Major trauma Flashcards
What forms the basis for the standard of trauma care in the UK?
Advanced trauma life support
What forms the initial assessment of a major trauma patient?
Primary survey + resuscitation of vital organs
A-E assessment
The pririties of the primary survery are always the same, regardless of what has caused the injury
What are the 5 key components of the primary survey in major trauma?
- Airway mantenance + c-spine protection
- Breathing + ventilation
- Circulation + haemorrhage control
- Disability (neurological status)
- Exposure and environmental control: completely undress patient whilst avoiding hypothermia
>>This is generally not done as a sequence, if staffing and direction permits, all done simultaneously<<
Important to remember whilst doing a primary survey?
Talk to your patient
Deal with any encountered problem before moving on ‘FIND the bleeding STOP the bleeding’
After any intervention, return to the start of the primary survey
What does airway maintenance with c-spine control involve?
All major trauma patients have an unstable cervical spine fracture until proven otherwise - high cervical injury can lead to loss of respiratory drive
Ensure airway is patent
Simple airway maneuvres: jaw thrust, chin lift
Suction should be available
Be aware of obstructions: blood, swelling, obstruction due to injury
Crepitus: crunchy feeling in neck suggests direct laryngeal injury
What is an oropharyngeal airway?
Rigid plastic tube that sits along the top of the mouth and ends at the base of the tongue
Prevents tongue occluding epiglottis in patients with reduced GCS
Patient gags when you insert oropharyngeal airway - what to do?
The gagging indicaes the patient will not tolerate to OP airway - remove it and try a nasopharyngeal airway
Which airway adjunct is used for more alert patients?
Nasopharyngeal
What is a nasopharyngeal airway?
Flexible rubber tube inserted through the nose. ends at the base of the tongue
Prevents tongue covering epiglottis
Better tolerated that OP airway
Why are patients with a reduced conscious level at higer risk of airway obstruction?
Relaxation of smooth muscle causing:
- occlusion of the oropharynx by the tongue
- occlusion of the laryngopharynx by the epiglottis
Causes of airway obstruction
Lumen: vomit, secretions, blood, foreign body
In wall: infection e.g. tonsilitis, epiglottitis, trauma to larynx, tumour, anaphylaxis, angioedema
From outside airway: penetrating neck injury, tumour, oesophageal foreign body
How is airway compromise identified?
Conscious patients + airway compromise
- Patients usually sit up and look distressed
Look for: swollen tongue, sooty sputum (thermal injury), neck haematoma, rashes (anaphylaxis), wheeze/ laboured breathing (asthma), facial fractures, crepitus (laryngeal trauma)
Unconscious patients + airway compromise
Examine for:
- snoring/ added airway noises (indicating partial airway obstruction), abnormal chest and abdo wall movement (suggesting obstruction), lack of fogging of oxygen mask
What are the simple airway manoeuvres?
- Suction: vomit, blood, secretions
- Chin-lift
- Place pillow under patients head (unless obese) - flexes neck
- Jaw thrust - use this on its own if you suspect your patient has a c-spine injury
What are the simple airway adjuncts?
Oropharyngeal (OP) and nasopharyngeal (NP) adjuncts
- Designed to address airway obstruction and free the airway practitioner
- Both generally only tolerate by unconscious patients esp. OP
- If patient is tolerating airway adjuncts consider the need for intubation
How to insert an OP airway adjunct
- Insert OPA ‘upside down’
- Twist 180 once inserted halfway (behind the tongue)
- The flanged front end should sit just in front of the teeth (See image)
If this causes vomiting, gagging or laryngospasm - remove immediately
When should NP aoirways absolutely be avoided?
If patient has facial injuries - particularly mid-face as there is risk the tube can enter the brain
Once a patent airway is secured, meaning air can enter and exit the lungs, what question should we ask?
Does the patient require
a) passive ventilation: oxygen mask
b) assisted ventilation
Determined by: depth of chest wall movement, rate of chest wall movement, coordination of breaths, o2 sats, pco2 via ABG
What is done if ventilation is needed?
