Trauma Flashcards
What does ATLS stand for
Advanced trauma life support (ATLS)
Specific order of evaluations and interventions that should be followed in all injured patients and age groups?
The management of every trauma patient comprises which 4 stages
Primary survey
Resuscitation
Secondary survey
Initiation of definitive care
How is Airway Maintenance with Cervical Spine Protection performed?
- What patients need definitive airway support
How is breathing and Ventilation assessed in a trauma setting
Signs of Tension Pneumothorax
Decreased breath sounds
Hyperresonance on percussion
Shock
Circulation and Hemmorage control
- What signs should be checked?
- What investigations?
- Treatment
How to Assess a patient’s Disability level
How is a patient’s Exposure and Environment optomized
Adjuncts used during the Primary Survey
What to be cautious of for Catheter insertion?
What occurs during a Secondary Survey?
What is shock?
Major Types?
Inadequate tissue perfusion and oxygenation
Types of Shock:
- Haemorrhagic: the acute loss of circulating blood volume. Approx 7% of body weight. The blood volume of a child is 8% to 9 % of body weight
- Cardiogenic: myocardial dysfunction caused by blunt cardiac trauma or tamponade
- Neurogenic: isolated intracranial injuries DO NOT cause shock. Classic picture: hypotensionwithout tachycardia or cutaneous vasoconstriction. The failure of fluid resuscitation to restore organ perfusion suggests either continuing hemorrhage or neurogenic shock.
- Septic: due to infection (if arrival delayed hours)
__________________________:
- Tracheal Deviation
- Distended neck veins
- Tympany
- Absent Breath sounds
Management?
Tension Pneumothorax
Management:
- Needle Decompression (Large bore 2nd intercoastal space midclavicular line)
- Tube thoracostomy
__________________________:
- Distended neck veins
- Muffled Heart Sounds
Management?
Cardiac Tamponade
Management:
- Venous Access
- Volume Replacement
- Thoracotomy
- Pericadiocentesis
__________________________:
- Tracheal Deviation
- Flat neck veins
- Percussion dullness
- Absent breath sounds
Management?
Massive Hemothorax
Management:
- Venous Access
- Volume Replacement
- Tube Thoracotomy
- Surgical Consult
__________________________:
- Distended Abdomen
- Uterine Lift (Pregnant)
Management?
Intraabsominal Hemorage
Management:
- Venous Access
- Volume Replacement
- Surgical Consult
- Displace Uterus from vena cava
Haemorrhage Control
Warmed isotonic electrolyte solutions (normal saline or Hartmann’s): This provides transient intravascular expansion and further stabilizes the vascular volume by replacing the fluid
- 1 L
- Persistent infusion of large volumes of fluid and blood to achieve normal blood pressures is not a substitute for definitive control of bleeding.
- In penetrating trauma, delaying aggressive fluid resuscitation until definitive control may prevent additional bleeding.
- Excessive fluid administration can exacerbate the lethal triad (Coagulopathy, Acidosis, Hypothermia)
What is the Lethal Triad? (Triangle of Death)
Lethal Triad
- Coagulopathy
- Acidosis
- Hypothermia
Massive fluid resuscitation results in dilution of platelets and clotting factors along with the adverse effect of hypothermia on platelet aggregation and the clotting cascade, which contributes to coagulopathy.
What is Permissive Hypotension
In truama, balancing the goal of organ perfusion with the risks of rebleeding by accepting lower-than-normal blood pressure. The goal is balance, not the hypotension.
What groups should be given special consideration in Trauma?
Children
Elderly
Pregnant Women
Athletes (signs of shock late)
How is preparation for transferring an individual done?
Optimal preparation for transfer includes direct communication between the receiving and referring doctor – using the ISBAR template, documentation of every intervention and safe transfer by escorting by adequate medical personnel
Which is the most common extra-dural bleed?
