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Satia's MRCS copied decks > Trauma > Flashcards

Trauma Flashcards

1
Q

Stages of damage control surgery / orthopaedics

A

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)

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2
Q

Criteria for damage control sugery and not ETC`

A

Hypothermia <34

Acidosis, pH <7.2

Serum lactate >5

Coagulopathy

Blood pressure <70mmHg

Transfusion of 15 units

Injury severity score >36

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3
Q

Permissive hypotension in major trauma

A

Aim is to maintain tissue perfusion not achieve normotension

Target 70-90 mmHg

If head injury, target >90mmHg

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4
Q

Fluid resuscitation in major trauma

A

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

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5
Q

Massive transfusion protocol

A

Adminster:
-Packed red cells
-Fresh frozen plasma
-Platelets

in a 1:1:1 ratio

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6
Q

Use of tranexamic acid in major trauma

A

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

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7
Q

Whole body CT in major trauma

A

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

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8
Q

Log-rolling ?pelvic fratcure

A

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.

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9
Q

Goals of resuscitation

A

HR <100

BP: normotensive

UO >30ml/hr

Avoid hypothermia (<35)

Normal pH i.e. not acidotic

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10
Q

Early total care

A

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

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11
Q

Lactate and decision for ETC or DCS

A

<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

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12
Q

Ischaemic cerebral blood flow

A

Normally 55ml / min /100g of brain parenchyma

Ischaemia results when flow drops <20ml / min / 100g

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13
Q

Normal cerebral perfusion pressure

A

~75-105mmHg

CPP (75–105 mmHg) =
MAP (90–110 mmHg) – ICP (5–15 mmHg)

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14
Q

Herniation during raised ICP

A

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

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15
Q

Classification of head injury severity

A

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

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16
Q

Discharge criteria for minor head injuries

A

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

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17
Q

Indications for CT head as per NICE within 1 HOUR

A

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

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18
Q

Indications for CT head as per NICE within 8 HOURS

A

CT head within 8 hours

-Age >65 years

-Coagulopathy (warfarin, aspirin, DOAC)

-Dangerous mechanism i.e. fall from height

-Retrograde amnesia >30 minutes

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19
Q

Management of extradural haematoma

A

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.

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20
Q

Management of traumatic SAH

A

Very different to primary SAH

Traumatic SAH tends not to result in vasospasm (nimodipine given in this case)

Usually managed conservatively with neuro-observations and management of parallel trauma

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21
Q

Sites of brain contusion

A

Tend to occur at sites of roughening within the skull

e.g. inferior frontal lobes
inferior temporal poles

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22
Q

Diagnosis of diffuse axonal injury

A

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

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23
Q

Traumatic intra-cranial and extra-cranial arterial dissection

A

Dissection of carotid extra-cranially:
-Headache
-Neck pain
-Focal ischaemic deficits

Intracranial dissection often affects the vertebral
artery
–> result in subarachnoid bleeding.

