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
Paediatric Blunt Trauma
2022.2 CBD station
8yr old child fall out of tree (blunt trauma)
Routine trauma series for paediatrics:
- C-spine xray
- CXR
- pelvic xray
CT abdo:
- liver laceration
- spleen laceration
- ureteric injury
- duodenal haematoma
- duodenal perforation
- pancreatic haematoma
Most abdominal injuries are solid organ injuries that are managed conservatively, non-operatively
Paediatric BIG Score - prognostic tool
Oxygenation - High flow oxygen NRBM target SaO2 >95%
IV access or early IO
Give tranexamic acid 15mg/kg IV
Fluid resuscitation 10ml/kg with RBC through fluid warmer
MTP RBC: FFP: platelets 1:1:1 ratio
Warmed 0.9% NS 10ml/kg IV if no blood available
Analgesia - fentanyl 0.5mcg/kg IV
Reduce exposure - cover with warm blankets, Q1h temp target normothermia 36-37deg
Check BSL - treat hypoglycemia with 2ml/kg 10% dextrose
Allow parents to be present
- they will help with history and child co-operation
Be mindful of non-accidental trauma
MONITORING IN MASSIVE HAEMORRHAGE:
- Q1h VBG, FBC, Coags including fibrinogen
pH >7.2
- ionised calcium > 1mmol/L = give 0.1ml/kg 10% calcium chloride IV
- treat K+ >6mmol/L with insulin actrapid 0.1u/kg IV + 10ml/kg 10% dextrose
- check fibrinogen, keep > 1g/L, give cryoprecipitate 10ml/kg IV
- consider giving factor 7 after 2 cycles of blood/ffp/platelets
- keep platelets > 50
Normoglycemia target 4-10mmol/L
Temperature 36-37
Paediatric trauma
Indications for Transfer to a Pediatric Trauma Center
Mechanism of injury:
Ejection from motor vehicle
Fall from a significant height
MVA with death of another vehicle occupant
Injuries:
Multiple severe trauma
More than three long-bone fractures
Spinal fractures or spinal cord injury
Amputations
Severe head or facial trauma
Penetrating head, chest, or abdominal trauma
Pregnant Trauma
2023.1 CBD station
the management of a pregnant patient who has been involved in an accident
interpret the chest xray
- Do not defer radiology for concerns of fetal radiation exposure
- Risk to fetus is highest during first 15 weeks of pregnancy
*Discuss with radiologist can request low radiation dose protocol
Domestic violence:
- Incidence is increased in pregnancy
* Most commonly struck area is abdomen
* Consider domestic violence
as a cause of trauma
OBSTETRIC RELATED INJURIES:
Placental abruption - USS cannot rule out placental abruption
Uterine rupture
Preterm labour
Fetal-maternal haemorrhage
- Kleihauer test used to detect and quantify extent of FMH
- administer Rh D immunoglobulin if
Rh D negative
Amniotic fluid embolism
DIC
Premature rupture of membranes
Foetal demise
PREGNANCY RELATED INJURIES:
- liver and splenic injury (enlarged in pregnancy)
- bladder rupture
- ureteric rupture
- ovarian vein laceration –> retroperitoneal haemorrhage
Pelvic fractures –> high rate of foetal demise
Pneumothorax:
If chest tube indicated → insert 1–2 intercostal spaces higher than usual
Use cryoprecipitate early and aim to
maintain fibrinogen levels above 2.5 g/L
Cardiac monitoring and pulse oximetry
AIRWAY + BREATHING:
- HFNP 60L/min + 15L NRBM
Lateral displacement of uterus to left or left lateral tilt with a wedge
2x large bore IV lines
BSL, VBG, FBC, UEC, LFT, Coags including fibrinogen, Calcium, Group and Screen
Tranexamic Acid 1g IV, followed by 1g over 8hrs
Early cryoprecipitate
Early activation of Massive haemorrhage protocol
Perform eFAST
- free fluid is just as easy to see as non-pregnant patients
- foetal assessment - FHR, placenta, presentation, estimate gestational age
FOETAL MONITORING
- CTG in >23 weeks