The middle meningeal artery is the most commonly injured, located over temporal fossa
What is normal Intracranial pressure and at what level is the brain at risk of ischemia?
Components of the Glasgow Coma Scale
Memory Aid?
Scores for Coma, Moderate and Mild brain injury
Memory Aid
- 4 Eyes
- Jackson 5
- 6 Cylinder Motor
Scores
■ GCS <8 - generally accepted as the definition of coma or severe brain injury
■ GCS 9-12 - moderate brain injury
■ GCS 13-15 - mild brain injury
Signs of basilar skull fractures?
Periorbital ecchymosis (Raccoon eyes)
CSF from the nose (rhinorrhoea) or ear (otorrhea)
Retro auricular ecchymosis (Battle’s sign)
Characteristics of an Extradural (aka. Epidural) Hematoma
Management?
Relatively uncommon, approx. 0.5% of patients with brain injuries
Biconvex shape- push adherent dura away from the inner aspect of the skull
Often at the temporal or temporoparietal region from tear to middle meningeal artery
Classically a lucid interval from the time of injury to neurological deterioration
Treatment: Surgical evacuation
Characteristics of a Subdural Hematoma
Types?
Management?
More common than extradural
Conform to contours of the brain, crescent-shaped or curved, (think sUbdural = cUrved)
Often result from the shearing of bridging blood vessels of the cerebral cortex
May be:
- Acute - symptoms within 48 hours
- Subacute - symptoms within 3-14days
- Chronic - symptoms after 2 weeks or longer
Treatment: Craniotomy and clot evacuation to reduce the mass effect
Three priorities in the management of intracranial injuries
Resuscitation
Rapid Diagnosis of brain lesion
Prevention of secondary brain insults
Medical Therapies for Intracranial Injuries
Anticoagulation Reversal
■ Antiplatelet agents
■ Warfarin
■ Heparin
■ Direct thrombin inhibitors (dabigatran)
Antiplatelet agents – give platelets
Warfarin - FFP, vitamin K, prothrombin complex concentrate
Heparin - protamine sulfate
Direct thrombin inhibitors (dabigatran) -idarucizumab
Signs of Brain Death with no possibility of recovery
GCS = 3
Non - reactive pupils
Absent brainstem reflexes e.g. oculocephalic, gag reflex, corneal reflex
No ventilatory effort
Absence of confounding factors e.g. hypothermia, drug or alcohol intoxication
Consider organ donation with family
Discharge Advice for Patients with a Head Injury
Supervision for 48 hours
Tell to return if:
- Confusion
- Drowsiness
- Seizures
- LOC
- Visual disturbance
- Headaches
- Vomiting
Types of injury/causes of airway obstruction
Potential types of injury
- Laryngeal injury
- Posterior dislocation of the clavicular head
- Penetrating trauma from knives or bullets
Causes
- Swelling
- Bleeding
- Vomitus
How to assess for Obstruction of the Airway?
How to assess for Breathing Problems?
