major trauma abcde 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.
what is cardiac tamponade
A cardiac tamponade describes a large pericardial effusion and can be caused by blunt force or, more commonly, penetrating trauma to the chest.
management cardaic tamponade
removing the fluid via pericardiocentesis – inserting a needle and aspirating the fluid, either using surgical landmarks or under ultrasound guidance. If pericardiocentesis is indicated, then the patient is likely to require cardiothoracic surgery and should be discussed with the cardiothoracic team.
ddx obstructive shocka dn distended JVP in trauma, how can you differentiate
Tension pneumothorax
Cardiac tamponade
Bedside ultrasound can differentiate between the two conditions when clinical examination is inconclusive.
Disability
CABCDE
GCS
Pupils
An oval-shaped pupil, sluggish reaction to light, “blown pupil” or deviated pupil suggests raised ICP or herniation.
Organise an urgent CT head if there is any concern about intracranial bleeding and if a whole-body CT has not already been requested.
criteria for CT within 1 hour head injury
GCS < 13 on initial assessment
GCS < 15 at 2 hours post-injury
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
criteria for CT head within 8 hours head injury
Adults with any of the following risk factors who have experienced some loss of consciousness or amnesia since the injury:
age 65 years or older
any history of bleeding or clotting disorders including anticogulants
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
If a patient is on warfarin who have sustained a head injury with no other indications for a CT head scan, perform a CT head scan within 8 hours of the injury.
what may be used in life-threatening rising ICP whilst theatre beng prepared
IV mannitol/ frusemide may be required.
head injury ddx priamry brain injury
focal: contusion/haematoma
- extradural
- subdural
- subarachnoid
diffuse: diffuse axpnal injury
what is secondary brain injury
Secondary brain injury occurs when cerebral oedema, ischaemia, infection, tonsillar or tentorial herniation exacerbates the original injury.
The normal cerebral auto regulatory processes are disrupted following trauma rendering the brain more susceptible to blood flow changes and hypoxia
The Cushings reflex (hypertension and bradycardia) often occurs late and is usually a pre terminal event
Pathophysiology cushings reflex
raised ICP –> blood not entering brain resulting in hypoperfusion –> systolic BP increases to make sure the pressure is high enough to enter the brain…
increasdef BP –> baroreceptors –> slow HR (bradycardia
reduced perfusion to brainstem from swelling or possible brainstem herniation –> irregualr respirations
triad of cushings reflex symptoms /signs
opposite of shock therefore:
- BP high
- HR low
- RR low (irregular respirations)
normal range ICP
The normal ICP ranges from 5-15 mmHg.
management of extradural hematoma
stabilising the patient followed by surgical intervention with a burr hole or craniotomy to evacuate the haematoma.
blood vessel implicated by extradural hematoma
middle meningeal artery
eminem getting hit by a lemon
ct scan subdural hematoma
concave crescent-shaped
blood vessel implicated in subdural hematoma
bridging veins
old man drinking alcohol in a cave with a bridge outside and a crescent moon in the sky
management subdural hematoma
Small or incidental acute subdurals can be observed conservatively.
If big or signs then surgical options include monitoring of intracranial pressure and decompressive craniectomy.
Causes SAH
Ruptured cerebral aneurysm or trauma
conditions associated with berry aneurysms
adult polycystic kidney disease
Ehlers-Danlos syndrome
Coarctation of the aorta
ct scan for SAH
Acute blood (hyperdense/bright on CT) is typically distributed in the basal cisterns, sulci and in severe cases the ventricular system.
may be normal - do LP
lumbar puncture for SAH
LP is performed at least 12 hours following the onset of symptoms to allow the development of xanthochromia (the result of red blood cell breakdown).
Xanthochromia helps to distinguish true SAH from a ‘traumatic tap’ (blood introduced by the LP procedure).
As well as xanthochromia, CSF findings consistent with subarachnoid haemorrhage include a normal or raised opening pressure
Management SAH
- referral to neurosurgery after confirmation
- coil by interventional radiologists
- or craniotomy
- 21-day course of nimodipine (a calcium channel inhibitor targeting the brain vasculature)
- Hydrocephalus is temporarily treated with an external ventricular drain
“A 23-year-old man was driving a car at high speed whilst intoxicated, he was wearing a seat belt. The car collides with a brick wall at around 140km/h. When he arrives in the emergency department he is comatose. His CT scan appears to be normal. He remains in a persistent vegetative state.”
diffuse axonal injury
if they also have a bleed it will be subdural
About 90% of survivors with severe diffuse axonal injury remain unconscious. The 10% that regain consciousness are often severely impaired.
Management
Preventing secondary brain injury eg swelling etc.
“A 25-year-old male is brought to the emergency department after being struck on the side of the head with a bottle in a nightclub. According to one of his accompanying friends, he was knocked unconscious initially but then regained consciousness. An ambulance was called after the patient lost consciousness again. The admission CT head scan shows an intracranial haemorrhage.”
extradural hematoma
hypersensitive in bi-convex/lentiform brain ct
extradural hematoma
lemon shape (lemon thrown at head)
bi-convex - if youre vexxed you puff out in anger
“A 59-year-old man attends his GP with increasing mild confusion. This came on 2 weeks ago and has been getting progressively worse, both in his and his husband’s opinion. His past medical history is significant for being in a road traffic collision 6 weeks prior. At the time, he was discharged from the emergency department with no injuries but did suffer a head injury. Since then, he reports no headache, nausea or changes in vision.”
subdural hematoma
slow onset, fluctuating conscioussness/confusion
Sudden onset occipital headache (‘thunderclap’ or ‘baseball bat’), severe (‘worst of my life’
Nausea and vomiting
Meningism (photophobia, neck stiffness)
subarachnoid haemorrhage
Star sign
SAH
Process of invetsgigating SAH
- CT head non-contrast (may show star sign)
- Lumbar puncture (xnathachromia)
- CT angiography (gold standard - shows where lesion is)
In a SAH, what artery would be implicated if they had a occulomotor nerve palsy
posterior cmmunicating artery
How does a 3rd nerve palsy present? how do you know if surgical or not?
3rd nerve palsy:
eye is deviated ‘down and out’
ptosis
Indication that it is surgical:
pupil may be dilated
trauma
more likely to be painful
(posterior communicating artery)
non-surgical causes of thirs nerve palsy:
- DIABETES
- vasculitis
