Trauma Flashcards
Triage
• Based on ABCDE
• Multiple casualties:
o Number of patients and severity do not exceed capability of facility
o Life threatening problems and multiple system injuries treated first
• Mass casualties:
o Number of patients and severity exceed capability of facility and staff
o Patients with greatest chance of survival are treated first
Colour coded.
-Red - life threatening injury which requires immediate intervention/operation.
- Yellow - injuries that may become life or limb threatening if care is delayed beyond several hours.
- Green - the walking wounded who have only suffered minor injuries.
- Black - dead patients
- Blue - ‘expectant’ patients - severely injured but given the number of casualties requiring immediate care, have been given palliative treatment while first caring for the red patients. (those who are severely injured who normally will be prioritised as red patients if only 2 or 3 casualties requiring immediate care)
Primary survery
• A
o Assess airway for patency
▪ Chin lift, jaw thrust
▪ Clear foreign bodies
▪ Oropharyngeal/nasopharyngeal airway – mouth to EAM
▪ Intubate/ cricothyroidotomy/ jet insufflation
o C-spine immobilisation
• B
o Sats, RR
o Trachea
o Percuss chest
o Auscultate chest
o Manage:
▪ Put on O2
▪ Ventilate if required
▪ Alleviate tension pneumothorax, seal open pnuemothroax
▪ Add CO2 monitoring + pulse oximeter
• C
o HR, BP, peripheries, level of consciousness
o Sources of bleeding
o Manage:
▪ Apply pressure / put on tourniquet
▪ IVC x 2, take bloods, warmed IVF as required
• D
o GCS, pupils, lateralising signs
o BSL
• E
o Expose patient
o Prevent hypothermia
• Adjuncts
o Abg
o Ecg
o Catheters – NGT, IDC
o XR chest, pelvis
o FAST
MIST
Mechanism and time of injury
Injuries found and suspected
Symptoms and signs
Treatment initiated
AMPLE history
Allergies
Medications
Past medical history
Last meal
Events
Primary vs secondary vs tertiary survey
Primary - assessment of life threatening injuries.
Secondary - assessment from head to toe to exclude any injuries once stabilised from potential life threatening injuries.
Tertiary - exclude any potential missed injuries following primary and secondary survey.
Trauma spiel
1) Concurrent assessment and resuscitation based on ATLS principles
2) Start haemostatic resuscitation and activate a massive transfusion protocol.
3) Actively prevent and treat coagulopathy, acidosis and hypothermia.
4) Make an early clinical decision regarding the need for damage control surgery
massive transfusion protocol
Definition
o Massive transfusion
▪ Replacement of >1 blood volume in 24h or >50% blood volume in 4h
o Activation criteria
▪ Actual or anticipated 4 units RBC in <4h + HD unstable +/- anticipated ongoing bleeding
▪ Severe abdominal, thoracic, pelvic, multiple long bone trauma
▪ Major obstetric, GI or surgical bleeding
• Goals
o Early recognition of blood loss
o Maintenance of perfusion and oxygenation by restoring blood volume and Hb
o Arrest of bleeding
o Judicious use of blood components to correct coagulopathy
• Once activated
o 4 units RBC, 2 units FFP (all coag factors) [some use ratio 1:1:1]
o Consider 1 unit platelets (1 pooled = 4 units), tranexamic acid (if trauma)
o Add cryoprecipitate (factors VIII, XIII, vWF, fibrinogen) if fibrinogen <1g/L (10 units)
• Monitor every 30-60 mins
o FBC, coags, ionized calcium, ABG
• Targets o Temp >35, pH >7.2, BE <-6, lactate <4, Ca _1.1, plt >50, PT <1.5x normal, INR <1.5, fibrinogen >1
TEG
Thromboelastography
Aims
Goal directed therapy
Rapid results - visual profile
Replacement according to needs rather than coagulation profile
How is it performed
Collected whole blood placed in small cup
In the cup, a pin connected to a detector is suspended
The cup is oscillated
Fibrin strings form between cup and pin
Transmited onto detector via the pin and a trace is formed
Result time 3-10 mins
Results
R (time to taken to start clotting)
FFP
K and alpha Angle (time clot to reach fixed strength)
cryoprecipitate
Maximal amplitude (strength of clot)
platelets
Ly30 (excess fibrinolysis)
Tranexamic acid
Burns (definition and principles)
Definition
o Tissue damage sustained due to exposure to temperatures outside normal physiological range
o Principles
▪ Institution of adequate airway and breathing
▪ Prevention and treatment of burn shock
▪ Prevention and treatment of infection
▪ Provision of permanent and durable skin cover
▪ Correction of functional disabilities
▪ Correction of cosmetic concerns
▪ Rehabilitation and reintegration into society
o Aspects of management
▪ Fluid resuscitation
▪ Pain control
▪ Prevention of infection
▪ Pharmacomodulation of hypermetabolic state
▪ Nutrition
Pathophysiology of burns
1) Thermal injury causes coagulative necrosis of epidermis and variable depth of skin
NB chemical and electrical burns cause direct injury to cellular membranes + heat transfer
Depth of injury depends on temperature, type of heat, duration of exposure
