Trauma Flashcards
List the 9 points of the FPHC Consensus statement on Pelvic Fractures
1) A Pelvic Binder is a treatment intervention and should be applied early.
2) A select group of patients may not need a binder applied.
3) No one pelvic binder device can currently be recommended over another.
4) Adequate training must be provided to avoid misplacement of devices.
5) Associated femoral fractures should also be reduced
6) Patients should not be log rolled or transported on a spinal board
7) The use of pelvic binders is associated with the risk of low pressure necrosis
8) The pelvic binder should be placed next to skin.
9) A pelvic binder should be applied prior to extrication (??)
HOTT Principles
H - Hypovolaemia
O - Oxygenation
T - Tension Pneumothorax
T - Tamponade
What are the landmarks for needle thorocentesis?
1st) 2nd intercostal space mid clavicular line
2nd) 5th intercostal, Mid-axilla
2nd) 4th intercostal space mid axilla
Abdominal injury is present in what percentage of major trauma cases?
40%
Internally, the abdomen can be divided into three layers. What are they?
The peritoneum
The retroperitoneum
The pelvic cavity
Crush Injury: Definition
A crush injury is a direct injury resulting from crush
Crush Syndrome: Definition
Crush syndrome is the systemic manifestation of muscle cell damage resulting from pressure or crushing
Toxic substances released in crush syndrome
Phosphate
Urate
Myoglobin
Potassium
Fluid resuscitation in Crush Syndrome - consensus view
An initial fluid bolus of 2 litres of crystalloid should be given intravenously.
This should be followed by 1-1.5 litres per hour.
The fluid of choice is normal saline, warmed if possible
If possible, fluid should be started prior to extrication, however, gaining intravenous access and the administration of fluid should not delay extrication and transport to a definitive care
Once the patient reaches hospital, 5% dextrose should be alternated with normal saline to reduce the potential sodium load.
Tourniquets in crush syndrome - consensus view
The use of tourniquets should be reserved for otherwise uncontrollable life threatening haemorrhage. There is no evidence at the moment to support the use of tourniquets in the prevention of reperfusion injury following extrication
Fluid resuscitation for children with crush syndrome
Initial bolus of 20mls per kg
Traumatic cardiac arrest FPHC consensus statement recommendations
1 - Hypovolaemic cardiac arrest should be managed with aggressive
haemorrhage control and early surgical intervention.
2 - Chest compressions may be interrupted in order to provide definitive treatment of hypovolaemia
3 - Definitive airway management with a tracheal tube should be achieved at the earliest opportunity if the healthcare provider is adequately trained in this intervention. If advanced airway support cannot be provided then basic airway support using airway adjuncts and bag valve mask ventilation should be performed.
4 - Bilateral thoracostomies should be performed in traumatic cardiac arrest to rule out tension pneumothoraces. These should be made using a surgical technique and a thoracostomy tube sited once the patient is stabilised.
5 - Resuscitative emergency thoracotomy should be performed for patients with penetrating trauma to the chest or epigastrium within 10 minutes of loss of cardiac output.
Classification of Pelvic fractures
Anterior-Posterior compression
Lateral compression
Vertical sheer
3 layers of meninges
Pia mater (inside)
Arachnoid mater
Duramater (outside - adhered to skull)
Factors contributing to secondary brain injury
Hypotension
Hypoxaemia
Hypoglycaemia
Hyperglycaemia
Hypocapnia
Munro-Kellie doctrine
The sum of volumes of brain, CSF, and intracranial blood is constant. An increase in one should cause a decrease in one or both of the remaining two.
Glasgow Coma Scale
Eyes
1 No eye opening
2 Eye opening to pain
3 Eye opening to sound
4 Eyes open spontaneously
Verbal response
1 No verbal response
2 Incomprehensible sounds
3 Inappropriate words
4 Confused
5 Orientated
Motor response
1 No motor response.
2 Abnormal extension to pain
3 Abnormal flexion to pain
4 Withdrawal from pain
5 Localising pain
6 Obeys commands
Signs of a base of skull fracture
- Bilateral periorbital haematoma (racoon eyes)
- Rhinorrhoea
- Subconjunctival haemorrhage
- Masoid bruising (battle’s sign)
- Otorrhoea
- Haemotympanium
Neuroprotective care bundle
Systolic BP >100mmHg, <150mmHg
SPO2 >94%
ETCO2 4.0-4.5kpa
BM = normal
Temperature = normal
TXA if GCS <13 and within 3 hours of injury
Cerebral perfusion pressure equation
CPP = Mean arterial pressure (MAP) - Intercranial pressure (ICP)
5 points of the FPHC Consensus Statement on minimal patient handling.
- The long spinal board is an extrication device and should no longer be used for providing spinal immobilisation during transport to definitive care.
- The scoop stretcher should be used for patient transfer and to provide spinal immobilisation.
- Patients should be managed according to a package of ‘Minimal Handling Considerations’.
- The patient should be immobilised on the Scoop Stretcher with ‘scoop-to-skin’.
- When the total time immobilised on a Scoop Stretcher is likely to exceed 45 minutes consideration should be given to using a Vacuum Mattress
Thoracostomy landmarks in the pregnant patient
3rd or 4th Intercostal space, mid axilla line
What percentage of spinal cord injuries are due to trauma?
90%
What percentage of spinal cord injuries from trauma are due to RTCs
50%
Detail the spinal column
5 regions
Cervical - 7 vertebrae
Thoracic - 12 vertebrae
Lumbar - 5 vertebrae
Sacral - 5 vertebrae
Coccyx - 4 vertebrae
Where does the spinal cord sit?
