Trauma Flashcards
Management of profuse bleeding liver
Pack liver and close abdomen with bagota bag
Management of burn victim that complains of tingling of his leg and it appears dusky
Escharotomy
Formula for fluid resuscitation for burn patient and which fluid
Harmtan or Ringer lactate
2 ml of lactated Ringers x patients body weight in kg x % TBSA for second- and third-degree burns
3ml if <14 or <30kg child
4ml if electrical burns
1/2 to be given in first 8 hrs
Remaining half in next 16 hrs
To maintain urine output of 30ml/hr
Mx of very hypocalcaemic patient
10ml of 10% Ca gluconate over 10 mins
Best access for bilateral haemopneumothoraces and a suspected haemopericardium
Clam shell thoracotomy
Imaging for facial trauma planning
CT facial bones
When to CT head in 1 hour
GCS of 12 or less on admission
GCS < 15 2 hours after admission
Suspected open or depressed skull fracture
Suspected skull base fracture (panda eyes, Battle’s sign, CSF from nose/ear, bleeding ear)
Focal neurology
Vomiting > 1 episode
Post traumatic seizure
?anticoagulants
Best method for re-warming after hypothermia
Warmed Intra peritoneal
Le Fort fractures
1- horizontal nasal septum through maxilla and backwards through pterygoid region, loose teeth
2-pyrimidal from nasofrotnal suture to process of maxilla, infraorbital parasthesia, palatal mobility, malocclusion fo teeth
3- horizontal across frontoethmoid, superior lateral orbit, craniofacial dislocation, haemotympani, flat face
CVP 13 with reduced BP
Tamponade
PE ECG changes
PRAT
Peaked p waves
RAD, RBBB
Atrial arrhythmia
TWI- V1-3
Tall R V1
S1,Q3,T3
Haematemesis following burns cause
Curling ulcer
Management of flail chest
If sats <90
Intubate and ventilate
Calculate GCS
E- spontaneous
To speech
To touch
None
S- normal
Confused
Words
Sounds
None
M- normal
Localise to pain
Withdraws
Abnormal flexion to pain
Extension
None
Presentation of aortic dissection
Tearing chest pain
Hypertensive /hypo
Pregnancy or connective tissue
Can compromise right CA- inferior ischaemia
- A blood pressure difference greater than 20 mm Hg
- Neurologic deficits (20%)
- Early Diastolic murmur may be found
What meds worsen compartment syndrome
Anticoagulants
Patient has raised ICP with CT showing increased oedema what tx
Mannitol
CXR findings of diaphragm rupture
Hemidiaphragm is not visible
Bowel loops in the lower half of the hemi-thorax
Mediastinum is displaced
Often caused by A lateral blunt injury during a road traffic accident
Massive PE management
Thrombolysis with alteplase
Vertigo, dysarthria and collapse dx
Basillar artery occlusion
Lateral medullary syndrome sx
ipsilateral ataxia, nystagmus, dysphagia, facial numbness, cranial nerve palsy with contralateral hemisensory loss §
Youngster with left flank bruising ix
If harm-dynamically stable-First USS
High K, Low Na, hypotensive tx
Hydrocortisone 100mg IV
Patient with penetrating thorax trauma followed by an arrest mx
Thoracotomy
Ct shows cerebral contusion but no localising clinical signs
Intra cranial pressure device monitoring
Mx torsades de pointes
MgSO4
Dx of flail chest
> /= 2 rib fractures in more than 2 ribs
Test for CSF
Beta 2 transferrin assay
ECG changes for PCI or thrombolysis
ST elevation of > 2mm (2 small squares) in 2 or more consecutive anterior leads (V1-V6) OR
ST elevation of greater than 1mm (1 small square) in greater than 2 consecutive inferior leads (II, III, avF, avL) OR
New Left bundle branch block
Sudden anaemia and low reticulocytes
Parvovirus
Sick euthyroid biochem
Everything low with systemic illness
In the majority of cases however the TSH level is within the normal range (inappropriately normal given the low thyroxine and T3).
Reversible with illness recovery
When do patients with burns require fluid resuscitation
Adults >15% BSA
Children >10%
When should burns patients be transferred to burn centre
All full thickness
>2% in children, 5% adults
Partial >5 in <16 or >20 in adults
Hands, feet, perineum,
extreme of ages,
circumferential burns,
NAI
Not healed in 2w
Signs of inhalation injury
Major haemorrhage transfusion in trauma
Packed red cells, FFP and platelets are administered in a ratio of 1:1:1.
