List I - Core Conditions Flashcards

Question

What is the recommended definitive treatment of distal radius fractures in adults (skeletally mature)?

Answer 1

* Consider manipulation and a plaster cast in adults with dorsally displaced distal radius fractures * When surgical fixation is needed for dorsally displaced radius fractures in adults (skeletally mature): * Offer k-wire if: - No fracture of the articular surface of the radial carpal joint is detected or - Displacement of the radial carpal joint can be reduced by closed manipulation * Consider open reduction and internal fixation if closed reduction of the radial carpal joint surface is not possible

Answer 2

* In children (skeletally immature) with dorsally displaced distal radius fractures (including fractures involving a growth plate) who have undergone manipulation, consider: - A below elbow plaster cast or - K-wire fixation if the fracture is completely displaced (off-ended)

Answer 3

* Offer - Oral ibuprofen or oral paracetamol, or both for mild to moderate pain - Intranasal or IV opioids for moderate to severe pain (use IV opioids if IV access has been established)

Answer 4

* Offer - Oral paracetamol for mild pain - Oral paracetamol and codeine for moderate pain - IV paracetamol supplemented with IV morphine titrated to effect for severe pain (Use IV opioids in caution in frail or older adults) (Do not offer NSAIDs to frail or older adults with fractures)

Answer 5

* Consider a femoral nerve block or fascia iliac block in the ED

Answer 6

* Consider IV regional anaesthesia (Bier's block) in the ED * Can be performed by health care practitioners trained in the technique (not necessarily anaesthetics) * Do not use gas and air (nitrous oxide and oxygen) on its own

Answer 7

* Admit all and consider 1 of the following according to age: - Prematurity and birth injuries - simple padded splint - 0 to 6 months - Pavlik's harness or Gallows traction - 3 to 18 months (but not children over 15 kg) - Gallows traction - 1 to 6 years - straight leg skin traction (impractical in children over 25 kg) with possible conversion to hip spica cast to enable early discharge - 4 to 12 years (not children over 50 kg) - elastic intra-medullary nail - 11 years to skeletal maturity (weight more than 50 kg) - elastic intra-medullary nails supplemented by end-caps, lateral entry ante-grade rigid intra-medullary nail or sub-muscular plating

Answer 8

* Consider advising immediate unrestricted weight bearing as tolerated for people who have had surgery for distal femoral fractures

Answer 9

* In the pre-hospital setting, consider the following for people with suspected long bone fractures of the legs: - Traction splint of adjacent leg splint if the suspected fracture is above the knee - Vacuum splint for all other suspected long bone fractures

Answer 10

* For adults (skeletally mature) with displaced low energy proximal humerus fractures: - Offer non-surgical management for definitive treatment of uncomplicated injuries - Consider surgery for injuries complicated by an open wound, tenting of the skin, vascular injury, fracture dislocation or a splint of the humeral head

Answer 11

* Common site of fracture especially in osteoporotic, elderly females. * Blood supply to the femoral head runs up the neck and thus avascular necrosis is a risk in displaced fractures * Pain * Classical signs are a shortened and externally rotated leg

Answer 12

* Location - Intra-capsular - Extra-capsular * Garden system - Type I - Type II - Type III - Type IV

Answer 13

* Intra-capsular | - Sub-capital: from the edge of the femoral head to the insertion of the capsule of the hip joint

Answer 14

* Extra-capsular | - Can either be trochanteric or subtrochanteric (lesser trochanter is the dividing line)

Answer 15

* Type I - Stable fracture with impaction in valgus * Type II - Complete fracture but undisplaced * Type III - Displaced fracture, usually rotated and angulated, but still has boney contact * Type IV - Complete boney disruption * Blood supply disruption is most common following types III and IV

