Trauma Flashcards
Isolated Head Injury
2021.2 Simulation Station - Isolated Head injury (Assessment and Management)
- Prepare for Intubation
- ?Anticoagulation that needs reversal
- Assess for raised ICP and brain herniation
- CT scan
- Neurosurgical input
- Decompressive craniectomy vs. burr hole
- Transfer to trauma unit
NEUROPROTECTIVE INTUBATION:
Maintain inline manual stabilisation of the cervical spine
Elevate head of bed to 30deg - this will be maintained throughout intubation
OPTIMISE:
PREOXYGENATE with high flow oxygen 15L NRBM and nasal prongs for at least 5min
POSITION - raise the head of bed 30 degrees
Tragus in line with sternal notch, face plane parallel to ceiling (optimise visualisation of cords)
AIRWAY MANOUVRES:
- jaw thrust (no chin lift in c-spine injury)
- OPA
- NPA
Blunt sympathetic response from laryngeal manipulation - pre medication with fentanyl 100mcg IV
(give 3min before induction)
Prevent hypotension:
- pre induction fluid bolus 500ml 0.9% NS IV bolus aiming for SBP 120-160mmHg
- Vasopressors
push dose metaraminol 0.5mg aliquots Q5min aiming for SBP 120-160mmHg
- Adrenaline 10-20 mcg aliquots (0.1mcg/kg) IV every 2 - 3min
Sedation with ketamine 1-2mg/kg IV (haemodynamically stable, neuroprotective properties)
Paralyse with rocuronium 1.2mg/kg IV
AIRWAY PLAN:
Plan A - video laryngoscope with hypercurved D blade, size 7.5 ETT preload onto fixed stylet
Run 30sec drills
Plan B - place size 4 LMA
Plac C - declare CICO situation and proceed to FONA
POST INTUBATION SEDATION
- propofol 4-12mg/kg/hr (anti-seizure properties and decrease cerebral metabolic rate)
- fentanyl 1-5mcg/kg/hr (analgesia)
NEUROPROTECTIVE VENTILATION STRATEGIES:
RR 18
TV8ml/kg
PEEP 5mmHg
FiO2 100% initiall target SaO2 >94%
target PCO2 35-40mmHg
TARGETS to prevent secondary brain injury:
normal temp 36.5-37.5
normal glucose 4-7mmol/L
Place arterial line to monitor BP
aim SBP 110-160mmHh
Seizure prophylaxis:
levetiracetam 40mg/kg IV max 4.5g
Neurosurgical attendance for decompressive craniectomy
Burr hole if rural
Arranged retrieval to trauma service
PREPARE FOR SAFE TRANSFER
- invasive BP monitoring
- sedation (propofol & fentanyl)
- vasopressors
- anti-seizure medication (midazolam)
- hypertonic saline or manitol
- Update the family on plan for transfer and expected course
Assess for raised ICP and brain herniation:
POCUS eye - papilloedema & optic nerve sheath diameter >6mm
Cushings reflex - bradycardia & hypertension
BRAIN HERNIATION:
uncal herniation:
- compression of the occulomotor nerve –> ispilateral fixed dilated pupil
- contralateral hemiparesis
Central transtentorial herniation:
- bilateral pin-point fixed pupils
- bilateral babiski
- increased tone
- progress to hyperventilation and decorticate posturing
Cerebellotonsillar herniation:
- flaccid paralysis
- bradycardia
- respiratory arrest
- sudden death
Treat raised ICP:
- 3% NS 3-5ml/kg IV following by infusion 0.1ml/kg/hr to maintain Na+ 155-165
OR
- Mannitol 0.5–1 gram/kg
250ml bag = 50g
500ml bag = 100g
Adult Head Injury
2023.2 Case based discussion
Adult with isolated head injury. Drops GCS and requires intubation.
