new things 15/02 Flashcards
Subdural haematoma features:
Elderly
Alcoholic
Head injury
Insidious onset
Fluctuating levels of consciousness
Rupture of bridging veins that cross the subdural space is the common cause.
Investigation of choice for PSC?
MRCP/ERCP
Recent chemo + fever >38 management:
Immediate prescription of IV tazocin.
Do not wait for wcc, suspect neutropenic sepsis.
Extradural vs subdural haemorrhage:
Extradural = lucid period, usually following major head injury.The majority occur in the temporal lobe where the middle meningeal artery is damaged.
Subdural = fluctuating consciousness, often following trivial injury in elderly or alcoholics.
Majority occur in frontal / parietal lobes.
Which artery is most likely to be damaged in an extradural haemorrhage?
Middle meningeal artery
How to manage patients with intracranial bleeds that become unresponsive :
Urgent CT head to check for hydrocephalus.
What does the Modified Glasgow Score entail and what is it used for?
Severity of pancreatitis:
PaO2
Age
Neutrophilia
Calcium
Renal function - Urea
Enzymes - LDH, AST
Albumin
Suagr
Investigations in acute pancreatitis:
Serum amylase.
Note a diagnosis can be made without imaging if characteristic pain + Amylase >3x upper limit of normal
Early ultraound imaging for aetiology e.g. gallstones.
Other options would include contrast enhanced CT.
Serum lipase is more sensitive and specific and expensive, but has a longer half life so may be useful in late presentations.
What are the 3 components of the triad of death?
Hypothermia
Acidosis
Coagulopathy
Describe the process of tension pneumothorax causing obstructive shock:
Air enters the thoracic cavity and punctures the lung but cannot escape.
Its a one way air leak from damaged wall or lung, leading to increase in pressure, collapsing the affected lung.
Mediastinal shift occurs.
Occlusion of the vena cava, reducing venous return to heart, reducing cardiac output and therefore causing obstructive shock.
Clinical signs of tension pneumothorax:
Respiratory distress
Absent breath sounds on one side
Tracheal deviation
Hyperresonance on affected side
Tachycardia and hypotension
Minimal chest movement
Management of a tension pneumothorax:
Emergency
15L trauma mask
Grey venflon in 2nd intercostal space miclavicular line to buy some time
Chest drain
Check x-ray
Clinical signs of cardiac tamponade:
Pulsus paradoxusus
Distended neck veins
Tachycardia
Hypotension
Muffled heart sounds
Complications of chest trauma:
Hypovolaemic shock
Obstructive shock
Hypoxic arrest
Cardiac arrest
Empyema
Intrathoracic infection
Death
3 most common organs affected in abdominal trauma:
Liver
Kidneys
Spleen
What is management of abdominal trauma based on?
Haemodynamic stability of the patient
Specific abdomen pathology
3 types of management in abdominal trauma and indications:
Conservative, if haemodynamically stable
IR
Immediate damage control laparotomy if unstable, or evidence of e.g. perforation or mechanism e.g. stabbing through peritoneum
Goals of damage control laparotomy:
Stop bleeding
Infection control
Abdominal packing
Temporary closure device e.g. laparostomy
Clinical signs in abdomen trauma:
Haematoma, seatbelt sign
Shoulder tip pain due to blood irritating the diaphragm
Hypovolaemic shock
Haematuria
Abdo pain, rigid, distension
How are liver, spleen and kidney injuries classified in trauma:
Grade I-V (kidney and spleen) and VI in liver.
Clinical signs of basal skull fractures:
Anterior cranial fossa = raccoon eyes, csf leaking from nose (separates on pillow)
Petrous temporal bone: Battle’s sign, mastoid bruising, CSF leaking from eyes, haemotypanum, cranial nerve signs e.g. facial paralysis / hearing loss.
Describe the aetiology of diffuse axonal injury:
Rapid aceleration/ deceleration causes shearing of axons diffusely - can cause persistent vegetative state after trauma.
Traumatic brain injury can be permanent. Describe the relationship between grade of TBI and GCS:
GCS 13-15 = mild
GCS 9-12 = moderate
GCS 3-8 = severe, can’t protect airway, need to be intubated.
Describe Cushing’s reflex:
Hypertension and bradycardia, a pre-terminal sign as brain is herniating through foramen magnum.
Investigations in head trauma:
Full neuro exam if possible
Neuro obs every 30-60 mins
Blood gas for gas exchange
CT Trauma or head and neck
MRI/EEG later on
What are 2 factors that contribute to poor prognosis in a head injury?
Hypotension
Hypoxia
Initial management in head trauma:
Stop / reverse blood thinners
Resus
CT scan
Neurosurgery review
Consider transfer depending on site
2 types of surgical management in head trauma:
Burr hole decompression
Trauma craniectomy
Complications of head trauma:
TBI
Disability
CND infection
Coning - herniation of cerbellar tonsils through foramen magnum, causing compression of the brainstem and respiratory arrest.
What is a complication of all types of trauma:
Death
What is the role of a pelvic binder?
Tamponades bleeding, a factor in C of A-E.
Stabilises fracture.
Should only be taken off by orthopaedic surgeons.
Discuss initial assessment of a patient presenting with trauma / shock:
Hx and AMPLE if possible.
A-E assessment with c-spine control in A and haemorrahge contorl in C.
Resuscitation is included in the A-E in trauma e.g. control of bleed.
Secondary survery, looking for other injuries / wounds etc.
Trauma series CXR and pelvic xr
FAST
Trauma CT (head neck CAP) if stable enough
Intervention e.g. theatre, IR, ICU
Tertiary survey 24 hours later once distracting injuries have been dealt with.
Describe the 4 types of shock and causes of each:
Hypovolaemic - haemorrhage, burns, other fluid loss
Obstructive - cardiac tamponade, tension pneumothorax, PE
Cardiogenic - heart pump failure
Distributive - septic, anaphylaxis, neurogenic
Patients who’s vital signs / response may be abnormal in shock:
Young patient e.g. athlete with very low HR to start with, may not detect he is tachycardic until later.
Drugs e.g. BB, patients may not be able to amount an appropriate tachy response.
Elderly - e.g. polypharmacy, depressed response.
What do you get when you put out a major haemorrhage 2222 call?
6U prcs
4U FFP that needs defrosted
+/- platelets.
No doctors will come to a major haemorrhage call.