OSCE Flashcards
Neurogenic shock
Occurs after transection of autonomic spinal fibers, usually above T6
Hemodynamic phenomenon comprising loss of vasomotor tone and impaired cellular metabolism
Clinically presents with hypotension, bradycardia, and poikilothermia
Occurs within 30 minutes of cord injury, and lasts up to 6 weeks
Management includes airway support, fluid resuscitation, atropine, and vasopressors
Spinal shock
Due to acute spinal cord injury - hematoma, edema, and inflammation
Absence of all voluntary and reflex neurological activity below the level of the injury
- decreased reflexes
- loss of sensation
- flaccid paralysis
Transient - lasts days to months
May occur with neurogenic shock
Hemothorax - signs and symptoms
Hemodynamic instability Pleuritic chest pain Respiratory distress Mediastinal shift Reduced chest rise Decreased air entry Dullness to percussion Flat neck veins X-ray findings - blunting of costophrenic angle (erect film) - requires at least 350ml fluid - haziness of affected thorax (supine film) - air-fluid interface
Tension pneumothorax - signs and symptoms
Pleuritic chest pain Hemodynamic instability Respiratory distress Mediastinal shift Decreased chest rise Percussion increased resonance Distended neck veins
Simple pneumothorax - signs and symptoms
Pleuritic chest pain Dyspnea Tachypnea Subcutaneous emphysema Decreased chest movement Decreased air entry Percussion increased resonance X-ray findings - visible visceral pleural line - absence of lung markings distal to visceral pleural white line (usually apical on erect, and mediastinal on supine) - large if greater than 2cm at the level of the hilum - deep sulcus sign (larger costodiaphragmatic recess)
Site for ICD
5th intercostal space, anterior to the mid axillary line
Indications for splinting
Temporary immobilization of sprains, fractures, and reduced dislocations
Control of pain
Prevention of further soft tissue or neurovascular injuries
Burn injuries
Basilar skull fracture - clinical presentation
Raccoon eyes (periorbital ecchymosis) Battle sign (mastoid ecchymosis) Otorrhoea (blood or CSF) Rinorrhoea (blood or CSF) Seventh nerve palsy Eighth nerve palsy Optic nerve entrapment (rare) Hemotympanum and blood in external auditory canal
Zones of the neck
1 - inferior aspect of cricoid cartilage to thoracic outlet
2 - cricoid cartilage to angle of mandible
3 - angle of mandible to base of skull
Structures at risk in zone 1 of the neck
Great vessels (subclavian vessels, brachiocephalic veins, common carotid arteries, aortic arch, and jugular veins)
Trachea
Esophagus
Lung apices
Cervical spine, spinal cord, and cervical nerve roots
Thyroid and parathyroid glands
Signs of a significant injury in the zone I region may be hidden from inspection of the chest or the mediastinum
Structures at risk in zone 2 of the neck
Carotid and vertebral arteries
Jugular veins
Pharynx, larynx, trachea, and esophagus
Cervical spine and spinal cord
Zone II injuries are likely to be the most apparent on inspection and tend not to be occult. Additionally, most carotid artery injuries are associated with zone II injuries.