2) Jackson’s model of burn wound
- Zone of coagulation (zone of necrosis) Irreversible damage with denaturing of cellular protein
- Zone of stasis (zone of ischaemia) Increased capillary permeability due to inflammatory cytokine response
Decreased tissue perfusion to vascular damage/leakage
- Zone of hyperaemia (zone of inflammation)
Expect complete recovery from injury in 7-10 days
3) Systemic response
Occurs due to cytokine release
Massive fluid shifts due to vascular permeability/inflammatory response
Classification of burns
• Superficial epidermal – 1st degree
▪ Epidermis only
▪ Dry, red, warm, blanches, no blisters
▪ Can be painful
▪ Normal or hypervascular
▪ some desquamation
▪ Heals in 7-10 days, no scar
• Partial thickness – 2nd degree
o Superficial dermal
▪ Epidermis and upper dermis
▪ Pale, pink, blisters, blanches with pressure
▪ Very painful
▪ Hyperrvascular
▪ Heals in 7-14 days, colour match defect, risk of hypertrophic scar
o Deep dermal
▪ Epidermis, significant part of dermis
▪ Blotchy, pale, blisters over pale deep dermis
▪ Decreased sensation
▪ Sluggish cap refill
▪ Heals in 21 days, high risk of hypertrophic scar
• Full thickness – 3rd degree
▪ Epidermis, dermis and adnexal structures all involved
▪ White, waxy, charred, no blisters, no cap refill
▪ No sensation
▪ No circulation
▪ Does not heal, wound contraction, heals by secondary intention
Primary survery for burns
Primary survey
o Airway:
look for history/signs impending airway obstruction
Face/neck burns, singed facial hair, carbon deposits oropharynx, hoarseness, carboxyhaemoglobin >10%
Immediate/early intubation if: stridor, circumferential neck burns, risk factors + prolonged transfer rqd to burn centre.
o Breathing:
assess for thermal/inhalation injury
carbon monoxide poisoning
CO higher affinity for haemoglobin, displaces O2. dissociates slowly.
Rx: 100% oxygen - CO dissociates ½ life 40min (rather than 4hr on RA)
torso burns restricting respiration – may need escharotomy
o Circulation:
crystalloid boluses to maintain UO 0.5-1ml/kg/hr
Parkland’s formula: 4ml CSL x wt in kg x % BSA 2nd/3rd degree burns over 24 hr (with ½ over first 8 hours, second ½ over 16hrs)
o Disability:
Assess GCS.
If altered, consider carbon monoxide poisoning, concurrent trauma or shock
o Exposure:
Stop the burning – remove clothes/chemicals/irrigate with water
Cool the burn: aim to achieve 20 minutes cool running water within 3 hours
Assess extent - body surface area: “rule of 9s”. Palm = 1% BSA or Lund-Browder chart
Assess depth of burns
Keep warm: Cover pt (warm blankets/bear hugger), warm room, warmed fluids
Escharotomy
Technique
o Minimal analgesia or anxiolytic usually required
o Electrocautery preferred
o Longitudinal incisions traversing depth of eschar until subcutaneous tissue spouts
o Extend to non-burned tissue proximally and distally
o Consider fasciotomy if improved perfusion and return of soft compartment is not confirmed
▪ Especially electrical burns
Electrical burns
• Normal overlying skin can coexist with deep muscle necrosis
• Types of injury
o Local thrombosis
o Nerve injury
o Muscle injury requiring fasciotomy
o Cardiac arrhythmia
o Rhabdomyolysis
• Management:
o Supportive
o IVF resuscitation
Criteria for burns transfer
• BSA >10%
• Burns to face, eyes, ears, hands, feet, genitalia, over joints
• Full thickness any age, any size
• Electrical or chemical burns
• Inhalational injury
• Burn in patient with comorbidities
• Concomitant trauma
• Children
• Suspected maltreatment or neglect
Cold injuries
• Types:
o Frost nip
▪ Pain, pallor, numbness
▪ Reversible with warming
o Frostbite
▪ Freezing of tissue with intracellular ice crystals
• Microvascular occlusion, anoxia
• Some damage on reperfusion also
▪ Severity:
• 1st degree – hyperaemia, oedema, no necrosis
• 2nd degree – large vesicles with hyperaemia, oedema, partial thickness necrosis
• 3rd degree – full thickness and subcutaneous necrosis, haemorrhagic vesicle
• 4th degree – full thickness skin necrosis with muscle and bone gangrene
o Non-freezing
▪ Microvascular endothelial damage, stasis, vascular occlusion
• Trench foot
o Arterial vasospasm/ vasodilation
o → oedema, blistering, redness, ulceration → infection, cellulitis, gangrene
Management of frost bite
o Rewarm
▪ Warm blankets
▪ Warm fluids orally
▪ 40 degree circulating water to reheat
o Supportive
▪ Analgesia
▪ Cardiac monitoring
o Limb preservation
▪ Thrombolysis can be considered if:
• <24h of injury
• Multiple digits/ proximal amputation
• No contraindication
▪ Preferably intraarterial TPA then intraarterial heparin
• Can use IV TPA + IV heparin
▪ Prostacyclin (iloprost) IV infusion
• Useful if <48h from injury
o Wound care
▪ Non-adherent gauze, sterile padding
▪ Pledges between toes
▪ Cradle/tent
▪ Prevent infection
o Tetanus Rx
o Definitive:
▪ Autoamputation or therapeutic amputation
Pathophysiology/classification of blast injury
Detonation results in a positive impulse.
