Major Trauma Flashcards
What is major trauma?
Serious and often multiple injuries where there is a strong possibility of death or disability
What is the epidemiology of trauma?
4th leading cause of death in the west
Leading cause of death in the 1st 4 decades
Predicted to become the 3rd largest disease burden in the world by 2020
Economically important - most people injured are in work
Early intervention can be life saving - ‘golden hour’ + ‘platinum 10 minutes’
What are the key principles to major trauma?
Critically ill patient: ABCDE (as will die in that order)
Primary survey: (trauma) CABCDE Control catastrophic haemorrhage Airway + C-spine protection Breathing with ventilation Circulation with haemorrhage control Disability: Neuro status (head + spine) Exposure /Environment
What is the process of initial assessment?
Preparation
Triage
Primary survey (+/- adjuncts e.g. imaging +/- resus)
Transferring? (CT/theatre/another hospital)
Secondary survey (2nd more detailed assessment)
Monitoring and re-evaluation
What are some mechanisms for injury?
Blunt injury:
Road traffic collision - C-spine injury, blunt thoracic and cardiac injury, hollow viscus Berforation/solid organ injury, pelvic/acetabular/femur injuries
Assault - often head injuries either direct or from falling, stamping on abdo/chest
Fall from >20ft/2 floors - could injure anything
Crush injuries - building collapse, industrial injury
Sports injuries - splenic/renal injury in rugby, assault in football
Sharp injury:
Stabbing
Self-harm
Gun shot
Blast injury:
Primary - blast wave disrupts gas filled structures e.g. burst alveoli
Secondary - impact airborne debris
Tertiary - transmission of body (get thrown etc)
Quaternary - anything else - burns, building collapse etc
What are the priorities of trauma management?
Stop bleeding
Prevent hypoxia
Prevent acidaemia
Avoid traumatic cardiac arrest
What is an ATMIST handover?
Age Time - of incident Mechanism Injuries found Signs - observations Treatments - so far given
What are some signs on triage that would warrant transfer to a specialist major trauma centre?
Glasgow Coma Score <14
Sustained systolic blood pressure <90
Respiratory rate <10 >29
Chest injury with altered physiology
Traumatic amputation proximal to wrist/ankle
Penetrating trauma to neck, chest, abdomen, back or groin
Suspected open and/or depressed skull fracture
Suspected pelvic fracture
Spinal trauma suggested by abnormal neurology
Trauma along with facial and/or circumferential burns
Time critical (e.g. isolated burns in excess of 20%)
How do you manage catastrophic bleeding
Clear clots obscuring bleeding source Direct pressure +++ e.g. entire weight applied through a knee onto a femoral laceration Indirect pressure Torniquet Haemostatic agents e.g. ceelox
How do you apply a torniquet?
Apply 2-3 inches above bleeding source
Tighten - twist rod until bleeding stops
Ensure bleeding stopped and no distal pulse - will be painful and limb may become damaged bu will save life
If not working - apply a second torniquet above the first
What is a secure airway? How do you clear one?
Airway can be cleared by suction + kept clear with antiemetics until intubation and ventilation is possible
Log roll = a temporary manoeuvre which allows a patient to vomit whilst protecting C-spine - requires 5x people to assist
Expected time frame for securing/RSI = 45mins - so very important to call in major trauma as soon as known to give team time to prep
What are the absolute indications for intubation>
Inability to maintain and protect own airway regardless of consciousness level e.g. may be vomiting
Inability to maintain adequate O2 with less invasive manoeuvres
Inability to maintain normocapnia with less invasive manoeuvres
Deteriorating GCS <2 on motor
Significant facial injuries
Seizures
How do you mange burns?
In presence of burns or blast injury +
Hypoxaemia or hypercapnia
Deep facial burns
Full thickness neck burns
Consider early intubation as airway can swell
What are some relative indications for intubation?
Haemorrhagic shock + evolving metabolic acidosis
Agitated patient - e.g. lots of pain
Multiple patient injuries
Transfer to another area of the hospital/transition to other theatres
How do you manage the C-spine?
Keep them in neutral position - NOT NECK EXTENSION OR FLEXION (WORSE) AS CAN DISPLACE FRACTURES AND CAUSE SPINAL INJURY
Initially just with hands then with possible cuffs/collars:
Hard collar + speed blocks + tape (locks head in one place)
What are some high risk factors for C-spine injury that would warrant immobilisation?
Age 65 years or older
Dangerous mechanism of injury (fall from a height of greater than 1 metre or 5 steps, axial load to the head e.g. diving, high-speed motor vehicle collision, rollover motor accident, ejection from a motor vehicle, accident involving motorised recreational vehicles, bicycle collision, horse riding accidents)
Paraesthesia in the upper or lower limbs
What are some life threatening chest injuries one would find on a primary survey?
ATOM FC
Airway obstruction (including with a hole in it), disruption Tension pneumothorax Open pneumothorax Massive haemothorax Flail chest Cardiac tamponade
What are the signs of tension pneumothorax?
Most commonly: Agitation - 'air hungry' Hypoxia Hypotension (secondary to diminished venous return due to IVC/SVC compression) Tachycardia
Other possible:
Diminished breath sounds - though due to poor ventilation?
Hyperresonance - but could be a haemothorax on other side and misinterpreted at normal resonance
Deviated trachea - mostly a post mortem finding or impending death
Distended neck veins
How do you manage a tension pneumothorax?
Needle thoracocentesis - 2nd midclavicular line (but can miss, there are other places)
Thoracostomy followed by a large bore chest drain - thoracostomy will initially alleviate, drain will complete
What is an open pneumothorax?
Wound to chest wall communicating with pleural cavity - air passes through referentailly to trachea - large hole (small hole can become tension as wound seals on expiration and acts as one way valve)
What is a massive haemothorax ?
> 1500ml blood extravascular - can produce a tamponade effect - can rebleed upon decompression
Reduced air sounds, hyper resonant
Obtain IV access prior to decompression
1500ml blood or >200ml/hr consider urgent thoracotomy
Resusative thoracotomy -
What is a flail chest?
Fracture of 2+ ribs in 2+ places - ‘floating section ribs’
Broken ribs move paradoxically in respiration - negative impact on ventilation
Needs intubation and surgery e.g. plating of ribs
What are the signs of cardiac tamponade?
Becks triad:
Hypotension
Diminshed heart sounds
Distended neck veins
Though clinically not that useful
What region comprises the cardiac box?
Area of the chest overlying the heart, bounded by the midclavicular lines (laterally) and from the clavicles to the tip of the xiphoid process
On the back and the front
Any trauma here - high index of suspicion for cardiac trauma e.g. cardiac tamponade