CXR
Pelvic XR
Will need CT scans for chest trauma:
- rib fractures can injure the liver and spleen
- ovarian veins can rupture and cause retroperitoneal bleeding which cannot be detected with USS
INTUBATION PLAN:
POSITION:
- RAMPED
- Reverse trendelenburg
- Tragus in line with sternal notch
- Face parallel with ceiling
Increased risk of aspiration
- decanto or yankauer suction catheters
Increased risk of CICO
- prepare for surgical airway
- assess landmarks and mark front of neck
most experienced operator, video laryngoscope, hypercurved D blade with ETT preloaded onto a fixed stylet
Two person BVM
Rescue LMA
FONA
DRUGS:
Ketamine 1mg/kg IV
Suxamethonium 2mg/kg IV
Early involvement of obstetrics and neonatal teams
Steroids for premature labor
Perimortem C-section
Resuscitative hysterotomy
If CPR has commenced and woman is > 20 weeks, perform a resuscitative hysterotomy as quickly as possible
Benefits:
* relieves aortocaval compression
* redistribution of uterine blood to other organs
* Increases functional residual capacity allowing for better oxygenation
* Increases effectiveness of CPR
Pregnant Trauma
Airway considerations
- Laryngeal oedema consider smaller ETT and bougie.
- Increased aspiration risk - relaxed lower oesophageal sphincter due to progesterone, delayed gastric emptying – consider early intubation to protect the airway, cricoid pressure.
Breathing considerations
- Increase in Oxygen demand: due to increased metabolic rate – always apply supplementary oxygen to avoid relative hypoxia.
- Functional Residual Capacity (FRC) reduced – predisposes to desaturation, especially important to consider in RSI.
- Increased RR and Tidal Volumes – ‘normally’ should have compensated respiratory alkalosis, pH 7.4-7.47, pCO2 30mmHg, HCO3- 20,
- Decreased chest wall compliance due to weight gain/large breasts /large abdomen – makes bag mask ventilation more difficult.
- Diaphragm pushed up 4cm by the gravid uterus - Chest drains should be placed higher (e.g. 3rd or 4th inter-costal space)
Circulation (haemodynamic) considerations
Relative anaemia – expansion in plasma volume but not red cell volume.
Increased blood volume - masking shock from blood loss
Altered HR and BP –
- Increased heart rate (by 10-20bpm at term).
- Lowered BP (10-15mmHg in 2nd trimester).
- Making haemodynamic state difficult to assess
IVC compression - Supine hypotension from IVC compression - position in the left lateral position.
Haematological considerations
Transplacental haemorrhage – all Rhesus negative mothers should receive anti-D within 72 hours of injury. A negative Kleihauer-Betke test DOES NOT rule out clinically significant haemorrhage.
250iU units in first trimester, 625iU beyond first trimester
Kleihauer Betke test confirm the dose of Anti-D required post sensitising event. i.e if she needs
more than 625IU (if kleihauer >6ml will need inc dose andi-D)
Hypercoagulable state - Increased fibrinogen and D dimer
Musculoskeletal considerations
Increased joint laxity due to progesterone.
- Normal to see widened SI joints and pubis symphysis on X-ray.
Pelvic fractures - consider significant injury to foetus
Foetal considerations
- Continuous CTG required for minimal 6 hours post trauma in pregnancies >24 weeks, even for minimal trauma.
- Ultrasound is poor at excluding placental abruption.
- premature labour may go unnoticed especially if intubated, paralysed or mentally obtunded
Autonomic Dysreflexia
2023.1 discuss with RMO
Discuss the assessment and management of a patient
with complications from a spinal cord injury, which the junior doctor has not recognised.