Classification of injury
o Primary
▪ Direct effects of blast wave within body
▪ Affects parts of body with air-fluid interfaces
• Alveoli
• Tympanic membrane
• GI tract
o Secondary
▪ Penetrating injury from bomb-casing fragments, anti-personnel fragments (nails, nuts, bolts), environmental debris
▪ Manage as for penetrating trauma
o Tertiary
▪ Blast propels people onto a hard surface or causes objects to fall on victims
o Quaternary
▪ All other explosion related injuries
▪ Burns
▪ Asphyxia
▪ Radiation
▪ Toxins
▪ Psychological
Specific blast injuries
1) Tympanic membrane
▪ Commonest blast injury (lowest pressure threshold for injury)
▪ Symptoms
• Hearing loss, tinnitus, pain, dizziness
▪ Diagnosis confirmed on otoscopy
▪ Management
• Spontaneous healing in 75%
o 30% have permanent high frequency hearing loss
• Supportive treatment
o Keep ears dry
o Avoid loud noises
o No ear drops or antibiotics required
2) Pulmonary
▪ Injury occurs due to spalling and implosion at level of alveoli
- Symptoms
• Dyspnea, cough, haemoptysis, chest pain
▪ Management
• CXR – bat-wing bilateral fluffy infiltrates
• Chest drain not routinely required unless pneumothorax present
• Limited fluids – risk of APO
• Lung protective ventilation minimizing peak airway pressures
o GI
• Due to efficient propagation of blast through water
▪ Symptoms
• Can be subtle
• May have no external signs of injury
▪ Assessment
• XR / US / CT as appropriate
• Serial examination → peritonitis → surgery
• Delayed perforations can occur up to 14 days after injury
o Neuro
▪ Symptoms
• Headache, tinnitus, hypersensitivity to noise, amnesia, PTSD
▪ Mechanism
• Acceleration and deceleration of head as wave passes through
▪ Diagnosis
• Imaging with CT or MRI
▪ Management
• Supportive
o Cardiovascular
▪ Blast wave induces cardiogenic shock with myocardial compression without compensatory peripheral vasoconstriction
• Related to vagal overstimulation
▪ Management
• Guide fluid status using TOE or systemic pressure variation measurement
o Skeletal
▪ Management
• XRs
o Foreign bodies
o Articular involvement
• Tetanus
• IV ABX if open fracture
• Consider compartment syndrome/rhabdomyolysis (late presentation)
Monroe Kellie Doctrine
o Cranial cavity is a fixed volume containing parenchyma, CSF and blood
o An increase in 1 component implies an opposite and equal decrease in another
▪ If this does not occur, ICP rises
ICP
ICP
o CPP = MAP – ICP
o Aim to keep CPP >60, and ICP <20
• Cushing’s reflex
o Physiological response to raised ICP
o Hypertension (with widening pulse pressure), bradycardia, irregular respirations
o Mechanism
▪ Raised ICP → increased MAP to increase CPP
▪ Baroreceptors in aortic arch detect raised blood pressure and stimulate parasympathetic response via vagus nerve causing bradycardia
▪ Pressure rises to the point that there is compression of brainstem and respiratory centre → irregular respirations
Classification of head injuries
• By severity
o GCS 8 or less – severe
o GCS 9-12 – moderate
o GCS 13-15 – mild
• Skull fractures
o Cranial vault or skull base
▪ racoon eyes, battle’s sign, CSF rhinorrhoea, otorrhoea, 7-8 nerve dysfunction
o Linear or stellate
o Open or closed
• Intracranial lesions
o Diffuse
▪ Mild concussion
▪ Severe hypoxic ischaemic injury
▪ Diffuse axonal injury
o Focal
▪ Epidural haematoma
• Biconvex, lenticular
• Temporal/temporoparietal
• Lucid interval
• Middle meningeal artery
▪ Subdural haematoma
• Shearing of bridging veins
• Follow brain contours
• Cross suture lines
▪ Intracerebral haematomas/ contusions
• Frontal/temporal
• Evolve over a few days
• Need serial CT scanning
Management of head injuries
• Assessment:
o GCS
o Pupillary light reflex
o Focal neurological deficit
• CT scan:
o Indications for CT scan
▪ GCS <15 at 2 hours post injury
▪ Suspected open or depressed skull fracture
▪ Signs of basilar fracture
▪ Vomiting
▪ Older patients
o Relative indications
▪ LOC >5 minutes
▪ Amnesia >30 minutes
▪ Dangerous mechanism
• Mild injury
o Usually observation, discharge if patient will be appropriately supervised
• Moderate injury
o ICU admission for neurological observation
o Repeat CT in 24h or if deterioration
• Severe injury
o Neuroprotection
▪ Reduce ICP (ICP <20, CPP >70):
• Mannitol/hypertonic saline
• Hyperventilation
• Barbiturates
- nurse 30 degrees head up with head in neutral position
- sedation and paralysis
- EVD (CSF drainage)
- decompressive craniectomy
▪ Normoglycaemia
▪ Normothermia
▪ Normotension
▪ Normoxia
▪ Anticonvulsants
• Surgical management:
o Scalp wounds
▪ Clean and inspect wound thoroughly before suturing
▪ Haemostasis
▪ Clips/staples
▪ Inspect for CSF, foreign body
o Depressed skull fractures
▪ If degree of depression is greater than thickening of adjacent skull, open or grossly contaminated, needs operative intervention
o intracranial haemorrhage
- acute subdural haematoma -> indication for early evacuation -> 1cm subdural blood with midline shift
- epidural haematoma -> indications -> alteration of consciousness or change in neurologic function
▪ Craniotomy/burr holes by neurosurgeon
o Penetrating brain injuries
▪ Appropriate imaging
▪ Antibiotics
▪ ICP monitoring
Organs involved in zonal neck injuries.
