MSK - Life and Limb Threatening Trauma Flashcards
What is ATLS?
Advanced Trauma Life Support
What is A for in A->E? Explain the process and possible treatment.
Airway
Talking and alert?
Noises e.g. snoring, stridor
No noises
- Facial injuries put airway at risk
To treat:
Suction, removal of foreign body, Intubation
All trauma patients have high flow O2
C-spine control!
What is B for in A->E? Explain what you are to looking for?
Breathing
Thorasic cavity healthy or full of blood or air?
Is the thorasic cage damaged?
What should you inspect for when assessing breathing in A->E?
- Inspection: Evidence of chest injury, increased respiratory effort, asymmetrical chest
What should you palpate for when assessing breathing in A->E?
- Palpate: central trachea deviation, chest wall expansion, percussion (dull or hyper-resonate?)
What should you auscultate for when assessing breathing in A->E?
-Auscultation: Bubbling/gurgling noises, symmetrical air entry?
What Vital signs should you look for for when assessing breathing in A->E? (4)
SpO2
RR
Pulse
BP
What is a tension pneumothorax? (4 steps)
- Penetrating trauma makes hole in chest wall allowing air to be drawn in but preventing air from escaping.
- With each inspiration more air enters thorasic cavity, causing collapse of the lung and increased pressure inside.
- Pressure pushes mediastinum to the other side quashing remaining lung, compromising breathing.
- As pressure high enough to equal that in the great ving there is reduced venous return and eventually cardiac arrest.
What is the clinical diagnosis for a tension pneumothorax? (4)
- Decreased breath sounds on affected side
- Increased percussion note (Hyperresonant)
- Palpation finds deviation of trachea AWAY from affected side
- Engorged neck veins and reduced lung expansion.
How do you treat a tension pneumothorax?
- Insertion of a large bore needle through the chest wall at the 2nd intercostal space midclavicular line in adults and 5th intercostal space midaxillary line in children.
- Chest drain within 30 mins.
what is an open pneumothorax? (4)
- ‘Sucking chest wound’
- Air passes into thorasic cavity through path of least resistance through wound in chest wall, by-passing the lungs.
- Air expired through same hole, hence no tension effect
- Unable to oxygenate blood
How do you treat an open pneumothorax?
- Creating a one way valve only allowing air to escape.
- Place an occlusive dressing over the wound and tape on 3 sides.
- Chest drain needed for definitive management
What is a Flail chest?
2 or more ribs fractured in two or more places causing separation of a segment of the thorasic cage which moves independently, preventing effective ventilation.
How do you treat a flail chest?
Fix fractures with plates and screws to allow recovery, there is often over underlying injuries too.
What is the C for in A->E? What should you do to asses? (3)
Circulation - with hemorrhage control
- Recognise if circulation is compromised, could be pale, assess peripheral circulation, heart sounds, pulse and BP
- Establish x2 IV access allowing rapid fluid resis and blood samples.
- Control obvious sources, external pressure on peripheral wounds, pelvic binding to prevent exsanguination and hidden blood loss.
What is a massive haemothorax?
> 1500 mls of blood in the pleural cavity causing circulation and respiratory problems.
How do you treat a massive haemothorax?
Chest drain to decompress lungs, blood products to replace lost and cardiothoracic surgery to close the source.
What is a cardiac tamponade? (3)
Condition that can occur from penetrating trauma to the thorax.
As pericardium is a fixed sac like the skull, small pressure increased from blood in cavity had a big effect.
Leads to inability to pump in systole and dilate to fill during diastole.
What is the presentation of a cardiac tamponade?
Becks triad:
- Hypotension due to decreased stroke volume
- Jugular venous distension due to impaired venous return to the heart
- Muffled heart sounds due to fluid inside the pericardium
What is the treatment for a cardiac tamponade?
Pericardiocentesis = ultrasound guided insertion of the needle just under the xiphisternum aiming up to puncture the pericardium and extract blood that has collected there.
Urgent referral to cardiothoracics to identify and stop the cause of bleeding.
What is shock? (3)
- End organ dysfunction due to inadequate oxygen availability for tissues (perfusion). Upset of balance between Oxygen delivery and demand.
- Particularly effects oxygen sensitive tissues cardiac, gut, brain, renal.
- Organs keep functioning in the absence of oxygen, so metabolic acidosis develops from non-aerobic respiration which progresses to the lethal triad.
What is the lethal triad of trauma associated with shock?
