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MRCS- physiology + surgery > Trauma > Flashcards

Trauma Flashcards

1
Q

Stages of damage control surgery / orthopaedics

A

The stages of DCO are:
-Resuscitation
-Haemorrhage control
-Decompression
-Decontamination
-Fracture splintage

The aim is to avoid a second physiology hit from early surgical fixation of fractures in major trauma (i.e. delaying plating of a pelvis for 4 days)

Where physiological impact isn’t severe, Early Total Care of fractures is beneficial (i.e. complete fixation within 36 hurs)

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2
Q

Criteria for damage control sugery and not ETC`

A

Hypothermia <34

Acidosis, pH <7.2

Serum lactate >5

Coagulopathy

Blood pressure <70mmHg

Transfusion of 15 units

Injury severity score >36

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3
Q

Permissive hypotension in major trauma

A

Aim is to maintain tissue perfusion not achieve normotension

Target 70-90 mmHg

If head injury, target >90mmHg

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4
Q

Fluid resuscitation in major trauma

A

Aim to use bolus of blood e.g. 250ml

Excessive intravenous crystalloid or colloid
solutions should be avoided because they cause haemodilution, increase coagulopathy and increase the risk of adult
respiratory distress syndrome (ARDS)

Aim is to maintain tissue perfusion not achieve normotension

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5
Q

Massive transfusion protocol

A

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

in a 1:1:1 ratio

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6
Q

Use of tranexamic acid in major trauma

A

1g is given intravenously over 10 minutes,
followed by a further 1 g dose over 8 hours

Tranexamic acid should be given to all trauma patients suspected to have significant haemorrhage, including those with a systolic blood pressure of <110 mmHg or a pulse of over 110 per minute

It needs to be administered within 3 hours of injury

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7
Q

Whole body CT in major trauma

A

WBCT from the head to pelvis with IV contrast is the gold standard investigation of the severely injured adult blunt trauma patient

There is no role for selective scanning of body systems in these patients

WBCT scan is a time-critical investigation and should be
obtained as early as possible in resuscitation of the severely injured patient

Any patient undergoing immediate trauma laparotomy after blunt trauma without a WBCT scan should have a pelvic binder applied and not removed until a pelvic fracture is excluded
Such patients should have an immediate pelvic radiograph either in the emergency department, or as they arrive in the operating room

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8
Q

Log-rolling ?pelvic fratcure

A

Log-rolling should not occur until a pelvic fracture has been radiographically excluded

Disturbs hamatomas –> re-bleeding

Formal log-rolling of the blunt trauma patient to examine the back during the primary survey adds minimal useful clinical information, delays the WBCT scan and may cause harm to a patient with a pelvic fracture.

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9
Q

Goals of resuscitation

A

HR <100

BP: normotensive

UO >30ml/hr

Avoid hypothermia (<35)

Normal pH i.e. not acidotic

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10
Q

Early total care

A

Early total care describes the definitive management of a patient’s injuries within 36 hours of injury after a period of initial resuscitation

Allows early mobilisation

Reduced pulmonary complications

Enahnced recovery

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11
Q

Lactate and decision for ETC or DCS

A

<2 mmol/L – Early total care

2–3 mmol/L – Look at the trend (increasing or decreasing)

> 3 mmol/L – May be under-resuscitated; should either have further resuscitation or damage control surgery (DCS) if surgery is urgent

> 5 mmol/L – DCS

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12
Q

Ischaemic cerebral blood flow

A

Normally 55ml / min /100g of brain parenchyma

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

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13
Q

Normal cerebral perfusion pressure

A

~75-105mmHg

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

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14
Q

Herniation during raised ICP

A

If laterally placed lesion causing mess effect
Subfalcine herniation under falx cerebri
–> If frontal lobe trapped a clinical picture of stroke appears

Uncal herniation: uncus of temporal lobe under tentorium cerebeli
–> Third nerve compressed innitially –> blown pupil
–> Dropping GCS

Central herniation and tonsillar herniation
–> result in brainstem compromise
–> manifesting as Cushing’s triad and dropping GCS