Spinal canal, from the foraman magnum to around L1
Distribution of spinal injuries
Cervical - 55%
Thoracic - 15%
Thoracolumbar - 15%
Lumbosacral - 15%
Is immobilisation recommended for penetrating spinal injury?
No
Primary vs secondary spinal cord injury
Primary - time of injury, mechanical disruption/transection/distraction of cord
Secondary - Hypoxia, hypo perfusion, further mechanical movement.
Spinal shock, Symptoms
- Complete loss of function below the level of injury
- Complete or partial
- Flaccid paralysis
- Areflexia
- lasts 24-72 hours, before more definitive diagnosis/prognostication can be made.
Neurogenic shock , signs and symptoms
- Cord injury at or above T6
- Loss of autonomic outflow
- Vasodilation
- Hypotension
- Relative bradycardia
- Distributive shock
Spinal cord injury - Weakness/Paralysis on one side of the body, sensory deficit on the other side of the body
Brown-Sequard syndrome
Spinal cord injury - Incomplete lesion, arms weaker than legs
Central cord syndrome
(More common in elderly)
Spinal cord injury - Complete motor paralysis below lesion, loss of pain/temperature sensation, areflexia and autonomic dysfunction.
Anterior cord syndrome
Signs of SCI in the unconscious patient
- Neurogenic shock
- Priapism
- Diaphragmatic breathing
- E4, V1, M1
- Distended veins
- Pain response above clavicles only.
Vital capacity effects of spinal cord injury causing thoracic paralysis
Vital capacity can be reduced to 10-20% of normal.
3 factors determining the severity of crush syndrome
1) The force
2) The duration of force
3) The muscle mass involved
TXA loses 15% efficacy every _____ minutes
10 mins
Fluid Resuscitation targets in trauma
Penetrating central injuries = Central pulse or cerebration
Blunt poly trauma without TBI = SBP 80-100 (MAP 60-70)
Blunt poly trauma with TBI = SBP 100-120 (MAP 70-80)
Warfarin reversal
PCC
Prothrombin complex concentrate
Signs/Symptoms of raised ICP
Cushings Triad
Systemic hypertension
Bradycardia
Irregular respirations
+Pupillary dilation
Management of raised ICP
- Mannitol
- Hypertonic saline
- Hyperventilation to manage hypercapnia (target 3.5-4.0kpa)
- Avoid compression of the neck with tube ties etc.
- 30 degree head up position
Flail chest definition
The fracture of 2 or more adjacent ribs in 2 or more places, leading to segmental loss of continuity with the rest of the thoracic cage
The lethal triad
Coagulopathy
Acidosis
Hypothermia
What percentage of major trauma patients have hypo-calcaemia
Up to 60%
89% after blood administration
Transporting an amputated limb
Wrap in Saline soaked gauze and put in water tight bag.
Pack ice around the bag if available
Primary, Secondary, Tertiary and Quaternary blast injuries
Primary - Caused by the blast wave and pressure changes in the body. Eg Tympanic rupture, Blast lung
Secondary - Shrapnel from the blast
Tertiary - Trauma from falling or being thrown due to the blast wind.
Quaternary - Burns or any other injury from the blast. Includes psychological injury.
Police approach to ballistics scene
4 C’s
Confirm
Clear
Cordon
Control
Blast Lung - Symptoms
Dyspnea
Chest pain
Haemoptysis
Wheeze
Creps
Apnea
Bradycardia
Hypotension
Treatment of Eviserated bowel
Cover with cling film or saline soaked gauze
Open pelvic fracture mortality
Up to 50%
Taking a tooth to hospital/Dentist
Try to put it back into the hole in the gum. If it does not go in easily:
- put it in milk
- put it in saliva – by spitting into a container (if it’s your tooth) or having your child spit into a container (if it’s theirs)
- hold it in your cheek until you see the dentist – but do not have younger children do this in case they swallow it
Indications for pre-hospital thoracotomy
- Stab wound to chest or upper abdomen
- Loss of vitals <15 mins
- The suspected injury is suitable for temporary control.
Contraindications for pre-hospital thoracotomy
- Cardiac arrest secondary to blunt trauma
- Cardiac arrest secondary to gunshot wound
- Loss of vitals >15 mins
- Unskilled practitioner
Which adults require a CT scan following head injury?
- GCS <13 on assessment at ED
- GCS <15 2 hours after injury
- Suspected open or depressed skull fracture
- Any sign of basal skull fracture
- Post traumatic seizure
- Focal neurological deficit
- More than 1 episode of vomiting
or any loss of consciousness or amnesia with risk factors….
- Age 65+
- Any Hx of bleeding or clotting disorder
- Dangerous mechanism
- More than 30 mins’ retrograde amnesia of event immediately before the head injury
Classification of head injury
Mild = GCS 14-15
Moderate = GCS 9-13
Severe = GCS 3-8
Cerebral perfusion pressure =
MAP - ICP
5 NEXUS criteria
1) Focal neurologic deficit
2) Midline spinal tenderness
3) Altered level of consciousness
4) Intoxication
5) Distracting injury
Risk factors for poor outcome following rib fractures
Age >65
3 or more fractures
Bilateral flail chest
Chronic lung disease
Co-existent lung injury
Anticoagulant use
BMI >25
Spo2 <90% in ED
