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Trauma Flashcards

1
Q

What are the aims and objectives of the TBI SOP? (8)

A
  1. To ensure all TBI patients receive optimal pre-hospital care

To describe:
2. Rationale of clinical care for TBI
3. Triage for TBI
4. Appropriate analgesia/sedation in TBI
5. Indications/precautions for PHEA in TBI
6. Principles for prevention of secondary TBI
7. Indications + administration of hypertonic and TXA
8. Process for activation of RLH code black

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2
Q

What are the management principles for TBI patients (3)

A
  1. Prevent secondary TBI
  2. Treat other significant injuries
  3. Rapid transfer
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3
Q

What are the triage considerations for TBI?

A

Better outcomes shown at neurosurgical centre even if no surgical intervention - if in doubt call on call consultant

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4
Q

What should be used to sedate patients with TBI and a high GCS + low suspicion of raised ICP?

A

Midazolam

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5
Q

What should be used to sedate severely agitated patients needing a PHEA with TBI?
Why? (2)

A

Ketamine

  1. Some evidence it reduces ICP in patients whose ventilation is being controlled
  2. Causes less respiratory depression
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6
Q

What 3 things should we ensure when performing PHEA in TBI?

A
  1. Adequate induction agent and paralysis
  2. Gentle laryngoscopy
  3. Minimal tube movement
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7
Q

What 3 neurological signs must we remember to document in TBI pre-PHEA as a minimum?

A
  1. GCS
  2. Pupils
  3. Limb movements
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8
Q

With regards to ventilation and TBI what should we aim for to prevent secondary brain injury?(3)

A
  1. Avoid hypoxia + hyperoxia
  2. Avoid PEEP if able
  3. Aim ETC02 of 4.5
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9
Q

Why must we pay particular attention to BP in TBI?

A

Patient can lose their ability to auto-regulate cerebral blood flow. Hypotension can therefore lead to reduced cerebral oxygenation even if normal ICP

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10
Q

What BP should we aim for in isolated TBI?

A

SBP >120 and MAP >90

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11
Q

How should we control BP in polytrauma patient and TBI? (2)

A
  1. Control haemorrhage ‘meticulously’
  2. Aim SBP 100mmHg
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12
Q

If TBI what should be the upper limit SBP before we attend to control it?

A

Aim for SBP <150mmHg

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13
Q

What 4 things does the TBI SOP state we should do differently to package patients?

A
  1. Blocks/tape over collar, if collar then loose
  2. ETT tie loose to taped
  3. Head up 20-30 degrees
  4. Keep temp 35-38 degrees C using pharyngeal temperature monitor
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14
Q

When should we use hyptertonic saline? (2)

A

HI and either:
1. Unilateral/bilateral pupil dilatation / GCS < 8 (normally 3)
2. Progressive HTN (SBP >160mmHg) and HR <60bpm / GCS < 8 (usually 3)

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15
Q

What dose of hypertonic should we give?

A

6mk/kg 5% hypertonic (max 350ml)

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16
Q

How should hypertonic be given?

A

Via minimum 18G cannula over 10 mins

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17
Q

What additional advantage might hypertonic give to the polytrauma patient aside from reducing ICP? (2)

A
  1. Increase circulating volume
  2. Decreased inflammation
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18
Q

What 3 criteria should be met to give TXA in TBI according to the SOP?

A
  1. TBI
  2. < 2 hours from injury
  3. GCS 12 or less
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19
Q

What 3 criteria need to be met to activate a ‘Code Black’?

A
  1. Suspicion of significant TBI
  2. Pupillary signs suggestive of impending herniation OR Cushings response (SBP >160 and HR < 60)
  3. GCS 8 or less pre-PHEA
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20
Q

What percentage of 1) TBI and 2) severe TBIs lead to seizure?

A
  1. 2%
  2. 12-50%
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21
Q

What dose of keppra should be given to our 1) adults and 2) children in seizures post TBI?

