Trauma Flashcards
Unreliable bloods with IO
WBC Plt Na K Ca CO2
Compartment syndrome pressures
30mmHg
Delta pressure: DBP - CP (<30)
Classify open fracture
1: <1cm, clean
2: 1-5cm, clean
3: >5cm, contaminated, arterial bleed
4: amputated
Causes of rhabdo
Trauma (crush/prolonged lie) Prolonged seizure Thyroid storm Electrocution Drugs (SS, sympathomimetics) Envenomation: Snake, Funnel Web Sepsis (Nec Fasc, TSS) Burns
Management Rhabdo
IV fluids (UO >2ml/hr)
Bicarbonate 2ml/kg if:
- no hypocalcaemia
- ph <7.5
- urinary ph <7
- bicarbonate <30
Treat hyperkalaemia with calcium gluconate
Indications for RRT in rhabdo
Oliguria
Fluid overloaded
Refractory hyperkalaemia
Bites requiring Abx
Delayed presentation 8hrs Site: Face, Hands, Feet Tendon, joint, nerve involvement Deep (cannot debride) Immunocompromised Cat & Human > dog
Augmentin prophylaxis
Cef & Metro if established infection
ADT, rabies vaccine with bats
Complications of Extensor finger injury
Mallet finger Swan Neck (hyperextended PIP from delayed Mallet finger repair) Boutonnière deformity (PIP injury)
Indications for FB removal
Vegetative (will rot) Infection (contaminated) Allergic reaction to FB Close to fracture site Intra-articular Pressing on surrounding structures Toxicity (lead, spike with venom)
Grading urethral injury
1: contusion
2: stretch
3: partial tear
4: complete <2cm separation
5: complete >2cm separation
Features suggesting urethral injury
Blood at meatus
High riding prostate
Perineal/scrotal bruising
Bruising tracks to abdomen
XR features suggesting urethral injury
Separation PS
APC II or III
Displaced superior pubic rami fracture
Bilateral rami fractures
Indications for surgery for testicular trauma
Open
Large haematoma
Testicular rupture
Haematocoele
Indications for conservative management liver
Grade 1 or 2
Uni-lobar fracture
No devascularised segments
Minimal peritoneal blood
Indications for conservative splenic injury management
Haemodynamically stable Hb stable Young <55 Grade 1 or 2 Not anticoagulated
Indications for IR management of pelvic injury
Stable (<2 units per hour)
Blush >1.5cm on CT
Ongoing blood loss with no other source
Reasons to operate in pelvic injury
Unstable & eFAST positive
Going in anyway (other injuries)
Open pelvic fracture (PR/PV bleeding)
Needing >6 units despite binder
Pelvic fracture classification
Young-Burgess
APC
1: PS <2cm
2: PS and anterior SI
3: PS and both SI (open book)
Lateral:
1: Rami and ala
2: Rami and Iliac crest
3: 2 with APC 3
Vertical shear: upward displacement of rami, acetabulum with SI dislocation
Renal trauma grading
1: capsular haematoma
2: <1cm cortex
3: >1cm cortex
4: involves collecting system or vessels
5: shattered
Seat belt injuries
Chance fracture
Pancreatic injury
Mesenteric injury
Indications for traumatic laparotomy
Unstable with FAST Evisceration Penetrating through fascia Peritonism Diaphragmatic rupture Refractory shock
Dissection CXR
Apical capping Left pleural effusion Downward left bronchus Right NGT 2cm at T4 Loss of aortic knob Loss of PA window Widened mediastinum
Fracture scapula or 1/2nd rib
Oesophageal perforation features
Retrosternal pleuritic pain
Dysphagia/Odynophagia
Subcut emphysema
Left pleural effusion (particular matter)
V sign on CXR: at aorta and left diaphragm
Hamman sign: crunching sound with HB
Give IV ceftriaxone, no NGT
Indications for thoracotomy in haemothorax
Bloods loss >1.5L on insertion
Loss >200ml/hr for 3 hours
Loss >150ml/hr for 6 hours
Refractory shock
Note PPH (massive)
150ml/min
50% in 3hrs
100% in 6hrs
PECARN C-spine
Exam: Focal deficits GCS <15 Torticollis Substantial torso injury
History: Midline neck pain Diving Pre-existing condition High risk MVA
Ophthalmology for eyelid lac
Within 6mm medial canthus Involving border/inside Through tarsal plate Involving lacrimal duct Ptosis Perpendicular to lid margin
Neck wounds theatre (hard and soft)
Hard: Bubbling neck wound Blood in mouth Pulsatile Shocked with active bleeding Reduced GCS
Soft: Small haematoma Subcut emphysema Dysphagia Dysphonia
Unstable C-spine fracture
Peg fracture: 1 tip, 2 waist, 3 C2
Bilateral facet dislocation C5/6 (flexion)
Jefferson (crushed C1) (diving)
Tear drop C5 (flexion & compression)
Atlanto-occipital dislocation (decel)
Hangman (pars interarticularis C2) (extend)
Complications orbital blowout fracture
Eye injuries EOM (trapped) Infraorbital nerve Enophthalmos Epistaxis
Tripod fracture
Zygomatic arch
Zygomatico-frontal suture