Answer 16

* Un-displaced hip fracture | - Internal fixation, or hemi-arthroplasty if unfit

Answer 17

* Displaced hip fracture - Young and fit i.e. <70 years - reduction and internal fixation (if possible) - Older and reduced mobility - hemi-arthroplasty or total hip replacement NB offer total hip replacement rather than hemi-arthroplasty to patients with a displaced intra-capsular hip fracture who: - Were able to walk independently out of doors with no more than the use of a stick and - Are not cognitively impaired and - Are medically fit for anaesthesia and the procedure

Answer 18

* Extra-capsular hip fracture - Dynamic hip screw - If reverse oblique, transverse or sub-trochanteric intra-medullary device

Answer 19

* MRI | * CT if MRI not available within 24 hours

Answer 20

* Operate on patient with the aim to allow them to fully weight bear (without restriction) in the immediate post-operative period

Answer 21

* The Hip Fracture Programme!

Answer 22

* Primary brain injury | * Secondary brain injury

Answer 23

* Focal - contusion or haematoma | * Diffuse - diffuse axonal injury

Answer 24

* Result of mechanical shearing following deceleration, causing disruption and tearing of axons

Answer 25

* Extradural * Subdural * Intra-cerebral

Answer 26

To the side of impact: * Adjacent to (coup) * Contra-lateral to (contre-coup)

Answer 27

* When cerebral oedema, ischaemia, infection, tonsillar or tentorial herniation exacerbates the original injury * Normal cerebral auto regulatory processes are disrupted following trauma rendering the brain more susceptible to blood flow changes and hypoxia

Answer 28

* Hypertension and bradycardia - often occurs late and is a pre-terminal event

Answer 29

* Bleeding into the space between the dura mater and the skull * Often results from acceleration-deceleration trauma or a blow to the side of the head * Majority of epidural haematomas occur in the temporal region where skull fractures cause a rupture of the middle meningeal artery Features: * Raised intra-cranial pressure * Some patient may exhibit a lucid interval

Answer 30

* Bleeding into the outermost menigeal layer most commonly occurs around the frontal and parietal lobes * Risk factors include older age, alcoholism and anti-coagulation * Slower onset of symptoms than epidural haematoma * May be fluctuating confusion/consciousness

Answer 31

* Classically causes a sudden occipital headache * Usually occurs spontaneously in the context of a ruptured cerebral aneurysm but may be seen in association with other injuries when a patient has sustained a traumatic brain injury

Answer 32

* Collection of blood between the skull and the dura * Caused by low impact trauma * Classically presents with: - Loss of consciousness - Lucid interval then rapid decline in consciousness - Mass effect on the brain will cause uncal herniation and a fixed, dilated pupil due to third cranial nerve compression

Answer 33

* CT imaging will show hyperdense (bright) * Biconvex (or lentiform) collection around the surface of the brain * Definitive management is craniotomy and evacuation of the haematoma

Answer 34

* Fresh collection of blood under the layer of the dura mater of the meninges * Most commonly caused by trauma but can be caused by vascular lesions e.g. arteriovenous malformations * Typically caused by high speed injuries or acceleration-deceleration injuries and is therefore commonly associated with other brain injuries * Spectrum of severity of clinical presentation from an asymptomatic patient to severely comatose

Answer 35

* CT imaging will show hyperdense (bright) cresenteric collection surrounding the brain that is not limited by suture lines * Definitive treatment is a decompression craniotomy

Answer 36

* Old collection of blood that is under the layer of the dura mater of the meninges * More common in elderly patients, alcoholics, people on anti-coagulation or in infants due to fragility and/or predisposition of the bridging veins to bleed * Patients typically present several weeks after a mild head injury with progressive confusion, loss of consciousness, weakness or higher cortical function

Answer 37

* CT imaging will show a hypodense (dark), cresenteric collection around the surface of the brain that is not limited by suture lines * In symptomatic patients, definitive treatment is burr hole drainage

