Shock + Trauma Flashcards
Levels of care on wards
0 = normal ward 1 = CCOT 2 = single organ failure 3 = ventilation or >2 organ failure
ABG pros + cons
Pros - pO2
Cons - VBG + SpO2 usually adequate, painful
What are the life threatening thoracic injuries?
ATOM FC Airway obstruction Tension pneumothorax Open chest wound Massive haemothorax Flail chest Cardiac tamponade
What is HEPB?
To assess circulation
Hands
End organ perfusion - urine output
Pulse
BP
What are the causes of reflex syncope?
Vasovagal
Situational
Carotid sinus syncope
What are the causes of syncope due to hypotension?
Primary autonomic failure (Parkinsons)
Secondary autonomic failure (diabetes, spinal cord injuries)
Drug induced
Volume depletion
What are the causes of cardiac syncope?
Tachycardia
Bradycardia
Drug induced
Structural heart disease
What are the 4 main causes of collapse?
Head
Heart
Vessels
Drugs
What is the San Francisco syncope rule?
CHESS Congestive HF Haematocrit <30% ECG abnormal SOB Systolic <90
What is the OESIL risk score?
Age >65
History of CVD
Syncope w/o prodrome
Abnormal ECG
Score >2 = increased risk of cardiac death
What is the risk of shock + reperfusion?
Intracellular calcium overload = reduced myocardial contractility + ATP reduction
H+ excess causing reduced myocardial function
Increased lactic acid
What type of nerve damage can an anterior shoulder dislocation cause?
Axillary nerve damage - numbness in regimental badge area
What is ISS used for?
Scoring system as indicator of major trauma
Describe the pathology of neurogenic shock
Damage to T1-3
This is where autonomic sympathetic nervous system branches out
Causes bradycardia + hypotension
What are the Canadian C Spine rules?
Statifying pts with ?c spine injury - who needs radiography
Age >65 y/o
Dangerous mechanism of injury
If they’re able to be examined + actively rotate neck - don’t need radiography
What 4 areas to assess when faced with hypotension?
Heart rate
Volume status
Cardiac performance
SVR
What type of shoulder dislocation do epileptics typically get?
Posterior - light bulb sign
Causes of cardiogenic shock
Cardiomyopathies Cardiac valve problems Arrhythmias CHF Most commonly MI
Management of cardiogenic shock
Fluids, blood transfusions, vasopressors, ionotropes
Management of MI
What are the types of shock?
Hypovolemic, cardiogenic, obstructive, distributive
S+S of shock
Low BP, decreased urine output, confusion, high HR
Dry membranes, reduced skin turgor + reduced CRT
S+S hypovolemic shock
Rapid, weak, thready pulse Cool, clammy skin Rapid + shallow breathing Thirsty Cold + mottled skin
How is hemorrhagic shock classified?
Class 1-4
1 = <15% blood loss (<750ml), normal BP
2 = 15-30% blood loss (750-1500), fast HR, low BP
3 = 30-40% blood loss (1500-2000), fast HR, low BP, confusion
4 = >40% blood loss (>2000), critical HR + BP
S+S of cardiogenic shock
Distended jugular veins Weak or absent pulse Abnormal heart rhythms, tachycardia Pulsus paradoxus (in tamponade) Low BP
S+S of distributive shock
High or low temp
Tachycardia
High RR
What are the types of distributive shock?
Sepsis, anaphylaxis + neurogenic
What are the general causes of each type of shock?
Hypovolemic = fluid loss Cardiogenic = ineffective pumping due to heart damage Obstructive = blood flow to/ from heart is blocked Distributive = abnormal flow in small vessels
Causes of obstructive shock
Cardiac tamponade Tension pneumothorax PE Aortic stenosis Constrictive pericarditis
Management of shock
Fluids
Vasopressors
Mechanical support
Pathology of compartment syndrome
Increased pressure in compartment bounded by unyielding fascial membranes compromises circulation + function of tissues within that space
Common causes of compartment syndrome
Trauma to limb eg long bone fracture, penetrating trauma, ischemic-reperfusion injury, coagulopathy, extravasation of IV fluids, limb compression
S+S of compartment syndrome
Progressive pain out of proportion to injury
Tense swollen compartments
Pain with passive stretching of muscles
Motor deficits = late
Assessment of compartment syndrome
Surgeon review - measure compartment pressures
Use difference between diastolic BP + compartment pressure - <30 = elevated compartment pressure
What is a normal pressure of a tissue compartment?
0-8 mmHg
Management of compartment syndrome
Remove pressure Keep limb level with torso O2 + analgesics Manage BP Fasciotomy to fully decompress compartment
Complications of long bone fracture
Hemorrhage, DVT, compartment syndrome
Osteomyelitis, nonunion + osteoarthritis
What is a mangled extremity?
Injury to 3 of the 4: Bones Soft tissue Nerves Vessels
What are hard signs of vascular injury?
Pulsatile bleeding, expanding hematoma, distal ischemia
What signs in a facial injury indicate airway compromise?
Dysphonia
Oedema of oropharynx
Stridor
Mechanism of shoulder fracture
Falling from standing height
What classification is used for proximal humerus fractures?