Structures at risk in zone 3 of the neck
Submandibular and parotid glands Esophagus Trachea Vertebral bodies Carotid arteries Jugular veins Major nerves (including cranial nerves IX-XII, brachial plexus, phrenic nerve, stellate ganglion)
Injuries in zone III can prove difficult to access surgically
Examination findings for specific structures injured in the neck
Airways: Surgical emphysema
Vascular: Active bleeding, an expanding or pulsatile haematoma, a bruit, peripheral pulses, blood in sputum, air bubbling through the wound, hoarseness, and subcutaneous emphysema
Oesophagus: Surgical emphysema, odynophagia, sometimes haematemesis, and very little else
Neurological: Exclude injury to the spinal cord, Cranial nerves VII/IX/X/XII, to the brachial plexus, and the sympathetic chain (Horner’s syndrome)
Larynx: hoarseness, surgical emphysema
Management of stab neck
Airway - clear airway and intubate, ventilate and oxygenate as necessary. Consider surgical airway with tracheal and laryngeal injury
Breathing - exclude pneumothorax and hemothorax with zone 1 injuries
Circulation - fluid resuscitation, pressure, balloon tamponade, packing, Trendelenburg position to prevent air embolus, urgent surgical intervention
Disability - c-spine protection, detect head injury, consider injury to neurovascular structures of the neck with neurological fallout
Exposure - identify associated injury
Investigations
- X-ray chest and neck
- bronchoscopy
- hexabrix allow +/- esophagoscopy
- arteriography
- CT neck
- Doppler US
Balloon tamponade - technique
For penetrating injuries and significant haemorrhage/expanding haematoma
Establish definitive airway
Insert a size 18-20Fr Foley catheter into the wound
Direct it toward the site of bleeding
Inflate the balloon until bleeding resolves or moderate resistance is noted
Suture skin wound under tension
Compression wedge fracture c spine - mechanism of injury
Flexion injury - longitudinal pull is exerted on the nuchal ligament complex that, because of its strength, usually remains intact
Radiological features of vertebral wedge compression fracture
Buckled anterior cortex (increased concavity)
Loss of height of anterior vertebral body
Increased density due to bony impaction
Prevertebral soft tissues are swollen
Teardrop fracture
Assessment of cervical spine radiograph
Adequacy: C1-T1 tip visible on lateral, or supplementary swimmers view
Alignment (lateral)
- assess prevertebral soft tissue line, anterior vertebral line, posterior vertebral line, and spinolaminar line
- distance btw dens and C1
- distance btw axis and skull
- spinal canal (btw spinolaminar and posterior vertebral lines)
- vertebral malalignment >3mm implies dislocation
Alignment (AP)
- pedicles and spinous processes vertically aligned
- widening of interpeduncular distance suggests burst fracture
Bones
- compare size, shape and height
- assess corticated ring at C2
- exclude fracture of each transverse process
- fractured vertebral body demonstrates compression
- compression >50% suggests unstable fracture
Cartilage: compare disc spaces and look for narrowing
Soft tissue:
- anterior displacement of prevertebral soft tissue line suggestive of fracture (should be <2/3 of vertebral body width)
- line cannot be accurately assessed after ETT placement
- enlarged in crying children
C-spine fractures and diagnosis
C1 Jefferson fracture - open mouth view, lateral displacement of C1 lateral masses
C2 odontoid peg fracture - lateral view, C2 bony ring incomplete, posterior displacement of odontoid peg
Hangman fracture - lateral view, loss of alignment at C2/3 with anterior displacement of C2
Extension teardrop fracture - lateral view, fracture fragment seen at anterior inferior corner of C2
Flexion teardrop fracture - lateral view, C3-7, anterior inferior fracture fragment, widened facet joint, loss of alignment
C-spine dislocation injury - bilateral perched facets, on lateral view:
- loss of alignment
- ‘perching’ of facets
- no fracture visible
- widened prevertebral soft tissue due to hematoma
And AP view:
- widening of spaces btw spinous processes
- loss of alignment
Clay shovelers fracture - isolated fracture of spinous process
Operative vs non operative management of stab neck
Haemodynamically normal: operate only if there is evidence of injury to important structures. This requires special investigations and active observation by the same surgeon at 4-hourly intervals
Haemodynamically stable: Workup if facilities allow immediate investigation, and operate at the earliest sign of instability.