Causes: often painful stimuli below the level of spinal cord injury
- bladder distention in urinary retention
- constipation and faecal impaction
- any surgical procedures (even under GA)
- pressure sores
- urinary tract infections
Autonomic dysreflexia
- C-spine or high T-spine injuries (above T6)
- sympathetic surge triggered by stimulus below the level of the spinal cord injury
- usually a painful stimulus like urological procedure (cystoscopy), urinary retention, faecal impaction, pressure ulcer.
⚠️ Due to lack of sensation, patients may be unaware of these triggers.
Episodic severe hypertension is the hallmark finding.
Severe hypertension may lead to Posterior Reversible Encephalopathy Syndrome (PRES) or intracranial hemorrhage, if untreated.
Headache often occurs.
Exaggerated parasympathetic activation occurs above the level of cord lesion. This causes:
- Cutaneous flushing.
- Sweating.
- Nasal congestion;
- oral and respiratory secretions.
- Pupillary contraction, blurred vision.
Exaggerated sympathetic activation occurs below the level of cord lesion, causing:
- Pale, cool limbs.
- Piloerection.
May have baroreceptor mediated bradycardia
ASSESSMENT:
- bladder scan for urinary retention
- Examine skin for pressure sores
- PR for faecal impaction
MANAGEMENT:
(1) Relieve precipitant/painful stimuli
- place IDC to relieve retention
- stop any painful procedures
- disimpaction and enemas
(2) Treat hypertension:
Hydralazine 5mg IV, repeat in 5min
(beta blockers should be avoided as these could exacerbate reflex bradycardia)
Geriatric Trauma
2021.1 Case based discussion
Management of a geriatric patient who has fallen from a step ladder onto concrete.
PHYSIOLOGICAL DIFFERENCES:
*Serious injury with low mechanism trauma
*Poor physiological response mechanisms:
- don’t mount response to shock
*Osteoporosis:
- fractures (ribs, spine, pelvis, long bone)
*Arthritic changes:
- cervical spine injury likely
*Dentures:
- difficult BVM
*Medications:
- don’t mount physiological response on beta blockers & calcium channel blockers
*Anticoagulation
*Cognitive impairment and previous strokes make neurological assessments difficult
*Lung disease (COPD)
- low reserve, desaturate quickly
*Cardiovascular disease:
- IHD/heart failure need to be careful with RSI
- careful with fluid resuscitation –> can cause APO
*Liver and renal disease affects drug metabolism - reduced drug doses
*Poor skin integrity –> prone to pressure sores
*Prone to hypothermia
GERIATRIC FALLS:
Peripheral neuropathy
Muscle deconditioning
Slow reaction times
Visual impairment
Hearing impairment
Parkinson’s disease
Orthostatic hypotension
Polypharmacy
MANAGEMENT:
Immobilise the cervical spine
(prone to fractures) - important to maintain c-spine immobilisation
Bind the pelvis (prone to fractures)
Lower threshold to activate massive haemorrhage protocol
Anticoagulation reversal
Analgesia: (lower doses)
- ketamine 10mg IV, reassess
Use POCUS to guide resuscitation
- b lines in pulmonary oedema
- IVC
- hyperdynamic LV
Full CT trauma series
MODIFIED RSI & INTUBATION:
- is it truly indicated?
- is it line with the patients goals of care?
Preoxygenation:
leave dentures in for BVM ventilation
take out for for intubation
C-spine immobilisation makes adequate positioning difficult
- hyperangulated D blade with fixed stylet
Induction - lower dose:
- ketamine 0.5-1mg/kg IV
distribution time is slower, need to wait for it to take effect
Paralytic - use higher dose
- rocuronium 1.2mg/kg IV
RIB FRACTURES:
- morbidity and mortality correlates with increasing age and multiple rib fractures
- pulmonary contusions common
- lower rib fractures can injure liver and spleen
- pain leads to agitation and delirium
- pneumonia
- respiratory failure requiring mechanical ventilation
Adequate analgesia
- multimodal (panadol, nurofen, endone)
- regional nerve blocks
PCA - 10mcg iv bolus, lock out period 5min
they need to be able to sit up and cough effectively
Clear the spine as soon as possible so that they can sit up
Trauma Tube thoracostomy in elderly is associated with complications (empyema) and poor outcomes. Consider if this is really indicated.