- ACIDOSIS: pH <7.25, Base excess <-5 mmol/L, Lactate >2.5 mmol/L
- HYPOTHERMIA: <35 degrees temperature
- COAGULOPATHY: INR >1.5 Platelets <120 x10^9 /L
What types of shock are due to reduced delivery of O2? (4)
- Anaphylactic shock from constriction of blood vessels
- Cardiogenic shock due to inability for blood to pump
- Hemorrhagic shock due to loss of blood
- Neurogenic shock due to lack of nerve signals to blood vessels because of spinal cord damage
What type of shock is due to increased oxygen demand?
- Septic shock: when tissues metabolise faster to fight infection
what type of shock is most common in trauma
Hypovolemic/hemorrhagic shock
What are 5 places that blood loss can occur in hypovolemic shock?
- Intrathoracic cavity
- Intraperitoneal cavity
- Retroperitoneal cavity
- Thigh compartments
- Floor (outside the body)
What are the 4 classes of hypovolemic shock based on blood volume?
Class 1= 15% average <750 ml
Class 2= 15-30% average 750-1500 ml
Class 3= 30-40% average 1500-2000 ml
Class 4= >40% average >2000ml
How can you calculate circulating blood volume based on non-obese patients weight?
Nonobese adults have 70 ml of blood volume per kilogram of body weight.
EBV = 70ml x weight (kg)
How can you calculate circulating blood volume based off obese patients?
Obese EBV = 50ml x weight (kg)
As fat only contains 8-10% water whereas muscle contains much more.
How do bodies react to hypovolemic shock?
- At first will compensate with increased pulse and decreased urine output.
- Then lose the ability to compensate so BP decreases and urine output stops.
How do you treat hypovolemic shock?
- Fluid resuscitation
- Haemostasis via direct pressure on the wounds
- Pelvic binder
- Having a low threshold for administration of blood products
- Tranexamic Acid 1gm IV
What are the blood products? In what ratio are they given?
IN equal proportions RBCs, Platelets and Frozen fresh plasma (FFP)
What is the aim of treatment for hypovolemic shock? (2)
- Aim to achieve radial pulse
- Permissive hypotension @80 systolic allows organ perfusion without disturbing clot formation.
What does the D stand for in A->E? How do you asses this?
Disability - neurological problems and head injury
Glasgow coma scale (GCS):
Records best response for eye opening, verbal and motor responses with a total out of 15.
<8 = Bad and consider intubation
Check temperature and blood glucose
What is the AVPU scale?
To assess disability in trauma.
Alert
Verbal
Pain
Unresponsive
What is E for in A->E? What is it assessing?
- Exposure and environment control.
- Includes full examination of patient from top-toe while keeping patient warm as clotting is temperature dependant.
What are some common sites to miss injuries? (6)
back of head
Back
Buttocks
Perineum
Axillae
Skin Folds
What is a secondary survey?
To be completed after ABCs complete and stabilized.
Systemic top-toe exam with full log roll to look at important but non-life threatening injuries.
What are 4 limb threatening injuries?
Open fractures, Arterial injury, Nerve injury, Compartment syndrome.
History and exam, treament in open fracture assessment
History: type of injury, force, environment, immersion in waste/water
Exam: look, feel, move, neurovascular status performed once TAKE PHOTOS!
Gustilo-anderson classification of open fractures, 3 grades depending on size and amount/type of repair needed.
Treatment: Realign and splint, IV abx and tetanus, surgical referral.
What is an arterial injury and how is it caused?
It is disruption of a vessel structure either laceration, transection or intimal dissection.
Caused by kinking of a major vessel.
What could cause pulse loss?
Arterial spasms or loss of blood elsewhere - never assume, treat as suspected arterial injury until proven otherwise.
How do you treat an arterial injury?
Resuscitate patient, realign and splint limb , check vascular status after realignment.
What is a nerve palsy?
A sign of a nerve injury
What is neuropraxia?
Squashing or stretching of a nerve resulting in nerve ischaemia from contusion or traction.
Nerve structure remains intact and once cause is removed ion pumps continue to work hence recovers on its own.
What is Axonotmesis?
Myelin sheath disruption causing distal axon to die. Schwann cells and endothelium remain intact. Nerve recovers down pipe but scarred myelin sheath may prevent rull recovery.
What is Neurotmesis?
Complete transection of nerve. No myelin sheath to guide regeneration. Irreversible without surgical repair and unlikely to have full recovery even then.