Neer system
Management of proximal humerus fractures
Complex = refer to ortho
Immobilisation using sling
Closed management for impacted or non-displaced fractures (Neer one-part)
Early mobilisation with pendulum exercises
Management of open fractures
Dose of broad spectrum abx
Referral to surgeons
Management of hand fractures
Splinting
Referral to hand surgeons - within 2-3 days for closed unstable fractures, 7-10 days for closed stable fractures
3 main categories of knee injuries
Acute knee pain
Chronic knee pain associated with overuse
Knee pain without trauma or overuse, associated with systemic symptoms
Conditions causing anterior or medial knee pain
Patllar fracture Patellar or quadriceps tendinopathy Patellofemoral pain Patellar subluxation Pes anserinus (medial hamstring) tendon + bursa Osteoarthritis Tibial tuberosity - Osgood Schlatter Medial plica syndrome
Conditions causing lateral + posterior knee pain
Iliotibial band Popliteus tendinopathy Biceps femoris tendinopathy Semimembranous-gastrocnemius bursitis Degenerative meniscal tear Baker's cyst
Describe patellofemoral pain
Peri-patellar knee pain that increases with squatting, prolonged sitting, climbing or descending stairs, running downhill
How to elicit pain in patellofemoral pain
Retropatellar tenderness
Patellar compression test
Patellar inhibition test (Clarkes)
What muscles are weak in patellofemoral pain?
Vastus medialis oblique + gluteus medius
What is patellar subluxation?
Pts with hx of patella dislocation can develop subluxation, Ehlers Danlos §or if vastus medialis is weak
Knee ‘gives way’
Patellar apprehension test = positive
What is medial plica syndrome?
Trauma to peripatellar area or dislocations/ subluxation of patella, may develop thickening of medial patella plica
Causes impingement of medial edge of patella, causing pain worse with movement
Can cause audible pop
Features of iliotibial band syndrome
Insidious lateral knee pain that worsens with prolonged exercise
Common in runners
Assessed with Noble tests
Associated with hip abduction weakness
What structures are important in forefoot pain?
First MTP joint 5th MTP joint Plantar surface of MTP joint Intermetatarsal spaces Plantar calluses Dorsal proximal interphalangeal calluses
What structures are important in midfoot pain?
Navicular Dorsal tarsometatarsal joints Cuboid Base of 5th metatarsal Plantar fibromas Ganglia
What structures are important in hindfoot pain?
Medial insertion of plantar fascia on calcaneuus Plantar os calcis Insertion of Achilles tendon Tarsal tunnel Peroneal tendons Anterior talotibial articulation Anterior talus - lateral corner Sinus tarsi
What are the common conditions seen at first MTP joint?
Bunions Hallux rigidus (arthritis) Turf toe (forced hyperextension of great toe) Gout
What is Ilizarov frame surgery?
Type of external fixation used in ortho surgery to lengthen or reshape limb bones
Causes of distributive shock
Sepsis
Anaphylaxis
Neurogenic
Causes of hypovolaemic shock
Hemorrhage
Burns
High output fistulas
Dehydration
Common sites of bleeding
On the floor + 4 more: Floor (external) Chest Abdo Pelvis Long bones
Maintenance fluids canadian rule
4:2:1 0-10kg = 4ml/kg/h 10-20 = 2ml/kg/h Remaining weight = 1ml/kg/hr Replace ongoing losses (estimated 10% of body weight)
When can you clear a C spine?
Orientated to time, person, place No evidence of intoxication No posterior midline cervical tenderness No focal neuro deficits No painful distracting injuries
When should you get a CT of a C spine?
If X ray is unclear or suspicious
Any clinical indication of atlanto-axial subluxation
High suspicion but normal X ray
What signs in Hx + O/E indicate a potential C spine injury?
Midline neck pain, numbness, distracting pain, head injury, intxication, LOC
Posterior neck spasm, tenderness or crepitus, neuro deficit or autonomic dysfunction, altered mental state
What C spine x rays should be taken?
3 view:
Lateral C1-T1 + swimmer’s view
Odontoid view (open mouth)
What is in a secondary survey?
SAMPLE S+S Allergies Meds Past medical hx Last ins + outs Events leading up to this
Physical exam
Initial imaging
What views do you get on a FAST scan?
Subxiphoid pericardial window - shows heart chambers + pericardial effusion
Perisplenic - shows spleen, L kidney + any free fluid
Hepatorenal (Morrisons pouch) - shows liver, right kidney + any blood
Pelvic/ retrovesical (Pouch of Douglas) - shows bladder + any free fluid
What is the best imaging for intracranial injury?
Non contrast CT
what is the emergency rule for consent to treatment?
Consent is not needed when pt is at imminent risk from serious injury AND obtaining consent is not possible or would increase risk to pt
What are the associated injuries with MVC?
Head on = head, thoracic, lower extremity
T bone = head, C spine, thoracic, abdo, pelvic, lower extremity \
Rear end = hyper-extension of C spine
What is the cardiac box?
From sternal notch, nipples + xiphoid process
Any injury in this = be suspicious of cardiac injury
What are high risk mechanisms of injury?
MVC at high speed causing ejection from vehicle
Motorcycle collisions
Vehicle vs pedestrian
Fall from height >12ft
What is Waddle’s triad?
Vehicle vs pedestrian injuries
Tibia-fibula or femur fractures
Truncal injuries
Craniofacial injuries
What injuries are caused by seatbelts?
Retroperitoneal duodenal trauma
Intraperitoneal bowel transection
Mesenteric injury
L spine injury
When is an NG tube vs Foley used in abdo trauma?
Foley = unconscious pt who cannot void sponteneously
NG tube = used to decompress stomach. CI in basal skull fractures
What is the rule of thirds for stab wounds?
1/3 do not penetrate peritoneal cavity
1/3 penetrate but are harmless
1/3 cause injury requiring surgery
Management of open fractures
STAND Splint Tetanus prophylaxis Abx Neurovascular status Dressings