PELVIC FRACTURES:
- lateral compression fractures can bleed into retroperitoneum (not seen on FAST)
PROGNOSTICATION AND GOALS OF CARE IN OLDER TRAUMA PATIENTS
- difficult to prognosticate in the emergency department
- frailty is a strong indicator of poor prognosis
- this is a potentially life threatening problem and they could die from this injury
providing dignified care in line with the patients wishes
DISPOSITION:
- need to manage at a trauma centre (reduces mortality, better outcomes)
- require multidisciplinary care
Anaesthesics pain team
PT, OT, geriatrician, dietician
Spinal Cord Injury
Corticospinal tract - motor function
Spinothalamic tract - pain and temperature sensation
Dorsal colum - vibration and proprioception
CERVICAL SPINE IMAGING:
anterior vertebral line
posterior vertebral line
spinolaminar line
interspinous line
Denis spinal columns
- anterior column
- middle column
- posterior column
Assess prevertebral thickness
- 7mm at C2
- 2cm at C7
swelling or haematoma
widening between spinous processes
C1 atlas - jeffersons fracture (burst fracture with axial load)
C2 axis - odontoid fractures, hangman fractures - pars interarticularis
Transverse foramen fracture - vertebral artery injury –> needs CT angiogram
Bilateral facet joint dislocation
MRI for normal CT but can’t clear spine clinically
MRI for abnormal CT
- surgical planning (urgent haematoma evacuation)
- spinal cord prognosis
SPINAL SHOCK:
- flaccid paralysis and areflexia below level of spinal cord injury
- reversible
High cervical injuries will cause respiratory failure and will need intubation
return of bulbocavernous reflex is a sign that spinal shock is resolved and the neurological deficits that are present are permanent
NEUROGENIC SHOCK:
- spinal cord injury above T6 level.
- hypotension and bradycardia
- cutaneous vasodilation leading to hypothermia
- priapism
Prevention of secondary injury
Maintain MAP 85 with noradrenaline or adrenaline infusion
SPINAL CORD SYNDROMES:
CENTRAL CORD SYNDROME
- Incomplet paralysis
- extension injury
- good prognosis
- arms weaker than legs
- decrease in pain and temperature (arms worse than legs)
- bladder dysfunction
- vibration and proprioception maintained
ANTERIOR CORD SYNDROME
- flexion injury
- poor prognosis
- moto loss below lesion
- temp/pain loss below lesion
- proprioception maintained (only dorsal column is spared)
BROWN SEQUARD SYNDROME
“penetrating injury with hemitransection of the spinal cord”
- Ipsilateral weakness below the level of the lesion
*Ipsilateral loss of vibration sense and proprioception below the level of the lesion
*Contralateral loss of pain and temperature sensation below the level of the lesion
Complete transection - poor prognosis
complete loss of motor and sensory function below level of lesion
presences of bulbocavernous reflex
RIB FRACTURES
Rib fractures
” it takes great force to fracture the first and second ribs, Such fractures prompt investigation for myocardial injury, bronchial tears and major vascular injuries”
Complications:
- Pneumothorax
- Hemothorax
- Pulmonary contusion
Imaging
CXR
- 30% sensitive, 90% specific
- “for each fracture that is visualised, there is another that is not”
- Harder to see fractures that are not displaced
US
- Time consuming to image all ribs
- Uncomfortable for patient
CT
- CTA is the gold standard
- Indicated in any patient with 3 or more rib fractures seen on plain CXR
- Detects complications and may identify source of bleeding
o Intercostal and internal mammary arterial injuries may be suitable for interventional radiology
Management