Penetrating neck injury = breach in platysma
Vascular injury 25%
Aero-digestive injury 30%
Neural injuries
o CN 7-12
o Sympathetic chain
o Cervical/brachial plexus
o Spinal cord
Zone I: sternal notch to cricoid
o Structures at risk: trachea, oesophagus, major vessels (aortic arch, brachiocephalic, subclavian, common carotid, IJV), thoracic duct (on left), lung apices, c-spine, cord, nerve roots
o Mx: imaging/endovascular approach where possible. Surgical approach – median sternotomy, extend along anterior SCM
Zone II: cricoid to angle of mandible
o Structures at risk: trachea, pharynx, larynx, oesophagus, thyroid, major vessels (carotid sheath, vertebral), c spine, cord
o Mx: surgical exploration – ant SCM approach. No obvious injury on exam/imaging – consider observation, panendoscopy/laryngoscopy/contrast swallow
Zone III: angle of mandible to base of skull
o Structures at risk: trachea, oesophagus, parotid/submandibular gland, major vessels (internal/external carotid, IJV, vertebral), spine, cord
o Mx: imaging/endovasc approach where possible. Surgical approach – extend ant SCM incision, divide omohyoid (avoid injury glossopharyngeal n).
Hard signs of penetrating neck injury
Definition
Injuries extends deep to platysma
o Shock
o Pulsatile bleeding or expanding haematoma
o Audible bruit or palpable thrill
o Airway compromise
o Wound bubbling
o Subcutaneous emphysema
o Stidor
o Neurological signs of evolving stroke
Specific neck injuries Mx
Venous
o Small vessels – ligate
o IJV injury <50% lumen - repair 6/0 prolene
o IJV >50% unilateral - ligate
Arterial
o Proximal & distal control
o Injury without contusion/vessel loss – primary repair
o Injury with contusion/vessel loss – resection + anastomosis or graft
o External carotid – can ligate
o Internal carotid – shunt if not repairable
o Vertebral – endovasc control or ligation
Tracheal
o Repair single layer absorbable suture
o Tracheostomy 2nd cartilaginous ring if significant injury
Oesophageal
o Debride, repair in 2 layers. Contrast swallow 1/52.
o Large volume tissue loss – distal ligation, proximal oesophagostomy, jejunostomy feeding tube.
Thoracic duct
o Rare, zone 1 or 2 injury on left. Ligation to prevent chylothorax.
o Delayed diagnosis with chylothorax – chest tube, low fat diet.
Le Forte fractures
o midface fracture patterns with separation of tooth bearing bone and cranium. Involves bilateral pterygoid plate fractures plus:
o Type 1: horizontal fracture through the maxilla superior to the maxillary dentition.
o Type 2: pyramidal fracture through the maxilla and orbit, outlining the nose.
o Type 3: fracture of the facial bones from the skull, a complete craniofacial separation
Goals: restoration of the continuity of the facial bones with the cranium and reduction of fractures with the goal of returning the patient to the preinjury occlusion.
Mx: ORIF/ MMF
Mandibular fracture
o 2nd commonets facial fracture
o Classified by location
▪ Angle and body > symphysis/parasymphysis
o Assessment
▪ Symptoms –trismus, malocclusion, numbness, loose or missing teeth
▪ Palpate mandible, inspect dental wear, test mental nerve
▪ CT facial bones
o Management
▪ CR if greenstick
▪ Maxillomandibular fixation
▪ ORIF depend on type and extent of fracture
Nasal fractures
o Commonest fractured facial bone
o Unilateral, bilateral, non-displaced, displaced
o Assessment
▪ Epistaxis, nasal airway obstruction, cosmetic deformity, change in smell
▪ Palpate bones, dorsum
▪ Intranasal examination for septal haematoma
▪ Look for halo sign with suspected CSF leak / can test beta 2 transferrin
o Management
▪ CR -> Within 10 days of injury
▪ OR with osteotomy -> Can revise poorly healed CR (3 months) or in some complex acute fractures
▪ External fixation with nasal splint
▪ Drain any septal haematoma to prevent cartilage necrosis, septal perforation
Nasoethmoidal fractures
o High impact blunt trauma to mid face
o Assessment
▪ Telecanthus, enopthalmos, epiphora, nasal airway obstruction, epistaxis
▪ Visual acuity check, evaluate eye lids and globe position, palpate nasal bones, intranasal examination
▪ CT usually required
o Treatment
▪ ORIF
Frontal fractures
o Strongest facial bone but prone to traumatic injury due to location
o Assessment
▪ Forehead laceration with numbness, epistaxis, rhinorrhoea
▪ Palpation of frontal bar, assess frontal sensation, visual acuity, intranasal examination
▪ CT bones and sinuses
o Treatment
▪ Non-displaced anterior table fracture → no treatment
▪ Displaced anterior table fracture → surgery if cosmesis poor or involving nasofrontal duct
▪ Undisplaced posterior table fractures → observation, evaluate sinus with serial CT
▪ Displaced posterior table fractures / pneumocephalus → exploration frontal sinus cranialisation
Zygomaticomaxillary fractures
o 4 suture lines involved
▪ Lateral orbital wall, orbital floor, anterior maxillary sinus, lateral maxillary sinus, zygomatic arch
o Assessment
▪ Epistaxis, vision changes, numbness in mid face, malar depression, enophthalmos, trismus, malocclusion