Needs CT scan
Needs referral to neurosurgical services
d) Ref: Tintinalli’s
Prevent raised ICP - raise head of bed 30 degrees
Anticipate difficult intubation due to potential c-spine injury/in line immobilisation
Blunt sympathetic response from laryngeal manipulation - pre medication with fentanyl
Prevent hypotension - have vasopressors on stand by
- metaraminol 0.5ml aliquots
Maintain SaO2 >90%,
Maintain low normal PCO2 35-40
Maintain normothermia 36-37
Maintain normoglycemia 4-7mmol/L check Q1h
Maintain BP 140/80 - place arterial line for continuous monitoring
Seizure prophylaxis:
levetiracetam 15-40mg/kg IV
Treat raised ICP:
- 3% NS 3-5ml/kg IV following by infusion 0.1ml/kg/hr to maintain Na+ 155-165
OR
- Mannitol 0.5–1 gram/kg
Immediate Neurosurgical attendance to facilitate decompressive craniectomy
Maintain cervical spine precautions
Geriatric Head Injury
2022.2 Case based discussion
75 year old patient who has presented with a head injury.
Interpret the CT scan
Consider the patient’s chronic medical conditions
*serious injury with low mechanism trauma
*osteoporosis & arthritic changes increase likely-hood of cervical spine injury - ensure c-spine immobilisation and CT imaging is required
*cognitive impairment and previous strokes makes neurological assessment difficult
*anticoagulation
*cardiovascular disease (heart failure)
- be careful with fluid resuscitation (APO)
- be careful with induction agents
*liver and renal impairment affects drug metabolism - this will change my medication dosing
Consider the patient’s wishes/advanced care directives when making decisions
- discussions with family and next of kin is required
NEUROPROTECTIVE INTUBATION:
Prevent raised ICP - raise head of bed 30 degrees
Anticipate difficult intubation due to potential c-spine injury/in line immobilisation
PREOXYGENATE:
HFNP 30L + NRBM 15L
PRETREATMENT:
fentanyl 1-2mcg/kg IV 3-5mcg prior to induction
Blunt sympathetic response from laryngeal manipulation
PREVENT HYPOTENTION:
careful fluid resuscitation
- 250ml fluid bolus - guided by POCUS IVC assessment
Noradrenaline infusion starting at 0.05mcg/kg/min
INDUCTION:
use smaller doses
- ketamine 1mg/kg IV
slower distribution, wait to take effect
PARALYTIC:
use normal dose
rocuronium 1.2mg/kg IV
AIRWAY PLAN:
manual in-line stabilisation
A - videolaryngoscope, hyperangulated D-blace, 7.5 ETT railroaded over fixed stylet
B - size 4 LMA
C - FONA access
NEUROPROTECTIVE VENTILATION STRATEGY:
RR 18
TV 8ml/kg
PEEP 5mmHg
FiO2 100% target SaO2 >94%
PCO2 35-40mmHg
PREVENT SECONDARY BRAIN INJURY:
SaO2 >94%,
PCO2 35-40
Normothermia 36-37
Normoglycemia 4-7mmol/L check Q1h
Maintain BP 140/80 - place arterial line for continuous monitoring
Seizure prophylaxis:
levetiracetam 15-40mg/kg IV
Treat raised ICP:
- 3% NS 3-5ml/kg IV following by infusion 0.1ml/kg/hr to maintain Na+ 155-165
OR
- Mannitol 0.5–1 gram/kg
Immediate Neurosurgical attendance to facilitate decompressive craniectomy
Neuroprotective Intubation
Intracranial haemorrhage
Subarachnoid haemorrhage
Severe traumatic brain injury
1) Consider airway management prior to imaging or transport.