Get correct size face mask and a self inflating bag
Check airway doesn’t need suctioning
Apply mask
Jaw thrust
Squeeze bag firmly at 10 breaths per min
*Ideal if two people do this: one does bag squeeze, other does jaw thrust
If a patient needs ventilating and they wear dentures - what do we do?
Keep dentures in or pack cheeky with gauze
Why might bag-mask ventilation be difficult?
Dentures:keep them in or put gauze in cheeks
Unstable fractures: consider early intubation
Beard: apply gel to improve seal
Stiff/ immobilised neck: no option availble - do not force elderly patients neck
COPD/ astha: aggressive medical therapy
You’ve tried to ventilate the patient but failed - next step?
Call for sensior airway help - patient may need intubating
Optimise patient positioning
Try 2x NPA + OPA
Try a laryngeal mask airway (type of supraglottic airway device)
How can we assess breathing?
Resp rate
Breath sounds
Chest movement
Air entry
Sats
Problem with breathing - what could the cause be?
An airway problem: air cannot get in despite efforts
A ventilation problem: problem with the process of breathing itself
How can circulation be assessed
BP
Skin colour + temperature
Pulse rate and character
Cap refill
Patient is haemorrhaging - what do we do to restore volume?
Blood products, packed red cells
- Used to be cyrstalloid but this is no longer recommended
Important to consider when assessing circulation in a young/ healthy patient?
They often have a lot of physiological reserve and maintain their BP before suddently dropping off
Management of poor circulation
2 Large bore cannulas to allow for fluid resus
Constantly reassess
Blood not crystalloid
Find a bleed, stop a bleed
Disability assessment
Baseline neurological evaluation
GCS/ AVPU
Pupillary response for ICP
If GCS <8 - intubate
GCS <8?
INTUBATE 🫁 😵
ABCD
Exposure - what to do?
Completely undress patient
Look for any other injuries
Avoid hypothermia
Head to toe exam
What are the adjuncts to the primary survey?
- ECG
- Vital sgns
- ABGs
- Pulse oximeter
- Urinary/ gastric catheters
- Urinary output > sign of end organ damage > insert catheter to monitor (beware of urethral injuries)
FAST scan to look for bleeding in: hepatorenal recess (Morrison’s pouch), splenorenal recess, pelvis, paricardium
CT: done within 30 mins
Analgesia
Main mode of investigation in major trauma?
CT - guidelines say this should be avai;able within 30mins of patient arriving
What is a secondary survey?
Systematic review of the back and front of the patient looking for all injuries
What is involved in the history taking of a secondary survey?
AMPLE
Allergies: do they have any allergies?
Medication: are they taking any?
Past medical hx: any medical conditions, epilepsy, heart disease, injuries, surgery
Last meal: when did they last eat and drink
Event/ environment: what happened and where, ask people nearby
Components of the secondary survey
Head
Neuro: GCS + pupil response - compare w/ primary survey, CN assessment, fundoscopy, evaluate for spinal cord injury
Scalp: palpate for haematoma/ fracture, look for wounds
Maxillofacial: signs of fracture/ crepitus, basal skull fracture
Neck: neck bruit (carotid dissection), palpate spine
Thorax
Respiratory exam
Rib fractures (if first rib is fractures, suspect vascular damage)
Life threatening injuries: ATOM PD (aortic, tracheal, oesophageal, myocardial, pulmonary, diaphragmatic) - see subsequent cards
Abdomen
Abdo examination
- most common site of significant bleeding from blunt trauma = spleen
- most common stab wound site = liver
If any trauma to abdomen - CT regardless of whether patient is stable
Pelvis
Fracture: pain on palpation, unequal leg length, instability
Always suspect palevic injury when inability to void
Lower GU tract: bladder/ urehtral injuries
Genital region: vagina (blood/ lacerations), rectum, perineum
Extremities
Full MSK examination
Long bones have potential for significant blood loss
Neurovascular impairment
Spinal column
- Full in-line immobilisation if: under influence of drugs/ alcohol/ confused, spinal pain, hand/ foot weakness/ numbness, priapism, hx of spinal problems
😳 **Don’t let embarrassment stop you from checking everywhere** 😳
Aortic injuries
Tears of aorta or pulmonary arteries associated with blunt or deceleration injuries e.g. car crash/ fall from height
Aorta is fixed in position at three points
- Aortic valve
- Ligamentum arteriosum (most common site of shearing injury)
- Dipahragm
>> Sudden deceleration causing shearing at attachment points <<
Shearing of the ligamentum arteriosum, which attaches to pulmonary artery, is fatal in 90%
Management: Surgical repair, control hypertension (SBP no more than 110), control tachycardia (labetalol)
What is the investigation of choice in aortic injuries?