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15
Q

Classification of head injury severity

A

Using the GCS

GCS 15 with no LOC = minor head injury

GCS 15 or 14 with LOC = mild head injury

GCS 9-13 = moderate head injury

GCS 3-8 = sevre head injury

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16
Q

Discharge criteria for minor head injuries

A

Minor = GCS 15 with no LOC

Criteria:
-GCS 15/15 with no focal neurology
-Normal CT if they have had one
-Patient not under influence of drugs or alcohol
-Patient accompanied by responsible adult
-Verbal and written safety netting re. vomiting, developing focal neurology

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17
Q

Indications for CT head as per NICE within 1 HOUR

A

CT head within 1 hour

-GCS <13 at any point

-GCS <15 at hours post injury

-Focal neurology present

-Suspected skull fracture

  • > 1 episode of vomiting

-Post-traumatic seizure

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18
Q

Indications for CT head as per NICE within 8 HOURS

A

CT head within 8 hours

-Age >65 years

-Coagulopathy (warfarin, aspirin, DOAC)

-Dangerous mechanism i.e. fall from height

-Retrograde amnesia >30 minutes

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19
Q

Management of extradural haematoma

A

Extradural haematoma mandates urgent transfer to the most accessible neurosurgical facility, for immediate evacuation in deteriorating or comatose patients or those with large bleeds

Close observation with serial imaging in other cases

The prognosis for promptly evacuated extradural haematoma, without associated primary brain injury, is excellent.

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20
Q

Management of traumatic SAH

A

Very different to primary SAH

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

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

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21
Q

Sites of brain contusion

A

Tend to occur at sites of roughening within the skull

e.g. inferior frontal lobes
inferior temporal poles

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22
Q

Diagnosis of diffuse axonal injury

A

Confirmation is only at post-mortem histologically

Clinical diagnosis made in consideration with mechanism of injury and clinical picture

CT findings of haemorrhagic foci at carpos callosum and dorsolateral rostral brainstem are indicative

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23
Q

Traumatic intra-cranial and extra-cranial arterial dissection

A

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

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

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24
Q

Key therapeutic goals in severe head injury

A

pCO2 = 4.5–5.0 kPa

pO2>11 kPa

MAP = 80–90 mmHg

ICP <20 mmHg

CPP >60 mmHg

[Na+] >140 mmol/L
[K+] >4 mmol/L

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25
Q

Post TBI Seizures

A

60% in severe TBI

-Started on prophylactic phenytoin

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26
Q

Feeding in TBI

A

Enteral feeding started within 72 hours

Give metoclopramide or erythromycin as pro-kinetic

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27
Q

Glasgow outcome score (GOS)

A

Used to grade outcome

5 - Independent and working

4- Moderate disability

3 - Severe disability

2- Vegetative state

1- Dead

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28
Q

Stability of spinal injuries

A

Three column theory

Anterior

Middle

Posterior

If two of the three columns are injured = unstable

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29
Q

End of the spinal cord

A

L1/L2 where it continues as the conus medullaris then to the cauda equina

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30
Q

ASIA scoring levels

A

A: complete spinal cord injury

B: sensation present but motor function absent

C: sensation present, motor present but not functional MRC garde 3/5)

D: Sensation and motor present MRC grade >3/5

E: Normal function

A= absolutely nothing can be done
E= excellent news

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31
Q

Absolute indication for surgical fixation in spinal trauma

A

Deteorating neurological function

Neurological deficit determines management
Deteriorating neurological status requires surgical intervention
Corticosteroids are ineffective

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32
Q

Occipital condyle fracture Mx

A

Relatively stable fracture

Mx: Hard collar 6-8 weeks

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33
Q

Occipitoatlanto dislocation Mx

A

Caused by high-energy trauma

Often fatal

Can dislocate anterior, posterior or vertical

Power’s ratio is used to assess skull translation.

Treatment is with a halo brace or occipitocervical fixation.