Answer 38

* Intra-cerebral or intra-parenchymal haemorrhage is a collection of blood within the substance of the brain * Causes include: - Hypertension - Vascular lesion - e.g. aneurysm or arterio-venous malformation - Cerebral amyloid angiopathy - Brain tumour or infarct (e.g. in stroke patients undergoing thrombolysis) * Patients present similarly to ischaemic stroke - therefore crucial to obtain a CT head in all stroke patients prior to thrombolysis or with decrease in consciousness

Answer 39

* CT imaging will show hyperdense (bright lesion) within the substance of the brain * Treatment is often conservative under the care of stroke physicians * Large clots in patients with impaired consciousness may warrant surgical evacuation

Answer 40

* SAH is a bleed into the subarachnoid space which is deep to the subarachnoid layer of the meninges * Most common cause is trauma * In non-traumatic (spontaneous) SAH, the most common cause is a ruptured aneurysm but can be caused by an arteriovenous malformation, mycotic aneurysm, pituitary apoplexy or can be idiopathic * Classical presentation of spontaneous SAH is a sudden onset severe headache, neck stiffness and photophobia

Answer 41

* CT imaging will show hyperdensity within the cisterns or the brain and the sulci * In cases where the clinical diagnosis is certain but the Ct imaging is inconclusive, a lumbar puncture should be performed after 12 hours to look for xanthochromia * Treatment is directed at the cause of the bleed

Answer 42

* Intra-ventricular haemorrhage is a collection of blood within the ventricular system of the brain * In children it can occur due to the prematurity of the periventricular vascular structures * In adults it may be caused by an extension of SAH, vascular lesions (e.g. aneurysms or arteriovenous malformations) or tumours * In neonates the vast majority of IVH occur in the first 72 hours after birth - mechanism suggested is result of birth trauma combined with cellular hypoxia and delicate neonatal CNS

Answer 43

* CT imaging appears as hyper-density within the dark CSF spaces within the ventricles * Patients with intra-ventircular haemorrhage at risk of obstructive hydrocephalus and this would require surgical CSF diversion

Answer 44

If patients have any of the following: * Any loss of consciousness (knocked out) as a result of the injury from which the person has now recovered * Amnesia for events before or after the injury (problems with memory) * Persistent headache since the injury * Any vomiting episodes since the injury * Any previous brain surgery * Any history of bleeding or clotting disorders * Current anticoagulant therapy * Current drug or alcohol intoxication * Any safe guarding concerns (e.g. non accidental injury or a vulnerable person is affected) * Irritability or altered behaviour (easily distracted, not themselves, no concentration, no interest in things around them) particularly in infants and children under 5 years * Continuing concern by helpline staff about the diagnosis

Answer 45

If any of the following are present, refer to the emergency department: * GCS <15 on initial assessment * Any loss of consciousness as a result of the injury * Any focal neurological deficit since the injury * Amnesia for events before or after the injury * Persistent headaches since the injury * Any vomiting episodes since the injury * Any seizure since the injury * Any previous brain surgery * A high energy head injury * Any history of bleeding or clotting disorders * Current anti-coagulant therapy * Current drug or alcohol intoxication * Safeguarding concerns * Continuing concern by the professional about the diagnosis

Answer 46

* Irritability or altered behaviour, particularly in infants and children aged under 5 years * Visible trauma to the head * No one is able to observe the injured person * Continuing concern by the injured person or their family or carer about the diagnosis

Answer 47

* Attempt full cervical spine immobilisation for patients who have sustained a head injury and present with any of the following risk factors (unless other factors prevent this): - GCS less than 15 in initial assessment by the healthcare professional - Neck pain or tenderness - Focal neurological deficit - Paraesthesia in the extremities - Any other clinical suspicion of cervical spine injury (Maintain cervical spine immobilisation until full risk assessment including clinical assessment (and imaging if necessary) indicates it is safe to remove the immobilisation device

Answer 48

* Problems restricted to a particular part of the body or a particular activity, for example, difficulties with understanding, speaking, reading or writing, decreased sensation, loss of balance, general weakness, visual changes, abnormal reflexes and problems walking