Contrast CT thorax
What is the most reliable sign of aortic injury on CXR?
Widened mediastinum
Other:
- Fractures of 1st and 2nd rib
- Obliteration of aortic knob
- Deviation of trachea
- Presence of pleural cap
Tracheal injuries
Uncommon but can be caused by penetrating/ blunt trauma
Can result in free air in neck, chest wall, mediastinum
Bronchoscopy can confirm diagnosis
Oesophageal injuries
Occur following penetrating & (rarely) blunt injury
May cause gastric contents to be forced into oesophagus causing tearing and leaking of acid into mediastinum or pleural space - can cause mediastinitis which rapidly causes sepsis
Clinical picture is identical to post-emetic oesophageal rupture (Boerhaave syndrome)
Most commonly undiagnosed fatal thoracic injury?
Blunt myocardial injury (contusion)
Occurs when there is direct compression of the heart due to blunt trauma or rapid deceleration
Often associated with sternal fractures
Diagnosis: troponin, ECG changes, echo
Normal ECG on admission virtually eliminates this problem
Pulmonary contusion
Injury to lung tissue associated with blunt trauma - a bruise of the lung
Leads to blood and oedema within alveoli
SUSPECT IN ALL WITH FLAIL CHEST
Causes impaired gas exchange
Clinical picture: increasing resp. distress + hypoxia
Diagnosis: CXR or CT
Management: supportive while contusion resolves, if severe patients need early intubation and ventilation
Important not to fluid overload because increased capillary leakage can lead to pulmonary oedema
Which is the most commonly injured abdominal organ?
Spleen
What is crush syndrome?
Systemic manifestation of muscle cell damage/ rhabdomyolysis
Causes: direct injuries, severe burns, compartment syndrome, myositis, grand mal fitting
Usually due to crush injuries >> tissue ischaemia >> necrosis + rhamdomyloysis >> cellular components re-enter circulation e.g. myoglobin, K+ uric acid and CK >> arrhythmia, AKI, metabolic acidosis
Management: fluids, dialysis if renal failure occurs
Hard and soft signs of arterial injury
Hard signs = immediate transfer to theatre >90% risk of arterial injury
- Pulsatile haemorrhage
- Rapidly expanding haematoma
- Palpable thrill/ bruit
- Absent distal pulses/ signs on ischaemia (palor, paraesthesia, paralysis, perishingly cold)
Soft signs = further investigation 30% risk arterial injury
- Hx of arterial bleeding which has since ceased
- Small, non-expanding haematoma
- Subjectively decreased pulse
- Unexplained hypotension
- Neurologic deficit originating in a nerve adjacent to a named artery
- High risk orthopaedic injury e.g. fracture, doslocation, penetration
What are the three peaks of trauma
- Seconds - mins: e.g. laceration of brain
- Mins - hrs: e.g. haemothorax
- Days - weeks: e.g. sepsis
Discuss tension pneumothorax
Air trapped in the pleural space under positive pressure due to one way valve
>> Compresses lung
>> Impaired venous return
>> Trachea deviates away
>> Heart can be compressed
Features: chest pain + respiratory compromise, tachypnoea, raised JVP
Examination: decreased breath sounds on affected side, hyper-resonance and tracheal deviation away from affected side
Management: needle thoracentesis - 2nd intercostal space, mid-clavicular line OR if skills permit - finger thoracostomy in 5th intercostal space >> both followed by chest drain
Pitfalls of thoracentesis: tends to get overused, lack of hiss/ bubble used as evidence of no tension pneumothorax, standard cannula might not reach pleural space, can cause pneumothorax itself
What is an open pneumothorax?
