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Clinical Surgery > Trauma > Flashcards

Trauma Flashcards

1
Q

What does ATLS stand for

A

Advanced trauma life support (ATLS)

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2
Q

Specific order of evaluations and interventions that should be followed in all injured patients and age groups?

A
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3
Q

The management of every trauma patient comprises which 4 stages

A

Primary survey

Resuscitation

Secondary survey

Initiation of definitive care

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4
Q

How is Airway Maintenance with Cervical Spine Protection performed?

  • What patients need definitive airway support
A
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5
Q

How is breathing and Ventilation assessed in a trauma setting

A
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6
Q

Signs of Tension Pneumothorax

A

Decreased breath sounds

Hyperresonance on percussion

Shock

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7
Q

Circulation and Hemmorage control

  • What signs should be checked?
  • What investigations?
  • Treatment
A
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8
Q

How to Assess a patient’s Disability level

A
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9
Q

How is a patient’s Exposure and Environment optomized

A
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10
Q

Adjuncts used during the Primary Survey

What to be cautious of for Catheter insertion?

A
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11
Q

What occurs during a Secondary Survey?

A
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12
Q

What is shock?

Major Types?

A

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)
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13
Q

__________________________:

  • Tracheal Deviation
  • Distended neck veins
  • Tympany
  • Absent Breath sounds

Management?

A

Tension Pneumothorax

Management:

  • Needle Decompression (Large bore 2nd intercoastal space midclavicular line)
  • Tube thoracostomy
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14
Q

__________________________:

  • Distended neck veins
  • Muffled Heart Sounds

Management?

A

Cardiac Tamponade

Management:

  • Venous Access
  • Volume Replacement
  • Thoracotomy
  • Pericadiocentesis
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15
Q

__________________________:

  • Tracheal Deviation
  • Flat neck veins
  • Percussion dullness
  • Absent breath sounds

Management?

A

Massive Hemothorax

Management:

  • Venous Access
  • Volume Replacement
  • Tube Thoracotomy
  • Surgical Consult
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16
Q

__________________________:

  • Distended Abdomen
  • Uterine Lift (Pregnant)

Management?

A

Intraabsominal Hemorage

Management:

  • Venous Access
  • Volume Replacement
  • Surgical Consult
  • Displace Uterus from vena cava
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17
Q

Haemorrhage Control

A

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)
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18
Q

What is the Lethal Triad? (Triangle of Death)

A

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.

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19
Q

What is Permissive Hypotension

A

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.

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20
Q

What groups should be given special consideration in Trauma?

A

Children

Elderly

Pregnant Women

Athletes (signs of shock late)

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21
Q

How is preparation for transferring an individual done?

A

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

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22
Q

Which is the most common extra-dural bleed?

A

The middle meningeal artery is the most commonly injured, located over temporal fossa

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23
Q

What is normal Intracranial pressure and at what level is the brain at risk of ischemia?

A
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24
Q

Components of the Glasgow Coma Scale

Memory Aid?

Scores for Coma, Moderate and Mild brain injury

A

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

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25
Q

Signs of basilar skull fractures?

A

Periorbital ecchymosis (Raccoon eyes)

CSF from the nose (rhinorrhoea) or ear (otorrhea)

Retro auricular ecchymosis (Battle’s sign)

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26
Q

Characteristics of an Extradural (aka. Epidural) Hematoma

Management?

A

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

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27
Q

Characteristics of a Subdural Hematoma

Types?

Management?

A

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

28
Q

Three priorities in the management of intracranial injuries

A

Resuscitation

Rapid Diagnosis of brain lesion

Prevention of secondary brain insults

29
Q

Medical Therapies for Intracranial Injuries

A
30
Q

Anticoagulation Reversal

■ Antiplatelet agents

■ Warfarin

■ Heparin

■ Direct thrombin inhibitors (dabigatran)

A

Antiplatelet agents – give platelets

Warfarin - FFP, vitamin K, prothrombin complex concentrate

Heparin - protamine sulfate

Direct thrombin inhibitors (dabigatran) -idarucizumab

31
Q

Signs of Brain Death with no possibility of recovery

A

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

32
Q

Discharge Advice for Patients with a Head Injury

A

Supervision for 48 hours

Tell to return if:

  • Confusion
  • Drowsiness
  • Seizures
  • LOC
  • Visual disturbance
  • Headaches
  • Vomiting
33
Q

Types of injury/causes of airway obstruction

A

Potential types of injury

  • Laryngeal injury
  • Posterior dislocation of the clavicular head
  • Penetrating trauma from knives or bullets

Causes

  • Swelling
  • Bleeding
  • Vomitus
34
Q

How to assess for Obstruction of the Airway?