Consequences of Tension Pneumothorax
“One-way valve” leak occurs from the lung or through the chest wall => Air is forced into the pleural space with no escape, collapsing the affected lung => mediastinum is displaced to the opposite side leading to:
o Decreased venous return ➔ Reduced cardiac output
o Compression of the opposite lung
o Obstructive shock may result
Causes of Tension Pneumothorax
The most common cause is mechanical ventilation in patients with lung injury
Also as a result of simple pneumothorax following penetrating or blunt trauma
Presentation of Tension Pneumothroax
Tracheal deviation AWAY from the side of the injury
Unilateral absence of breath sounds
Elevated hemithorax without respiratory movement
Hyperresonant to percussion
Neck vein distension
Cyanosis (late manifestation)
Management of Tension Pneumothorax
CLINICAL DIAGNOSIS➔ DO NOT WAIT FOR RADIOLOGICAL CONFIRMATION
Insert Large bore cannula into 5th intercostal space, slightly anterior to the mid-axillary line
- Beware cannula may kink, or chest wall may be too thick to effectively reach the pleural space
- Continuously reassess
- Finger thoracostomy may be performed if needle decompression is unsuccessful
Chest drain insertion is mandatory after needle or finger decompression
Management of an OPEN Pneumothorax
Opening in the chest wall that is ≥2/3 the diameter of the trachea, air passes preferentially through the chest wall defect with each inspiration
Effective ventilation is thereby impaired ➔ Hypoxia and hypercarbia
Cause/Dangers of Massive Hemothorax
Penetrating or blunt trauma that disrupts the systemic or hilar vessels
Can compromise respiratory efforts by compressing the lung and preventing adequate oxygenation and ventilation
Management of Massive Hemothorax
Establish large calibre intravenous lines
Infuse crystalloid, give blood as soon as possible
Chest drain insertion (28-32 French) and drainage of haemothora:
- 5th intercostal space
- Anterior to the mid-axillary line
Indications for Urgent Thoracotomy?
Immediate return of 1500 mL or more of blood
Initial output <1500ml, but continued loss of >200ml/hr for 2-4 hrs
Incomplete evacuation of blood from the chest
Persistent need for blood transfusion
Penetrating anterior chest wounds medial to the nipple line and posterior wounds medial to the scapula
Differentiating Tension Pneumothorax and Massive Haemothorax
- Breath Sounds
- Percussion
- Tracheal Position
- Neck Veins
- Chest Movement
Signs of Cardiac Tamponade
Beck’s Triad
- Distended Neck Veins
- Muffled Heart Sounds
- Hypovolemia
Kussmaul’s Sign: A rise in venous pressure with inspiration when breathing spontaneously
Pulseless electrical activity (PEA) on ECG in a trauma patient in cardiac arrest may indicate cardiac tamponade
Diagnosis of Cardiac Tamponade?
eFAST can effectively identify cardiac tamponade or pericardial effusion
- 90-95% accurate
- Beware ➔ concomitant haemothorax may result in both false positive or negative
Management of Cardiac Tamponade
IV fluid will improve cardiac output transiently while preparations are made for surgery
If surgical intervention is not possible, pericardiocentesis can be therapeutic, but it does not constitute definitive treatment for cardiac tamponade.
Types of Traumatic Cardiac Arrest
Hypovolemic: Pulseless electrical activity (PEA) on ECG
“True” cardiac arrest (Ventricular fibrillation, Asystole)
Causes of traumatic circulatory arrest
Severe Hypoxia
Tension Pneumothorax
Profound Hypovolemia
Cardiac Tamponade
Cardiac Herniation
Severe Myocardial Contusion
Primary Management of traumatic circulatory arrest
Start CPR
ABC Management
2 X Large-bore IV cannulas (Intraosseous if unable to get IV)
Secure airway with an endotracheal tube
Administer mechanical ventilation with 100% oxygen (Monitor ECG and oxygen saturation)
To alleviate potential tension pneumothorax perform bilateral finger or tube thoracostomies
Rapid fluid (ideally blood) resuscitation
Administer epinephrine (1 mg) if ventricular fibrillation is present
resuscitative thoracotomy may be required if there is no return of spontaneous circulation (ROSC)
Secondary Survey of patients with thoracic trauma
Potentially Life-Threatening Thoracic Injuries to Be Aware of
Simple pneumothorax
Haemothorax
Rib Fractures, Flail Chest and Pulmonary Contusion