- vomiting
- rapidly dropping GCS
- agitation
Main goals is to avoid hypotension and hypoxia
Head of bed up 30degrees
PREOXIGENATE:
- High flow nasal prongs with non-rebreather over top
PRETREATMENT:
- fentanyl 2mcg/kg IV 3-5min prior to induction
INDUCTION:
- ketamin 1.5mg/kg IV
- haemodynamically stable
- analgesic properties
- neuroprotective properties
- quick onset, long duration of action (useful with longer active paralytic)
PARALYTIC:
- rocuronium 1.2mg/kg IV
- longer acting, will keep still for imaging
POST INTUBATION SEDATION:
- propofol 3-5mg/kg/hr (antiseizure properties)
- fentanyl (analgesia, propofol does not have analgesic properties)
NEUROPROTECTIVE VENTILATION STRATEGY:
RR 18
TV 8ml/kg
PEEP 5mmHg
FiO2 100% target SaO2 >94%
PCO2 35-40mmHg
Facial Trauma with Loss of Vision
2022.1 Examination station
An adult with facial trauma and loss of vision
DIFFERENTIAL DIAGNOSES:
- orbital compartment syndrome with retrobulbar haematoma
- open globe injury
- traumatic retinal tear or detatchment
- lens dislocation
- hyphaema
EXAMINATION:
use eyelid retractors
VA with pin hole, counting fingers, hand movement, light perception
INSPECTION - lid lacerations, periorbital swelling and bruising, chemosis, proptosis, protrusion of intra-ocular contents
extra-ocular movement - entrapment of the inferior rectus muscle - unnabe to look up
Pupils - tear drop, RAPD
Slit lamp exam of the anterior chamber - hyphaema
Tanometer - IOP - high in orbital compartment syndrome, low in globe rupture
ORBITAL COMPARTMENT SYNDROME:
- proptosis
- reduced VA
- RAPD
- raised IOP >40mmHg
GLOBE RUPTURE:
- flat anterior chamber
- protrusion of intra-ocular contents
- lacerations at the limbus with protrusion of the iris
- tear drop shaped pupil
- lower than normal IOP
- reduced VA
RETINAL TEAR/DETACHMENT:
- RAPD
- flashes or floaters
- reduced VA
Pelvic Fractures
2016 station
PR exam to assess for open pelvic fractures - will need antibiotics and operative management of bowel transection
Retrograde urethrogram - to look for urethral injury that may warrant suprapubic catheter placement
RADIOLOGY
Lateral compression fracture
AP compression (open book)
Vertical shear
Acetabular fractures
XRAY FINDINGS:
- Pelvic binder in-situ
- Disruption pelvic ring
- Superior and inferior pubic rami
- Pubic symphysis diastasis (open book pelvic fracture)
- SIJ widening
- Disruption of arcuate lines –> sacral alar fracture
- Disruption of superior acetabular margin
- Disruption of shentons line - right
- Disruption of illeopectineal lines
- Disruption of ischiopectineal lines
- Femoral head dislocations
b)
Activate massive transfusion protocol - 1:1:1 PRBC: Platelet: FFP
Rapid infusion catheter or 2x large bore IVC at least 18G
1g tranexamic acid IV stat
Temperature control 36.5-37.5
Targets:
ionised calcium >1
INR < 1.5
Fibrinogen >1.5 (>2 in obstetric patients)
Hb >80
Plt >50
pH >7.2
lactate <4
Pelvic angiography +/- embolization internal illiac
REBOA (Resuscitative endovascular balloon occlusion of the aorta)
Pelvic packing in OT
ORIF in OT
Preparation for transfer:
- blood products
- analgesia - ketamine
- arterial line and monitoring
- IDC
- update family of plan
Teaching: Pelvic binder management
2022.1 - Teaching Station
*EM Board Bombs ep 11, 33, 106
*EM quick hits 30
*EM cases ep 119 trauma
*Emergency medicine procedures
Medical Expertise: Use and application of pelvic binders (45%)
* Selects an appropriate procedure after considering indications, contraindications, and
potential complications
* Describes the important features of common procedural equipment.
Medical Expertise: Management after binder application (30%)
* Anticipates and manages common complications during and after a procedure
* Adapts the performance of a procedure in response to unforeseen complications when
performing a procedure.
Scholarship and Teaching (25%)
* Effectively delivers a teaching session which teaches procedural skills and use of equipment
* Integrates basic principles of adult learning to proficiently deliver a teaching session to a
small audience.
Candidates were required to meet with the junior registrar (role player) and to:
* teach them about the use of pelvic binder systems
* describe the fitting of a pelvic binder system
* explain post pelvic binder application management
* answer any questions they may have.