▪ Palpate zygoma, intraoral, intranasal, mouth opening, visual acuity, extraocular muscle function, midface sensation
▪ CT facial bones
o Treatment
▪ ORIF
Orbital fractures
o Inferior, lateral, medial orbital rim
▪ Isolated orbital floor fracture = blowout fracture
• Extraocular muscle entrapment
o Assessment
▪ Vision changes, forehead, midface numbness, enophthalmos, dystopia, chemosis, hyphema subconjunctival haemorrhage
▪ Palpate orbital rims, assess globe position, visual acuity, facial muscles
▪ CT
o Treatment
▪ Reconstruction of orbital floor
NEXUS criteria
▪ If none of the following are present, C-spine can be cleared clinically (NSAID)
• Focal neurological deficit
• Midline spinal tenderness
• Altered level of consciousness
• Intoxication
• Distracting injury
Stable vs unstable fractures
o Denis classification
▪ Anterior column – anterior ½ vertebral body
• Stable fracture
▪ Middle column – posterior ½ vertebral body
• Unstable
▪ Posterior column – pedicles and lamina of vertebrae
• Unstable
Neurogenic and spinal shock
• Neurogenic
o Impaired descending sympathetic pathways in cervical/upper thoracic cord
▪ Loss of vasomotor tone, sympathetic innervation to heart
▪ Rare if below T6
o Results in vasodlation, pooling of blood and hypotension
▪ Bradycardic or no tachycardic response to hypovolaemia
o Usually partially unresponsive to fluid resuscitation
▪ Vasopressors should be used if suspected/identified
• Spinal shock
o Flaccidity and loss of reflexes after spinal cord injury
o Duration variable
Classification of spinal injuries
• Level
o Sensory and motor
• Severity
o Incomplete
o Complete
o Paraplegia
o Quadriplegia
Central cord syndrome [ MUD – motor upper distal ]
▪ Loss of motor upper > lower
• Motor > sensory loss
• Distal > proximal
▪ Usually hyperextension injury in patient with canal stenosis in C-spine
▪ Anterior spinal artery compromise
▪ Characteristic pattern of recovery
• Lower extremity first
• Bladder next
• Proximal upper extremity and hands last
Anterior cord syndrome
▪ Paraplegia
▪ Dissociated sensory loss with pain/temperature loss
• Dorsal column spared
▪ Due to infarction in anterior spinal artery territory
Brown sequard
▪ Hemisection of cord due to penetrating trauma
▪ Ipsilateral motor loss (corticospinal)
▪ Ipsilateral joint position (dorsal column)
▪ Contralateral pain and temperature (spinothalamic)
Conus medullaris
▪ Injury to sacral cord, lumbar nerve roots
▪ Areflexic bladder, incontinence bowels, knee jerk preserved, ankle jerk lost
▪ Similar to cauda equina but often bilateral
Cauda equina syndrome
▪ Injury to nerve roots not spinal cord
▪ Muscle weakness and decreased sensation
▪ Decreased bowel and bladder control
C-spine cord injury
▪ Areflexia
▪ Diaphragmatic breathing
▪ Forearm flexion
▪ Response to pain above clavicle only
▪ Hypotension and bradycardia – sympathetic loss
▪ Priapism – parasympathetic loss
Type of C-spine injuries
o Atlanto-occipital dislocation
▪ Traumatic flexion and distraction
▪ Most die from brainstem destruction, apnoea, profound impairment
o Atlas fracture
▪ Jefferson fracture (C1 burst fracture)
• Due to axial loading (heavy object lands on head or patient lands on top of head)
• Anterior and posterior disruption with lateral displacement of lateral masses
• Unstable spinal injury
▪ Unilateral or lateral mass usually stable
o C1 rotatory subluxation
▪ Usually children
▪ Persistent rotation of head
o Axis fractures
▪ Odontoid – hyperflexion injury
• Type 1 – tip of odontoid
• Type 2 – base of dens
• Type 3 – base of dens and obliquely into body
▪ Posterior element
• Hangman’s fracture – pars interarticularis of C2
o Extension type injury
Thoracic spinal injuries
▪ Anterior wedge compression
• Axial loading with flexion
• Usually stable
▪ Burst
• Vertical axial compression
• Usually unstable – fracture of anterior and middle column
▪ Chance [ 3 column injury ]
• Transverse fracture through vertical body
• Flexion about an axis anterior to vertebral column
o MVA, lap belt restraint
▪ Fracture dislocation
• Extreme flexion or severe blunt trauma causing disruption to all posterior elements
• Usually result in complete neurological deficits
o Thoracolumbar fractures (T11-L1)
▪ Acute hyperflexion and rotation
• Fall from height, restrained drivers
▪ Usually unstable
▪ Injury to cord at this level commonly causes bladder/bowel dysfunction, lower extremity neurology
Imaging for C-spine/spinal injuries
• CT C spine
• XRs:
o Need to see base of skull and all 7 vertebra
▪ Pull down shoulders or do Swimmer’s view
o Odontoid view, AP, lateral
• Ligamentous injury – needs MRI or treatment with collar and reevaluation
• Neurological deficitis – MRI if possible
• Assessing sagittal c-spine xray
o Ensure adequacy
o Identify 4 lines
▪ Anterior vertebral line
▪ Posterior vertebral line
▪ Spinolaminar line
▪ Posterior spinal line (Spinous processes)
o Assess all bones
o Assess cartilage spaces
o Assess dens
o Assess extraaxial soft tissue
▪ 7mm at C3, 3cm at C7
Defintion of barogenic oesophageal trauma.
