MCQs Flashcards
Ratio of blood products
2 RBCs : 1 unit FFP
Once on 4th unit RBC -> platelets
What blood to ask for in major haemorrhage
1 unit O-ve
1 unit type specific
Rest fully crossmatched
priorities in TBI
hyperoxaemia
maintain normal PaCO2
MABP > 90
neurosurgery consult
Fluids in resuscitation
crystalloids (hartmann’s/saline)
No more than 1L
Hypothermia level which increases bleeding x 2
35 degrees celsius
1st marker haemorrhage shock
pulse pressure (vasoconstriction - increases diastolic pulse pressure - pulse pressure decreases)
chest drain size pneumothorax
28
chest drain size haemothorax
32
very distressed child
intranasal diamorphine 0.1mg/kg
dermatomal/myotomal changes in C5 - where is the injury likely to include to
C3 (2 above)
diaphragmatic supply
C3, C4, C5
keeps diaphragm alive
Low BP + low HR + warm
neurogenic shock
GCS - M total
6
GCS - V total
5
GCS - E total
4
M6
obeys command
M5
localises to pain
M4
withdraws from pain
M3
abnormal flexion
M2
abnormal extension
V5
normal
V4
confused
V3
inappropriate words
V2
sounds
E4
opens spontaneously
E3
opens to voice
E2
opens to pain
pain control chest drain
xylocaine - to muscular & nerve level as well as skin
needle decompression/finger thoracotamy/chest drain insertion site
5th ICS (nipple level/breast fold), anterior to midaxillary line, above rib
2nd rib at
manubrium
Inspection for B
skin colour, use of accessory muscles, chest wall equally rising, obvious external injuries, seesaw pattern, neck veins
Inspection from end of bed C
GCS, skin colour, pain/discomfort/agitation, sweating,
Inspection for A
foreign bodies, obvious fractures, blood/vomit, dentures
temperature for warmed fluids
39 degrees
Areas of major haemorrhage
chest abdo pelvis retroperitoneum long bones/limb amputation (on the floor)
TXA Dosing
1g within 3 hours
1g over 8 hours
immediately when walk into scenario
C-spine control
then: ask nurse for oxygen, observations, IV access & bloods
collar & blocks & tape
MIST
M – Mechanism of injury/illness
I – Injuries (sustained or suspected)
S – Signs, including observations and monitoring
T – Treatment given
Bloods in trauma patient
VBG, FBC, U&Es, coagulation, G&S, crossmatch, glucose, pregnant test,
Exposure examination
perineum, rectum & vagina, log roll for back, MSK
larynx/trachea injury
neck injuries
may cause obstruction due to swelling/bleeding
urgent definitive airway - may need early surgical airway
3Ps of indications for definitive airway
Provide - immediate - most qualified in room
Protect - urgent - most qualified in dept
Puff - soon - most qualified in hospital
triad of symptoms laryngeal trauma
hoarseness, subcut emphysema, palpable fracture
- early definitive airway
triad of symptoms laryngeal trauma
hoarseness, subcut emphysema, palpable fracture
- early definitive airway
B examination pattern
look, feel (incl percuss), listen (incl HS)
how to measure NPA
diameter same as little finger, usually right nostril, follow curve of NPA
paralytic for drug assisted intubation
1-2mg/kg/ succinylcholine IV
needle size for needle cricothryoidotomy
adults 12-14G (orange)
paed 16-18G (grey-green)
can use for 20 mins, 1sec on 4 sec off
tube size for surgical cicothyroidotomy
5-7 in adult
not recommended for children < 12
pulse oximetry accuracy decreased by
profound anaemia/hypothermia
sats of >95% correlate with PaO2 of
> 70mmHg or 9.3kPa
shock =
loss of end organ perfusion
best treatment for haemorrhage shock
stop the bleeding!!!!