Zygomatico-maxillary suture
Traumatic SAH classification
1: normal neuro
2: confused with no motor
3: confused with motor
4: GCS 7-12
5: GCS <6
SAH complications
Vasospasm Seizure Hydrocephalus Re-bleeding Death Residual neurological deficits
PECARN Head
Evidence of skull fracture & GCS not 15 then image
If not above: Observe +\- image if: Non-frontal haematoma Vomiting Severe headache Mechanism (5ft/3ft)
Position of spinal tracts
Spinothalamic (pain & temp)
Anterolateral
Corticospinal (motor)
Posterolateral
Dorsal (fine touch, proprioception)
Posterior
Central Cord Syndrome
Hyperextension
Motor, pain and temp mainly upper
Bladder and bowel ok
Anterior cord syndrome
Flexion or diving
Anterior spinal infarct
All except dorsal column
Brown sequard
Hemisection
Ipsilateral motor and dorsal loss
Contralateral pain and temp loss (2 levels lower)
Dorsal Column injury
Penetrating or hyperextension
Loss of dorsal column only
Burns BSA
Adults (Wallace) Head and neck 9% Upper limb 9% Front chest & abdo 18% Leg 18%
Babies (Lund & Browder)
Head and neck 20%
1% to legs every year from 1yr
Buttock 2% each
Indications to intubated smoke inhalation
Stridor
Signs of smoke inhalation
Swelling to neck
Usual (GCS, combative, unprotected)
When to use Parkland formula
Partial/Full thickness burns only
>10% children
>15% adults
Superficial consider Brooks 2ml/kg
Deep consider Parkland 4ml/kg
Half over 8 hours, remaining over 16 hours
Indications for MTP
2 of 4: SBP <90 HR >120 Penetrating injury FAST positive
Classification of shock
1: 750ml, 15%, HR normal
2: 750-1500ml, 30%, HR 120
3: 1500ml to 2000ml, 40%, HR 140
4: >2000ml, >40%
In trauma also use:
Rapid responder
Transient responder
Non-responder
Massive transfusion
4 units per hour (MTP)
>10 units in 24 hours
Trauma Call Criteria
Mechanism with age/co-morbidities
Vitals: HR 120, BP 90, RR 30, GCS 13, Sats 90%
Injuries:
- high voltage
- penetrating
- blunt to high risk (skull/flail)
- open fracture or amputation
- serious crush
- spinal injury
- burns (10% child, 15% adult)
- 2+ long bone fractures
Physiological difference with kids
MV determined by RR CO determined by HR Sensitive to catecholamines (late crash) High metabolic demand (hypoglycaemia) Higher O2 demand (desaturate faster) Less type 1 respiratory fibres (tire faster)
Hypotension in Paeds
SBP less than 70 + (age x 2)
Anatomical difference in kids
Bigger head (scalp lac) High fulcrum (C1/2) SCIWORA Small airway (obstruction) Contusions Large unprotected abdo organs Abdominal bladder Thick capsule (less haemoperitoneum) Fractures: greenstick & plastic deformity Large BSA (hypothermia) Fontanelle (late clinical IOP)
Physiological differences pregnancy
Airway hyperaemia FRC reduced (desat) Higher diaphragm (ICC) Dilutional anaemia Increased clotting factors (5-10) 25% placenta with no autoregulation (will dump volume here) Uterus pressing IVC Lax oesophageal tone (aspiration) PVR reduced 20%
Pregnancy specific traumatic injuries
Placental abruption Uterine rupture Uterine irritation (PPROM) Isoimmunisation Direct Fetal Injury (pelvic fracture)
Indications for C-section on CTG
HR >160 or <100
Decelerations
Loss of variability
Geriatric physiological differences
Delicate mucous membranes (bleed) Slow gastric emptying (aspiration) C-spine arthritis (fracture) Osteoporosis (fractures) Drug sensitivity Increase pulm contusions Pressure areas (bony) Vascular disease (AAA, dissection, MI, AKI) Higher risk of fluid overload
Types of blast injuries and areas affected
Spalling: shock wave fluid/air interface
Implosion-explosion: gas areas (lung)
Shearing force: brain from bone (SDH)
ENT: TM rupture, dislocation ossicles Lungs: pulm oedema GIT: perforations CNS: ICH Placenta: abruption
Immediate complications to high voltage injury
Vascular compromise
Rhabdomyolysis
Compartment Syndrome
Arrhythmias
Contrast risk factors
Anaphylaxis Metformin (hold if eGFR <30) eGFR <30ml/min (x7) Age >70 Concurrent nephrotoxic drugs Hyperthyroidism
What is ramping and 6 factors contributing
Unable to transfer CARE of patient within clinically appropriate timeframe due to lack of space.
Factors:
- Inpatient access block
- SSU access
- communication with AV (bypass)
- Review & treat AV corridor patients
- Stream cubicle pts (can move out?)
- monitoring Flow (oversight)
Indications for TXA
Trauma PPH Hereditary angioedema Thrombolysis bleed Traumatic hyphema Dental bleeding topically Menorrhagia