oesophageal trauma which commonly locates in the distal oesophagus with an increased intra-oesophageal pressure couple with closure of upper oesophageal sphincter
Diagnosis and investigations for oesophageal trauma.
Diagnosis
Clinical suspicion is the key
Mackler’s Triad: pain, emphysema & vomiting (rarely seen)
o Submucosal emphysema in 2/3 cervical, <1/3 thoracic perforations
Fever late sign
Presentation may reflect anatomical location
o Abdomen: acute abdomen
o Thorax: pain, SOB, crepitus
o Cervical: pain, dysphagia, subcutaneous emphysema
Investigations
Leucocytosis, lactic acidosis, raised inflammatory markers
Plain films
CT – extraluminal air >92%
Contrast swallow o Choice of contrast:
Gastrograffin: less mediastinitis, worse aspiration, less sensitive than barium
Barium: more sensitive (1/4 missed injuries with gastrograffin seen with barium)
Oesophagoscopy
o May alter management in up to 60% of patients
o Direct visualisation of perforation compared with risk of increased contamination
Management of oesophageal trauma.
Key Principals
Question: Can mediastinal contamination +/- pleural free be contained by drainage alone?
Contamination
o Determines systemic response
o Determines treatment options
Potential interventions
o Drain
o Primary closure
o Decompression
o Oesophageal exclusion
Management Approach
EMST/CRISP
Non-operative
o Percutaneous drain
o ICC
o Thorascopic drainage
o GIT decompression
Endoscopic
o Clips – clean cases, small perforations
o Stents
Will still need appropriate drainage
Contraindicated in long perforation
No trial data stent vs open
Complication: stent migration & fistularisation
Operative
o When to operate
- walled off perforation/minimal symptoms/no sepsis -> conservative Mx -> failure -> reinforced primary repair with gastric fundus/pleural flap/muscle flap -> failure -> resection or exclusion and diversion with cervical oesophagostomy, gastrostomy, jejunostomy and delayed reconstruction.
- free perforation + less than 72 hours -> reinforced primary repair with gastric fundus/pleural flap/muscle flap -> failure -> resection or exclusion and diversion with cervical oesophagostomy, gastrostomy, jejunostomy and delayed reconstruction.
- free perforation + longer than 72 hours -> resection or exclusion and diversion with cervical oesophagostomy, gastrostomy, jejunostomy and delayed reconstruction.
- free perforation + resectable Ca/megaoesophagus/severe stricture/caustic ingestion -> resection with immediate or secondary reconstruction.
o Cervical
Many managed non-operatively
Buttress repair with muscle
Role oesophagostomy where damage extensive
o Thoracic
Key is removal/debridement of necrotic material/tissue
Drain
Primary repair feasible even in delayed cases (role of bougie)
Consider buttress
Role of resection of controlled fistula
Decortication
o Abdominal
Remove contaminated materal
Primary repair (bougie)
Gastroplasty using fundus
Washout
o Generalisations
Leak test repair
Drains
Nutrition -> feeding jejunostomy
Delayed imaging prior to theatre
DPL
now redundant
o Indication: multiple blunt trauma. No indication emergent laparotomy, exam equivocal, CT/US not available, suspected bowel injury.
o Procedure: infraumbi open or closed technique, aspirate. If blood/enteric fluid -> laparotomy.
If not -> 100ml saline, then aspirate for cell count/gram stain (positive = >100,000 RBC or >500 WBC per cubic millimetre or bacteria present.
Four views of FAST
Focussed assessement with sonography for trauma.
