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AIP: Trauma > Penetrating injury > Flashcards

Penetrating injury Flashcards

1
Q

What are the 2 groups that penetrating injury can be broken down into?

A

high and low velocity

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2
Q

What is the difference in the way that high and low velocity penetrating injury cause damage?

A
  • low velcoity: tends to push internal organs out of the way following fascial planes
  • high velocity will normally have a shock wave that will cause deceptive damage compared to the entry wound and won’t push organs aside
    • these can also ricochet off bones
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3
Q

In addition to the velocity of penetrating injury, what is another important factor when considering penetrating injury and its effects?

A

direction of penetrating injury

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4
Q

Why is it important to think about the direction of penetrating injury?

A

injuries to the abdomen can still hit lungs or heart

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5
Q

What is important to remember about penetrating chest wounds?

A

they are potentially life-threatening, even if innocuous

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6
Q

What is the most common cause of penetrating abdominal injry?

A

stab wounds (still more comon than GSW in the UK)

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7
Q

What are 4 mechanisms of penetrating abdominal injury?

A
  1. Stabbing
  2. Gunshot wound (GSW)
  3. Fragmentation in explosion
  4. Impalement
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8
Q

What are 4 key aspects of the initial assessment in penetrating abdominal injury?

A
  1. History
  2. Examination - fully expose
  3. Assess neurological status of limbs to check for spinal cord injury (if patient conscious)
  4. Plain X-ray if stable patient
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9
Q

What are 6 things to ask about in the history for penetrating abdominal trauma?

A
  1. Time of injury
  2. Type of weapon or round
  3. Distance from assailant
  4. Number of wounds or shots
  5. Position of patient when penetration occurred
  6. Amount of external bleeding at scene
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10
Q

What should the examination involve in penetrating abdominal trauma?

A

fully expose patient early in primary survey to identify any concealed wounds - including flanks, back, groins, buttocks, perineum, rectal examination

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11
Q

What is important to remember about the size of the wound in penetrating abdominal trauma?

A

size of external wound does not determine the likelihood or severity of intra-abdominal injuries

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12
Q

What is the role of plain x-rays in penetrating abdominal trauma?

A

useful in stable patients to identify location of any retained bullet and allow prediction of the trajectory e.g. has it gone from chest to thigh, passing through the thorax and abdominal cavity

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13
Q

What is important to remember about any foreign bodies in penetrating abdominal trauma?

A

any foreign body or knife must only be removed in theatre at laparotomy under direct vision, to enable control of any potential haemorrhage or contamination

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14
Q

What are 3 aspects of wound care for penetrating abdominal trauma?

A
  1. Cover wound with sterile dressing. Any protruding bowel or omentum should be covered with warm saline soaked swabs and not handled or pushed back into the abdomen
  2. Check tetanus status and consider need for prophylaxis
  3. Give IV antibiotics according to local prescribing guidelines
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15
Q

What are 3 additional investigations following initial assessment, for penetrating abdominal injury?

A
  1. Local wound exploration
  2. Serial examinations
  3. Laparoscopy
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16
Q

What does local wound exploration involve for penetrating abdominal injury?

A

evaluation of stab wound using LA before extending and probing the wound

performed in theatre by surgeon, who will be able to proceed to laparoscopoy or laparotomy if indicated

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17
Q

Is local wound exploration performed for gunshot wounds to the abdomen?

A

no - these should all have a laparotomy

18
Q

What is the benefit of performing serial examinations in penetrating abdominal trauma?

A

good sensitivity and negative predictive value for evaluating patients with minor penetrating abdominal trauma

19
Q

For how long and how frequently are serial abdominal examinations performed for minor penetrating abdominal trauma?

A
  • patient admitted for observation for at least 24h
  • hourly assessment of haemodynamic status
  • at leats 4-hourly assessment for clinical abdominal signs
20
Q

What is done if the patient develops any signs of bleeding or peritonism during the 24-hour period of observation for minor penetrating abdominal trauma?

A

laparotomy performed

21
Q

What should be done for a patient admitted for 24h for a minor penetrating abdominal injury who develops pyrexia/tachycardia/localised tenderness on CT?

