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Acute Care Block-Year 4 > Major Trauma and Burns > Flashcards

Major Trauma and Burns Flashcards

1
Q

who is involved in pre-hospital care?

A

doctor, paramedic, emergency care practitioner, technician, nurse, voluntary ambulance crew, first aider, military medic.

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2
Q

what organisations are involved in prehospital care?

A

ambulance service, air ambulance, hospital emergency teams, independent doctors, community nurses, GP visiting services. (insurance companies, negligence companies, professional bodies)
Non medical: fires and rescue service, police service, coastguard, RNLI

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3
Q

what are the challenges with prehospital care?

A
  • Environment :Weather, Light, Noise, Space, Dangers – people, fire etc
  • Equipment – different to in hospital, needs to be carried, packed and hard to find/access
  • Patient assessment – history from witnesses, history from patient, examine patient, examine scene
  • High pressure
  • Complex scenes/multiple patients
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4
Q

name some adjuncts to the primary survey?

A
  • Vital signs
  • ABGs
  • Pulse oximeter and CO2
  • Urinary/gastric catheters
  • Urinary output
  • ECG
  • Focused abdominal sonogram in trauma (FAST). – show abdominal bleeding
  • X-rays chest and pelvis – CT more commonly used eg haemothorax
  • CT – within 30 mins of arrival
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5
Q

what is a secondary survey?

A
  • This is done after primary survey completed, ABCDEs are reassessed and vital functions are returning to normal
  • Look for injuries in order of significance
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6
Q

SECONDARY SURVEY

what does the acronym AMPLE stand for in history taking?

A
  • Allergies
  • Medications
  • Past illnesses/pregnancy
  • Last meal
  • Events/ environment / mechanism
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7
Q

describe head examination as part of the secondary survey?

A
  • External exam
  • Scalp palpation
  • Comprehensive eye and ear examination
  • Visual acuity
  • Pitfalls: unconsciousness, periorbital oedema, occluded auditory canal
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8
Q

describe neck examination as part of the secondary survey?

A
  • Mechanism – blunt versus penetrating
  • Symptoms – airway obstruction, hoarseness
  • Findings – crepitus, haematoma, stridor, bruit
  • Pitfalls: delayed signs and symptoms, progressive airway obstruction, occult injuries
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9
Q

describe chest examination as part of the secondary survey?

A
  • Inspect
  • Palpate
  • Percuss
  • Auscultate
  • X-rays
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10
Q

describe abdomen examination as part of the secondary survey?

A
  • Inspect/auscultate
  • Palpate / percuss
  • Re-evaluate
  • Special studies
  • Pitfalls: hollow vicious injury, retroperitoneal injury
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11
Q

describe pelvis examination as part of the secondary survey?

A
  • Pain on palpation
  • Leg length unequal
  • Instability
  • X-rays if needed
  • Pitfalls: excessive pelvic manipulation
  • Underestimating pelvic blood loss
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12
Q

describe perineum examination as part of the secondary survey?

A
  • Contusion, hematomas, lacerations, urethral blood

* Pitfalls urethral injury

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13
Q

describe rectal examination as part of the secondary survey?

A

Sphincter tone, pelvic fracture, rectal wall integrity, blood

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14
Q

describe vaginal examination as part of the secondary survey?

A
  • Blood, lacerations

* Pitfalls ; pregnancy

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15
Q

describe brain examination as part of the secondary survey?

A
  • GCS
  • Pupil size and reaction
  • Lateralising signs
  • Frequent re-evaluation
  • Prevent secondary brain injury
  • Early neurological consult needed
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16
Q

describe neurological assessment as part of the secondary survey?

A
  • Whole spine
  • Tenderness and swelling
  • Complete motor and sensory exams
  • Reflexes
  • Imaging studies
  • Pitfalls; altered sensorium, inability to cooperate with clinical exam
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17
Q

what is the lethal 6

A

Immediate life threatening injuries that need to be addressed in the primary survey

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18
Q

what are the lethal 6?

A 
airway obstruction
tension pneumothorax
cardiac tamponade
open pneumothorax
massive haemorrhage
flail chest
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19
Q

THE LETHAL 6

describe airway obstruction

A

Most commonly unconscious patient is the tongue. They need to be intubated whilst protecting C-spine as airway oedema can be progressive and treacherous

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20
Q

THE LETHAL 6

describe tension pneumothorax

A

Collapsed lung, It occurs when a one way valve air leak occurs, air escapes into pleural space but cant return. The mediastinum is then displaced to opposite side decreasing venous return and compressing opposite lung, heart, great vessels and trachea. Most commonly caused by penetrating chest trauma, mechanical positive pressure ventilation, accidental lung puncture from medical procedure, blunt chest trauma. Need immediate decompression via large bore needle into 2nd intercostal space along midclavicular line

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21
Q

THE LETHAL 6

describe cardiac tamponade

A

Commonly due to penetrating trauma. Blood accumulates in pericardial sac and puts pressure on heart and prevents it filling adequately with each contraction.
Presents with becks triad: narrowing pulse pressure, jugular vein distension, muffled heart sounds. This requires surgery