hepatorenal space, splenorenal fossa, pelvis/pouch of douglas, pericardium
Grading of splenic injury
Grade 1 - subcapsular haematoma <10%, laceration <1cm
Grade 2 - subcapsular haematoma 10-50%, laceration 1-3cm, intraparenchymal haematoma <5cm
Grade 3 - subcapsular haematoma >50%, laceration >3cm, intraparenchymal haematoma >5cm
Grade 4 - laceration involving segmental or hilar vessels producing >25% devascularisation, active bleeding confined within splenic capsule
Grade 5 - active bleeding into the peritoneum, shattered spleen
Management of splenic injury
Patient unstable/positive FAST/non responder to resuscitation -> laparotomy
Patient stable -> CT scan
CT scan -> class 1 to 3 -> conservative Mx, vaccination, serial monitoring (vitals, Hb, abdo exam)
-> active bleeding -> embolisation, surgery if not available or grade 5
-> associated with other injuries -> laparotomy
Grading of liver trauma
Grade 1 - subcapsular haematoma <10%, laceartion <1cm
Grade 2 - subcapsular haematoma 10 - 50%, laceration 1-3cm, intraparenchymal haematoma <10cm
Grade 3 - subcapsular haematoma >50%, laceartion >3cm, intraparenchymal haematoma >10cm
Grade 4 - parenchymal disruption 25-75% of lobe
Grade 5 - parenchymal disruption >75% of lobe/major hepatic vein injury
Grade 6 - hepatic avulsion
Grading of renal trauma
Grade 1 - contusion, subcapsular haematoma without laceration
Grade 2 - retroperitoneal haematoma, laceration <1cm
Grade 3 - laceration >1cm but no urine leak
Grade 4 - laceration renal cortex, medulla and collecting system or vascular injury
Grade 5 - avulsion of hilum, devascularised kidney
Grading of pancreatic trauma
Grade 1 - minor contusion/laceration without duct injury
Grade 2 - major contusion/laceration without duct injury
Grade 3 - distal parenchymal injury with duct disruption
Grade 4 - proximal (to right of SMA) parenchymal injury with duct disruption
Grade 5 - massive pancreatic head disruption
Management of liver trauma
Stable patients with grade 1 -3 injuries -> managed conservatively.
Unstable patients, grade 4/5 injuries -> laparotomy.
Key principles of surgery
- incision
- exposure (retractor)
- push, pack, pringle
o Packing – above and below – fold packs in halfs or quarters – aim to put liver back into normal anatomical position
Considering suturing omentum into laceration
o Manoeuvres
Pringle – if packed and ongoing bleeding. Punch hole in avascular part of hepatogastric ligament and occlude with vascular sling. Can Pringle 30-40 minutes
Finger fracture – open capsule with diathermy and then explore injury with fingers and then compress bleeding vessels with finger (behind clamp and tying)
Balloon tamponade with catheter
Mobilisation – consider in experienced hands when caval injury
Consider post theatre embolization for ongoing bleeding despite packing (packing will not control arterial bleeding)
- argon
- diathermy
- tachosil, floseal, surgiflow
- suture
Key principles of abdominal trauma
Vascular – exposure, proximal/distal control, primary repair/patch repair/graft/bypass/ligate depending on vessel
Small bowel - <50% transverse primary repair 3/0 PDS. >50% resection + anastomosis (handsewn preferable, but stapled quicker.
Colon – primary repair, resection and primary anastomosis or diversion for high risk patients (Hartmann’s, colostomy + mucous fistula, repair/anastomosis + LI)
Kidney – CT with 10min delayed phase for urine leak. Gr 1&2: non op. > Gr 3: consider embolization or surgery (repair, partial or total nephrectomy
Duodenum – expose D1,2,3 & Kockerise for posterior aspect. Palpate D4. Primary repair, intraluminal drain (consider retrograde for decompression, antegrade for feeding. Diversion (Bilroth II) for severe trauma or compromised anastomosis.
Pancreas – expose body via lesser sac, mobilise TC. Head/neck with Kocherisation. Gr 1/2: non operative +/- drain. Gr 3: distal pancreatectomy. Gr 4 subtotal pancreatectomy or distal roux-en-y pancreaticojejunostomy. Gr 5: distal roux en y pancreaticojejunostomy or Whipples.
Mx of urological trauma injuries
Bladder
DC -> foley IDC
R -> suture repair, double layer, absorbable suture
Ureter
DC -> stent + exteriorise or ligate + percutaneous nephrectomy
R -> urologist
Renal artery -> repair end to end or interposition 6mm PTFE graft
Renal vein -> ligate proximal to gonadal or adrenal veins
Managementt of surgical soul
IVC/right renal pedicle -> Cattel-Braasch + pack
SMA/SMV -> kocherise and direct pressure
Head of pancreas -> kocherise and direct pressure
All fail -> supracoeliac clamp + infrarenal aortic clamp
Management of retroperitoneal haematoma
Supramesocolic (midline, zone 1)
Blunt - explore
Penetrating - explore
Exposure - Mattox
Clamp - supracoeliac
Inframesocolic (zone 1)
Blunt - explore
Penetrating - explore
Exposure - Cattell Braasch/infrarenal aorta
Clamp - Infrarenal aorta/IVC
Lateral (zone 2)
Blunt - no explore
Penetrating - selective
Exposure - kidney mobilisation
Clamp - hilar
Pelvic (zone 3)
Blunt - no explore
Penetrating - explore
Exposure - walking the clamps
Clamp - distal aorta/IVC
Management of chest trauma
Left anterolateral thoracotomy
- 4th ICS, rapid entry sternum to mid axillaray line, rib spreader (Finochietto) +/- extend to other side/divide sternum 3rd ICS on right.
