Part two - trauma

Question 0

Liver injury scale

Answer 0

I
Haematoma - subcapsular, <10% surface area
Laceration - capsular tear, <1cm parenchymal depth

II
Haematoma - subcapsular, 10-50% surface area: intraparenchymal <10cm in diameter
Laceration - capsular tear 1-3cm parenchymal depth, <10cm in length

III
Haematoma - subcapsular, >50% surface area or ruptured subcapsular or parenchymal haematoma; intraparenchymal haematoma >10cm or expanding
Laceration - 3cm parenchymal depth

IV
Laceration - parenchymal disruption involving 25-75% hepatic lobe or up to 3 segments within a single lobe

V
Laceration - parenchymal disruption involving >75% hepatic lobe or >3 segments within a single lobe
Vascular - juxtahepatic venous injuries; i.e. Retrohepatic vena cava / central major hepatic veins

VI
Vascular - hepatic avulsion

Advance one grade for multiple injuries up to grade III

Question 1

Spleen injury scale

Answer 1

I
Haematoma - subcapsular, <10% surface area
Laceration - capsular tear, <1cm parenchymal depth

II
Haematoma - subcapsular, 10-50% surface area; intraparenchymal, <5cm in diameter
Laceration - capsular tear, 1-3cm parenchymal depth that does not involve a parenchymal vessel

III
Haematoma - subcapsular, >50% surface area or expanding; ruptured subcapsular or parenchymal haematoma; intraparenchymal haematoma 5+cm or expanding
Laceration - >3cm parenchymal depth or involving trabecular vessel

IV
Laceration - involving segmental or hilar vessels producing major devascularisation (>25% of spleen)

V
Laceration - completely shattered spleen
Vascular - hilar vascular injury with devascularised spleen

Advance one grade for multiple injuries up to grade III

Question 2

Pancreas injury scale

Answer 2

I
Haematoma - minor contusion without duct injury
Laceration - superficial laceration without duct injury

II
Haematoma - major contusion without duct injury or tissue loss
Laceration - major laceration without duct injury or tissue loss

III
Laceration - distal transection or parenchymal injury with duct injury

IV
Laceration - proximal transection or parenchymal injury involving ampulla

V
Laceration - massive disruption of pancreatic head

Advance one grade for multiple injuries up to grade III
Proximal pancreas = to the right of SMV

Question 4

Parkland formula for fluid requirement

Answer 4

% burnt BSA x 4mL x mass (kg) = requirement in first 24 hours

• If BSA >60% use 3mL
• from the time of burn, not from admission time
• first half given in the first 8 hours, the other half in the next 16 hours
• limited evidence that changing to a colloid in the next 24 hours will reduce capillary leakage
• aim UO 0.5-1.0mL/kg/hour for adults and 1.0-2.0mL/kg/hr for kids
• if too much fluid given -> third spacing ->ARDS
• exception is myoglobinuria where aim for >1mL/kg/hr

Question 5

Failure rates for non-operative management of splenic trauma

Answer 5

Grade I - 5%
Grade II - 10%
Grade III - 20%
Grade IV - 40%
Grade V -80%

Question 6

What are the zones of the retroperitoneum?

Answer 6

Zone 1 = central retroperitoneum
- medial to renal hilar
- duodenum, pancreas, IVA, aorta, coeliac axis, SMA, proximal renal vessels
Zone 2 = lateral retroperitoneum
- lateral to renal hilar
- kidneys, adrenal, proximal GUT
Zone 3 = pelvic retroperitoneum
- rectum, iliac vessels and their branches/tributaries

Question 7

How are retroperitoneal haematomas managed?

Answer 7

Explore:

• All penetrating injuries
• All zone 1 injuries after proximal and distal control
• Only pulsatile or expanding injuries in zones 2 and 3

Question 8

Life threatening injuries to address in primary survery

Answer 8

A = airway obstruction
T = tension pneumothorax
O = open pneumothorax
M = massive haemothorax
I   = incomplete (flail) chest 
C = cardiac tamponade

Question 9

Define massive haemothorax

Answer 9

Rapid accumulation of >1500mL or one-third of blood volume into chest cavity

Question 10

Indicators of requiring thoracotomy

Answer 10

> 1500mL
one-third patient’s blood volume
200mL for 2-4 hours
Persistent need for transfusion
Penetrating anterior wounds medial to nipple
–damage to hilar structures, great vessels, heart, tamponade
PATIENT’S PHYSIOLOGIC STATUS

Question 11

Beck’s triad for cardiac tamponade

Answer 11

Venous pressure elevation
Reduced arterial pressure
Muffled heart sounds

Question 12

Widened mediastinum

Answer 12

Assume AORTIC RUPTURE
If stable transfer to cardiothoracic unit
Permissive hypotension
Operative or endoscopic repair ASAP
Generally, abdo injuries take priority over chest injuries

Question 13

ED thoracotomy

Answer 13

Try to avoid
Theatre: good lighting, equipment, auto transfusion, bypass
However, if patient in extremes with BP 40mmHg or less despite volume resuscitation then perform left anterolateral thoracotomy and tamponade hole in heart with foley

Question 14

Define disseminated intravascular coagulation

Answer 14

A systemic process producing both thrombosis and hemorrhage. It is initiated by a number of defined disorders and consists of the following components:

• Exposure of blood to procoagulants such as tissue factor and cancer procoagulant
• Formation of fibrin within the circulation
• Fibrinolysis
• Depletion of clotting factors
• End-organ damage