tachycardia in infant is
> 160
tachycardia in 1-5 year old
> 140
tachycardia in 5-15
> 120
tachycardia in adults
> 100
types of shock
haemorrhage cardiogenic incl cardiac tamponade/air embolus/MI tension pneumothorax neurogenic septic
normal adult blood volume is
7% of body weight (70kg = 5L) (78ml/kg)
normal child blood volume is
8-9% of body weight (70-80ml/kg)
class 1 haemorrhage approx blood loss
15% (750ml)
class 1 haemorrhage signs
normal HR normal BP normal pulse pressure normal RR normal UO normal GCS base deficit 0 to -2
class 1 haemorrhage management
monitor
class 2 haemorrhage approx blood loss
15-30% (750-1.5L)
class 2 haemorrhage signs
normal/high HR norma BP low pulse pressure normal RR normal UO (20-30ml/hour) normal GCS base deficit -2 to -6
class 2 haemorrhage management
IV fluid bolus challenge (500ml-1L)
- responder - fine leave
- transient responder/responder - blood transfusion/major haemorrhage
class 3 haemorrhage approx blood loss
31-40% (1.5L-2L)
best assessment of fluid ressusc in adults
urine output of 0.5ml/kg/hour
most important principle for head injury
avoid hypotension
pads urine output target > 1 year
1ml/kg/hour
succinylcholine onset of action
paralysis < 1 min
duration < 5 mins
can cause severe hyperkalaemia
starling’s law
muscle fibre length related to contractile properties of myocardial muscle
class 3 haemorrhage signs
high HR normal/low BP low pulse pressure normal/high RR low urine output low GCS base deficit -6 to -10
class 3 haemorrhage management
control the bleeding
major haemorrhage protocol
class 4 haemorrhage approx blood loss
> 40% (>2L)
class 4 haemorrhage signs
high HR low BP low pulse pressure high RR low UO low GCS base deficit > -10
class 4 haemorrhage management
control the bleeding
major haemorrhage protocol
anticipate arrest
blood loss in tibia/humeral fracture
750ml
blood loss in femur fracture
1.5L
blood loss in pelvic fracture
2L or more
remember gastric decompression!!
can cause unexplained hypotension & cardiac dysrhtymia
pads < 40kg fluid resuscitation
20ml/kg (bolus with 10ml/kg initially)
urine output target in < 1 year
2ml/kg/hour
minimum size of need for IV access
18G (green)
- aim have grey (16G) or orange (14G) which are bigger
massive transfusion =
> 10 units within 24 hours or > 4 units in 1 hour
Ohm’s law
BP is proportional to cardiac output and systemic vascular resistance
BP (V) = CO (I) x SVR (R)
tracheobronchial tree injury presentation
LIFE THREATENING haemoptysis cervical subcut emphysema tension pneumothorax cyanosis
method for CXRs
identify patient name, DOB, date of XR, & technically ok outside in - foreign bodies - soft tissues - pleura - diaphragm - lungs - heart - mediastinum
method for pelvic XRs
3 Os - pelvic & ischial
3 joints - pubic symphysis, SIJs & hips
3 lines - schentoins, pubic symphysis, trace bone outlines
tracheobronchial tree injury diagnosis confirmation
bronchoscopy
how to confirm diaphragm rupture
pass NG tube and re XR - will not go below if ruptured
tracheobronchial tree injury management
immediate airway - may require intubation of only the uninjured bronchus
open pneumothorax (sucking chest wound) management
dressing attached on 3 sides
massive haemothroax =
> 1.5L in one side of chest (if drained immediately/200ml for 2-4 4 hours -> thoracotomy)
- ensure IV access
kussmaul’s sign
rise in venous pressure with inspiration when breathing spontaneously - consider tamponade
cardiac tamponade management
thoracotomy/sternotomy
- needle pericardioscentesis is temporising measure
VF give
epinephrine 1mg