- cut inferior pulmonary ligament
- evacuate blood
- control bleeding
- pack chest wall
- compress pulmonary hilum (twisting)
- release cardiac tamponade
- aortic clamping
Chest wall bleed -> suture ligate
Pulmonary injury
- stapled non anatomic resection
- pulmonary tractotomy
- central lung -> control with hilar punch then repair artery, vein or staple lobe/pneumonectomy
Heart
- control bleeding -> finger, foley, satinsky, compress RA
- repair -> non absorbable 4-0 suture with pledges
Subclavian artery
-proximal control -> left anterolateral or median thoracotomy
- distal control -> supraclavicular/infraclavicular incision
- DC -> ligate and fasciotomy
- R -> direct or 8mm dacron interposition graft
Major neck vessels management
Carotid
- proximal -> extend incision to sternal notch or median sternotomy
- distal -> intraluminal fogarty
- protect vagus nerve
- DC -> shunt or ligate
- R -> lateral suture, patch, end to end, graft
Vertebral
- bone wax
- angioembolisation
Pelvic fracture classification
o Young & Burgess (mechanism)
Lateral compression
AP compression
Vertical shear
Management of plevic fracture
o Stabilisation is critical– pelvic binder (or in past C-clamp) if SBP <70
o Resuscitation/ Initial management
Stabilised -> CTA -> embolization if arterial blush, OT for packing if no blush (venous bleeding)
Unstable -> OT for external fixation + pelvic packing (always pack pre-peritoneal) +/- laparotomy -> then embolisation
o Post op:
Restoration of normal physiology
Consider angiography
Completion imaging as required
o RTT 24-48 hr for R/O packs, definitive Rx.
Unstable pelvic fracture
o Vertical shear
o Lateral compression opens >= posteriorly
o Open book: anterior + SIJ open >= anterior part
Massive haemothorax
o 1500ml or 1/3 blood volume. Impaired ventilation & shock. Absent breath sounds, dull percussion, “white out” on CXR
o Mx: Large calibre 36F ICC 5th ICS. Consider autotransfusion. Consider thoracotomy if >1500ml initially or 200ml/hr for 2-4hr with compromised physiology or ongoing transfusion requirement.
Tension pneumothorax
o One way valve air leak from lung or chest wall, air enters pleural space, collapsing affected lung. Reduced AE, hyperresonant, distended neck veins, cyanosis.
o Mx: needle thoracostomy, ICC 5th ICS.
Open pneumothorax
o Wound 2/3 diameter trachea – preferential air entry via wound into pleural space. Can cause tension pneumo.
o Mx: one way valve dressing. ICC. Definitive closure.
Flail segment/pulmonary contusions
o Chest wall segment out of continuity (3 or more ribs, 2 or more places). Ventilatory dysfunction from pulmonary contusion, paradoxical chest wall movement, reduced respiration due to pain.
o Mx: oxygen, analgesia (opiates, LA block – paravertebral, intercostal, epidural), intubation/ventilation.
Cardiac tamponade
o Injury to heart, great vessel, pericardial veins causing bleeding into pericardial space and impaired cardiac function. Shock, elevated CVP/distended neck veins, muffled heat sounds.
o TTE/FAST 90% accurate.
o Mx: Pericardiocentesis. Needle via sub xiphoid approach, needle aspiration +/- catheter insertion with seldinger technique.
Indication for resuscitative/ED thoractomy
- loss of vital signs in ED with highly suspicious intrathoracic trauma
- < 10mins pre hospital CPR
- cardiac tamponade
- profound refractory shock with SBP <70mm Hg despite bil chest decompression and haemostatic resuscitation
Emergency thoracotomy
Access
▪ Position supine, abduct left arm
▪ Splash prep
▪ Sternum to mid axillary line inferior to nipple – 4-5th intercostal space
▪ Divide soft tissue and muscles with scissors or scalpel
▪ Incise pleura and enter chest
▪ Finochietto retractor with handle laterally
▪ Can convert to clam shell by dividing sternum using Lebsche knife or heavy shears
1) Pericardotomy and control of cardiac injuries
▪ Incise pericardium longitudinally from aortic root to apex, anterior to phrenic nerve
• Ideally grasp and pull pericardium away from heart
▪ Evacuate pericardial blood and fluid
▪ Digital pressure or sutures to control injuries
2) Control of intrathoracic haemorrhage
▪ Digital pressure initially to bleeding from great vessels then straight or side biting vascular clamps
▪ Aim for temporary control then formal repair in operating theatre
• Can clamp pulmonary hilum if required
• If clamp not available, twist hilum 180 degrees after releasing inferior pulmonary ligament
3) Occlusion of descending aorta
▪ Usually done by feel
▪ Retract lung medially and slide hand back along left lateral thoracic wall onto aorta anterolateral to vertebral body
▪ Digital compression then vascular clamp after dissection of overlying pleura off aorta
• Avoid cross clamping > 30 minutes
4) Open cardiac massage
▪ Better output than closd CPR
▪ 1 or 2 handed technique – hold heart in 2 hands and gently ‘clap’ to compress heart from apex to aortic root
▪ Internal cardiac defibrillation with 15-30J can be performed
5) Bronchovenous air embolism
▪ Due to traumatic alveolovenous communications allowing air into coronary artery or ventricular outflow
• Usually presents with profound hypotension or cardiac arrest after ETT and positive pressure ventilation (increases gradient for air emboli formation)
▪ Take down inferior pulmonary ligament
▪ Isolate injured lung and clamp pulmonary hilum
▪ Disperse air embolism
- Cardiac massage can disperse air within coronary arteries
- Place patient in Trendelenberg to trap air in apex of ventricle then needle aspirate apex/ atrium/ aortic root