AKA a communicating pneumothorax or sucking chest wound
Hole in the chest
Rare - usually due to shot gun injury
Unlikely to be missed clinically
As patient breathes in, the hole in the chest competes with the trachea for delivery of air
Diagnosis: resp distress, bubbling wound on expiration
Management: high flow oxygen, sterile dressing taped down at 3 sides to allow air out but not in, insert drain, repair wound
What is a massive haemothorax?
Blood in pleural space with volume of >1500mL or 1/3 patients blood volume
- Uncommon
- Due to blunt/ penetrating trauma
- Causes hypovolaemic shock and decreased ventilation
Features: shock, dullness to percussion, reduced/ absent breath sounds, can be seen on x-ray
Management: restore circulating volume, drain blood (AFTER CIRCULATING VOLUME RESTORED), thoracotomy may be required if bleeding is >1500ml or ongoing loss of >200ml every 2hrs
Flail chest
Series of rib fractures in >1 place causing a section of free-floating chest wall
>> Minumum of 2 fractures in 2 ribs <<
Fairly common
Significant force is required so look for other injuries too
Potential source of significant haemorrhage
Diagnosis: abnormal chest movement - inwards on expiration & outwards on inspiration , respiratory distress, painful (very)
Investigations: O2 sats, ABG, CXR
Management: high flow o2, manage any haem thoraces/ pneum thoraces, pain management is important, surgery to stabilise fractures rarely indicated
Features of sternal fracture
Frequently occurs following RTAs due to steering wheel/ seatbelt
Anterior chest pain + localised tenderness over sternum + bruising/ swelling
Investigations: ECG to rule out arrhythmias, STEMI or myocardial contusion
If ECG changes, check tropnonin
Request CXR and lateral sternal x-ray
Management: admit ig signs of myocardial contusion/ other injuries
Ig sternal fracture occurred in isolation, ECG normal and no other injuries consider discharge with NSAIDs+ co-codamil + GP follow up
Cardiac tamponade
Collection of fluid in pericadial sac causing haemodynamic compromise >> compression of heart >> inadequate filling >> reduced CO
Exclude/ confirm using FAST scan
50-200ml blood is enough to cause pulseless electrical activity cardiac arrest in which the ECG shows a rhythm which should produce a pulse but it doesn’t
Diagnosis: Beck’s triad (low BP, muffled heart sounds, raised JVP), Kussmaul’s sign (JVP rises on inspiration instead of falls), FAST scan
Management: thoracotomy is preferred choice as blood is oftn clottes so has to be scooped out, consider pericardiocentesis if patient is peri-arrest to buy time
What is Kussmaul sign?
JVP rises on inspiration instead of falling as would be appropriate
This occurs when there is fluid in the pericardial sac that impaires venous return and inspiration causes further compression of the heart and blood shoots back up jugular vein
What is Beck’s triad?
Seen in cardiac tamponade 🫀🫀🫀
- Low BP
- Muffled heart sounds
- Raised JVP
*Only a small number of cases of cardiac tamponade present with all 3 features*
What is used at the bed-side to diagnose cardiac tamponade?
FAST scan
Focussed assessment with sonography for trauma
Which 4 areas is a FAST scan used to look at?
- Pericardium
- Right flank: perihepatic view/ Morrison’s pouch - DONE FIRST AS BLOOD COLLECTS HERE FIRST
- Left flank: perisplenic
- Pelvis
Blood appears as a black, echo free area
Visible free fluid in the abdomen implies a minimum volume of ~500mL
Can a patient have a normal ECG in cases of cardiac contusion?
No - normal ECG effectively rules out cardiac contusion
What is ALI and ARDS?