A

laparoscopy, laparotomy or CT scan performed

22
Q

What should be the next step if, after 24h of observation for minor penetrating abdominal trauma, the patient remains well?

A

can start normal diet and discharge can be considered

23
Q

What is the usefulness of laparoscopy in penetrating abdominal trauma?

A

diagnostic laparoscopy (under GA in theatre) may be useful for identifying peritoneal penetration following abdominal stab wounds or diaphragmatic injury

24
Q

What are 2 things that diagnostic laparoscopy may miss in penetrating abdominal injury?

A
  1. Bowel injury
  2. Retroperitoneal injury
25
Q

What are 7 indications for laparotomy following penetrating abdominal trauma?

A
  1. Stab wound with peritoneal penetration
  2. Any gunshot wound to the abdomen
  3. Evisceration (organ removal from body)
  4. Retained foreign bodies
  5. Peritonitis
  6. Haemodynamically unstable with penetrating abdominal injury
  7. Haemodynamically stable with positive CT scan
26
Q

What are 3 areas where penetrating injuries to the abdomen are likely to be missed?

A
  1. Buttocks
  2. Groin
  3. Back
27
Q

What must be done regarding forensics for a patient with penetrating abdominal injury?

A
  • ensure a member of staff informs the police that you have ‘a patient’ in the department with a stab wound or GSW
  • if patient has arrived by ambulance, usually accompanied by a police officer
28
Q

When is it justifiable to break patient confidentiality for patients with penetrating abdominal injury?

A

if there are issues of public interest, and to protect the safety of your department and staff

29
Q

What must you make sure that is done regarding future forensic requirements for patients with penetrating abdominal trauma?

A

ensure all patient’s clothes, belongings and any weapons are kept secure to be given to an identified police officer for forensic examination

30
Q

What are 5 structures that may be damaged by penetrating objects that traverse the mediastinum?

A
  1. Heart
  2. Great vessels
  3. Tracheobronchial tree
  4. Oesophagus
  5. Lungs
31
Q

What is the mortality of mediastinal penetrating injury?

A

20%

32
Q

What are 4 mechanisms which may lead to penetrating mediastinal injury?

A
  1. Stabbing
  2. Gunshot wond
  3. Impalement on an object
  4. Blast fragmentation
33
Q

What are 5 possible clinical features of mediastinal penetrating injury?

A
  1. Entry and/or exit wounds
  2. Signs of tension pneumothorax
  3. Open pneumothorax
  4. Massive haemothorax
  5. Cardiac tamponade
34
Q

What are 4 examples of investigations to perform for mediastinal penetrating injury?

A
  1. CXR: pneumothorax, foreign body, widened mediastinum
  2. FAST USS: free fluid in the pericardial sac
  3. CT for stable patients, with contrast vascular and GI studies
  4. 12-lead ECG and echocardiogram if suspected cardiac injury
35
Q

What are 7 aspects of immediate management of mediastinal penetrating injury?

A
  1. Oxygen, monitoring, IV access with crossmatch
  2. Treat any life-threatening airway or chest injury
  3. IV fluid boluses to maintain a SBP 90 mmHg
  4. Remove all patient clothing (avoiding cutting through ballistic holes) and keep for police evidence
  5. Search for wounds including log roll to look at back, and checking groin, buttocks, perineum and axilla
  6. Seek urgent surgical opinion
  7. Analgesia e.g. titrated IV morphine
  8. Treat wounds by cleaning, application of sterile dressing, check need for tetanus prophylaxis and IV antibiotics according to hospital policy
36
Q

What is meant by ballistic holes in cloting?

A

bullet entry holes in the fabric

37
Q

What should the aim for blood pressure be when treating mediastinal penetrating injury?

A

SBP 90mmHg

38
Q

What analgesia may be used for mediastinal penetrating injuries?

A

titrated IV morphine

39
Q

How should wounds of penetrating mediastinal injury be treated? 4 aspects

A
  1. cleaning
  2. application of sterile dressing
  3. check need for tetanus prophylaxis
  4. IV antibiotics according to hospital policy
40
Q

What is one of the key pitfalls with penetrating mediastinal injury?

A

under-estimating small external wounds which have no correlation with the degree of internal injury

AIP: Trauma (20 decks)

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