TEACHING:
- introduce
- establish rapport
- enquire about level of experience
- prior learning
- check understanding
- opportunity to ask questions
- summarise
- suggested reading/learning resources
INDICATIONS:
- blunt trauma
- hypotension/cardiac arrest
- suspected pelvic fractures
HOW IT WORKS:
- decrease pelvic diameter,
- decreasing the anatomic bleed space in open book and vertical shear fractures
CONTRAINDICATIONS:
- lateral compression fracture
COMPLICATIONS:
- painful to apply if fractures are present
- incorrect application is common
- may cause further harm in lateral compression fractures
- pressure sore with prolonged use
Clinical assessment of pelvic injuries is unreliable
Early pelvic binding if shocked or suspect pelvic fracture
Place pelvic binder on bed prior to patient arrival
Given analgesia - ketamine 10mg IV
- this is painful for the patient
need to bind the greater trochanters
binding the legs together to further reduce the pelvic diameter
check correct position - greater trochanters
check tension
document time of application
Pitfalls:
- helps tamponade venous bleeding and cancellous bone bleeding, won’t tamponade arterial haemorrhage
- incorrect placement is common - need to bind the greater trochanters
WHEN TO REMOVE:
- if haemodynamically stable with no fractures on imaging
don’t log roll the patient
PR and PV exam for blood = open fracture requiring antibiotics
IDC - haematuria = bladder injury
(need for CT cystourethrogram)
Massive Transfusion Protocol
2023.2 RMO discussion
Teach a junior doctor about blood
transfusion protocols.
“7T’s of MTP”
Trigger
Team
TXA
Testing
Target
Temperature Control
Termination
know your local MTP protocol
HEPARIN
- 1mg protamine per 100 units heparin
- give maximum of 50mg protamine slow IVI as initial dose
CLEXANE (ENOXAPARIN):
- 1mg protamine per 1mg clexane
- give maximum of 50mg protamine slow IVI as initial dose
Warfarin reversal:
- prothrombinex 50IU/kg
- vitamin k 10mg IV
Dabigatran
- prothrombinex 50IU/kg IV
- tranexamic acid 1g IV
- idarucizumab (praxbind) 5g IV
Apixaban & Rivaroxaban
- prothrombinex 50IU/kg
- tranexamic acid 1g IV
- adexanet alpha (factor 10a) - not available in australia yet
Prothrombinex contains factors 2, 9, 10
- European countries give PCC’s and Cryoprecipitate instead of giving FFP
- can consider if you are in a rural hospital that does not have FFP
- PCC kept at room temperature (can be kept in resus)
- don’t need blood group
- no pathogens
- don’t cause TRALI
Studies currently looking at the use of whole blood instead of blood products - evidence is not out yet
BLOOD PRODUCT VOLUMES:
PRBCs 260mls +/- 15mls
Platelets 367mls +/- 16mls
FFP 278mls +/- 13 mls
Cryoprecipitate 36mls +/- 2mls
cryoprecipitate contains:
0.2g fibrinogen in each unit
von willebrand factor
factor 8
factor 13
give it if fibrinogen <1
tranexamic acid 1g IV bolus, then 1g IV in 100ml NS over 8hrs
**most beneficial if given in the <1h post trauma (needs to be given within 3hrs of trauma)
CRASH2 trial
TRIGGER: (when to activate the MTP)
Clinical Judgement:
- bleeding in shocked state
(positive shock index)
Lower threshold to activate:
- elderly
- anticoagulation medication
- medications that blunt the sympathetic response (beta blockers, non-dihydropyridine calcium channel blockers)
TEAM:
Lab and blood bank notification
Haemorrhage control/Source control
- early notification of surgeon, gastroenterologist, interventional radiologist
TXA:
1g IV, followed by 1g over 8hrs within the first 3hrs in trauma (CRASH2 reduce mortality)
TESTING:
Baseline bloods:
- Fibrinogen
- Coags (INR & PT)
- VBG - pH
- FBC - Hb, platelets
- Calcium
- K+
- Bhcg (o negative blood)
Q1 hour bloods
- fibrinogen
- INR
- FBC (Hb & platelets)
- VBG (pH, lactate)
- Calcium
- K+
TARGETS: (haematologic and metabolic targets)
*Hb > 80
*Platelets >100
*Fibrinogen >1.5
*INR <1.5
*Ionised calcium >1
*pH >7.2
Fibrinogen needs to be >2g/L in obstetric patients
The citrate preservative in blood products binds to serum calcium making it inactive. Calcium is important in regulating coagulation and haemostasis.