Answer 49

* For example, pedestrian struck by motor vehicle, occupant ejected from motor vehicle, fall from a height of greater than 1 metre or more than 5 stairs, diving accident, high speed motor vehicle collision, rollover motor accident, accident involving motorised recreational vehicles, bicycle collision, or any other potentially high energy mechanism

Answer 50

* Signs include clear fluid running from the ears or nose, black eye with no associated damage around the eyes, bleeding from one or both ears, bruising behind one or both ears, penetrating injury signs, visible trauma to the scalp or skull of concern to the professional

Answer 51

* Stabilisation of ABC is done before attention to other injuries * Patients with impaired consciousness GCS <15 should be assessed immediately * GCS 8 or less should ensure early involvement of anaesthetist or critical care physician for definitive airway management (ET tube) * Trained member of staff should assess all patients presenting to the ED with a head injury within a maximum of 15 minutes or arrival at hospital - part of this assessment should establish whether they are high risk or low risk for clinically important brain injury and/or cervical spine injury

Answer 52

* Any of the following risk factors present following head injury in adults, perform a CT head scan within 1 hour of the risk factor being identified: - GCS less than 13 on initial assessment in the emergency department. - GCS less than 15 at 2 hours after the injury on assessment in the emergency department. - Suspected open or depressed skull fracture. - Any sign of basal skull fracture (haemotympanum, 'panda' eyes, cerebrospinal fluid leakage from the ear or nose, Battle's sign). - Post-traumatic seizure. - Focal neurological deficit. - More than 1 episode of vomiting A provisional written radiology report should be made available within 1 hour of the scan being performed.

Answer 53

* Any of the following risk factors who have experienced some loss of consciousness or amnesia since the injury, perform a CT head scan within 8 hours of the head injury: - Age 65 years or older. - Any history of bleeding or clotting disorders. - Dangerous mechanism of injury (a pedestrian or cyclist struck by a motor vehicle, an occupant ejected from a motor vehicle or a fall from a height of greater than 1 metre or 5 stairs). - More than 30 minutes' retrograde amnesia of events immediately before the head injury A provisional written radiology report should be made available within 1 hour of the scan being performed.

Answer 54

* Any of the following risk factors present following head injury in children, perform a CT head scan within 1 hour of the risk factor being identified: - Suspicion of non-accidental injury - Post-traumatic seizure but no history of epilepsy. - On initial emergency department assessment, GCS less than 14, or for children under 1 year GCS (paediatric) less than 15. - At 2 hours after the injury, GCS less than 15. - Suspected open or depressed skull fracture or tense fontanelle. - Any sign of basal skull fracture (haemotympanum, 'panda' eyes, cerebrospinal fluid leakage from the ear or nose, Battle's sign). - Focal neurological deficit. - For children under 1 year, presence of bruise, swelling or laceration of more than 5 cm on the head. A provisional written radiology report should be made available within 1 hour of the scan being performed. * For children who have sustained a head injury and have more than 1 of the following risk factors perform a CT head scan within 1 hour of the risk factors being identified: - Loss of consciousness lasting more than 5 minutes (witnessed). - Abnormal drowsiness. - Three or more discrete episodes of vomiting. - Dangerous mechanism of injury (high-speed road traffic accident either as pedestrian, cyclist or vehicle occupant, fall from a height of greater than 3 metres, high-speed injury from a projectile or other object). - Amnesia (antegrade or retrograde) lasting more than 5 minutes A provisional written radiology report should be made available within 1 hour of the scan being performed.

Answer 55

Observe for a minimum of 4 hours after the head injury, if during observation any of the following risk factors are identified, perform a CT head scan within 1 hour: - GCS less than 15. - Further vomiting. - A further episode of abnormal drowsiness A provisional written radiology report should be made available within 1 hour of the scan being performed. If none of these risk factors occur during observation, use clinical judgement to determine whether a longer period of observation is needed.

