
4) Early intubation, mechanical ventilation (positive pressure)
Why is cervical spine immobilization important in trauma care?
Cervical spine has a high flexibility and mobility and is prone to injury
Cervical spinal cord injuries can cause permanent paralysis and can be fatal
All trauma patients were presumed to have neck injury until proven otherwise
Techniques for manual grips for in-line C-spine immobilization
o Keep the head and spine in the neutral position manually
o Avoid traction or compression as it increases the risk of spinal cord injury
Techniques:
1) Head grip
2) Trap squeeze
3) Chin grip
Head grip C-spine immobilization technique
Trap squeeze C-spine immobilization technique
Chin grip C-spine immobilization technique
Contraindications to C-spine neutral position
Patient resistance to movement Neck muscle spasm Increased neck pain Commencement/ increase of neurological deficit Compromise of the airway/ ventilation
In these situations, the patient’s head must be immobilized in the position in the which it was initially found
Rigid neck collar
Correct sizing method **
Correct movement restriction
Is rigid collar alone enough for immobilization??
Sizing: measure the gap between the top of the shoulder to the bottom of chin**
Movement restriction: If properly sized, can limit:
Flexion by 90%
Extension, lateral flexion, and rotation by 50%
The neck collar must not inhibit the patient’s ability to open the mouth or the provider’s ability to open the patient’s mouth
Rigid neck collar alone does not provide adequate immobilization – must always be used with manual/ mechanical immobilization
Detrimental effects of poorly fitted rigid neck collar
Methods for applying rigid neck collar
Posterior-first method
Anterior-first method
Log - roll
Function
Indications
Principle: turn the patient in one piece (log) and minimize lateral/ rotational force onto the spine during turning (keep the patient’s entire body in neutral alignment)
Indications:
o Positioning a trauma patient onto a spinal board to facilitate patient transport
o Turning a trauma patient with suspected spinal injury to exam the back
Explain the roles of person A,B and C during log-roll
Log-roll
Procedure
spinal board and straps
Procedure
Complications of prolonged spinal board immobilization
o Pressure ulcers on bony prominence (>1h)
o Impaired respiration (due to excessive strapping over the chest)
o Risk of aspiration if the patient vomits - log roll the patient and the board as a unit and suction the airway as needed
Pelvic fracture
- Risk of mortality
- Treatment
Unstable pelvic fractures can result in life-threatening haemorrhage
blood loss as high as 2-3 units per break
mortality >25% esp elderly
Treatment: pelvic binder – SAM sling
Principle:
Limit the volume of the pelvic cavity to create a tamponade effect stop further bleeding
Provide safe and effective reduction and stabilization of pelvic fractures
SAM sling
Procedure
Femur fracture
- Risk
- Treatment
Risk: 1-2 L of blood can accumulate in the thigh at the site of femur fracture
Treatment:
Apply a traction splint(aka hare splint) - a metal frame that extends from the proximal end of the thigh to a point distal to the heel
Functions:
Realign fracture fragments and decrease the potential space in the thigh for blood loss
Immobilize a fractured femur
Reduce pain
Prevent further damage to neurovascular structures
Traction splint/ hare splint
- Indications
- Contraindications
Indication: suspected femur shaft fracture, as suggested by limb shortening/ deformity/ swelling/ crepitus/ ecchymosis of the injured thigh
Contraindications:
Pelvic fractures, hip injuries with gross displacement
Open femur fracture
Significant knee injuries
Avulsion/ amputation of the ankle/ foot
Distal tibia-fibula or ankle fracture in the same extremity
Procedure for traction splint
SAM splint
- Construction
- Use
Used for temporary splinting in A&Es and ambulances in Hong Kong
= thin core of soft aluminum alloy sandwiched between two layers of foam
Malleable (creating curves can add strength to the splint), lightweight, waterproof, radiolucent, and reusable
SAM splint for wrist
Procedure
Procedure for roller bandage on SAM wrist splint
Arm sling procedure