A

40ml/kg for both

Max 4.5g in adults
Max 3.0g in children < 18

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22
Q

What are the aims and objective of the spinal injury SOP? (4)

A
  1. Outline the assessment, treatment and triage of patients with suspected/confirmed spinal injuries
  2. Describe dynamic risk assessment for immediate extrication
  3. Describe types of immobilistion
  4. Describe treatment and triage of spinal cord injury
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23
Q

What does the background of the SCI SOP say?

A

Have a low threshold for spinal precautions but not at the expense of addressing a A, B or C problem

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24
Q

How are ‘spinal precautions’ defined?

A

A group of devices and a system for patient handling that aims to decreased spinal cord damage

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25
Q

What are the mentioned indications for spinal precautions in the SOP? (6)

A
  1. Mechanism consistent with SCI
  2. Signs/symptoms of SCI
  3. Neck/back pain
  4. Reduced GCS
  5. Intoxicated
  6. Distracting injury
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26
Q

Under what circumstances does the SCI SOP say we can ‘clear’ a c-spine pre-hospital? (4)

A

Non-severely injury + :
- no neck pain
- full ROM
- no neurology

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27
Q

Under what circumstance does the SCI SOP state we can elect not to immobilise the c-spine that has not been ‘cleared’?

A

Neck pain only but full ROM and no neurology

Must handed over that not ‘cleared’

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28
Q

In terms of SCI what should prompt a lower threshold for RSI?

A

High spinal injury

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29
Q

What does the SCI SOP say about hypotension? (2)

A
  1. Exclude other causes of hypotension
  2. 25-50mg aliquots adrenaline
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30
Q

What does the SCI SOP state about spinal boards?

A

Only to be used for extrication not transfer

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31
Q

What 3 extrication devices does the SCI SOP mention?

A
  1. SARA
  2. MIBS
  3. Scoop
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32
Q

What does the SCI SOP say about triaging suspected SCI?

A
  1. If positive signs SCI then MTC
  2. If not, use clinical judgement
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33
Q

What is the minimum neurological examination required pre-RSI in SCI?

A
  1. Limb movement
  2. Sensory level
  3. CV findings
  4. Priapism
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34
Q

What spinal cord syndrome is the most common?

A

Central cord syndrome

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35
Q

What tract does central cord syndrome affect?

A

Corticospinal

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36
Q

Which demographic and mechanism usually leads to central cord syndrome?

A

Elderly and hyperflexion

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37
Q

What are the features of central cord syndrome? (2)

A
  1. Motor deficit upper > lower limbs
  2. ‘Burning sensation in upper limb extremities
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38
Q

What is the usual cause of anterior cord syndrome?

A

Direct injury to anterior spinal causing injury to anterior spinal artery

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39
Q

What is the usual mechanism that leads to anterior cord syndrome?

A

Flexion/compression of spine

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40
Q

What are the classic neurological findings of anterior cord syndrome?

A
  1. Motor loss lower>upper
  2. Dissociated sensory loss - loss of pain/temperature below level
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41
Q

Which of the spinal cord syndromes has the best prognosis in terms of function?

A

Brown-Sequard

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42
Q

What is the mechanism leading to Brown-Sequard syndrome?

A

Hemi-transection of the cord (usually penetrating trauma)

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43
Q

What are the neurological findings in Brown-Sequard Syndrome?

A
  1. Ipsilateral paralysis and loss of proprioception/vibration and touch
  2. Contralateral loss of pain/temp
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44
Q

What is the evidence from the Cochrane review re: abx in open fractures?

A

Decrease wound infection but not osteomyelitis/amputation/death

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45
Q

What is the BOAST consensus statement around abx in open fractures?

A

< 1 hour of injury

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46
Q

What should we consider additionally in open fractures to reduce need for removing dressings?

A

Photo

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47
Q

Should we irrigate open fractures?

A

No

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48
Q

What abx should we give in open fractures?