Haemodynamically unstable: Immediate operation for:
- shock not responding to resuscitation
- active bleeding
- an expanding or pulsatile haematoma
- an absent or diminished peripheral pulse
- a bruit
- bubbling of air through the wound
- significant haemoptysis
Burns - fluid management
Parkland formula - 4ml/kg/%BSA
Ringers lactate
First half over first 8 hours from injury
Second half over next 16 hours
Burns - mortality
%BSA + age
Signs and symptoms of burn inhalation injury
Explosion with burns to head and torso History of impair mentation and/or entrapment in burning environment Head and neck burns Singeing of eyebrows and nasal vibrissae Carbon deposits and acute inflammatory changes in the oropharynx Carbonaceous sputum Hoarseness and strider Tracheal tug Respiratory distress Elevated carboxyhemaglobin levels
Carbon monoxide poisoning
20-30% - nausea headache
30-40% - confusion
40-60% - coma
>60% - death
Half life: 250 minutes (room air) 40 minutes (100% oxygen)
Types of inhalation injury
Airway Injury Above the Larynx - Inhalation of hot gases resulting in thermal injury
Airway Injury Below the Larynx - Inhalation of products of combustion resulting in chemical injury ; SIRS
Systemic Intoxication –Absorption of compounds such as carbon monoxide or cyanide resulting in systemic effects
Assessing BSA in burns
Adults
- rule of 9: head, each upper limb, anterior lower limb, posterior limb
- 18%: anterior torso, posterior torso
- 1%: perineum
Kinders
- rule of 9: anterior head, posterior head, each upper limb
- 18%: anterior torso, posterior torso (each butt cheek 2.5%)
- 7%: anterior lower limb, posterior lower limb
Burn depth
1st degree: erythema, pain, no vesicles
2nd degree: erythema or mottled, swelling and vesicles, wet and exudative, painfully sensitive
3rd degree: dark, leathery, dry, waxy white, mottled, translucent, painless
Vertical shear fracture treatment
Reduction of hemi pelvic with reduction
Circular compression
NB anterior external fixation ineffective
Management goals in head injury
MAP > 90 Normovolemia PO2 80-100 SATS > 95 PCO2 30-35 Mannitol 0.5-1.0mg/kg/hour IVI over 15 minutes Temp 35-37 Phenytoin 11mg/kg IVI loading dose No steroids Early enteral feeding Sucralfate DVT prophylaxis (NB brain bleeds) Pressure sore prevention Drain mass lesions \+/- ICP monitoring
Rib fracture - complications
Hemopneumothax at all levels
1-3 - aorta, subclavian vessels, trachea, main bronchi
4-8 - lung contusion, cardiac contusion, cardiac rupture
<5 - diaphragmatic rupture
9-12 - spleen, kidney, liver
Flail chest - definition and treatment
3 or more ribs fractured in 2 or more places
Assessment
- X-ray may not show contusion initially - repeat in 24-48 hours
- CT chest if available
- pulse oximetry
- serial ABG (6 hourly)
Intubation and ventilation depending on blood gas analysis
- PO2/ FiO2 < 200
- PCO2 > 45
- respiratory rate > 30
- use of accessory muscles on FiO2 65%
- sats < 95% on polymask
Oxygen supplementation
Adequate analgesia
Judicious fluid administration
Signs and symptoms of contained aortic rupture
High index of suspicion
Systolic murmur over the precordium
Hoarseness (compression of the recurrent laryngeal nerve)
Horner’s syndrome
Paraplegia
Hypertension in the arms, hypotension in the legs
On CXR: Widened mediastinum (>8cm on erect film) Loss of aortic knuckle Obscuration of aortopulmonary window Widened paratracheal stripe Widened paraspinal interface Right tracheal deviation Depression of left main bronchus Elevation of right main bronchus Pleural or apical cap Left hemothorax Fracture of scapulae, 1st and 2nd ribs
Rib fracture management
Exclude and treat pulmonary contusion
Exclude and treat hemo-pneumothorax
Analgesia:
- Ibuprofen 400mg bd
- Morphine 0.1-0.5mg/kg/hr IVI PRN
- Intercostal block: 0.5ml 0.5% bupivicaine
- Intrapleural block: 10ml 0.5% bupivicaine, 10ml 1% lignocaine, 30ml saline
- Epidural
- strapping with adhesive tape
Physiotherapy
Correct ETT placement on CXR
5cm from carina (level T5-7) or
Halfway btw clavicles, just above aortic knuckle
Branches of axillary artery
First part
- superior thoracic
Second part
- thoracoacromial
- lateral thoracic
Third part
- subscapular artery
- anterior humeral circumflex
- posterior humeral circumflex
