Trauma Flashcards
Death from injury occurs in what time periods
First peak: within seconds to mins
- very few can be saved due to severity of injuries
Second peak: within minutes to hours
- deaths occur due to life-threatening injuries
Third peak: after several hours to weeks
- deaths from sepsis to MOF
What is the golden hour in trauma
Period when medical care can make maximum impact on death and disability (addresses second peak of deaths)
Initial trauma management
AIRWAY (risks to airway in trauma = foreign body, facial, mandibular, laryngeal, tracheal #)
- C spine stabilisation until C spine injury excluded (immobilisation device/manual in-line stabilisation)
- Is airway patent? If speaking the airway is not threatened
- Manouvres: head tilt and chin lift or jaw thrust
- Suction
- Adjunct: NPA or OPA
- Definitive airway if req: ETT or surgical
BREATHING (tension pneumothorax, open haemothorax, flail chest, pulmonary contusion, massive haemothorax)
- High flow O2 with non-rebreathing reservoir bag mask
- RR, auscultate, tracheal deviation, expansion, symmetry, subcutaenous emphysema
- Tx life threatening conditions e.g., tension pneumothorax
CIRCULATION
- Assess for shock
- Control external bleeding with direct pressure
- 2 wide bore IV cannulas (12G)
- FBC, UEC, Group and XM (at least 2 units), coags
- Consider ABG + arterial lactate
- Commence bolus of CSL or .9% NS
- Unmatched O Rh- only if immediately lifethreatening –> matched PRBCs and FFP
- Consider surgical control of bleeding (laparotomy or thoracotomy) or radiological embolisation
DISABILITY
- AVPU and GCS
- Reduced consciousness: exclude hypoxia and hypovolaemia –> assume head injury until proven otherwise
EXPOSURE
- Undress and assess
- Use warm blankets and warm IV fluids to prevent hypothermia
ESTABLISH MONITORING
Continuous: pulse, non-invasive BP, ECG, SpO2
Urinary catheter (after excluding urethral injury)
SECONDARY SURVEY
- Hx: allergy, medication Hx, PMHx, last ate, events and environment leading up
- Ex: top to toe and reassess vitals
- Diagnostic Ix
Where are the major sites of blood loss
Thorax
Abdomen and retroperitoneum
Pelvis
Long bones
Floor/external blood loss
Traumatic injuries in order of mortality
- Loss of airway
- Inability to breathe
- Loss of circulating blood volume
- Expanding intracranial mass
Diagnostic studies considered in trauma
XR
USS
CT
Diagnostic peritoneal lavage
History taking: burns patient
Mechanism of burn: heat, friction, chemical, radiation
Duration of exposure
Time since burn
Immediate first aid and management since
Other injuries?
Examination: burns patient
Assess distribution
- TBSA affected via rule of 9s + pt hand ~1% of TBSA
- Special areas: face, genitalia, palms
- Airway: singed nasal hairs/eyebrows, cough, hoarseness, stridor, swollen face/lips, blistered palate, sooty sputum, respiratory effort, dyspnoea –> intubate
- Circumferential burns
Assess for depth
Assess for NAI
- delayed presentation
- injury incompatible with Hx
- shapes/patterns/symmetrical/immersion
Rule of 9s in burns
Anterior and posterior head = 9% each
Anterior and posterior torso = 18% each
Each lower limb = 18%
Each upper limb = 9%
Immediate burns management
Stop burning process
Remove all clothes/jewellery
20 minutes+ under cool running water (beware hypothermia)
Resuscitation via primary survey
Intubate if inhalational injury suspected
100% humidified O2 for all pts
2 large bore IVs: FBC, UEC, clotting, UECs, carboxyhaemoglobin, ABG
IV CSL 3-4ml/% TBSA burned
- 1/2 in next 8 hours then 1/2 over next 16 hours
Urinary catheter and continuous vitals monitoring
Wash burn and cover with cling film
IV morphine
Tetanus prophylaxis if required
Refer to burns unit
Definitive burns Mx
Superficial dermal: heal within 2 weeks without scar
Wash burns with saline and clorhexidine, non-adherent dressings, regular inspection
Debride large blisters
Elevate limbs to reduce pain and swelling
Topical silver sulphadizine on deep burns to reduce risk of infection
Escharotomy for circumferential full thickness burns to chest that limit ventilation or limbs that limit circulation
- indications: pain at rest or on passive movement of distal joints –> late = loss of sensation or pulses
Discuss use of XR in trauma
Lateral cervical spine, AP chest, AP pelvis screening radiographs
- Portable radiography should be done in ED or operating theatre even in haemodynamically unstable pt
- Need for C spine XR in haemodynamically stable pt is assessed clinically
- CXR should be obtained for pt with penetrating injuries of the chest, back, or abdomen: may reveal subdiaphragmatic free air, foreign body, pneumothorax or haemothorax
- If CT is needed XR of chest and pelvis in pts with blunt trauma not needed
Discuss use of USS in trauma
Ultrasound (FAST exam) = Focused Assessment with Sonography for Trauma (FAST)
- unstable pt: essential part of primary circulation survey
- used primarily to detect pericardial and intraperitoneal blood
- hemodynamically stable: can be delayed until secondary survey
- pelvic bleeding and retroperitoneal bleeding not well visualised
Discuss role of diagnostic peritoneal tap or lavage in trauma
Similar to FAST in unstable patient in whom a source of bleeding has not been found
- used to detect intraperitoneal blood when FAST is unavailable or indeterminate in hemodynamically unstable patients
- used to determine type of intraperitoneal fluid when e.g., blood vs urine in setting of a pelvic fracture
Discuss role of CT in trauma
Indicated when:
Source of haemorrhage in unstable trauma patient cannot be determined using diagnostic imaging studies immediately available at bedside
Additional information is needed to direct operative care
Alternative is to take pt directly to theatre depending on probably injuries, CT availability, pt clinical status etc.
What are the levels of acuity used in a triage system
Immediately life-threatening (category 1)
Imminently life-threatening (category 2)
Potentially life-threatening or important time-critical treatment or severe pain (category 3)
Potentially life-serious or situational urgency or significant complexity (category 4)
Less urgent (category 5).
Outline triage method