A

Augmentin

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49
Q

What abx should we give in open fractures if penicillin allergic and what important effect might this have?

A
  1. Clindamycin 600mg
  2. Enhances sux and roc effect
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50
Q

What are the aims + objectives of the penetrating trauma SOP? (3)

A
  1. To ensure all patients with penetrating trauma receive timely and effective interventions and transfer
  2. Describe the broad philosophy of clinical care for penetrating disease
  3. Describe the triage policy for penetrating trauma
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51
Q

What are the 2 main points in the Background section of the penetrating trauma SOP?

A
  1. A proportion of these need urgent surgery, therefore minimise scene time
  2. Patients may have relative/true bradycardia therefore any change in physiology is concerning
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52
Q

What, in penetrating trauma, should prompt rapid transfer to MTC and delaying complete examination till then?

A

Wound in the ‘danger zone’

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53
Q

What should we attempt to avoid in penetrating trauma to aid with forensics?

A

Cut through the clothes around the stab/gunshot site

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54
Q

How should bleeding penetrating trauma to the chest be managed?

A

Pack with haemostatic dressing then sleak

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55
Q

How should penetrating trauma to the neck be managed? (3)

A
  1. Consider RSI
  2. Direct pressure and haemostatic gauze
  3. Consider foley/epistats but may lead to vagal response, stop if this happens
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56
Q

What analgesia is recommended for penetrating trauma?

A

Opiates

57
Q

When should we transfuse patients with penetrating trauma? (2)

A
  1. Stop talking
  2. SBP <80mmHg
58
Q

Describe the neck zones in trauma

A

Zone 1 - clavicle/sternum to cricoid
Zone 2 - cricoid to mandible
Zone 3 - angle of mandible

59
Q

If loss of output with zone 1 neck or trunk injury what should be done?

A

Thoracotomy - pull over or consider landing aircraft to do this

60
Q

How should eviscerated bowel by managed?

A

Cover with wet dressing - blast bandage with plastic sheet best of our kit

61
Q

What penetrating trauma should go to MTC? (3)

A
  1. Chest
  2. Neck
  3. Suspected vascular injury
62
Q

What is the only trauma service that Norwich lacks?

A

Neurosurgery

63
Q

What are the 3 principles or haemorrhage?

A

1, Limit blood loss
2. Increase clot formation
3. Decrease clot disruption

64
Q

How should an femoral # and unstable pelvis be managed?

A
  1. Pull femur to length
  2. Apply pelvic binder
  3. KTD
65
Q

How can we manage a midshift humeral #? (2)

A
  1. KTD
  2. Benecase

NB: can be difficult to split, consider risk:benefit of scene time

66
Q

If removing a tourniquet what should we ensure?

A

Monitoring on - complications associated with long term use

67
Q

How should bleeding scalp wounds be managed?

A

Suture

68
Q

What can be used to stop arterial bleeding distally?

A

Proximal indirect pressure

69
Q

What does the haemorrhage SOP say about permissible hypotension? (2)

A
  1. Non-compressible haemorrhage
  2. In first 60mins
70
Q

When should be ensure before we commence resusitation with blood products/adjuncts?

A

Haemmorrhage control has been optimised

71
Q

After 60 mins what does the haemorrhage SOP say about permissive hypotension?

A

After 60 mins weigh up consequence of multi-organ failure/coagulopathy

‘Novel hybrid’ approach maybe more appropriate

72
Q

How should we volume resusitate hypotensive patients with blunt injury and HI? (3)

A
  1. Talking - don’t transfuse
  2. Not talking - transfuse to talking
  3. I+V = SBP 100mmHg
73
Q

How should we volume resusitate hypotensive patients with blunt injury and no HI? (3)

A
  1. Talking - don’t transfuse
  2. Not talking - transfuse to talking
  3. I+V/unconscious - aim for what you think would maintain CPP (around SBP 60-80mmHg)
74
Q

What is needed to trigger a MHP (EoE) or Code Red (London)? (3)

A
  1. SBP <90 at any time
  2. Non-responder to fluid
  3. Suspected/confirmed haemorrhage
75
Q

What is the aim of the TCA SOP?

