Surgery SC031: Chopped And Stabbed Wound In Gang Fight: Nerves And Vascular Injury, Classification Of Injuries Flashcards
Advanced trauma life support (ATLS)
- Training program for medical providers in the management of acute trauma cases
- Developed by American College of Surgeon
- Emphasise the primary management of the injured patient (often with lack of full history)
—> starting at the point in **time of injury + **continuing throughout
1. Initial assessment
2. Life-saving intervention
3. Re-evaluation
4. Stabilisation (when needed)
5. Transfer to a facility in which the patient can receive specialised care, such as a trauma centre
Goals:
- **Systematic and **concise standardised approach to the care of trauma patienst
- Standard care for ***initial assessment + treatment
- ATLS program is to treat the greatest threat to life first
—> lack of definitive diagnosis / detailed history should not slow the application of indicated treatment for life-threatening injury, with the most time-critical interventions performed early
Initial assessment
Phase 1:
- Primary survey + Resuscitation
Phase 2:
- Secondary survey
Phase 1: Primary survey + Resuscitation
Objective: To **identify + **treat any ***immediately life-threatening condition
Primary survey
1. Airway maintenance + Cervical spine protection
- patent airway, no stridor (obstruction in major airway) —> ask patient to talk (evaluate airway, brain)
- cervical injury presumed —> neck collar
- Breathing + Ventilation
- equal breath sounds
- frail segment - Circulation, Haemorrhage control
- BP, Pulse
- occult / overt bleeding
- young patients compensate better than elderly patients - Disability
- e.g. CNS
- GCS score - Exposure and Environmental control
- undress patient
- prevent hypothermia
Airway and Breathing algorithm
Need for intubation
—> Manual in-line-stabilisation + Pre-oxygenation + Consider rapid sequence intubation (apply cricoid pressure)
—> Successful tracheal intubation
—> Confirm placement, fix tracheal tube (auscultation, CO2 detector, CXR)
—> Unsuccessful tracheal intubation
—> Valve mask ventilation
—> Repeat intubation (senior laryngoscopist, change blade, optimal position, OELM (optimum external laryngeal manipulation))
—> Successful
—> Confirm placement, fix tracheal tube (auscultation, CO2 detector, CXR)
—> Unsuccessful
—> Cricothyrotomy + place cuffed tracheal tube
Airway mis-management in trauma patients
- Failure to ***recognise the inadequate aiway in trauma victim
- Failure to ***establish a clear airway with / without an airway protection device
- Failure to recognise airway device is ***incorrectly placed
- ***Displacement of a previously established airway
- Failure to recognise the need for ***ventilation
- ***Aspiration of gastric contents
Resuscitation
- Occur ***simultaneously with Primary survey (ABCDE)
1. Oxygenation + Ventilation
- Shock management
- IV lines
- Warmed IV fluids (cold fluid may make bleeding worse —> ∵ coagulopathy) - Management of life-threatening problems identified in Primary survey
Adjuncts to Primary survey + Resuscitation
- X-ray
- CXR
- Pelvic (e.g. pelvic fracture: stable / unstable (need pelvic binder))
- C-spine (need to include C7, T1 junction, even if normal —> still keep neck collar on)
—> easy to obtain, give a lot of information about condition (e.g. pneumothorax) + how ABCDE was performed (e.g. intubation) - Focused assessment with sonography for trauma (FAST scan) / Diagnostic peritoneal lavage (DPL)
- FAST scan: free fluids in abdomen, liver, pelvis
- DPL: draw fluid out to see if blood-stained - Orogastric tube (decompress stomach, can use NG tube if confident no head trauma), Urine output (NOT put in catheter if pelvic fracture)
- Monitor
- BP
- Pulse
- RR —> Capnography
- SaO2 —> Pulse oximeter
- ECG
- GCS scale
Phase 2: Secondary survey
Begins when:
- Primary survey (ABCDE) is **complete + secured
- Resuscitation efforts are well established
- Patient’s vital signs are **stabilised
- Examine the patient from **head to toe + **front to back
- Log roll with neck collar on
—> spinal injury may result in motor / sensory loss / incontinence / lax anal tone
—> spinal shock = **flaccid paralysis, **areflexia, ***autonomic dysfunction (low BP)
- Head, neck, chest, abdomen, pelvis, perineum, extremities
- Assimilate the history (AMPLE)
- Allergies
- Medications currently used (e.g. aspirin, anticoagulants —> may exacerbate bleeding, phenytoin (underlying epilepsy))
- Past illness / pregnancy
- Last meal
- Events / Environmental leading to injuries
Spinal shock
2 meanings:
1. **Flaccid paralysis + **Areflexia for 1-2 weeks after injury
- Acute damage to spinal cord —> ***Denervation response —> Completely Areflexic + Weak muscle tone