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22
Q

THE LETHAL 6

describe open pneumothorax

A

Occurs when theres a open hole in the chest, usually due to penetrating injury or impalement. Pleural space is open to atmosphere and causes eqiibrium between intrathoracic and atmospheric pressure. Ventilation occurs due to negative pressure. Diaphragm and intercostal muscles contract, causing lungs to expand and fill with air. If there isn’t a pressure gradient you cant breathe

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23
Q

THE LETHAL 6

describe massive haemothorax

A

When blood collects in pleural cavity. Rapid accumulation of greather than 1500mL blood. Caused by laceration to lung, penetrating trauma with blood vessel disruption. Left side more common than right sided. Blood should be removed ASAP

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24
Q

THE LETHAL 6

describe flail chest

A

Unstable segments of 2-3 or more ribs that are fractured in at least 2 different places. These free floating segments result in paradoxical motion – all or part of lung inflates during inspiration and balloons out during expiration

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25
Q

what are the hidden 6?

A 
thoracic aortic disruption
tracheobronchial disruption
blunt myocardial injury
diaphragmatic injuries
oesophageal injuries
pulmonary contusion
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26
Q

HIDDEN 6

thoracic aortic disruption

A

Leading cause of immediate death, impedes perfusion to organs. Usually due to rapid deceleration from high speed impact, complete tears are usually fatal at the scene. Most commonly occurs at descending portion distal to left subclavian artery. Treat with aortic repair and maintaining BP

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27
Q

HIDDEN 6

tracheobronchial disruption

A

Rare
Due to penetrating or blunt trauma
High mortality – most die in first hour

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28
Q

HIDDEN 6

blunt myocardial injury

A

Due to high speed deceleration collisions, steering wheel impacts.
At risk of sudden dysrhymias and need monitoring for 24 hours

29
Q

HIDDEN 6

diaphragmatic injuries

A

Left side more prone to injury than right as it isn’t protected by liver. Left posterolateral portion is weakest
Supportive care is main treatment

30
Q

HIDDEN 6

oesophageal injuries

A

High mortality, due to penetrating trauma to cervical oesophagus

31
Q

HIDDEN 6

pulmonary contusion

A

Bruised lung due to haemorrhage into lung tissue . diffuse haemorrhage follows blunt trauma. Gas exchange impairment
Usually due to high velocity deceleration injury eg hitting steering wheel

32
Q

how is cardiac tamponade confirmed?

A

FAST scan

33
Q

what is the treatment of cardiac tamponade?

A

fluid resuscitation in increase pre-load, if haemodynamically stable refer for surgical exploration, thoracotomy if patient presents within 10 mins of cardiac arrest

34
Q

describe the clinical assessment of flail chest?

A

palpation and inspection, CXR to identify associated pneumothorax, haemothorax and pulmonary contusions

35
Q

what is the treatment of flail chest?

A

depends on number of factors; clinical condition, size of flail chest, associated injuries, age, co-morbidities, destination. For patients with major trauma; take better control of respiratory compromise, address pain, chest drain, fluid resuscitation, surgery

36
Q

what are the 3 zones of a burn?

A
  • Zone of coagulation – largest area of damage – irreversible
  • Zone of stasis – decreased tissue perfusion, potentiallt salvageable
  • Zone o f hyperaemia – outer area
37
Q

what is the pathophysiology of burns?

A
  • Stimulate inflammatory response

* Capillary permeability increases leading to exudate and oedema

38
Q

what are the systemic changes seen in a patient with burns?

A

• Release of cytokines and inflammatory medaitors

Cardiovascular changes
• Capillary permeablity increased
• Peripheral and splanchnic vasoconstriction
• Myocardial contractility is decreased

Respiratory changes
• Bronchoconstriction
• Adult respiratory distress syndrome

Metabolic changes
• Basal metabolic rate increases

39
Q

what are the potential complications of burns?

A
  • AKI- due to hypoperfusion / sepsis
  • Infection
  • Constrictions – compartment syndromes
40
Q

describe airway involvement in a patient with burns?

A
  • Hoarse voice
  • Stridor – indication for immediate intubation
  • Facial burns
  • Singeing of eyebrows
  • Carbon deposits
  • Carbonaceous sputum
  • Explosion with burns to head or torso
  • Impaired conscious level, confined space
41
Q

BURNS

how can you stop the burning process whilst continuing A-E?

A
  • Remove clothing
  • Remove chemicals
  • Rinse with copius amounts of water
  • Temperature control
42
Q

following ABCDE what are the next steps in patient with burns?

A
  • IV access
  • Bloods
  • Monitoring
  • Urinary catheter
  • Fluids – crystalloid
43
Q

What formula is used to calculate fluids given to patients with burns?