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24
Q

Key therapeutic goals in severe head injury

A

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

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25
Post TBI Seizures
60% in severe TBI -Started on prophylactic phenytoin
26
Feeding in TBI
Enteral feeding started within 72 hours Give metoclopramide or erythromycin as pro-kinetic
27
Glasgow outcome score (GOS)
Used to grade outcome 5 - Independent and working 4- Moderate disability 3 - Severe disability 2- Vegetative state 1- Dead
28
Stability of spinal injuries
Three column theory Anterior Middle Posterior If two of the three columns are injured = unstable
29
End of the spinal cord
L1/L2 where it continues as the conus medullaris then to the cauda equina
30
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
31
Absolute indication for surgical fixation in spinal trauma
Deteorating neurological function Neurological deficit determines management Deteriorating neurological status requires surgical intervention Corticosteroids are ineffective
32
Occipital condyle fracture Mx
Relatively stable fracture Mx: Hard collar 6-8 weeks
33
Occipitoatlanto dislocation Mx
Caused by high-energy trauma Often fatal Can dislocate anterior, posterior or vertical Power’s ratio is used to assess skull translation. Treatment is with a halo brace or occipitocervical fixation.
34
Atlas fracture (Jefferson #) Mx
Fracture of C1, Atlas Associated with axial loading Some are stable and some are unstable depending on displacement and assoicated transverse ligament injury Mx: most treated with halo-brace
35
Power's ratio
Used in occipitoatlanto dislocation Power’s ratio BC/OA ≥1 indicates anterior translation ≤0.75 indicates posterior translation.
36
Atlantoaxial instability
Non-physiological movement between atlas and axis It can be translational or rotatory Resolves either spontaneously or with traction followed by a cervical collar. Isolated, traumatic transverse ligament rupture leading to C1/2 instability is uncommon and is treated with posterior C1/2 fusion
37
Odontoid fractures
Three types of peg fractures Neurological injury is relatively rare and the majority are treated with hard collar/ halo jacket for 3 months Mx: if unstable --> surgical fixation with anterior compression screw stable --> halo jacket / hard collar Posterior C1/2 fusion is considered in cases of non-union
38
Types of odontoid fractures
Type 1: Chipped the top Type 2: base of adentoid fracture Type 3: Involved the lamellar/ vetrebral body
39
Traumatic sponylolisthesis of the axis
= Hangman;s fracture Traumatic spondylolisthesis of C2 on C3 4 types Significant displacement / facet dislocation --> posterio rstabilisation surgical fixation
40
Types of subaxial cervical spine injury (i.e. C3 and below)
C3 - C7 Compression fractures: flexion injuries Burst fractures: axial loading injuries Facet dislocation: distraction - flexion injuries Tear-drop fractures: hyper-extension injuries
41
Fractures of spine in ank spond
Usually require operative fixation Sometimes collar contra-indicated so specialist advice required
42
Classifying thoracic and thoracolumbar spinal fractures
Arbeitsgemeinschaft für Osteosynthesefragen classification Three main types A - C with increasing instability and risk of neurological injury Type A: vertical body compression fractures Type B: Involve distraction of the anterior or posterior elements Type C: rotational injurt that often is in association with A or B B and C --> surgical fixation
43
Duodenal, pancreatic and/or aortic ruptures are also associated with these injuries
Chance fractures are flexion-distraction injuries of the thoracolumbar spine Assoc with lap belt injury
44
Lumbar spinal injuries
Less likely to cause neurological compromise More capacious Lumbar lordosis means kyphosis less likely to develop Mx: usually non-operative
45
Increase in interpedicular distance
= burst fracture
46
Types of incomplete spinal cord injury
= peri-anal sensation remains intact - some functioning cord Types: Central cord syndrome Brown-Séquard syndrome (hemisection) Anterior spinal syndrome Posterior cord syndrome Cauda equina syndrome
47
Later complications of spinal cord injury
Pressure ulcers Neurogenic pain Spasticity Autonomic dysreflexia: paroxysmal syndrome of hypertension, hyperhyderosis, bradycardia, flushing and headache --> most comonly due to bladder distension or faecal loading Neurological deterioration: Post traumatoc syringomyelia (PTS ) may occur in up to 28% of SCI patients DVT / PE Osteoporosis Heterotopic ossification may affect the hips, knees, shoulders and elbows
48
Fractures of the mandible
Neck of the condyle is the most common site Also angle of the mandible and canine region Numbness over mental nerve is common Tx: ORIF with sloppy diet for 2 weeks
49
Zygomatico-orbit complex fractures
4-legged stool With exception of isololated zygomatic process and infra-orbital rim fractures --> all involve orbit Altered sensation over infra-orbital nerve is common Mx: ORIF at one of the for legs +/- double/triple point fixation
50
Classification of maxillary fractures
Type 1: Transverse fracture through the maxillary sinuses, lower nasal septum, pterygoid plates Type 2: Oblique fracture crossing zygomaticomaxillary suture, inferior orbital rim, nasal bridge Type 3 Fracture above the zygomatic arch, through the lateral and medial orbital walls and nasofrontal suture
51
Diplopia ir orbital injuries
Monocular = eye damage -Dislocated lens -Retinal detachment / damage Binocular diplopia = motility issue -Rectust muscles
52
Diplopia ir orbital injuries
Monocular = eye damage -Dislocated lens -Retinal detachment / damage Binocular diplopia = motility issue -Rectus muscles
53
Diplopia in orbital floor fracture
Indictaes entrapment of inferior rectus / inferior oblique Diplopia on up-gaze On imaging may appear undisplaced = trap-door deformity Mx: surgical emergency as pressure necrosis causing irreversible damage
54
Retrobulbar haemorrhage
= surgical emergency as leads to blindess Decreasing visual acuity Pain Loss of pupillary response Tense proptosis Medical management: Acetazolamide, mannitol and steroids Surgical Mx: Lateral canthotomy and cantholysyis
55
CSF leaks from carniofacial trauma
Fracture of frontal or ethmoidal sinuses creating communication between cranial cavity and nasal cavity Dural tear needed for CSF to leak Most common site of injury is the posterior wall of the frontal sinus, however fractures of the ethmoid and sphenoid sinus can also cause CSF leaks Initial CSF leaks are not treated Persistent CSF leaks >10 days --> dural repair using open anterior fossa repair (necessitating a frontal craniotomy