34
Q

Atlas fracture (Jefferson #) Mx

A

Fracture of C1, Atlas

Associated with axial loading

Some are stable and some are unstable depending on displacement and assoicated transverse ligament injury

Mx: most treated with halo-brace

35
Q

Power’s ratio

A

Used in occipitoatlanto dislocation

Power’s ratio
BC/OA ≥1 indicates anterior translation

≤0.75 indicates posterior translation.

36
Q

Atlantoaxial instability

A

Non-physiological movement between atlas and axis

It can be translational or rotatory

Resolves either spontaneously or with traction followed by a cervical collar.

Isolated, traumatic transverse ligament rupture leading to C1/2 instability is uncommon and is treated with posterior C1/2 fusion

37
Q

Odontoid fractures

A

Three types of peg fractures

Neurological injury is relatively rare and the majority are treated with hard collar/ halo jacket for 3 months

Mx: if unstable –> surgical fixation with anterior compression screw
stable –> halo jacket / hard collar

Posterior C1/2 fusion is considered in cases of
non-union

38
Q

Types of odontoid fractures

A

Type 1: Chipped the top

Type 2: base of adentoid fracture

Type 3: Involved the lamellar/ vetrebral body

39
Q

Traumatic sponylolisthesis of the axis

A

= Hangman;s fracture

Traumatic spondylolisthesis of C2 on C3

4 types

Significant displacement / facet dislocation –> posterio rstabilisation surgical fixation

40
Q

Types of subaxial cervical spine injury (i.e. C3 and below)

A

C3 - C7

Compression fractures: flexion injuries

Burst fractures: axial loading injuries

Facet dislocation: distraction - flexion injuries

Tear-drop fractures: hyper-extension injuries

41
Q

Fractures of spine in ank spond

A

Usually require operative fixation

Sometimes collar contra-indicated so specialist advice required

42
Q

Classifying thoracic and thoracolumbar spinal fractures

A

Arbeitsgemeinschaft für Osteosynthesefragen classification

Three main types A - C with increasing instability and risk of neurological injury

Type A: vertical body compression fractures

Type B: Involve distraction of the anterior or posterior elements

Type C: rotational injurt that often is in association with A or B

B and C –> surgical fixation

43
Q

Duodenal, pancreatic and/or aortic ruptures are also
associated with these injuries

A

Chance fractures are flexion-distraction injuries of the thoracolumbar spine

Assoc with lap belt injury

44
Q

Lumbar spinal injuries

A

Less likely to cause neurological compromise

More capacious

Lumbar lordosis means kyphosis less likely to develop

Mx: usually non-operative

45
Q

Increase in interpedicular distance

A

= burst fracture

46
Q

Types of incomplete spinal cord injury

A

= peri-anal sensation remains intact
- some functioning cord

Types:
Central cord syndrome
Brown-Séquard syndrome (hemisection)
Anterior spinal syndrome
Posterior cord syndrome
Cauda equina syndrome

47
Q

Later complications of spinal cord injury

A

Pressure ulcers

Neurogenic pain

Spasticity

Autonomic dysreflexia: paroxysmal syndrome of hypertension, hyperhyderosis, bradycardia, flushing and headache
–> most comonly due to bladder distension or faecal loading

Neurological deterioration: Post traumatoc syringomyelia (PTS ) may occur in up to 28% of SCI patients

DVT / PE

Osteoporosis

Heterotopic ossification may affect the hips, knees, shoulders and elbows

48
Q

Fractures of the mandible

A

Neck of the condyle is the most common site

Also angle of the mandible and canine region

Numbness over mental nerve is common

Tx: ORIF with sloppy diet for 2 weeks

49
Q

Zygomatico-orbit complex fractures

A

4-legged stool

With exception of isololated zygomatic process and infra-orbital rim fractures –> all involve orbit

Altered sensation over infra-orbital nerve is common

Mx: ORIF at one of the for legs
+/- double/triple point fixation

50
Q

Classification of maxillary fractures

A

Type 1:
Transverse fracture through the maxillary sinuses, lower nasal septum, pterygoid plates

Type 2:
Oblique fracture crossing zygomaticomaxillary suture, inferior orbital rim, nasal bridge

