Management of major injuries

Question 1

Open-book pelvic fractures may cause uncontrollable bleeding from?

Answer 1

Retroperitoneal

Question 2

Dosage of Ketamine

Answer 2

0.1–0.5 mg/kg intravenously and a general anaesthetic in doses of 2–4 mg/kg.

Question 3

three-stage approach of ATLS

Answer 3

1 Primary survey and simultaneous resuscitation – a rapid assessment and treatment of life-threatening injuries.

2 Secondary survey – a detailed, head-to-toe evalua- tion to identify all other injuries.

3 Definitive care – specialist treatment of identified injuries.

Question 4

diagnostic signs of tension pneumothorax

Answer 4

absent breath sounds, hyper-resonance, surgical emphysema and deviated trachea are found.

Question 5

indications for orotracheal intubation

Answer 5

• apnoea
• inability to maintain the airway by other means
• needtoprotecttheairwayfromaspirationofblood
  and stomach contents
• impending airway obstruction, e.g. inhalational
  burn, expanding neck haematoma, facial fractures
• closed head injury with GCS below 8
• inability to maintain adequate oxygenation and
  ventilation with a face mask or BVM assembly

Question 6

IMMEDIATELY LIFE-THREATENING CHEST INJURIES

Answer 6

1 Tensionpneumothorax
2 Openpneumothorax(sucking chest wound)
3 Massivehaemothorax
4 Cardiactamponade
5 Flailchest
6 Disruptionoftracheobronchialtree

Question 7

POTENTIALLY LIFE-THREATENING CHEST INJURIES (SECONDARY SURVEY)

Answer 7

1 Simplepneumothorax
2 Haemothorax
3 Pulmonarycontusion
4 Tracheobronchialtreeinjury
5 Bluntcardiacinjury
6 Traumaticaorticdisruption
7 Traumaticdiaphragmaticinjury
8 Mediastinaltraversingwounds

Question 8

Stages of shock

Answer 8

Stage 1
- <15 %
<750 ml

Stage 2
15-30%
750-1500 ml
Tachycardia >100
Increase capillary refill >2 seconds
Cool, pale and clammy skin

Stage 3
- 30-40%
1500-2000ml
Marked tachycardia >120
Marked tachypnoea >30 bpm
SBP <100mmHg
Significant mental status changes

Stage 4
- >40%
>2000ml
- Severe tachycardia >140 bpm
Respiratory distress
SBP <70 mmHg
Moribund, decreased conscious level
Minimal urine output

Question 9

key physical signs pathognomic of basal skull fracture

Answer 9

• periorbital ecchymosis (bruising – ‘raccoon’ or ‘panda’ eyes)
• retroauricular ecchymosis (Battle sign – bruising behind ears)
• otorhinorrhea (CSF leakage from nose and ears)
• VIIth and VIIIth cranial nerve dysfunction (facial
  paralysis and hearing loss).

Question 10

indications for a head CT are:

Answer 10

• GCS<13onfirstEmergencyDepartmentassessment
• GCS <15 2 hours after initial assessment
• suspected open or depressed skull fracture
• clinical basal skull fracture
• post-traumatic seizure
• focal neurological deficit
• > 1 episode of vomiting
• amnesia of events >30 minutes before impact
• post-injury amnesia if:
  – age >65 years
  – associated with coagulopathy
  – due to a dangerous mechanism of injury (pedes-
  trian versus motor vehicle, ejection from motor vehicle, fall from height >1 m).

Question 11

AETIOLOGY OF CIRCULATORY SHOCK

Answer 11

Reduction in cardiac output
* HYPOVOLAEMICSHOCK–reduced circulating volume causing a reduction in venous return and cardiac output, e.g. haemorrhage

• OBSTRUCTIVESHOCK–mechanical obstruction to normal venous return or cardiac output, e.g. tension pneumo- thorax, cardiac tamponade or massive pulmonary embolism
• CARDIOGENICSHOCK–failureof cardiac pump to maintain cardiac output, e.g. post myocardial infarction

Reduction in peripheral resistance
* DISTRIBUTIVESHOCK–adropin peripheral resistance due to vasodila- tation, which is often associated with
an increase in cardiac output but not sufficient to maintain blood pressure, e.g. anaphylaxis, neurogenic shock, SIRS, septic shock

• ENDOCRINESHOCK–intheintensive care setting hypothyroidism, hyperthy- roidism and adrenal insufficiency can all lead to reduced tissue perfusion

Question 12

Clinical features of FES

Answer 12

Pathognomonic signs are petechiae on the trunk and axillae and in the conjunctival folds and retinae.

Question 13

What is Crush syndrome

Answer 13

Crushed limb is under perfused and myonecrosis follows, leading to release of toxic metabolites when limb if freed and generating repercussion injury

Membrane damage and capillary fluid reabsorption failure result in swelling that lead to compartment syndrome

Tissue necrosis also causes systemic problems eg: renal failure from free myoglobin, metabolic acidosis with hyperkalemia and hypocalcemia