causes fo cardiac arrest in trauma
severe hypoxia tension pneumothorax profound hypovolaemia cardiac tamponade cardiac herniation severe myocardial contusion severe brain injury
IO sizing
paeds - pink
bigger paed (>40kg) - blue
yellow - adult
warfarin reversal
FFP
Vit K
prothombin complex concentrate
factor VIIa
herparin/LMWH reversal
protamine sulfate
dabigatran reversal
idarucizumab
DPL positive
GI contents, food, oil, >10cc blood in haemodynamically unstable
indications for laoporotomy
abdo trauma + HD unstable GSW transversing peritoneum evisceration bleeding from stomach, rectum & GU tract following penetrating trauma free air/rupture diaphragm CT findings
common diaphragm injury
5-10 cm in length & involves posterolateral left hemidaphram
open book pelvic fracture commonly in
petrol pessary - abrupt stop on motorcycle
pelvic binder can stay on for
max 12 hours
can stay on spinal board for max
2 hours
monro-kellie doctrine
explains ICP (box has limited space)
pulse pressure
systolic - diastolic
normal > 40mmg
MABP
diastolic x 2 + systolic
divided by 3
cerebral pulse pressure =
MAP - ICP
- MAP of 50-150mmhg is auto regulated for constant cerebral blood flow
severe brain injury
GCS 3-8
moderate brain injury
GCS 9-12
mild brain injury
GCS 13-15
admission indications for mild brain injury
no ct available but is required, CT abnormal, skull fracture, CSF leak
focal neurological deficit
GCS does not return to normal within 2 hours
neurosurgery consultation for
moderate & severe brain injury
CT head for
moderate & severe brain injury
mild with - GCS < 15 at 2 hours after, skull fracture suspected, vomiting (> 2), age > 65, anticoagulants, LOC (>5mins), dangerous mechanism, amnesia before impact
severe brain injury management
frequent examination PaCO2 35-40 mannitol if signs of herniation neurosurgery consider levetiracetam for seizures
seizure in TBI
acute - phenytoin loading 1g IV (no faster than 50mg/min)
maintenance - phenytoin 100mg/8hours
management of moderate BI
CT admit observe with frequent GCS for 12-24 hours neurosurgery consider repeat CT at 24 hours
mannitol dose
1g/kg over 5 mins if signs of herniation
0.25-1g/kg for raised ICP
burr hole
10-15mm drill hole in skull - use if neurosurgeons not readily available
C5 dermatome
badge patch
C6 dermatome
thumb
C7 dermatome
middle finger
C8 dermatome
little finger
T4 dermatome
nipple
T8 dermatome
xiphisternum
T10 dermatome
umbilicus
T12 dermatome
symphysis pubis
L4 dermatome
medial aspect of calf
L5 dermatome
webspace between 1st & 2nd toe
S1 dermatome
lateral border of foot
S3 dermatome
ischial tuberosity area
S4 & S4 dermatome
perianal region
C5 myotome
elbow flexion
C6 myotome
wrist extension
C7 myotome
elbow extension
C8 myotome
finger flexors
T1 myotome
finger abductors
L2 myotome
hip flexors
L3 myotome
knee extension
L4 myotome
ankle dorsiflexion
L5 myotome
big toe dorsiflexion
S1 myotome
ankle plantar flexion
S2, 3, 4
anal tone
injury to what spinal level can cause impairment of sympathetic pathways
T6 and above (neurogenic shock)
assessment of spine
look, feel, patient move
corticospinal tract
anterior & lateral segments of cord
motor power on same side
spinothalamic tract
anterolateral cord
pain & temperature on opposite side
- test by pinprick
dorsal columns
posteromedial aspect
position and light touch on same side
- vibration & proprioception
area of greatest flexion & extension in c-spine
C5-C6 (most vulnerable)
image neck if
age > 65
dangerous mechanism
pareasthesia
unable to rotate neck through 45 degrees with no pain
do not image neck if