Type 3
Fracture above the zygomatic arch, through the lateral and medial orbital walls and nasofrontal suture

51
Q

Diplopia ir orbital injuries

A

Monocular = eye damage
-Dislocated lens
-Retinal detachment / damage

Binocular diplopia = motility issue
-Rectust muscles

52
Q

Diplopia ir orbital injuries

A

Monocular = eye damage
-Dislocated lens
-Retinal detachment / damage

Binocular diplopia = motility issue
-Rectus muscles

53
Q

Diplopia in orbital floor fracture

A

Indictaes entrapment of inferior rectus / inferior oblique

Diplopia on up-gaze

On imaging may appear undisplaced = trap-door deformity

Mx: surgical emergency as pressure necrosis causing irreversible damage

54
Q

Retrobulbar haemorrhage

A

= surgical emergency as leads to blindess

Decreasing visual acuity
Pain
Loss of pupillary response
Tense proptosis

Medical management:
Acetazolamide, mannitol and steroids

Surgical Mx:
Lateral canthotomy and cantholysyis

55
Q

CSF leaks from carniofacial trauma

A

Fracture of frontal or ethmoidal sinuses creating communication between cranial cavity and nasal cavity

Dural tear needed for CSF to leak

Most common site of injury is the posterior wall of the frontal sinus, however fractures of the ethmoid and sphenoid sinus can also cause CSF leaks

Initial CSF leaks are not treated

Persistent CSF leaks >10 days –> dural repair using open anterior fossa repair (necessitating a frontal craniotomy

56
Q

The Deadly Dozen

A

6 immediately life-threatening
-Airway obstruction
-Tension pneumothorax
-Pericardial effusion
-Open pneumothorax
-Massive haemothorax
-Flail chest

6 life-threatening
-Aortic injuries
-Tracheobronchial injuries
-Myocardial contusion
-Rupture of the diaphragm
-Oesophageal injuries
-Pulmonary contusion

57
Q

Closure of open chest wounds

A

MUST have remote chest drain in first if wounds are sucking

Temporary closure with three sided dressing

If chest drian isn’t inserted one could convert a leaking pneumothoax into a closed pneumothorax –> tension

58
Q

Indications for urgent thoracotomy

A

Initial drainage of more than 1500 mL of blood

OR

Ongoing haemorrhage of more than 200 mL/h over 3–4 hours

Clamping a chest drain to tamponade a massive haemothorax is not helpful.

59
Q

Flail chest

A

On inspiration, the loose segment of the chest wall is
displaced inwards and therefore less air moves into the lungs

On expiration, the segment moves outwards (paradoxical respiration).

60
Q

Mx of flail chest

A

Oxygen administration, adequate analgesia (including opiates) and physiotherapy.

If chest tube is in situ, topical intrapleural local analgesia introduced via the tube

Ventilation is reserved for cases developing respiratory failure despite adequate analgesia and oxygen

Internal fixation of the ribs may be useful in isolated or severe chest injury and pulmonary contusion

61
Q

Diagnosis of oeosphageal perforation

A

Oesophagogram in the decubitus position

and

oesophagoscopy confirm the diagnosis in the great majority of casesa

62
Q

Indications for a FUTILE EDT

A

CPR in the absence of endotracheal intubation for more than 5 minutes;

CPR for more than 10 minutes (despite endotracheal
intubation);

Blunt trauma when there have been no signs of life at the scene

63
Q

Aims of ED thoracotomy

A

Internal cardiac massage;

Control of haemorrhage from injury to the heart or lung

Control of intrathoracic haemorrhage from other sources

Control of massive air leak

Clamping of the thoracic aorta to preserve the blood supply to the heart and brain, and cutting off the arterial supply distally, in a moribund patient with a major distal penetrating injury.