Complication of trauma
ALI = acute lung injury
ARDS = acute respiratory distress syndrome
Can be caused by trauma
Features: acute onset (within 1 week), bilateral opacities on CXR, severe hypoxaemia
Pathophysiology of ARDS
Interstitial fluid in lungs despite normal pulmonary arterial and venous pressures
Fluid causes lung stiffness which impaires gas exchange >> hypoxia
Fluid can also promote cytokine release which can promote fibrosis
Stages
- Exudative: oedema
- Repair and fibrotic change >> causes loss of elasticity, emphysema formation and damage to vasculature
Common after blunt trauma affecting the thorax
Other causes: Sepsis (most common), acute pancreatitis, pneumonia, aspiration of gastric contents , fat embolism, inhalation injury
How might ARDS present?
1st sign is often an unexplained tachypnoea leading to hypoxaemia, central cyanosis and dyspnoea
Fine crackles heard throughout lungs
Management of ARDS
ICU: supportive ventilation with PEEP
Prone position
Fluid resus + diuretics
NO to improve ventilation of unaffected lung
Coagulopathy following trauma
Following trauma, coagulation, anti-coagulation and fibrinolysis are disproportionately affected >> impaired haemostasis
Clinical features: Bleeding, prothrombotic state, disseminated intravascular coagulation
Management: control primary cause, manage clotting abnormalities, multi-organ support
Fat embolisation following trauma
Fat particles within blood stream
Symptoms generally begin within 24hrs
Systemic manifestations
Respiratory distress: inflammatory response in lungs - tachycardia, tachypnoea, hypoxia
Neurological problems: due to hypoxia/ emboli lodging in cerebral circulation - mild headache >> comatose
Petechial rash: emboli promotes local platelet aggregation >> widespread inflammatory reaction in the skin, also seen in eyes + retina
>> Can also cause renal failure
Aetiology: long bone fractures, massive soft tissue injury, severe burns, orthopaedic procedures
Skin rash, tachypnoea + hypoxia + tachycardia, headache/ confusion following trauma - thoughts?
Fat emboli
Investigations for fat emboli following trauma
Fat in: urine + sputum
CXR: snow storm but often normal
May show up on CTPA
- Usually clinicians rely on physical examination
What are Gurd’s criteria?
Used to assess presence of fat emboli
Major criteria: petechiae, CNS depression, pulmonary oedema
Minor criteria: tachycardia, low grade temperature, retinal emboli, fat in urine/ sputum, thrombocytopenia, increased ESR
>>Diagnosis requires at least 1 major criteria + at least 4 minor criteria<<
How is are fat emboli managed?
Supportive
- Immobilise fracture
- Optimise oxgenation
- DVT prophylaxis
Mortality = 5-15%
Persistent neurological deficits may occur
How soon after trauma would you expect to see signs of fat emboli?
24-72 hrs
What % of trauma patients develop PE/ DVT?
50%
3rd most common cause of death in the 24hrs following major trauma
When to suspect major trauma
High speed collisions, vehicle ejection, rollover and prolonged extraction
Death of another individual in same collision
Pedestrians thrown uo or run over by a vehicle
Falls of >2m
When would you suspect c-spine injury?
Neck pain
Loss of consciousness
Assume all major trauma patients has a c-spine injury until proven otherwise
Use of TXA in major trauma
Give 1g IV over 10mins within 3hr of injury
Followed by 1g IVI over 8hrs
What are the phases of treatment of patients with major trauma?
- Primary survey
- Resuscitation phase
- Secondary survey
- Definitive care phase
Key feature = re-evaluation throughout
We start with airway management unless…
Catastrophic haemorrhage
What is the resuscitation phase?
Treatment continues for the problems identified during the primary survery
Adjuncts to primary survey e.g. airway adjunct, chest drain, urinary catheter
Sometimes surgery is required for haemorrhage control before the secondary survey is done
What is the definitive care phase?