Most common area for aortic rupture
Distal to subclavian artery
Rib fracture with pneumothorax mx
Chest drain
Ix of trauma in pregnancy
FAST scan (high false negs in pregnancy)
if neg - CT
Colon trauma mx
If unstable- Resection and colostomy
Definitive mx of reduced gcs and unilateral dilated pupil
Parietaltemporal craniotomy
Rural units or no neurosurgery- Burr hole
CT head immediate in paeds
- Loss of consciousness lasting more than 5 minutes (witnessed)
- Amnesia (antegrade or retrograde) lasting more than 5 minutes
- Abnormal drowsiness
- Three or more discrete episodes of vomiting
- Clinical suspicion of non-accidental injury
- Post-traumatic seizure but no history of epilepsy
- GCS less than 14, or for a baby under 1 year GCS (paediatric) less than 15, on assessment in the emergency department
- Suspicion of open or depressed skull injury or tense fontanelle
- Any sign of basal skull fracture (haemotympanum, panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign)
- Focal neurological deficit
- If under 1 year, presence of bruise, swelling or laceration of more than 5 cm on the head
- Dangerous mechanism of injury
Mx of spleen trauma
Conservative- grade 1-3
Resection
Hilar injuries- grade 4 or 5
Major haemorrhage
Major associated injuries
Tx of VT and drug CI in VT
Tx- amiodarone
CI- verapamil
Parasthesia, tinnitus and drowsy after LA mx
Intralipid 20%
Metoclopramide SE and tx
Oculogyric crisis- Restlessness, agitation
Involuntary upward deviation of the eyes
Mx- Procyclidine
Full thickness burns to torso and increasing ventilation pressure mx
Escharotomy
Orbital apex syndrome
Extension of superior orbital fissure syndrome and includes compression of the optic nerve passing through the optic foramen. It is indicated by features of superior orbital fissure syndrome and ipsilateral afferent pupillary defect.
If burn patient has soot in oropharyngeal and burn nasal hairs- management?
Intubation
How short gut syndrome causes broad VT
Hypomagnesaemia
Latest sign in compartment syndrome
Loss of pulse
Prilocaine SE and mx
methaemoglobinaemia
Cyanosis and dyspnoea. This disorder occurs because of the change haemoglobin to a ferric subtype rather than ferrous (Fe2+)
Give methylene blue
Mx of mediastinal travelling trauma
o All patients should undergo CT angiogram and Oesophageal Contrast Swallow. o Indications for thoracotomy are largely related to blood loss.
Mx of haemothroax
A wide bore 36F chest drain.
o Indications for thoracotomy include:
→ loss of more than 1.5L blood initially
→ ongoing losses of >200ml per hour for >2 hours.
When to use large vs small chest drains
- Large bore chest drains -trauma and haemothorax drainage.
- Smaller diameter chest drains - pneumothorax or pleural effusion drainage.
Mx of aortic dissection
Beta-blockers: aim HR 60-80 bpm and systolic BP 100-120 mm Hg.
Urgent surgical intervention: type A dissections. This will usually involve aortic root replacement
Management of urethral trauma
Ascending urethrogram
Suprapubic catheter
Pelvic fracture and void inability
Suspect bladder or urethral injury
Mx of bladder injury
IVU or cystogram
If low grade- contusion, hamatoma- conservative
Extraperitoneal- catheterise for 10d
Laparotomy if intraperitoneal (direct blow)l, conservative if extra (pelvic fracture)
Mx of vascular trauma
Simple lacerations of arteries is directly closed
Transection of the vessel is treated by either end to end anastomosis (often not possible) or an interposition vein graft.
Superior orbital fissure syndrome
Complete opthalmoplegia and ptosis (Cranial nerves 3, 4, 6 and nerve to Levator Palpebrae Superioris)
→ Relative afferent pupillary defect
→ Dilatation of the pupil and loss of accommodation and corneal reflexes
→ Altered sensation from forehead to vertex (frontal branch of trigeminal nerve)
Nasal fracture mx
→ Control epistaxis
→ CSF rhinorrhoea implies that the cribriform plate has been breached and antibiotics will be required.
→ Usually best to allow bruising and swelling to settle and then review patient clinically.
→ Major persistent deformity requires fracture manipulation, best performed within 10 days of injury.