Intercostal nerve blocks
Epidural if multiple lower rib fractures
Criteria for admission
- 3 or more rib fractures
- COPD, asthma, smokers
- Have complications (pneumothorax, haemothorax, pulmonary contusion)
- Pain not controlled with oral analgesia (must be able to deep breath and cough)
- Inability to cope at home with no social supports
HDU/ICU admission for high risk groups
- > 3 fractures
- Flail chest
- Elderly
- Respiratory compromise
Erector spinae block
- Preferred for 3 or more rib fractures
- Ropivacaine through a catheter placed deep to the erector spinae muscle
- Performed under US guidance
- 15ml 0.2% ropivacaine every 3hrs
- Simpler to perform than epidural
- Avoids potential to cause pneumothorax from intercostal blocks
Intercostal nerve blocks
- Bupivacaine 0.5% with adrenaline
- Inject 2ml each segment (max 20ml)
- Anaesthetise level above and below the fracture, posterior to mid-axillary line,
- Suitable for 1-2 rib fractures
- Limitations:
o Only temporary relief, bupivacaine lasts 8-12hrs, bd injections required
o Risk of pneumothorax performing block 1.5% incidence for each rib blocked
o Difficult to block 1st-7th ribs and posterior rib fractures
o Bupivacaine cardiotoxic if accidental intravascular injection
Epidural - HDU/ICU setting - Reduces mortality and pulmonary complications - Complications o Total spinal anaesthesia o Hypotension o Masking of abdominal injuries
Chest wall stabilisation surgery - Not commonly performed - Possible indications o Flail chest with >3 rib fractures in >2 places o Especially if fractured and displaced o Chest wall deformity o Open rib fractures
FLAIL CHEST
- 3 or more ribs fractured with at least 2 fractures of the same rib
- Paradoxical chest wall motion
- Pulmonary contusion common
- Ventilatory support
Penetrating Neck Injuries
Zone 1: Clavicles - cricoid cartilage
- spinal cord
- carotid and vertebral arteries
- sympathetic chain
- phrenic nerve
- trachea
- oesophagus
- thoracic duct
- lungs apices
- superior mediastinum
Zone 2: Cricoid cartilage - angle of mandible
- spinal cord
- carotid and vertebral arteries
- trachea
- oesophagus
- larynx
Zone 3: Angle of mandible - base of skull
- spinal cord
- carotid and vertebral arteries
- pharynx
c) Reference: Tintinalli’s table
Hard signs:
- shock unresponsive to fluid resuscitation
- expanding or pulsatile haematoma
- active arterial bleeding
- air bubbling from wound
- thrill or bruit
- stridor/respiratory distress
- dysphonia
- haemoptysis
Soft signs:
- hypotension in the field
- non expanding and non-pulsatile haematoma
- subcutaneous emphysema
- hoarse voice
- proximity wounds
- neck tenderness
d) Reference: Tintinalli’s table
Clinical Factors Indicating Need for Aggressive Airway Management:
- Stridor
- Acute respiratory distress
- Airway obstruction
- Haemetemesis/Haemoptysis
- Expanding neck hematoma
- Profound shock
- Extensive subcutaneous emphysema
- Alteration in mental status, GCS <8
- Tracheal shift
MANAGEMENT:
sit up right
preoxygenate 15L NRB and NP
(no positive pressure ventilation - this will worsen subcutaneous emphysema)
2x large bore IV cannulae
Lateral Canthotomy and Cantholysis Procedure
Reference: Tintinalli’s
Prep with betadine
Infiltrate up to 4mg/kg lignocaine with adrenaline to lateral canthus
Use Kelly clamp to horizontally clamp the lateral canthus and lateral orbital rim for 1min (crush tissue to minimize bleeding)
make a 2cm incision to the clamped tissue using sterile scissors
retract the lower eye lid to expose the lateral canthus ligament
cut the inferior crus
cut the superior crus if IOP does not drop