Answer 56

* For patients (adults and children) who have sustained a head injury with no other indications for a CT head scan and who are having anticoagulant treatment, perform a CT head scan within 8 hours of the injury. A provisional written radiology report should be made available within 1 hour of the scan being performed.

Answer 57

For adults who have sustained a head injury and have any of the following risk factors, perform a CT cervical spine scan within 1 hour of the risk factor being identified: - GCS less than 13 on initial assessment. - The patient has been intubated. - Plain X-rays are technically inadequate (for example, the desired view is unavailable). - Plain X-rays are suspicious or definitely abnormal. - A definitive diagnosis of cervical spine injury is needed urgently (for example, before surgery). - The patient is having other body areas scanned for head injury or multi-region trauma - The patient is alert and stable, there is clinical suspicion of cervical spine injury and any of the following apply: * Age 65 years or older * Dangerous mechanism of injury (fall from a height of greater than 1 metre or 5 stairs; axial load to the head, for example, diving; high-speed motor vehicle collision; rollover motor accident; ejection from a motor vehicle; accident involving motorised recreational vehicles; bicycle collision) * Focal peripheral neurological deficit * Paraesthesia in the upper or lower limbs. A provisional written radiology report should be made available within 1 hour of the scan being performed

Answer 58

For adults who have sustained a head injury and have neck pain or tenderness but no indications for a CT cervical spine scan, perform 3 view cervical spine x-rays within 1 hour if either of these risk factors are identified: - It is not considered safe to assess the range of movement in the neck - Safe assessment of range of neck movement shows that the patient cannot actively rotate their neck to 45 degrees to the left and right The x-rays should be reviewed by a clinician trained in their interpretation within 1 hour of being performed.

Answer 59

* Range of movement in the neck can be assessed safely before imaging only if no high risk factors and at least one of the following low risk features apply, the patient was: - Involved in a simple rear end motor vehicle collision - Comfortable in a sitting position in the emergency department - Has been ambulatory at any time since injury - Has no midline cervical spine tenderness - Presents with delayed onset of neck pain

Answer 60

For children who have sustained a head injury, perform a CT cervical spine scan only if any of the following apply (because of the increased risk to the thyroid gland from ionising radiation and the generally lower risk of significant spinal injury): - GCS less than 13 on initial assessment. - The patient has been intubated. - Focal peripheral neurological signs. - Paraesthesia in the upper or lower limbs. - A definitive diagnosis of cervical spine injury is needed urgently (for example, before surgery). - The patient is having other body areas scanned for head injury or multi-region trauma. - There is strong clinical suspicion of injury despite normal X-rays. - Plain X-rays are technically difficult or inadequate. - Plain X-rays identify a significant bony injury. The scan should be performed within 1 hour of the risk factor being identified. A provisional written radiology report should be made available within 1 hour of the scan being performed.

Answer 61

For children who have sustained a head injury and have neck pain or tenderness but no indications for a CT cervical spine scan, perform 3-view cervical spine X-rays before assessing range of movement in the neck if either of these risk factors are identified: - Dangerous mechanism of injury (that is, fall from a height of greater than 1 metre or 5 stairs; axial load to the head, for example, diving; high-speed motor vehicle collision; rollover motor accident; ejection from a motor vehicle; accident involving motorised recreational vehicles; bicycle collision). - Safe assessment of range of movement in the neck is not possible (see recommendation 1.5.10). - The X-rays should be carried out within 1 hour of the risk factor being identified and reviewed by a clinician trained in their interpretation within 1 hour of being performed.

