Trauma Flashcards
Stages of damage control surgery / orthopaedics
The stages of DCO are:
- Resuscitation
- Haemorrhage control
- Decompression
- Decontamination
- Fracture splintage
The aim is to avoid a second physiology hit from early surgical fixation of fractures in major trauma (i.e. delaying plating of a pelvis for 4 days)
Where physiological impact isn’t severe, Early Total Care of fractures is beneficial (i.e. complete fixation within 36 hurs)
Criteria for damage control sugery and not ETC`
Hypothermia <34
Acidosis, pH <7.2
Serum lactate >5
Coagulopathy
Blood pressure <70mmHg
Transfusion of 15 units
Injury severity score >36
Permissive hypotension in major trauma
Aim is to maintain tissue perfusion not achieve normotension
Target 70-90 mmHg
If head injury, target >90mmHg
Fluid resuscitation in mjaor trauma
Aim to use bolus of blood e.g. 250ml
Excessive intravenous crystalloid or colloid
solutions should be avoided because they cause haemodilution, increase coagulopathy and increase the risk of adult
respiratory distress syndrome (ARDS)
Aim is to maintain tissue perfusion not achieve normotension
Massive transfusion protocol
Adminster:
- Packed red cells
- Fresh frozen plasma
- Platelets
in a 1:1:1 ratio
Use of tranexamic acid in major trauma
1g is given intravenously over 10 minutes,
followed by a further 1 g dose over 8 hours
Tranexamic acid should be given to all trauma patients suspected to have significant haemorrhage, including those with a systolic blood pressure of <110 mmHg or a pulse of over 110 per minute
It needs to be administered within 3 hours of injury
Whole boydy CT in major trauma
WBCT from the head to pelvis with IV contrast is the gold standard investigation of the severely injured adult blunt trauma patient
There is no role for selective scanning of body systems in these patients
WBCT scan is a time-critical investigation and should be
obtained as early as possible in resuscitation of the severely injured patient
Any patient undergoing immediate trauma laparotomy after blunt trauma without a WBCT scan should have a pelvic binder applied and not removed until a pelvic fracture is excluded
Such patients should have an immediate pelvic radiograph either in the emergency department, or as they arrive in the operating room
Log-rolling ?pelvic fratcure
Log-rolling should not occur until a pelvic fracture has been radiographically excluded
Disturbs hamatomas –> re-bleeding
Formal log-rolling of the blunt trauma patient to examine the back during the primary survey adds minimal useful clinical information, delays the WBCT scan and may cause harm to a patient with a pelvic fracture.
Goals of resuscitation
HR <100
BP: normotensive
UO >30ml/hr
Avoid hypothermia (<35)
Normal pH i.e. not acidotic
Early total care
Early total care describes the definitive management of a patient’s injuries within 36 hours of injury after a period of initial resuscitation
Allows early mobilisation
Reduced pulmonary complications
Enahnced recovery
Lactate and decision for ETC or DCS
<2 mmol/L – Early total care
2–3 mmol/L – Look at the trend (increasing or decreasing)
> 3 mmol/L – May be under-resuscitated; should either have further resuscitation or damage control surgery (DCS) if surgery is urgent
> 5 mmol/L – DCS
Ischaemic cerebral blood flow
Normally 55ml / min /100g of brain parenchyma
Ischaemia results when flow drops <20ml / min / 100g
Normal cerebral perfusion pressure
~75-105mmHg
CPP (75–105 mmHg) =
MAP (90–110 mmHg) – ICP (5–15 mmHg)
Herniation during raised ICP
If laterally placed lesion causing mess effect
Subfalcine herniation under falx cerebri
–> If frontal lobe trapped a clinical picture of stroke appears
Uncal herniation: uncus of temporal lobe under tentorium cerebeli
- -> Third nerve compressed innitially –> blown pupil
- -> Dropping GCS
Central herniation and tonsillar herniation
- -> result in brainstem compromise
- -> manifesting as Cushing’s triad and dropping GCS
Classification of head injury severity
Using the GCS
GCS 15 with no LOC = minor head injury
GCS 15 or 14 with LOC = mild head injury
GCS 9-13 = moderate head injury
GCS 3-8 = sevre head injury
Discharge criteria for minor head injuries
Minor = GCS 15 with no LOC
Criteria:
- GCS 15/15 with no focal neurology
- Normal CT if they have had one
- Patient not under influence of drugs or alcohol
- Patient accompanied by responsible adult
- Verbal and written safety netting re. vomiting, developing focal neurology
Indications for CT head as per NICE within 1 HOUR
CT head within 1 hour
- GCS <13 at any point
- GCS <15 at hours post injury
- Focal neurology present
- Suspected skull fracture
- > 1 episode of vomiting
- Post-traumatic seizure
Indications for CT head as per NICE within 8 HOURS
CT head within 8 hours
- Age >65 years
- Coagulopathy (warfarin, aspirin, DOAC)
- Dangerous mechanism i.e. fall from height
- Retrograde amnesia >30 minutes
Management of extradural haematoma
Extradural haematoma mandates urgent transfer to the most accessible neurosurgical facility, for immediate evacuation in deteriorating or comatose patients or those with large bleeds
Close observation with serial imaging in other cases
The prognosis for promptly evacuated extradural haematoma, without associated primary brain injury, is excellent.
Management of traumatic SAH
Very different to primary SAH
Traumatic SAH tends not to result in vasospasm
Usually managed conservatively with neuro-observations and management of parallel trauma
Sites of brain contusion
Tend to occur at sites of roughening within the skull
e.g. inferior frontal lobes
inferior temporal poles
Diagnosis of diffuse axonal injury
Confirmation is only at post-mortem histologically
Clinical diagnosis made in consideration with mechanism of injury and clinical picture
CT findings of haemorrhagic foci at carpos callosum and dorsolateral rostral brainstem are indicative
Traumatic intra-cranial and extra-cranial arterial dissection
Dissection of carotid extra-cranially:
- Headache
- Neck pain
- Focal ischaemic deficits
Intracranial dissection often affects the vertebral
artery
–> result in subarachnoid bleeding.
Key therapeutic goals in severe head injury
pCO2 = 4.5–5.0 kPa
pO2>11 kPa
MAP = 80–90 mmHg
ICP <20 mmHg
CPP >60 mmHg
[Na+] >140 mmol/L
[K+] >4 mmol/L
Post TBI Seixures
60% in severe TBI
-Started on prophylactic phenytoin
Feeding in TBI
Enteral feeding started within 72 hours
Give metoclopramide or erythromycin as pro-kinetic
Glasgow outcome score (GOS)
Used to grade outcome
5 - Independent and working
4- Moderate disability
3 - Severe disability
2- Vegetative state
1- Dead
Stability of spinal injuries
Three column theory
Anterior
Middle
Posterior
If two of the three columns are injured = unstable
End of the spinal cord
L1/L2 where it continues as the conus medullaris then to the cauda equina
ASIA scoring levels
A: complete spinal cord injury
B: sensation present but motor function absent
C: sensation present, motor present but not functional MRC garde 3/5)
D: Sensation and motor present MRC grade >3/5
E: Normal function
A= absolutely nothing can be done E= excellent news
Absolute indication for surgical fixation in spinal trauma
Deteorating neurological function
Neurological deficit determines management
Deteriorating neurological status requires surgical intervention
Corticosteroids are ineffective
Occipital condyle fracture Mx
Relatively stable fracture
Mx: Hard collar 6-8 weeks