sitting in ED ambulatory at arrival delayed onset of neck pain no midline cervical tenderness able to rotate neck through 45 degrees no dangers mechanism young no neurology
screen for carotid/vertebral artery injury
in c1-c3 fracture
temporal lobe herniation would compress
oculomotor nerve (CNIII) - pupillary dilation (unopposed sympathetic)
uncle herniation
corticospinal tract compression - weakness in opposite side of body
basilar skull fracture
raccoon eyes
battle’s sign
CSF leak from nose/ear
dysfunction of CNs 7 & 8 - facial paralysis/hearing loss
BP targets in brain injury
50-69years old systolic >100
15-59 years old & > 70 years systolic >110
low PaCO2 in BI
cerebral vasoconstriction
disproportionately greater loss of motor strength in arms & fingers compared to legs & feet
hyperextension injury in C-spine stenosis
central cord syndrome
paraplegia & bilateral loss of pain & temperature
anterior cord syndrome
brown-sequard syndrome
ipsilateral motor loss (corticospinal) & proprioception (dorsal)
contralateral loss of pain & temp (spinothalamic)
metabolic acidosis, high potassium, low calcium, DIC
rhabdo
ABPI
SBP of injured leg divided by SBP of uninjured arm
< 0.9 is abnormal
open fracture wound < 1cm minimal contamination
cefazolin
if anaphylactic clindamycin
open fracture wound 1-10cm, commuinuted fracture§
cefazolin
if anaphylactic clindamycin
open fracture severe soft tissue damage, substantial contamination
cefazolin (if anaphylactic clindamycin) + gentamicin (2.5mg/kg in child, 5mg/kg in adult)
open fracture contaminated with farmyard, soil, standing water
tazocin (piperacillin + tazobactam)
nerve at risk in elbow injury
ulnar
- index & little finger abduction, little finger sensation
nerve at risk in wrist fracture/dislocation
median distal
- thenar contraction with opposition, sensation to tip of index finger
nerve at risks in supracondylar fracture of humerus
median, anterior interosseous
- index finger flexion
Nerve at risk in distal humeral fracture/anterior shoulder dislocation
musculocutaenous
- elbow flexion, sensation of lateral forearm
nerve at risk in anterior shoulder dislocation/proximal humeral fracture
axillary
- motor to deltoid, sensation to lateral shoulder
nerve at risk in pubic rami fracture
femoral
- knee extension, sensation to anterior knee
nerve at risk in obturator ring fractures
obturator
- hip adduction, medial thigh sensation
nerve at risk in knee dislocation
posteror tibial
- toe flexion, sensory to sole of foot
nerve at risk in fibular neck fracture/knee dislocation
superficial peroneal
- ankle eversion, sensory to lateral dorsal of foot
nerve at risk in fibular neck fracture/compartment syndrome
deep peroneal
- ankle/toe dorsiflexion, sensation to dorsal 1st & 2nd toe web space
nerve at risk in posterior hip dislocation
sciatic nerve
- ankle dorsiflexion/plantar flexion, sensation to foot
nerves at risk in acetabular fracture
superior gluteal
- hip abduction, sensory to upper buttocks
inferior gluteal
- hip extension, sensory to lower buttocks
acid or alkali burn worse
alkali
carboxyhemoglobin < 20%
asymptomatic
carboxyhemoglobin 20-30%
headache & nausea
carboxyhemoglobin 30-40%
confusion
carboxyhemoglobin 40-60%
coma
carboxyhemoglobin >60%
death
treatment of carboxyhemoglobin poisoning
100% oxygen (decreases T12 from 4 Horus to 40mins) & intubate
fluids in shock in burns
2ml/kg/% of body surface area burned in first 24 hours
- give 1/2 in first 8 hours
- remaining in subsequent 16 hours
3ml/kg/% body surface burned in paeds
fluids in electrical injury