TEMPERATURE:
36.5-37.5
TERMINATION:
- normalising haematological and metabolic parameters
- haemodynamic stability
Prevent blood wastage:
- return products as soon as you know you don’t need them
Lethal Triad:
- Hypothermia
- Coagulopathy
- Acidosis
HYPOTHERMIA:
- minimise exposure
- bair hugger or warm blankets
- warm fluid/fluid warmer
- increase room temperature
- continuous core temperature monitoring - oesophageal probe 15cm
COAGULOPATHY:
- give tranexamic acid 1g IV (inhibit fibrinolysis)
- avoid haemodilution coagulopathy with crystalloids
- administer 1:1:1 ration of RBC:platelets:FFP to minimise transfusion related coagulopathy
ACIDOSIS:
- prevent hyperchloraemic metabolic acidosis by avoiding large volumes of normal saline
- prevent respiratory acidosis by ensuring adequate ventilation - decompress pneumothoraces, intubation and mechanical ventilation
Trauma
2021.1 Case based discussion
Assessment and management of an unstable patient with significant lower limb trauma
who has arrived via primary retrieval (helicopter) following a high-speed motor bike collision.
Femur traction splint for femur fracture
Identify immediate life threats on primary survey:
*Airway obstruction - dynamic airway in stab wound to neck
*Tension pneumothorax
*Massive internal or external hemorrhage
*Open pneumothorax
*Flail chest
*Cardiac tamponade
*Intracranial bleed with raised ICP –> herniation
Management of immediate life threats:
- direct pressure, torniquets, splinting obvious fractures
- bilateral finger thoracostomies
- pelvic binder application
- 1g tranexamic acid IV (followed by 1g IV over 8hrs)
- Administer uncrossmatched blood, activate massive transfusion protocol
- hypertonic saline, hyperventilation, burr hole for brain herniation
- vasopressors for neurogenic/spinal shock
Risk Features:
*Positive shock index >1 - HR higher than SBP
*Drop in systolic BP over time
*Geriatric patients
*Anticoagulation
*Co-morbidities
Permissive hypotension:
- Systolic BP to maintain end-organ perfusion
CRASH 2 trial - tranexamic acid given within 3 hours reduces mortality
PREPARATION:
Team huddle:
- outline what we know
- what immediate life threatening injuries do we expect to see
- PPE and allocate roles
Prepare my gear:
- US to the bedside
- pelvic binder on the bed
- rapid infusers and fluid warmers
Do I need help:
- trauma call
- anaesthesia, surgery, radiology
Prepare myself:
- bathroom
- mental preparation and positive self talk
Ensure the rest of the department is sorted:
- order any tests/imaging
- refer worked up patients to inpatient
ASSESSMENT & MANAGEMENT:
- will be happening concurrently
- identify and treating immediate life threats
- what are the physiological priorities
AIRWAY & BREATHING:
Apply oxygen 15L NRBM
Dynamic airway - stab wound to neck with expanding haematoma or surgical emphysema
Identify that the patient will need intubation for airway protection and transfer - however, we need to resuscitate and optimize beforehand
CIRCULATION:
eFAST
IV ACCESS:
- 2x large peripheral IV
- IO in humerus (faster infusion rates than tibial)
Haemorrhage control:
- apply pelvic binder
- tranexamic acid 1g IV (given in the first 3hrs)
- resuscitate with blood to prevent dilutional coagulopathy
- send group and screen for x-match but order 4u of uncross-matched blood to start resuscitation
- use fluid warmer
Obstructive shock
- finger thoracostomies and chest tube placement
- management of tamponade
DISABILITY:
Intracranial haemorrhage with raised ICP and herniation
GCS + pupil assessment
EXPOSURE:
- Temperature control
- aim 36.5 -37.5
- limit exposure, warm blankets, warm fluid
DISPOSITION: “where is the patient going to next”
*arranging transfer to operating theatre
* early - referral to major trauma centre
*arranging retrieval
PREPARING FOR TRANSFER:
- needs IV access
- sedation and analgesia
- blood products
- arterial line
Penetrating Chest Trauma
2022.1 CBD station
discuss the assessment and management of a male patient with a single stab wound to right axilla. Patient is agitated.
interpret the CXR
manage the sucking chest wound
manage the pneumothorax
discuss effects of positive pressure ventilation on pneumothorax
manage the patients agitation
Sucking chest wounds – A “sucking” chest wound exists when air enters the pleural cavity preferentially via an open chest wound, rather than the lungs via the trachea. Placement of an occlusive dressing, taped on three sides, over a sucking chest wound can seal off air entry into the pleural cavity and prevent the expansion of a pneumothorax.