A

Parkland formula
• 4mls x %burn x wt kg total in 24 hours
• Give half in first 8 hours and remaining in subsequent 16 hours

44
Q

superficial burns

  1. bleeding on pinprick?
  2. sensation?
  3. appearance?
  4. blanching on pressure?
A
  1. brisk
  2. painful
  3. red, no blisters
  4. yes brisk return
45
Q

superficial partial thickness

  1. bleeding on pinprick?
  2. sensation?
  3. appearance?
  4. blanching on pressure?
A
  1. brisk
  2. painful
  3. pale pink, glistening, often blisters
  4. yes slow return
46
Q

deep partial thickness

  1. bleeding on pinprick?
  2. sensation?
  3. appearance?
  4. blanching on pressure?
A
  1. delayed
  2. dull
  3. cherry red
  4. no
47
Q

full thickness

  1. bleeding on pinprick?
  2. sensation?
  3. appearance?
  4. blanching on pressure?
A
  1. none
  2. none
  3. dry, white, leathery
  4. no
48
Q

which type of chemical burn is more serious?

A

alkali more serious than acid

49
Q

describe the features of electrical burns and what is important to monitor?

A
  • Can look small on outside
  • Deep muscle necrosis and myoglobin release
  • Monitor ECG
50
Q

describe management of minor burns?

A
  • Stop burning (water for 15-20 mins)
  • Analgesia (oral)
  • Assess size and depth of burn
  • Consider none accidental injury
  • Tetanus status
  • Consider site of burn
51
Q

describe how to recognise a non accidental burn?

A
  • History not consistent-could child climbinto bath
  • Lines of dermacation (glove and stocking, donut sparing)
  • No splash marks
  • Sparing of flexor creases
  • Maybe circumferential
  • Other red flags – delay in presentation, history from different carers slightly different
52
Q

describe some aspects of health promotion regarding

A
  • Risks in the home – curling tongs, hot plates

* Sunburn – cover up, sun protection

53
Q

describe the epidemiology of burns?

A
  • 0.5% UK population sustains burns annually
  • Commonly at home
  • Adult – flame most common then scold and contact burns
  • Children – scolds most common then contact and flame
54
Q

describe first aid for burns?

A
  • ABCDE
  • Stop burning process
  • Cool would – water irrigation for 20 mins 15 degrees (if chemical burn need to know what it is before irrigation)
  • Effective within first 3 hours from time of burn
  • Equally, hypothermia should be prevented
55
Q

BURNS

what are palmar rules?

A
  • Quick estimation
  • Patients hands not yours
  • Hand (palm and fingers) = 1%
  • Overestimate in women and underestimate in children
56
Q

BURNS

what is Wallace’s rule of nines?

A
  • 10 years up

* Percentage to each body area eg 18% anterior/posterior trunk

57
Q

BURNS

what is the lund and browder chart?

A
  • Divide body into areas of differing percentages of total

* Paediatric charts are available across age ranges

58
Q

epidermal depth burn

  1. colour
  2. blisters
  3. cap refill
  4. sensation
  5. healing
A
  1. red
  2. no
  3. present
  4. present
  5. yes
59
Q

superficial dermal depth burn

  1. colour
  2. blisters
  3. cap refill
  4. sensation
  5. healing
A
  1. pale pink
  2. small
  3. present
  4. painful
  5. yes
60
Q

mid-dermal depth burn

  1. colour
  2. blisters
  3. cap refill
  4. sensation
  5. healing
A
  1. dark pink
  2. present
  3. sluggish
  4. +/-
  5. usual
61
Q

deep dermal depth burn

  1. colour
  2. blisters
  3. cap refill
  4. sensation
  5. healing
A
  1. blotchy red
  2. +/-
  3. abscent
  4. abscent
  5. no
62
Q

full thickness depth burn

  1. colour
  2. blisters
  3. cap refill
  4. sensation
  5. healing
A
  1. white
  2. no
  3. absent
  4. absent
  5. no
63
Q

why is fluid resuscitation important physiologically?

A

Acute inflammatory response = vasodilation and increased permeability -> fluid shift from vessels to extracellular space ->worsening oedema and reduced circulating volume -> inadequate tissue perfusion = hypovolaemic shock

64
Q

what are the indications of fluid resuscitation in burns?

A
  • 10% TBSA children – children need dextrose/saline for addictional maintenance fluid
  • 15% tbsa adults
  • Parkland formula
65
Q

what is the referral criteria for a patient with burns?

A
  • Burns >3% adults, >2% children
  • Any full thickness
  • Any cirumferential burns
  • Slow to heal burns (>2 weeks)
  • Burns to special areas
  • Any chemical/electrical/friction burn or cold injury
66
Q

what are the clinical features of an epidermal burn?

A

epidermis only
skin is red and painful but no blisters
eg sun burn

67
Q

what are the clinical features of superficial partial thickness burn?

A

epideris and upper layer of dermis affected
skin is pale pink with blistering
capillary refill blanches and rapidly returns

68
Q

what are the clinical features of a deep partial thickness burn?

A

the epidermis, upper and deeper layers of dermis
skin appears dry or moist, blotchy and cherry red and may be painful or painless
there may be blisters
CRT - blanches with sluggish return or does not blanch

69
Q

what are the clinical features of full thickness burn?

A

burn extends through all the layers of skin to subcutaneous tissues
the skin is dry and white, brown or black in colour with no blisters
it may be describes as leathery or waxy
painless
CRT - does not blanch

Acute Care Block-Year 4 (8 decks)

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