A

To provide clear guidelines to aid team in management of TCA

76
Q

What are the objectives of the TCA SOP?

A
  1. Define TCA
  2. Provide understanding of background causes of TCA
  3. Provide algorithim to help guide treatment priorities
77
Q

What does the TCA SOP say about ALS? (2)

A
  1. Continue until hx/MOI confirmed
  2. ALS without attention to reversible pathology is unlikely to lead to ROSC
78
Q

In TCA what may PEA suggest?

A

Low flow

79
Q

What does HOT stand for?

A

H - ypovolaemia
O - oxygenation
T - ension PTX

80
Q

If we get ROSC post thoracotomy what should we do? (2)

A
  1. Transfer - ideally MTC if stable enough
  2. Consider bicarbonate and calcium
81
Q

If we do not get ROSC post thoracotomy what should we do in:
1. Children
2. Adults

A
  1. Take to local ED with resus ongoing
  2. Consider PLE
82
Q

What are the aims + objectives of the pelvic splintage SOP? (3)

A
  1. Ensure all patients with unstable pelvic injuries receive timely and effective splintage
  2. Define indications for use of pelvic splint
  3. Describe application of pelvic splint
83
Q

How does the pelvic splintage state we should examine a pelvis?

A

If not obviously deformed lightly grasp ASIS + assess symmetry + attempt small (<1cm) medial/lateral movement of ASIS

Only do this once

84
Q

What are the two suggested ways to apply a pelvic splint?

A
  1. At the same time as the scoop
  2. If very unstable then 2 person small lift+ shuffle binder up and secure before scoop
85
Q

What should we aim for when splinting a pelvis?

A

Anatomical alignment only

86
Q

What must we remember to check when placing on a binder?

A

Perineal region

87
Q

If a patient is very unstable what else can be done to help stabilise the pelvis apart from the splint?

A

Internally rotate the legs and stablise knees/ankles with bandage

88
Q

How do we inflate epistats?

A
  • 4 x 20ml syringe with normal saline
  • posterior (white port) 1st with around 10ml
  • middle balloon (green port) second with 20-30ml
  • inflate alternately little at a time
89
Q

What are the aims and objectives of the burns SOP? (3)

A

Aim: Ensure burns patients receive appropriate and timely treatment/triage and transportation

Objectives
1. Describe the clinical management of burns
2. To understand the appropriate triage of burns

90
Q

When arriving to a fire who should we check re: safety?

A

Fire incident commander

91
Q

What 3 things should be removed in a burn?

A
  1. Loose clothes, leave adherent clothes
  2. Jewelry (can retain heat)
  3. Hydrogel burns dressings (don’t cool enough)
92
Q

How should patients with burns be cooled initially/

A

10 mins with water 12-18 degrees C

93
Q

Why is cling film good for covering burns? (3)

A
  1. Reduce heat loss
  2. Non-adherent
  3. Effectively sterile
94
Q

What should we not cover with cling film in a burn? (2)

A
  1. Circumferentially
  2. Face
95
Q

Which 2 groups are at most risk of hypothermia following a burn?

A

Children and the elderly

96
Q

How should we attempt to get burns patients warm? (5)

A
  1. Oesophageal probe if I+V
  2. Fluid warmer
  3. Remove wet clothes
  4. Temp up if in DSA
  5. Usual EHAAT warming stuff once burns addressed
97
Q

What is the big difference betweem superficial and superficial partial burns?

A

Presence of blistering
slightly paler (pink as opposed to red)

98
Q

How are deep dermal burns described? (4)

A
  • dark pink/red or white
  • mottled/ stained / cherry red
  • delayed or absent CRT
  • Dull/variable sensation
99
Q

How are full thickness burns described? (5)

A
  • white/black/brown/yellow
  • dry and leathery
  • no CRT
  • no sensation

Eschar may be present

100
Q

What TBSA % burns mandate the Parkland formula in:
1. Paeds
2. Adults

A
  1. 10%
  2. 15%
101
Q

What is the Parkland formula?