- Return of anal tone / reflex usually signifies end of spinal shock —> Can properly assess motor + sensory function again —> Determine permanent deficits
- Phase 1 (0-1 day): Areflexia (Loss of descending facilitation)
- Phase 2 (1-3 day): Initial reflex return (Denervation supersensitivity)
- Phase 3 (1-4 week): Initial Hyperreflexia (Axon-supported synapse growth)
- Phase 4 (1-12 month): Final Hyperreflexia (Soma-supported synapse growth)
SpC Revision:
- Period of temporary loss of function after injury (hours - days)
- No motor / sensory function: cannot differentiate between complete / incomplete injury
- All reflexes absent
- Spinal shock is over if bulbocavernosus / anal wink reflex has returned (these are lowest local reflexes mediated by spinal cord level)
- Assess for motor / sensory function ONLY after spinal shock is over
(Web:
- loss of muscle tone and spinal reflexes below the level of a severe spinal cord lesion
- this “shock” does not imply a state of circulatory collapse (vs neurogenic shock) but of suppressed spinal reflexes below the level of cord injury
- it takes between days and months for spinal shock to completely resolve —> when it does, the flaccidity that was once seen gradually becomes ***spasticity (UMN lesions))
- Neurogenic shock
- **Sympathetic signal disruption in C1-T1
—> Sudden of sympathetic tone
—> **Vasodilation, Hypotension, Bradycardia, Warm, Flushed skin
—> Shock, Hypoperfusion of body
—> Require resuscitation
- C5 or below: affect Diaphragmatic breathing (Diaphragm innervated by C3-5)
- Above C3: ***Respiratory arrest (cannot breathe at all)
—> Require intubation, mechanical ventilation, cardiopulmonary support
Biomechanics of injury
Classification
1. Blunt trauma
- e.g. RTA
- Penetrating trauma
- e.g. knife, gunshot - Burns
- flame
- scald
- chemical
- electric
- radiation - Blast injuries
- e.g. bombs
- Blunt trauma
Force is ***dissipated over a wide area, minimising energy transfer at one spot
3 types of forces (often in combination):
1. Shearing (2 forces acting in **opposite directions)
- e.g. fall from height (e.g. acceleration-deceleration)
- maximum effects on **abdominal viscera at the points where organs are tethered (e.g. duodenojejunal junction, liver, spleen, aortic arch around ligamentum arteriosum)
- Tension (a force acting ***<90o to surface causing avulsions / flap formation)
- tissue necrosis - Compression (a force acting ***at 90o to surface causing avulsions / flap formation)
- contusion / haematoma
- raised internal pressure may result in rupture of hollow viscus
Potential injuries with fall from height
- Head injury
- Cervical injury
- Vertebral wedge fracture
- Pelvic fracture
- Tracheo-bronchial dislocation
- Pneumothorax / Haemothorax
- Rupture / Dissection of aorta
- Liver / Spleen laceration
- Rupture of bowel
- Lower limb / ankle / fracture of calcaneum / metatarsals
- Penetrating trauma
***Kinetic energy (KE = mass / 2x velocity^2) is transferred to tissues surrounding the track of weapon / missile
Depends on:
- Mean presenting area of weapon
- Tendency of weapon to deform / change pathway / fragment
- Density / Characteristics of tissue (e.g. through viscera)
- Impact velocity / damage to neighbouring tissue
3 conseqences:
1. Functional + Mechanical disruption of neighbouring tissues and energy transfer
- solid organs sutain severe damage (e.g. liver)
- lungs, muscles, bones may all be disrupted
- A core of covering clothing is carried deep into the wound —> cause contamination
- In gutshot wounds
- exit wound is usually larger than entry wound (∵ temporary cavitation effect extends along wound track)
- some missile may fragment on contact
Chopped vs Stabbed wounds:
- Cut wounds / Incised (Chopped) wounds: wounds caused by a sharp edged weapon / instrument
- Stabbed wounds: wounds where depth of wound > width of wound
- may be difficult to differentiate, depends on mode of injury
—> both classified as penetrating / sharp injury (X blunt injury)
Location:
1. Chest
2. Neck
3. Abdomen
Documentation
Important:
- Classify injuries correctly
- Note the details
—> location
—> size
—> shape
—> direction
—> presence of foreign bodies etc.
- Wound should be photographed / sketched before surgical repair
Penetrating injury to the chest
- Life threatening conditions need to be ruled out
-
**Cardiac + **Lung injuries presumed until proven otherwise
1. Cardiac tamponade
2. Open pneumothorax
3. Massive haemothorax (>0.5L: significant)
Penetrating injury to the chest:
- Big / Small wound is irrelevant to chance of injury to underlying organs
- Bleeding may be excessive / occult
- Open pneumothorax