64
Q

Management of liver injuries

A

Push

Pringle

Plug

Pack

65
Q

Damage to hepatic artery

A

Can be tied off

One CANNOT tie off portal vein, must be repaired
= 50% mortality if it is tied off
-If bleeding cannot be controlled it should be stented and tranfserred to complex trauma HBP unit

66
Q

Management of blunt pancreatic injuries

A

Pancreatic body (left is SMA) and tail –> closed suction drainage alone
If duct involved –> distal pancreatectomy

Proximal injuries (right of SMA) are treated as conservatively as possible, although partial pancreatectomy may be necessary

–> pylorus can be temporarily closed (pyloric exclusion) in association with a gastric drainage procedure, to minimise pancreatic enzyme stimulation

67
Q

Management of retropeitorneal bleeding

A

Haematomas split into three zones

Zone 1 (central): central haematomas
= Always explored, proximal and distal vascular control

Zone 2 (lateral): lateral haematomas s
= Only be explored if they are expanding or pulsatile.
Renal in origin and can be managed non-operatively

Zone 3 (pelvic)
=Only be explored if they are expanding or pulsatile. Pelvic haematomas are exceptionally difficult to control –> Compression or extraperitonea packing, and if the
bleeding is arterial in origin, with angioembolisation.

68
Q

Disruption of iliosacral joint is likely to damage which vessel

A

Iliac vessels

69
Q

Tile classification of plevic fractures

A

Type A
-Stable
-Lateral compression, which causes ncompression fractures of the pubic rami or compression fracture of the sacrum posteriorly

Type B
-Partial stability, ORIF required
-Disruption of the anterior pelvis and partial disruption of the posterior pelvis.
-Pelvis can open and close ‘like a book’
-Sacroiliac ligaments remain intact, there is no vertical
displacement

Type C
-Completely unstable
-Both anterior pelvis and the entire posterior pelvic complexes are disrupted
-Free to displace horizontally and vertically.

70
Q

Antibiotics in penetrating abdominal trauma

A

Prophylaxis antibiotics given if penetrating trauma

Ususally stat dose unless gross contamination then on-going abx may be required

71
Q

Gustilo and Anderson Open fracture classification

A

I: <1cm and clean

II: >1cm without excessive soft tissue damage

III: Characterised by high energy injury irrespective of the size of the wound
-Soft tissue damage
-High degree of contamination
A: adequate soft tissue coverage post-repair
B: inaqdequate soft tissue coverage post repair
C: associated arterial injury

72
Q

Salter Harris #s requiring surgery

A

III - V

73
Q

Fixation of scaphoid fracture

A

Displaced >1mm or unstable

Use headless compression screw

If undisplaced –> below elbow casting not including thumb

74
Q

Perilunate dislocation and lunate dislocation

A

Most common dislocation around capometacarpal joint
—> puts pressure on median nerve

Requires reduction, ligamentous repair and k-wire fixation

75
Q

Fixation of Smith’s fracture

A

Most volar fractures of the radius are unstable

Standard treatment is volar plate on volar buttress of radius

76
Q

If radial fracture is associated with splitting of the
lunate fossa fragment in the coronal plane and separation of the radial styloid

A

= failure

Intra-articular fracture that requires internal fixation with a plate

77
Q

Neer Classification

A

Proximal humeral fractrures

4 parts to the proximal humerus:
-Articular head fragment
-Lesser tuberosity
-Greater tuberosity
-Shaft

If a fragment is displaced by more than 1 cm or angulated by more than 45 degrees in respect of another fragment, it is considered a part.

May be undisplaced, 2 part, 3 part or 4 part.

Greater the number of parts, the higher the chances of
interruption of the vascularity to the humeral head and the more complex the injury

78
Q

Indications for surgical fixation of the clavicle

A

Displaced, comminuted fractures

2cm shortening

Ederly females

79
Q

Indications for a gamma nail

A

Unstable extra-capsular femoral fractures

+ reverse oblique fracture –> unstable

Dynamic hip screws can sometiems still be used

80
Q

Os calcis fractures

A

Fall from height

20% have associated lumbar spinal fracture

81
Q

Talar neck fracture.

A

Most common fracture of the talus

Caused by forced dorsiflexion

Blood supplied interupted in displaced fractures

Anatomical reduction and stable fixation of the talar neck should be performed

MRCS- physiology + surgery (32 decks)

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