A
35
Q

How to assess for Breathing Problems?

A
36
Q

Consequences of Tension Pneumothorax

A

“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

37
Q

Causes of Tension Pneumothorax

A

The most common cause is mechanical ventilation in patients with lung injury

Also as a result of simple pneumothorax following penetrating or blunt trauma

38
Q

Presentation of Tension Pneumothroax

A

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)

39
Q

Management of Tension Pneumothorax

A

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

40
Q

Management of an OPEN Pneumothorax

A

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

41
Q

Cause/Dangers of Massive Hemothorax

A

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

42
Q

Management of Massive Hemothorax

A

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
43
Q

Indications for Urgent Thoracotomy?

A

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

44
Q

Differentiating Tension Pneumothorax and Massive Haemothorax

  • Breath Sounds
  • Percussion
  • Tracheal Position
  • Neck Veins
  • Chest Movement
A
45
Q

Signs of Cardiac Tamponade

A

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

46
Q

Diagnosis of Cardiac Tamponade?

A

eFAST can effectively identify cardiac tamponade or pericardial effusion

  • 90-95% accurate
  • Beware ➔ concomitant haemothorax may result in both false positive or negative
47
Q

Management of Cardiac Tamponade

A

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.

48
Q

Types of Traumatic Cardiac Arrest

A

Hypovolemic: Pulseless electrical activity (PEA) on ECG

“True” cardiac arrest (Ventricular fibrillation, Asystole)

49
Q

Causes of traumatic circulatory arrest

A

Severe Hypoxia

Tension Pneumothorax

Profound Hypovolemia

Cardiac Tamponade

Cardiac Herniation

Severe Myocardial Contusion

50
Q

Primary Management of traumatic circulatory arrest

A

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)

51
Q

Secondary Survey of patients with thoracic trauma

A
52
Q

Potentially Life-Threatening Thoracic Injuries to Be Aware of

A

Simple pneumothorax

Haemothorax

Rib Fractures, Flail Chest and Pulmonary Contusion

Blunt Cardiac Injury

Traumatic Aortic Disruption

Traumatic Aortic Disruption

Blunt Oesophageal Rupture

53
Q

Signs/Investigations for simple pneumothorax

A

_Signs:

  • Decreased air entry to the affected side
  • Hyperresonance
  • Tachypnoea
  • No tracheal deviation (no tension)
  • Dyspnoea

Investigations:

  • Upright expiratory chest x ray
  • CT THorax
54
Q

Management of Simple Pneumothorax

A
55
Q

Causes/Signs of Hemothorax

A

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)
56
Q

Management of Hemothorax

A
57
Q

Concerns in the event of Rib Fracture

A

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

58
Q

Investigations/Management of Rib Fracture

A

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

59
Q

When is intubtation indicated for patient with rib fracture?

A

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

60
Q

Signs of traumatic aortic disruption on x-ray

A

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

61
Q

Signs of Retroperitoneal Hemmorgage

A

Cullen’s sign = ecchymosis of the peri-umbilical area

Grey-Turner’s sign = ecchymosis of the flank

62
Q

Why is the Lap-belt sign significant

A

Lap belt sign = 30% chance of mesenteric or intestinal injury

63
Q

Signs on Palpation of Abdominal Trauma

A
64
Q

What is FAST

A

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.
65
Q

Advantages of CT in Blunt Abdominal Trauma?

A

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

66
Q

Disadvantages of CT in Blunt Abdominal Trauma?

A

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

67
Q

Investigations in Abdominal Trauma

A

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.

Clinical Surgery (20 decks)

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