A

2-4ml/kg/%TBSA over 24 hours

102
Q

Over how long should the fluid in the Parkland formula be given?

A

24 hours

50% in first 8 hours
50% in second 16 hours

103
Q

What should be done with regards to infection control in burns?

A

Get allergy and tetanus status to hand over in hospital

No need to give pre-hospital abx

104
Q

What should we consider in burns in confined spaces? (2)

A
  1. CO
  2. Cyanide
105
Q

What should be done in suspected CO poisoning and why?

A

High flow 02 because this will decrease the half life of CO from 320 mins to 80mins

106
Q

What should we do in suspected cyanide poisoning?

A

Manage physiology
Hand over in hospital (no antidote with EHAAT)

107
Q

How should we position suspected airway burns pre-RSI and why?

A

Sit up if awake to decrease swelling to airway

108
Q

What are the indications for RSI in burns? (8)

A
  1. Enclosed space
  2. Burns to face/torso/necl
  3. Singed nasal hairs
  4. Carbonaceous sputum / soot particles in airway
  5. Change in voice - hoarseness/harsh couhg
  6. Dyspnoea
  7. Stridor
  8. Erythema/swelling in oropharync on direct visualisation
109
Q

What are the indications for prompt/mandated RSI in burns? (4)

A
  1. Change in voice - hoarseness/harsh couhg
  2. Dyspnoea
  3. Stridor
  4. Erythema/swelling in oropharync on direct visualisation
110
Q

What is the recommended lung protective strategy in burns?

A
  1. TV 6-8ml/kg
  2. plateau pressure < 30cmH20
111
Q

In burns what must we be aware of with tube tie?

A

Swelling over time can lead it to cut into skin - keep checking

112
Q

What is the most common reason to need surgical airway in burns

A

Burns to neck limited mouth opening

113
Q

What does the haemorrhage/vascular access SOP ‘policy’ section say? (4)

A
  1. Exclude a ventilator or obstructive cause for shock
  2. Maximise natural tamponade / clot production.
  3. Blood products should be considered for volume replacement where indicated.
  4. Inotropes are rarely indicated (unless neurogenic shock)
114
Q

What is first line for IV access at EHAAT?

A

14G/16G in antecubital fossa (preferably uninjured arm / ipsilateral chest wall injury)

115
Q

What does the haemorrhage/vascular access SOP state about ‘mission critical cannula’ should be secured? (3)

A
  1. Loop the giving set through 1st web space and back along forearm.
  2. Tape x 2.
  3. Cling bandage where possible.
116
Q

What is second line at EHAAT if IV access difficult?

A

Subclavian vein access with Multi-Lumen Access Catheter (MAC kit).

117
Q

What does the pelvic splintage SOP say about placing splints due to MOI?

A

No need if:
- GCS 15
- No CV instability
- No clinical findings to suggest significant pelvic injury

118
Q

What can a badly sited pelvic binder lead to? (2)

A
  1. May open the posterior elements of a disrupted pelvis.
  2. An over tightened splint can cause bony fragments to damage pelvic viscera.
119
Q

What are the aims (1) and objectives (2) of the maxfax SOP

A

To ensure that patients with facial injuries have appropriate assessment and
management on scene, especially where airway compromise or haemorrhage
present a threat to life.

  1. Describe the particular considerations for pre-hospital anaesthesia in maxillofacial
    injury.
  2. Describe the methods used to attempt to control excessive haemorrhage from
    maxillofacial injury.
120
Q

What is the background of the maxfax SOP?