4ml/kg/body surface burned
repercussion syndrome
acidosis, hyperkalaemia, local swelling
RR in infant
normal 30-40
RR in older child
normal 15-20
needle decompression in paeds
just above 3rd rib in midclavicular line - caution when using 14-18G needles
- chest drain same as adult but tunnel along rib
< 1 normal HR
< 160
< 1 normal BP
> 60
< 1 normal RR
< 60
< 1 normal UO
2ml/kg/hr
1-2 yr normal HR
<150
1-2yr normal BP
> 70
1-2yr normal RR
> 40
1-2yr normal UO
1.5ml/kg/hr
3-5yr normal HR
< 140
3-5yr normal BP
> 75
3-5yr normal RR
< 35
3-5yr normal UO
1.0 ml/kg/hr
6-12yr normal HR
<120
6-12yr normal BP
> 80
6-12yr normal RR
< 30
6-12yr normal UO
1.0ml/kg/hour
> 13 normal HR
< 100
> 13 normal BP
> 90
> 13 normal RR
< 30
> 13 normal UO
0.5 ml/kg/hr
weight estimation paeds
(2 x age in years) + 10
blood volume in infant
80ml/kg
blood volume in child 1-3 yrs
75ml/kg
blood volume in > 3 yrs
70ml/kg
IO needle infant
18G
IO needle > 3 yrs
15G
damage control resuscitation in paeds
- 10ml/kg bolus crystalloid
response - fine
nonresponder/transient - 10-20ml/kg pRBCs + 10-20ml/kg FFPs
V5 in < 4yrs
appropriate words, social smile, fixes & follows
V4 in < 4yrs
cries but consolable
V3 in < 4 yrs
persistently irritable
V2 in < 4yrs
restless, agitated
child tracks movement & holds head steady at
3 months
child rolls over at
6 months
child sits without support at
7 months
child stands whilst cruising at
9 months
- should be saying mama/dada at 8 months
child crawls at
10 months
child stands without support for a few seconds at
11 months
low normal PaCO2 in pregnancy (3.5-4.0)
impending resp failure
examination mandatory in pregnancy
vaginal
displace uterus to prevent vena cava compression
to the left
15-30 degrees
normal fibrinogen in pregnancy
?early DIC (usually x2)
3 vital signs of the eye
vision, pupils, intraocular pressure
normal eye pressure
8-21mmHg
anterior examination of eye
periorbita, extra ocular muscles, lids, lashes, lacrimal sacs, conjunctiva, sclera, cornea, iris, anterior chamber and lens
posterior examination of eye
red reflex, optic nerve, retina
decreased vision, elevated eye pressure, asymmetrical eye bulge, resistance to retropulsion and “rock hard eye” (tight eyelids agains globe)
retrobulbar haemorrhage with compartment syndrome
- need canthotomy & catalysis (call ophthalmologist)
chemical burn to eye
1L of saline, connected to Morgan lens. rinse for 30 mins (or after each 1L) and assess pH for normal (7)
test to locate small leaks of aqueous fluid from anterior chamber
seidel test
mild hypothermia
32-35
moderate hypothermia
30-32
severe hypothermia
< 30
mild hypothermia in injury
36
moderate hypothermia in injury
32-36
severe hypothermia in injury
< 32
cardiac irritability occurs at what body temp
33
VF occurs at what temp
below 28
asystole occurs at what temp
below 25
mild & moderate hypothermia management
mostly passive warming
severe hypothermia management
active warming - warm fluid lavage, haemodialysis, bypass
you are not dead until
you’re warm and dead
heat exhaustion occurs at
39
heat stroke occurs at
> 40 involves CNS (dizziness/confusion/seizures) and systemic inflammatory response (rhabdo, encephalopathy, ARDS)
2 types of heat stroke
classic nonexertional (heat waves, typically affecting young & old)
exertion heat stroke
young, fit & healthy
strenuous exercise
management of heat injuries
A-E 100% O2 consider definitive airway ABG, renal & urea nitrogen levels CXR remember hypoglycaemia, hyperkalaemia, acidosis seizures - benzos
goal temp decrease in heat stroke
decrease to < 39 in 30 mins
