Trauma Flashcards
Spinal Shock
vs
Neurogenic Shock
Spinal Shock
Temporary loss of neurological function (spinal cord concussion) and automonic tone below level of spinal cord lesion
Typically <24hrs but can be days to weeks
Flaccid paralysis
Areflexia
Neurogenic shock
Distributive shock due to lack of sympathetic tone w/ injuries above T6
Bradycardia
Hypotension
Labile temperature - poikilothermia
Loss of bulbocavernosus reflex (involuntary contraction of internal anal sphincter when glans of penis or Foley catheter tugged)
Return of this indicated resolving spinal shock, otherwise
Wound Infection - Risk Factors
- Location - Leg>thigh>arms>feet>chest>back>face>scalp
- Open >8-12 hrs, Face>24hrs
- Contamination - devitalised tissue, foreing matter, saliva, stool
- Blunt / crush
- SC sutures
- Repair material - sutures > staples > tape
- LA with adrenaline
- High velocity missile injury
- Immunosupression - DM
Indications for Tetanus - booster / Ig
DTaP only
- Fully imunised and DTaP > 10yrs
- Fully immunised + DTaP < 5yrs + dirty wound / old
DTaP + TIG
- Not immunised
Refer these pts on to have full course with 2nd dose at 6 weeks and 3rd at 1yr
Wounds - ABx prophylaxis
-
Bites
- Cat bites - all. (Staphylococcus, streptococcus and Pasturella multocida). Amox clav (875mg x 7d)
- Dog bites - controversial. Guidelines say limit to hand, very dirty, older patients, deep puncture and immunocompromised. Amox clav x7d
- Fight bites - human bites or assumed to the hand. First thoroughly look for tendon or joint damage. Streptococcus, staphylococcus, eikenella corrodens and bacteroides. Amox Clav , plastic surgery consultant opinion
- Intra-oral lacerations esp through-and-through
- Puncture wound of foot - no data supporting but should be considered especially in puncture through rubber shoe (pseudomonas). Ciproflox for pseudomonas, keflex for staph/strep. ?MRSA Septra or Doxycycline
- Delayed primary closure in high risk patient
- Open fractures / joints
- High velocity missile wounds
- Gross contamination / crush injury and immunospurresion
Parkland formula
TBSA (%) x wt x 3 - 4mL
1/2 fluid in first 8 hrs
1/2 fluid over next 16hrs
NB for kids add maintenance fluids
Le Fort Fractures
I - horizontal fractures of the maxilla that run above the teeth bearing alveolar process and the nasal f loor and hard palate
Separate teeth from upper face
II - pyramidal shaped extending from the upper nasal bridge at the apex, downwards through the medial wall of the orbits then on through the region of the zygomatico-maxillary suture lines.
Extend into orbital rim
III - extends through the upper nasal bridge, extend bilaterally across the orbits, to extend through the fronto-zygomatic sutures, then down through the zygomatic arches
Through orbital wall involving entire face
Unstable C-spine Injuries
C1
Jefferson
Posterior Neural arch
Atlanto-occipital dislocation
C2
Odontoid
Hangman’s fracture
Flexion-teardrop fracture
Extension tear-drop fracture (stable inflexion, unstable in extension
Bilateral facet dislocation
Spinal subluxation
Wedge fracture (if posterior column disrupted, >50% vertebral height or several #)
Stable C-Spine Injuries
Clay shoveler’s fracture (base spinous process, oblique)
Transverse process fracture
Unilateral facet dislocation
C-spine XR Rules
- Adequate views - C1-T1
- Alignment
- Ant Longitudinal Line
- Post Longitudinal Line
- Spinolaminal Line
- Spinour Process Line
- Bones
- Assess each vertebra for Fracture / Collapse / Avulsion
- Cartilage
- Soft tissue - Prevertebral ST swelling
- 6mm at C2 or 22mm at C6
- 6mm C2 or 14mm at C6 - kids
- Spaces
- Predental space - betw/ C1 tubercle and anterior face of dens
* <3mm adults
* <5mm children - Basion Dental interval
* <12mm XR
* <8.5mm CT - Power’s Ratio (atlanto-occipital dislocation
* AB/CD should be < 1 - Line of Swischuck - line from anterior aspect C1 to C3 spinous processes
* Anterior aspect of C2 should be < 2mm of this line
* Deviated > 2mm ? subluxation
* Deviated < 2mm ? pseudosubluxation
- Predental space - betw/ C1 tubercle and anterior face of dens
- Scan base skull, airway, sinuses
- AP and Odontoid views
[https://www.nyp.org/professionals/emergency-medicine/how-to-read-emergency-images/how-to-read-a-c-spine-film]
[https://dontforgetthebubbles.com/c-spine-x-ray-interpretation/
C-spine XR Rules - Odontoid view
Line 1
Lateral masses of C1 do not hang over lateral masses of C2
Line 2
No asymmetry of articular spaces between lateral masses of C1 and body C2
Line 3
No asymmetry between articular spaces of dens and C1
https://www.ebmconsult.com/articles/open-mouth-odontoid-radiograph
ASIA Impairment score
A = Complete
•no motor or sensory function below the lesion
B = Incomplete
•sensory but not motor function is preserved below the neurological level
C = Incomplete
•motor function preserved below the neurological level, with more than half of key muscles have a muscle grade < 3
D = Incomplete
•motor function preserved below the neurological level, and at least half of key muscles have a muscle grade of ≥ 3
E = Normal
•normal motor and sensory function
Extension vs Flexion Teardrop
Flexion
- Unstable 3 column
- Hyperflexion + axial load
- C5-6
- Assoc spinal cord injury - displaced posterior vert body into spinal canal
- Disrupted interspinous ligaments
- SURGERY
Extension
- Stable
- Hyperextension
- Usually C2
Trauma Laparotomy Indications
Immediate
- Evisceration
- Gunshot
- Penetrating injury - stab w/ breach of peritoneum
- Haemodynamic instability despite blood products
- Frank peritonism
- Free gas on imaging
- Ruptured diaphragm
Emergent
- Positive trauma USS
Blast injuries
- Primary - pressure effects - lung, ear, and gastrointestinal tract.
- Secondary – projectiles + penetrating injury
- Tertiary – when person is thrown through the air or effects due to wind i.e solid organ injury
- Quaternary – burns, asphyxia, toxic inhalants, psychological
Complications:
Lacerations, fractures, dislocations, crush injury, compartment syndrome, burns, DIC
Tip - if TM not ruptured then primary blast injury to other organs unlikely
Burns Referral Criteria
- Percentage
- Location
Escharatomy Indications
Ventilation
1. Inc airway pressures
2. Hypoxaemia
3. Difficulty ventilating
Circumferential Neck burns
Circumferential limb +
1. Decreased Doppler signal
2. Sats < 90% on affected limb
3. Pain. loss of senation or CRT > 2s = Early signs
Burns Chemical