A
  1. Due to the rich
    blood supply to the head and neck, it is possible to exsanguinate from facial injuries
  2. Aim to recreate a stable column for the facial skeleton, which will allow some restoration of anatomical alignment and
    hence minimise ongoing haemorrhage.
  3. Usually associated with an obstructed airway
    (actual or impending)
  4. For the epistat balloons to provide tamponade rest of the ‘column’ most first be in place
121
Q

What can causes epistats to be ineffective/worsen maxfax bleeding?

A

For the epistat balloons to provide tamponade
in the nasal space it is important the hard palate is braced against the lower jaw
[which is supported by a cervical collar] with dental blocks / McKesson props.

Failure to utilise all of these adjuncts will result in a mobile maxilla being pushed off the base
of the skull and increasing the space for bleeding.

122
Q

What does the maxfax SOP say about intubation?

A
  1. Position where most comfortable
  2. Additional suction
  3. Optimise 1st attempt
  4. Surgical airway kit out, landmarks identified and plan vocalised
  5. If ongoing haemorrhage post I+V contintue with bite blocks/collar/epistats
123
Q

What factors impact the severity of blunt chest trauma? (7)

A
  1. age >65 years
  2. high velocity trauma
  3. penetrating trauma
  4. History of COPD
  5. more than two rib fractures
  6. Respiratory Rate > 25
  7. hypoxemia
124
Q

What is the treatment priority in blunt chest trauma?

A

To maximise oxygen delivery as early as possible and avoid any ventilatory component to cellular hypoxia and shock.

125
Q

What are the 2 principles mentioned when performing interventions on patients with blunt chest trauma?

A
  1. All procedures should be performed using sterile technique.
  2. Formal assessment and confirmation of landmarks must take place prior to any surgical incision being made.
126
Q

Which does the blunt chest injury SOP state about bariatric patients?

A
  • They may have no/limited external signs.
    -Can become hypoxic quickly due to potential splinting/reduced alveolar recruitment, especially when supine
127
Q

What does the blunt chest injury SOP state about paediatric patients?

A

Given chest wall pliability can show no/limited external signs injury but have significant internal injuries

128
Q

What 3 ‘warning signs’ does the blunt trauma SOP state should trigger urgent reasssessment?

A
  1. Undetectable SATs
  2. Unexplained hypotension
  3. High airway pressures
129
Q

How does the blunt trauma SOP say we should examine for flail? (3)

A
  1. Stand at foot end and look for anterior flail
  2. Position yourself so you can look vertically down and then look for lateral flail
  3. Remember posterior flail (difficult if on scoop)
130
Q

What is the mortality of sternal injuries according to the blunt trauma SOP?

A

0.7-3.5%

131
Q

What percentage of blunt sternal trauma have cardiac complications (inc. aortic dissection)

A

1%

132
Q

What signs/symptoms should prompt clinicians to assess for Systemic Air Embolus (SAE) (3)

A
  1. Unexplained shock
  2. Cerebral symptoms
  3. Haemoptysis

(exclude tension PTX)

133
Q

Which burns mandate a burns centre? (5)

A

i. >15% TBSA in an adult
ii. >10% TBSA in a child
iii. Airway burns / Inhalational lung injury
iv. Burns to special areas – Face, hand, perineum or genitals, feet, flexures (particularly neck or axilla), over a joint which may affect mobility or function
v. Electrical / chemical burns

134
Q

What should we remember with electrical burns? (4)

A
  1. Small entry/exit wounds may hide larger damage internally through path of current
  2. May need lots of fluid
  3. High risk compartment syndrome - continually examine extremities to pulses/CRT
  4. Can have arterial/venous thrombi leading to distal schaemia
135
Q

How can electrocution lead to death? (3)

A
  1. VF/asystole
  2. Tetany of chest
  3. Trauma from being thrown
136
Q
A
137
Q

How much TXA should be given in TBI to 1)adults and 2) children?

A
  1. 2g
  2. 15-30mg per kg
138
Q

For RLH what should be done in the event of a suspected TBI meeting code black criteria that is haemodynamically unstable?

A

Request code red and code black

EHAAT sign off (7 decks)

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