MAJOR TRAUMA Flashcards
In a&e resus with . trauma coming in, what should you do to prepare for arrival?
Fast bleep for the trauma team (cardiothoracics, orthopaedics, anaesthetics,
Code red fast bleep if the patient is hypotensive ?haemorrhage - this will summon theatre staff in addition to the trauma team
what should you do once the patient has arrived on paramedic trolley?
“Are there any immediate concerns?” if yes eg airway - deal with that whilst they are on paramedic trolley. If no - transfer to hospital bed (log roll to protect c-spine)
What is your approach to major trauma assessment
(C) ABCDE Primary survey - looking for life threatening things
Airway (with c-spine protection)
assess as normal however avoid head tilt chin lift and opt for jaw thrust if c-spine not been ruled out
Assess C-spine using canadian c-spine rules
Hard collar - A hard collar may be used if there is no airway compromise or deformity of the neck.
If cant rule out, take to CT once stabilised
Catastrophic haemorhage
CABCDE
Identify any large volume external bleeding: direct pressure, haemostatic dressing application, or tourniquets
what are the canadian c-spine rules?
The patient is considered high risk if they meet one or more of the following criteria:
- Age 65 or older
- Dangerous mechanism of injury (fall from over one metre or down five or more steps, or an axial loading injury)
- Paraesthesia in any limb(s)
The patient is low risk if they meet none of the “high risk” criteria and meet one or more of the following criteria:
- Involved in a minor rear-end motor vehicle collision
- Comfortable sitting
- Ambulatory since the injury
- No midline cervical spine tenderness
- Delayed onset of neck pain
There is no risk if the patient has no high-risk factors, one or more low-risk factors, and they can rotate their head 45 degrees actively to the left and right.
Breathing
CABCDE
Bradypnoea in trauma may be secondary to raised ICP and is seen as part of the Cushing’s reflex. Consider other causes of a reduced RR such as opioid toxicity.
Tachypnoea in trauma may be due to chest injury (haemothorax, pneumothorax or flail chest), direct airway injury or obstruction, diaphragmatic rupture, shock, acidosis, pain or anxiety
Hypoxaemia may be due to airway obstruction or injury, chest injury such as pneumothorax, aspiration or bradypnoea, amongst other causes.
Chest trauma priamry survery
ATOM FC
Airway obstruction
Tension pneumothroax
Open sucking chest wound
Massive hemothroax
Flail chest
Cardiac tamponade
Portable x-ray if unstable
Circualtion
CABCDE
Causes of tachycardia (HR>99) may indicate hypovolaemia (e.g. a bleed), anxiety, or pain
Causes of bradycardia (HR<60) may be a late sign of hypovolaemia
Causes of hypertension include pain or anxiety
Causes of hypotension include hypovolaemia/shock, tension pneumothorax and cardiac tamponade
Younger patients are likely to maintain their blood pressure through compensation and may present with tachycardia and a normal BP until severe decompensation occurs.
Consider major haemorrhage (see major haemorrhage)
Approach to bleeding differentials in acute trauma
“Blood on the floor and four more”
- The chest - haemothorax, which in trauma is most likely caused by a rib fracture causing damage to the intercostal blood vessels.
- The abdomen. from injury to a solid organ, such as the spleen, or major blood vessel
- The pelvis. classically from a pelvic fracture
- In a limb from a broken bone. fractured long bones, such as the femur, can account for a significant volume of blood loss
On the floor – bleeding from a visible wound.
why may a patient not mount a tachycardia eg in repsonse to hypovolemia
due to regular medications, such as beta-blockers.
Presentation of a tension pneumothroax
Tracheal deviation away from the side of the pneumothorax
Reduced air entry on the affected side
Increased resonance to percussion on the affected side
Tachycardia
Hypotension
Tension pneumothorax → obstructive shock
jugular venous distension
haemodynamic instability
plan ?tension pneumothroax
Insert large bore cannula in 2nd intercostal space in the midclavicular line (above rib to avoid vascular/neuro bundle)
In patients with tension pneumothorax, perform chest decompression before imaging (usually CXR) only if they have either haemodynamic instability or severe respiratory compromise.
Next, insert chest drain into triangle of safety
what is the triangle of safety made up from?
5th intercostal space (or the inferior nipple line)
Midaxillary line (or the lateral edge of the latissimus dorsi)
Anterior axillary line (or the lateral edge of the pectoralis major)
what is an open pneumothroax
When a penetrating chest injury results in a pneumothorax, it creates a “sucking chest wound.”
Acutely, this is managed by covering the wound with a sterile dressing, securely taped on 3 sides. The open side creates a valve, allowing air to exit but not enter the chest cavity. Once stabilised, a chest tube can be inserted, and surgery may be considered later.
define massive hemothorax
Massive hemothorax is defined as blood drainage >1,500 mL after closed thoracostomy and continuous bleeding at the rate of 200 mL/hr for at least four hours.
causes of massive haemothroax
Hemothoraces are usually caused by an injury, but they may occur spontaneously due to cancer invading the pleural cavity, as a result of a blood clotting disorder, as an unusual manifestation of endometriosis, in response to Pneumothorax, or rarely in association with other conditions.
CXR massive haemothroax
CXR - blunting of costophrenic angles
management massive hemothroax
Insertion of a chest drain
IV warmed fluid resus, major haemorrhage protocol
what is a flail chest
More than 2 consecutive ribs on the same side of chest fractured in 2 or more places - causes paradoxical breathing so underlying lung isn’t ventilated- pain that it causes means people don’t breathe fully in
management of flail chest
Early intubation and ventilation are sometimes required, and later discussion with surgeons for repair.