Answer 62

* Can cause severe problems even after the infection has resolved, such as stiffness, loss of strength and loss of tissues such as skin, nerve and bone

Answer 63

* Type of hand infection that involves painful throbbing of the pulp of the fingertip

Answer 64

* Type of hand infection that involves the para-onychium which is the area around the fingernail

Answer 65

* Atypical mycobacterial infections * Bite wound infections * Cellulitis * Deep space infections * Felon * Herpetic whitlow * MRSA * Necrotising fasciitis * Paronychia * Septic arthritis/osteomyelitis * Tendon sheath infection (infectious tenosynovitis)

Answer 66

* More common types are mycobacterium marinum infection * Can develop after puncture wounds from fish spines or contamination of a simple wound or abrasion from stagnant water * Develop gradually and may be associated with swelling and stiffness without much pain or redness * Surgical removal of infected tissue may be necessary and is helpful to determine which medicine will help treat the infection * Patients with impaired immunity are more susceptible to atypical mycobacterial infections

Answer 67

* Bacteria from the skin or from the mouth can cause infection in the case of human or animal bites * Thorough washing, soaking or even surgical drainage of the bite wound is needed to clear the infection and wounds are often left open so that any infection can drain * "Fight bites" to the joint of the hand sometimes result in a chipped tooth being left in the joint of the hand, the tooth needs to be removed to prevent infection of the joint * Rabies infection from an animal may be serious or even fatal, so it is important to seek treatment as soon as possible after a bite wound

Answer 68

* Can cause redness, warmth and pain * May include fever or sickness * Usually happens due to a break in the skin * Antibiotics are needed immediately and some people need to be admitted to hospital for treatment

Answer 69

* Hand is divided into many separate compartments or deep spaces * One or more space can become infected even from a small puncture wound * An abscess can form in the muscle area at the base of the thumb (thenar space), the palm (deep palmar space), or the web spaces between the fingers * These infections can spread to other areas, even to the wrist and the forearm - need to be drained by surgery

Answer 70

* Painful throbbing infection of the pulp of the finger is called a felon * Closed space is separated into many small compartments, each of which fills with infection and pus * Felon can occur after gardening or other activities that involve sharp objects near the finger tip * Some felons will resolve with soaks and oral anti-biotics but many also need to be drained * If not treated early, destruction of the soft tissues and even bone can occur

Answer 71

* Herpetic whitlow is a viral hand infection usually on the fingers, caused by a herpes virus * More commonly seen in healthcare workers whose hands may be exposed to the saliva of patients carrying herpes * Condition is characterised by small, swollen, painful blood tinged blisters and sometimes numbness * Typically treated conservatively and usually resolves in several weeks without many after effects

Answer 72

* Bacteria resistant to methicillin * Present in health care, nursing homes, gyms, dorms, houses and day care centres * Skin infections usually look like boils or collections of pus * Sometimes need draining * Immediate treatment is important to prevent infection spreading

Answer 73

* Very rare but severe infection * Streptococcus pyogenes or other flesh eating bacteria enter the body through a cut * Bacteria toxins destroy skin, mucous and other soft tissue * Emergency - can be life threatening - very strong IV anti-biotics are required to treat it * Urgent surgery is required to remove the dead tissue

Answer 74

* Infection of the paronychium which is the area around the fingernail * In acute paronychia, bacteria can cause the skin around the nail to be red, swollen and tender * Early treatment with soaks and oral antibiotics can cure the infection * If pus is formed under the skin, surgery to drain the pus is needed * Chronic paronychia is caused by fungus - usually occurs in people whose hands are frequently wet * Cuticle area becomes mildly red and swollen, without drainage and only mild tenderness

Answer 75

* Wound near a joint can cause septic arthritis * Can even be caused by a small needle used to drain a cyst at a joint * Urgent surgical drainage and antibiotics are needed *

Answer 76

* Tendons that bend the fingers run from the wrist, through the palm, up the palm side of the fingers, especially near a joint on the palm side, the canal that the flexor tendon runs through can get infected * Can cause stiffness or even destroy and pop the tendon * A finger with a tendon sheath infection is swollen, red, and tender over the palm side of the finger and the finger stays slightly bent and is painful to extend * This infection usually requires that the patient be admitted to the hospital for IV antibiotics, soaks and possible surgical drainage

Answer 77

* Majority involve cats and dogs | * Generally polymicrobial but the most common isolated organism is Pasteurella multocida

