Orthopaedics- Trauma- Management of major trauma

Question 1

What is the basic structure of the Advanced Trauma Life Support guidelines?

Answer 1

Initial primary survey

Secondary survey

Question 2

What does the initial primary survey consist of?

Answer 2

The ABCDE evaluation:
Airway management with cervical spine control
Breathing and ventilation
Circulation and bleeding control
Disability (neurological evaluation)
Exposure and environmental control

Question 3

Name things which could cause airway obstruction in trauma

Answer 3

Foreign bodies
Facial fractures
Swelling from blunt trauma or burns
Reduced conscious level with loss of airway control

Question 4

List some signs of an obstructed airway

Answer 4

Noisy breathing
Gurgling
Stridor
Agitation from hypoxia and hypercapnia

Question 5

What can you tell about a patient who is able to speak?

Answer 5

They have a clear airway

Question 6

What Glasgow Coma Score implies loss of airway control?

What must be done?

Answer 6

8 or less

This requires placement of a definitive airway

Question 7

What must be done if an airway obstruction cannot be removed expediently?

Answer 7

Emergency cricothyroidotomy

A tube is inserted through the cricothyroid membrane

Question 8

What should be protected when assessing and managing airway problems?

Answer 8

The C-spine

Question 9

All major trauma patients should receive high flow oxygen via a tight fitting mask: true or false?

Answer 9

True

Question 10

How is oxygenation best assessed?

Answer 10

Pulse oximetry

Question 11

When does tension pneumothorax occur?

Answer 11

When a puncture in the lung results in a one way valve between the lung and pleural cavity resulting in accumulation of air around the lung which can result in collapse and severe respiratory distress.

Question 12

Name some signs of tension pneumothorax

Answer 12

Trachea may be palpably deviated to the opposite side of the pneumothorax
Respiratory distress 
Tachycardia 
Hypotension
Neck veins will be distended
No air entry on the affected side

Question 13

What is emergency management of a tension pneumothorax?

Answer 13

Needle decompression with a large bore needle in the 2nd intercostal space, midclavicular line before a chest drain is inserted

Question 14

How is an open pneumothorax treated?

Answer 14

A chest drain is inserted distant from the wound

Question 15

Describe how adequacy of circulation and perfusion can be assessed?

Answer 15

Pulse rate and volume
Blood pressure
Cardiac monitor- provides continuous information to detect tachycardia, bradycardia and any arrhythmia.

Question 16

All major trauma patients are given 2L of IV crystalloid initially: true or false?

Answer 16

True

Question 17

What is essential to gauge fluid balance in a major trauma patient?

Answer 17

Urinary catheterization and urine output monitoring.

Question 18

What is the minimum accepted urine output?

Answer 18

30ml/hour

Question 19

What is the first manifestation of hypovolaemic shock?

What is this followed by?

Answer 19

Tachycardia followed by reduction in blood pressure

Confusion and lethargy may also be present

Question 20

Name signs of cardiac tamponade

How is it confirmed?

Answer 20

Distended neck veins
Muffled heart sounds
Confirmed with echocardiogram

Question 21

Name signs of severely raised intracranial pressure from intracranial haemorrhage.

Answer 21

Pupils fixed and dilated

Question 22

How is level of consciousness determined?

Answer 22

Using the Glasgow coma score

Question 23

Which patients have a higher risk of subdural haematoma, and therefore have a lower threshold for CT scanning?

Answer 23

The elderly

Question 24

Why must trauma patients be kept warm?

Answer 24

Hypothermia can readily occur in unconscious or immobile patients.
Warmed IV fluids should be administered.

Question 25

What is a log roll?

Why should it be performed?

Answer 25

A manoeuvre by 4 trained staff to avoid rotation of the spine and inadvertent spinal cord injury if unstable spinal injury.
Should be performed to look for signs of spinal fracture (e.g. tenderness, swelling) and a PR exam should be performed to detect PR bleeding and assess anal tone and perianal sensation.

Question 26

Why is a nasogastric tube usually passed?

Answer 26

To prevent aspiration in the event of gastric dilatation which can occur in major trauma

Question 27

When may the secondary survey proceed?

Answer 27

After the primary survey is completed and the patient is stable.

Question 28

What is the secondary survey?

Answer 28

A head-to-toe examination to detect other injuries

A more thorough history of the injury, past medical history and fasting status (in case of surgery) is also obtained

Question 29

What is polytrauma?

Answer 29

Where more than one major long bone is injured or where a major fracture is associated with significant chest or abdominal trauma.

Question 30

What is SIRS and when does it occur?

Answer 30

Systemic Inflammatory Response Syndrome
It occurs when there is an amplification of inflammatory cascades in response to trauma with pyrexia, tachycardia, tachypnea and leukocytosis.

Question 31

What is ARDS and when may it occur?

What is required?

Answer 31

Acute Respiratory Distress Syndrome
May occur due to hypoperfusion, SIRS, aspiration or fat embolism with inflammation of the lung perenchyma leading to inflammatory exudates forming in alveoli and impairment of gas exchange.
Positive pressure ventilation is required.