Blunt Cardiac Injury
Traumatic Aortic Disruption
Traumatic Aortic Disruption
Blunt Oesophageal Rupture
Signs/Investigations for simple pneumothorax
_Signs:
- Decreased air entry to the affected side
- Hyperresonance
- Tachypnoea
- No tracheal deviation (no tension)
- Dyspnoea
Investigations:
- Upright expiratory chest x ray
- CT THorax
Management of Simple Pneumothorax
Causes/Signs of Hemothorax
Causes: Laceration of the lung, great vessels, an intercostal vessel, or an internal mammary artery from penetrating or blunt trauma
Signs:
- Decreased chest wall movement
- Penetrating injuries evident
- Decrease air entry to the affected side
- Dullness to percussion on the affected side
- Typically no signs of shock as not massive (<1500ml)
Management of Hemothorax
Concerns in the event of Rib Fracture
Flail Chest
- Two or more adjacent ribs fractured in two or more places
- can also occur when there is a costochondral separation of a single rib from the thorax
Pulmonary Contusion
- most common potentially lethal chest injury
- Children have far more compliant chest walls than adults and may suffer contusions and other internal chest injuries without overlying rib fractures
Observation of abnormal respiratory motion and palpation of crepitus from rib or cartilage fractures can aid diagnosis
Investigations/Management of Rib Fracture
Chest X-ray may suggest multiple rib fracture
If flail chest suspected, CT Thorax is indicated
Analgesia: IV or PO Opioids given locally (Paravertebral or serratus anterior nerve blocks) avoids respiratory depression of opioids
Humidified oxygen
Adequate ventilation
Cautious fluid resuscitation
When is intubtation indicated for patient with rib fracture?
Patients with significant hypoxia (PaO2 < 60 mm Hg or SaO2 < 90%) on room air may require intubation and ventilation within the first hour after injury
Signs of traumatic aortic disruption on x-ray
Widened mediastinum
Obliteration of the aortic knob
Deviation of Trachea to the RIGHT
Depression of LEFT mainstem bronchus
Elevation of RIGHT mainstem bronchus
Obliteration of space between pulmonary artery and aorta
Deviation of Esophagus (nasogastric tube) to the RIGHT
Left Hemothorax
Fractures of 1st or 2nd rib or scapula
If an aortic injury is suspected ➔ CT aortogram
Signs of Retroperitoneal Hemmorgage
Cullen’s sign = ecchymosis of the peri-umbilical area
Grey-Turner’s sign = ecchymosis of the flank
Why is the Lap-belt sign significant
Lap belt sign = 30% chance of mesenteric or intestinal injury
Signs on Palpation of Abdominal Trauma
What is FAST
Focused Assessment with Sonography for Trauma (FAST)
- The main aim of a FAST scan is to identify intra-abdominal free fluid (assumed to be
haemoperitoneum in the context of trauma). - Takes up to 500mls of free fluid for the FAST to be positive – if initially negative but
high suspicion for intraabdominal injury/haemorrhage consider repeat examination after a period of time.
Advantages of CT in Blunt Abdominal Trauma?
Defines the severity of organ injury and potential for nonoperative management
Detects severity and source of haemoperitoneum rather than just presence/absence
Often able to detect active bleeding
Ability to assess retroperitoneum and vertebral column
Ability to concurrently scan other areas (e.g. brain, thorax)
Negative imaging generally good indicator of the absence of clinically significant
injury
Disadvantages of CT in Blunt Abdominal Trauma?
Insensitive for mesenteric, bowel, and pancreatic duct injuries
IV contrast required – potential for allergic reactions
High cost
Difficult to obtain/potentially unobtainable in haemodynamically unstable patients
Radiation exposure
Investigations in Abdominal Trauma
Local wound exploration: Involvement of the abdominal fascia is considered a positive result.
Erect CXR: Subdiaphragmatic free air is indicative of peritoneal perforation; however, a normal examination does not rule it out.
FAST (Focused Assessment with Sonography for Trauma): The presence of free fluid in the abdomen is
indicative of peritoneal perforation/intraperitoneal organ injury, however, a normal examination does not rule it out.
CT abdomen is highly sensitive. The major advantage of CT is the ability to diagnose the injured organ(s) and to quantify the severity of injuries.