Answer 78

* Cleanse wound * Puncture wounds should not be sutured closed unless cosmesis is at risk * Current BNF recommendations are: - Co-amoxiclav or - If penicillin allergic - doxycycline + metronidazole

Answer 79

* Commonly cause multimicrobial infection, including both aerobic and anaerobic bacteria * Common organisms include: - Streptococci spp - Staphylococcus aureus - Eikenella - Fusobacterium - Prevotella * Risk of viral infections such as HIV and hepatitis C should also be considered

Answer 80

Relating to flexor tenosynovitis are 4 signs on physical examination: * Flexed posturing of the involved digit * Tenderness to palpation over the tendon sheath * Marked pain with passive extension of the digit * Fusiform swelling of the digit

Answer 81

* ABCDE approach * Airway maintenance with cervical spine protection * Breathing and ventilation * Circulation with haemorrhage control * Disability (neurological status) * Exposure and environmental control (completely undress the patient but avoid hypothermia)

Answer 82

* Aim to perform RSI within 45 minutes of the initial call to emergency services for patients who cannot maintain their airway and/or ventilation

Answer 83

* Consider using a supraglottic device if the patients airway reflexes are absent * Use basic airway manoeuvres and adjuncts if the patients airway reflexes are present or supra-glottic device placement is not possible * Transport the patient to a major trauma centre for RSI provided the journey time is 60 minutes or less * Only divert to a trauma unit for RSI before onward transfer if a patent airway cannot be maintained or the journey time to a major trauma centre is more than 60 minutes

Answer 84

* Assess for the diagnosis of pneumothorax for the purpose of triage or intervention * Consider use of eFAST to assist assessment if the equipment is available * Negative eFAST does not exclude pneumothorax * Perform chest decompression in a patient with suspected tension pneumothorax if there is haemodynamic instability or severe respiratory compromise * Use open thoracostomy instead of needle decompression if the expertise is available, followed by a chest drain via the thoracostomy in patients who are breathing spontaneously * Observe patients after chest decompression for signs of recurrence of the tension pneumothorax * Patients with an open pneumothorax: - Cover with a simple occlusive dressing and - Observe for the development of a tension pneumothorax

Answer 85

* In patients with tension pneumothorax, perform chest decompression before imaging only if they have either haemodynamic instability or severe respiratory compromise * Perform chest decompression using open thoracostomy followed by a chest drain in patients with tension

Answer 86

* Imaging for chest trauma patients should be performed urgently * Consider immediate chest x-ray and/or eFAST as part of the primary survey to assess chest trauma in adults with severe respiratory compromise * Consider immediate CT for adults with suspected chest trauma without severe respiratory compromise who are responding to resuscitation or whose haemodynamic status is normal * Chest x-ray and/or USS first line for chest trauma in children

Answer 87

* Simple dressings to control external haemorrhage * Tourniquet in patients with major limb trauma if direct pressure has failure to control life threatening haemorrhage * Pelvic binders if active bleeding is suspected from a pelvic fracture after blunt high energy trauma: - Apply a purpose made pelvic binder or - Consider an improvised pelvic binder (if purpose made not available) * IV tranexamic acid as soon as possible in patients with major trauma and active or suspected active bleeding - do not use IV TXA >3 hours after injury in patients with major trauma * Rapidly reverse anticoagulation - Use prothrombin complex concentrate immediately in adults with major trauma who have active bleeding and need emergency reversal of a vitamin K antagonist (do not use plasma to reverse a vitamin K antagonist) * Use physiological criteria to activate the major haemorrhage protocol (bleeding leads to a HR >110 bpm and/or systollic bp <90 mmHg * Use peripheral IV access or IO access

Answer 88

* Peripheral IV cannula or IO

Answer 89

* If haemorrhagic shock is the dominant condition, continue restrictive volume resuscitation or * If traumatic brain injury is the dominant condition, use a less restrictive volume resuscitation approach to maintain cerebral perfusion