56
The Deadly Dozen
6 immediately life-threatening -Airway obstruction -Tension pneumothorax -Pericardial effusion -Open pneumothorax -Massive haemothorax -Flail chest 6 life-threatening -Aortic injuries -Tracheobronchial injuries -Myocardial contusion -Rupture of the diaphragm -Oesophageal injuries -Pulmonary contusion
57
Closure of open chest wounds
MUST have remote chest drain in first if wounds are sucking Temporary closure with three sided dressing If chest drian isn't inserted one could convert a leaking pneumothoax into a closed pneumothorax --> tension
58
Indications for urgent thoracotomy
Initial drainage of more than 1500 mL of blood OR Ongoing haemorrhage of more than 200 mL/h over 3–4 hours Clamping a chest drain to tamponade a massive haemothorax is not helpful.
59
Flail chest
On inspiration, the loose segment of the chest wall is displaced inwards and therefore less air moves into the lungs On expiration, the segment moves outwards (paradoxical respiration).
60
Mx of flail chest
Oxygen administration, adequate analgesia (including opiates) and physiotherapy. If chest tube is in situ, topical intrapleural local analgesia introduced via the tube Ventilation is reserved for cases developing respiratory failure despite adequate analgesia and oxygen Internal fixation of the ribs may be useful in isolated or severe chest injury and pulmonary contusion
61
Diagnosis of oeosphageal perforation
Oesophagogram in the decubitus position and oesophagoscopy confirm the diagnosis in the great majority of casesa
62
Indications for a FUTILE EDT
CPR in the absence of endotracheal intubation for more than 5 minutes; CPR for more than 10 minutes (despite endotracheal intubation); Blunt trauma when there have been no signs of life at the scene
63
Aims of ED thoracotomy
Internal cardiac massage; Control of haemorrhage from injury to the heart or lung Control of intrathoracic haemorrhage from other sources Control of massive air leak Clamping of the thoracic aorta to preserve the blood supply to the heart and brain, and cutting off the arterial supply distally, in a moribund patient with a major distal penetrating injury.
64
Management of liver injuries
Push Pringle Plug Pack
65
Damage to hepatic artery
Can be tied off One CANNOT tie off portal vein, must be repaired = 50% mortality if it is tied off -If bleeding cannot be controlled it should be stented and tranfserred to complex trauma HBP unit
66
Management of blunt pancreatic injuries
Pancreatic body (left is SMA) and tail --> closed suction drainage alone If duct involved --> distal pancreatectomy Proximal injuries (right of SMA) are treated as conservatively as possible, although partial pancreatectomy may be necessary --> pylorus can be temporarily closed (pyloric exclusion) in association with a gastric drainage procedure, to minimise pancreatic enzyme stimulation
67
Management of retropeitorneal bleeding
Haematomas split into three zones Zone 1 (central): central haematomas = Always explored, proximal and distal vascular control Zone 2 (lateral): lateral haematomas s = Only be explored if they are expanding or pulsatile. Renal in origin and can be managed non-operatively Zone 3 (pelvic) =Only be explored if they are expanding or pulsatile. Pelvic haematomas are exceptionally difficult to control --> Compression or extraperitonea packing, and if the bleeding is arterial in origin, with angioembolisation.
68
Disruption of iliosacral joint is likely to damage which vessel
Iliac vessels
69
Tile classification of plevic fractures
Type A -Stable -Lateral compression, which causes ncompression fractures of the pubic rami or compression fracture of the sacrum posteriorly Type B -Partial stability, ORIF required -Disruption of the anterior pelvis and partial disruption of the posterior pelvis. -Pelvis can open and close ‘like a book’ -Sacroiliac ligaments remain intact, there is no vertical displacement Type C -Completely unstable -Both anterior pelvis and the entire posterior pelvic complexes are disrupted -Free to displace horizontally and vertically.
70
Antibiotics in penetrating abdominal trauma
Prophylaxis antibiotics given if penetrating trauma Ususally stat dose unless gross contamination then on-going abx may be required
71
Gustilo and Anderson Open fracture classification
I: <1cm and clean II: >1cm without excessive soft tissue damage III: Characterised by high energy injury irrespective of the size of the wound -Soft tissue damage -High degree of contamination A: adequate soft tissue coverage post-repair B: inaqdequate soft tissue coverage post repair C: associated arterial injury
72
Salter Harris #s requiring surgery
III - V
73
Fixation of scaphoid fracture
Displaced >1mm or unstable Use headless compression screw If undisplaced --> below elbow casting not including thumb
74
Perilunate dislocation and lunate dislocation
Most common dislocation around capometacarpal joint ---> puts pressure on median nerve Requires reduction, ligamentous repair and k-wire fixation
75
Fixation of Smith's fracture
Most volar fractures of the radius are unstable Standard treatment is volar plate on volar buttress of radius
76
If radial fracture is associated with splitting of the lunate fossa fragment in the coronal plane and separation of the radial styloid
= failure Intra-articular fracture that requires internal fixation with a plate
77
Neer Classification
Proximal humeral fractrures 4 parts to the proximal humerus: -Articular head fragment -Lesser tuberosity -Greater tuberosity -Shaft If a fragment is displaced by more than 1 cm or angulated by more than 45 degrees in respect of another fragment, it is considered a part. May be undisplaced, 2 part, 3 part or 4 part. Greater the number of parts, the higher the chances of interruption of the vascularity to the humeral head and the more complex the injury
78
Indications for surgical fixation of the clavicle
Displaced, comminuted fractures 2cm shortening Ederly females
79
Indications for a gamma nail
Unstable extra-capsular femoral fractures + reverse oblique fracture --> unstable Dynamic hip screws can sometiems still be used
80
Os calcis fractures
Fall from height 20% have associated lumbar spinal fracture
81
Talar neck fracture.
Most common fracture of the talus Caused by forced dorsiflexion Blood supplied interupted in displaced fractures Anatomical reduction and stable fixation of the talar neck should be performed

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