Early management of all injuries is addressed e.g. fracture stabilisation and emergency operative intervention
Important to have available, regarding airway management, when treating seriously injured patient
- O2
- Suction
- Airway equipment
- Senior ED/ ICU anaesthetic help if serious airway problem arrives/ is expected
How can a patient’s breathing be assessed
Talk to patient: lucid reply shows airway is patent, patient is breathing and blood is reaching brain
Look and listen to breathing
Partial obstruction: gurgling, snoring, stridor
Total obstruction: patient trying to breathe but unable, paradoxical chest movements but no breath sounds
Managing the obstructed airway
- Look in mouth for obstruction and remove with suction or Magill’s forceps
- Basic airway manoeuvres - lift chin and jaw thrust but do not flex or extend neck
- After any intervention look, listen and feel to reassess airway
- Use airway adjunct (OP/NP as appropriate)
5a. Airway patent + patient breathing: 15L o2 via non-rebreathe mask
5b. Airway pateint but breathing inadequate: ventilate with o2 bag and mask and prepare for tracheal intubation (ideally a 2 person job)
How is tracheal intubation confirmed?
- See tube pass through vocal cords
- Observe symmetrical chest movement
- Listen over axillae for symmetrical chest movement
- Confirm placement with end-tidal CO2 monitoring
Discuss surgical airways
Needed if the airway is obstructed by trauma, oedema or infection and tracheal intubation is not possible
1. Surgical cricothyroidotomy
- Feel thyroid and cricoid cartilages and cricothyroid membrane between them
- Clean area, give LA
- Hold thyroid cartilage and make transverse incision
- Slide a bougie tube into trachea, remove scalpel and railroad a 6.0mm cuffed tracheal tube into trachea
- Remove bougie tube, inflate cuff and connect tube to a catheter mount and ventilation bag
- Ventilate with o2 and secure tracheal tube
- Examine chest and check for adequate ventilation
2. Needle cricithyroidotomy - temporary measure while preparing for surgical cricothyroidotomy - Needle placed through cricoid membrane at a 45 degree angle with syringe attached
- Aspirate via syringe whilst advancing needle - aspiration of air confirmes you are in trachea - remove needle and keep cannula in
- Connect cannula to o2 at 15L/min with a side port/ hole in tube: occlude port/ hole for 1 second to allow air in, open for 4 seconds to allow air out
- Can be tolerate/ function for 45mins - proceed immediately to definitive airway
Site for insertion of surgical airway
Cricothyroid membrane/ ligament
Between thyroid cartilage and cricothyroid cartilage
Site for needle decompression in tension pneumothorax
2nd intercostal space, midclavcular line
Which side of the diaphragm most commonly ruptures?
Left (75%)
Liver tends to protect the right diaphragm
Patient has a major diaphragmatic rupture - what do you do?
Usually associated with herniation of stomach contents
Call surgeon and an anaesthetist as patient requires urgent intubation and IPPV (intermittent positive pressure ventilation)
Can result in abdominal contents in thorax
Chest drain insertion
Give IV opioids if patient conscious
Abduct arm fully, sterile gown and goggles/ face shield, clean skin, find 5th inercostal space mid axillary line
Give LA (lidocaine + adrenaline), make 2-3cm incision
Use blunt dissection with forceps to open tissues down to pleural space
Puncture pleura with forceps, insert gloved finger into cavity to ensure there are no adhesions, insert drain and connect to underwater seal
Suture drain in place and cover with dressive
Ensure underwater seal is swinging in the tube with respiration
Listen for air entry
>Refer to surgeon if drains >1500mL blood or 200mL every hr for 2hr
What are the reversible causes of cardiac arrest?
Hypoxia: secure airway and ventilate
Hypovolaemia: give blood and plasma e.g. 4U O-neg warmed packed RBCs stat
Tension pneumothorax: perform bilateral thoracostomies
Cardiac tamponade: if fluid seen on FAST scan do a clam shell thoracotomy - pericardiocentesis often fails because clots form in pericardial sac
Advantages of FAST scan
- Can be done in ED
- Quick: 2-3mins
- Non-invasive
- Repeatable
Disadvantages of FAST scan
- Operator dependant
- Doesn’t define injured organ - only presence of blood or fluid in abdomen or pericardium
- Looks at 4 areas only