Answer 90

* FFP:RBC 1:1 | * Follow the hospital major haemorrhage protocol

Answer 91

* Look * Feel * Move * Special test * Neuro-vascular status (pre and post manipulation and x-ray) * X-ray (pre and post manipulation)

Answer 92

* Site - Bone - Proximal, mid-shaft, distal - Articular * Configuration - Transverse - Oblique - Spiral - Segmental - Multi-fragmentory * Displacement - Translation - Angulation - Rotation - Shortening/impaction * Soft tissue - Open - Compromised - Tenting - Blisters - Firm/woody - Distal status - sensation, motor - Vascular (pulses, cap refil)

Answer 93

* Break in the skin and underlying soft tissue leading directly into or communicating with the fracture and its haematoma

Answer 94

* Lower limb 3.7% * Upper limb 3.3% (More common in young adult males and elderly females) * Vast majority of proximal and distal tibial fractures present with a significant soft tissue injury hence additional complexity when managing the injury

Answer 95

* Gustilo Anderson Classification | * Type 1, 2, 3a, 3b, 3c

Answer 96

* Wound length <1 cm * Minimal soft tissue damage, contamination and comminution * Periosteum intact * Adequate soft-tissue coverage * Vasculature intact

Answer 97

* Wound length >1 cm * Moderate soft tissue damage, contamination, or comminution * Periosteum intact * Adequate soft-tissue coverage * Vasculature intact

Answer 98

* Extensive wound * Extensive soft tissue damage, contamination, or comminution, segmental fracture * Periosteal stripping * Adequate soft-tissue coverage * Vasculature intact

Answer 99

* Extensive wound * Extensive soft tissue damage, contamination, or comminution, segmental fracture * Periosteal stripping * Inadequate soft-tissue coverage * Vasculature intact

Answer 100

* Extensive wound * Extensive soft tissue damage, contamination, or comminution, segmental fracture * Periosteal stripping * Inadequate soft-tissue coverage * Arterial damage

Answer 101

* Manage soft tissue injury * Minimise the risk of infection * Stabilise and repair the skeletal injury * Restore function of affected extremity

Answer 102

* ATLS * Common secondary to high velocity trauma - Check concomitant injuries - Thorough examination of all limbs - Neuro-vascular status of affected limbs - Compartment syndromes - Bleeding control - Vascular damage should be addressed surgically within 3 to 4 hours of injury, but may be delayed to 6 hours in warm limbs - Ascertain extent of injury by considering mechanism - Extent of environmental contamination

Answer 103

* Debridement should be performed using fasciotomy lines for wound extension where possible * Timing is advised as follows: - Immediately for highly contaminated wounds (agricultural, aquatic, sewage) or when there is an associated vascular compromise (compartment syndrome or arterial disruption producing ischaemia) - Within 12 hours of injury for other solitary high energy open fractures - Within 24 hours of injury for all other low energy open fractures

Answer 104

* Definitive soft tissue closure or coverage should be achieved within 72 hours of injury if it cannot be performed at the same time of debridement

Answer 105

* Should only be carried out when it can be immediately followed with definitive soft tissue cover

Answer 106

* Gross contamination of the wound * Compartment syndrome * Devascularized limb * Multiply injured patient

Answer 107

* Initially a limb is washed and alcoholic chlorhexidine tournique is prepped * Tissues are assessed systematically in turn, from superficial to deep (skin, fat, muscle, bone) and from the periphery to the centre of the wound * Non-viable skin, fat, muscle and bone are excised * If definitive treatment is not to be performed in a single step then a vacuum foam dressing (or anti-biotic bead pouch if there is significant segmental bone loss) is applied until definitive surgery is performed

Answer 108

* IV antibiotics should be administered as soon as possible, ideally within 1 hour of injury * Continue to be administered until primary closure of the wound, or for 72 hours whichever is sooner

Answer 109

* Infection * Non-union * Chronic regional pain syndrome * Amputation