Traumatic pneumothorax management:
Penetrating Chest Trauma
2022.1 Station
Young male with single stab wound to right axilla. Becomes extremely agitated.
Interpret the CXR
- Radiopedia lecture “chest trauma”
Discussed the effects of positive pressure ventilation in pneumothorax
Ep 174 Is Less More? Saving EM and Traumatic Pneumothorax – Highlights from CAEP 2022
MASSIVE HAEMTHORAX =
Large volume blood loss – >1500mls on initial chest tube placement
Ongoing blood loss from chest tube >200mls/hr for >2hrs
The need for ongoing blood transfusion due to haemodynamic instability
PPV causes the patients intrathoracic pressures to exceed atmospheric pressure, worsening the pneumothorax.
Tension Pneumothorax
EM rapid bombs ep 63 tension pneumothorax
Know USS findings of pneumothorax - they will show picture in M-mode
“Tension pneumothorax is a clinical diagnosis—ideally before a radiograph—and is immediately treated by needle decompression, finger thoracostomy and/or a tube thoracostomy”
“A site that is being more commonly used is the fourth to fifth intercostal space at the anterior axillary line, which is the shortest distance from the skin to the pleura”
Needle decompression
- 2nd intercostal space in the midclavicular line OR
- 4th intercostal space at the anterior axillary line
Safe triangle bordered by:
- 5th intercostal space
- pectoralis major
- latissimus dorsi.
SIZE
erect PA film measure apex - cupula <3cm = small
The British Thoracic Society definition:
Interpleural distance at the level of the hilum
2cm = 50% pneumothorax
<2cm = small
>2cm = large
Pneumothorax and POCUS
Absence of lung sliding.
Absence of Comet tails
Presence of the “lung point” or “transition point”
Absence of seashore sign in M mode (presence of
barcode sign)
Cervical Spine Injury
2020 Examination station
25yr old patient BIBA after MVA. Reports neck pain. C spine immobilisation applied.
The patient is in resus and has been assessed by the trauma team. They are haemodynamically stable with no obvious injuries.
Assess cervical spine and clear clinically.
Outline your focused assessment to clear the cervical spine
Then, perform the focused examination on the normal subject
Medical Expertise (80%)
- history (30%)
- examination (50%)
Prioritisation and Decision Making (20%)
NEXUS
- Absence of midline cervical tenderness
- Normal level of alertness and consciousness*
- No evidence of intoxication
- Absence of focal neurologic deficit
- Absence of painful distracting injury†
NSAID mnemonic
- Neurological deficit
- Spinal tenderness
- Alertness
- Intoxication
- Distracting injury
Distracting injuries include:
- long bone fractures
- visceral injuries
- crush injuries
- burns
- large lacerations
High sensitivity 99.6%
Low specificity 12%
Negative predictive value 99.9%
Not validated in patients >60yrs
CANADIAN C-SPINE RULES:
- Age 65 years or older
- A dangerous mechanism of injury*
- The presence of paresthesias in the extremities
- Simple rear-end motor vehicle crashes
- Patient able to sit up in the ED
- Patient ambulatory at any time
- Delayed onset of neck pain
- Absence of midline cervical tenderness
The patient is able to actively rotate neck 45 degrees (regardless of pain).
C-spine is cleared, no imaging needed
Dangerous mechanism
- Fall from height >1 metre (5 stairs)
- Axial load to head (e.g. diving)
- MVA high speed (greater than 100 km/hr),
- Rollover
- Ejection
- Motorised recreational vehicles
- Bicycle struck or collision
Highly sensitive 99.4%
More specific 45%
Negative predictive value 100%
(likelyhood that patient does not have c-spine injury)
Paediatric Blunt Trauma
2021.2 Case Based Discussion
Paediatric patient injured by a car
Interpret the CXR
Patient has pneumothorax
Pulmonary contusion is the most common pulmonary injury
deflating the stomach to improve breathing
Use POCUS for pneumothorax and tamponade
Small pneumothorax are usually managed conservatively
deflate the stomach before chest tube placement
use pigtail drain - useful in pneumo and haemothorax,
CT