Retrobullar haemorrhage presentation
Pain (usually sharp and within the globe)
Proptosis
Pupil reactions are lost
Paralysis (eye movements lost)
Visual acuity is lost (colour vision is lost first)
Retrobullar haemorrhage mx
Mannitol 1g/Kg as 20% infusion, Osmotic diuretic, Contra-indicated in congestive heart failure and pulmonary oedema
Acetazolamide 500mg IV, (Monitor FBC/U+E) Reduces aqueous pressure by inhibition of carbonic anhydrase (used in glaucoma)
Dexamethasone 8mg orally or intravenously
In a traumatic setting an urgent cantholysis may be needed prior to definitive surgery.
Skull fracture types
Linear- line
Comminuted - multiple fragments
Diastasis - suture line
Basillar- base
Min cerebral perfusion pressure in adults and kids
70 adults
40-70 children
Interpretation of pupil size in head injury
Unilateral dilated- 3rd nerve compressed- tentorial hernia
Bilateral dilated- poor CNS, bilateral 3rd
Unilateral dilated -Marcus gunn pupil- optic nerve injury
Escahrotomy incisions
Lateral aspects
Neck, arms, torso, legs
Indication for throacotomy for haemothorax
> 1500mls or >1/3 patients blood
Or continued >200ml/her for 2-4 hrs
Or ongoing transfusion required
What happens in ebb phase
Decreased body temp
Decreased oxygen
Lactic acidosis
Increase stress hormon
Decreased insulin
Hyperglycaemia
Insulin resistance
What happens in flow phase
Increased body temp
Increase o2 consumption
Negative nitrogen balance
Increase stress hormones
Hyperglycaemia - lipolysis and proteinolysis
Immunosuppresion
Type A vs B dissection
Type B- distal to subclavian artery
% BSA of palm
1%
Shock classes based of HR, RR, UO
1- No tachy
2- <120, RR>20, UO 20-30
3- HR 120-140, RR 30-40, 5-15
4- HR >140, RR >35, No urine
Grading splenic trauma
1- sub capsular haematoma >10% or laceration <1cm
2- laceration 1-3cm
Haem- 10-50%
3- >3cm or >50%
4- Laceration involving segmental or hilar vessels - major devasc
5- complete shattered spleen or hilarity injury- complete devasc
Neurogenic shock signs
Bradycardia, warm peripheries, hypotensive, BP not responding to IV fluids
Child pyrexia with an unhealed burn
Toxic shock syndrome
Normal compartment pressure and when to treat
3-4mmHg
> 30 fasciotomy
Diastolic and compartment <30 difference- fasciotomy
Flexor tendon zone injuries
1- between DIP and middle phalanx
2- between 1 and distal palmar crease
3- DPC and distal margin of carpal tunnel
4- overlying carpal tunnel
5- forearm and wrist up
What should be given to partial thickness burns
Non adhesive dressing
GI changes with burns
Curling ulcer
Decrease acid production
Acute dilatation
Ileus
Ix of odontoid process
Open mouth
But usually a CT if suspected
Ligaments of odontoid
Alar- occipital condyles
Apical- top of odontoid to foreamen magnum
Management of shoulder dislocation
Closed reduction under sedation and analgesia
Arm in sling until ortho review
Kocher- traction on adducted arm, externally rotated and adducted
Hippocratic- supine, heel in axilla while traction
Grade liver injuries
1- sub capsular haematoma <10% or laceration <1cm parenchymal depth
2- 10-50%, 1-3cm and <10cm long
3- >50% or >3mc depth
4- laceration 25-75% of hepatic lobe or 1-3 segments
5- >75% of lobe of >3 segments
pCO2 effects on blood blow and CSF
Reduced CO2 causes vasoconstriction
This reduces blood flow and reduces ICP
Full thickness burns appearance
Leathery white or charred black
Escharotomy timings and IV access in burns
Deep or full thickness around chest can cause resp arrest so may need to be done before transfer to burns unit
IV access can be done through burns skin
If percutaneous difficult can do IV cut down
When should tetanus be given in trauma
If penetrating injury
And not been immunised in past 10y
GCS to intubate
<8
Pregnant lady and hypovolaemic shock signs
Late due to big increase in circulation
Fetus first to suffer
Grading renal injuries
1- contusion, subcapsula haematoma, no laceration
2- perirenal haematoma, cortical laceration <1cm
3- >1cm without urinary
4- laceration through corticomedullary junction into collection or vascular,
Renal segmental artery or vein injury with contained haematoma
5- shattered kidney or vascular
Tranfusion in haemorrhage in trauma
Whole blood
Alternatively 1:1:1 abc, plts, plasma
Structure damaged on medial ankle twist
Deltoid:
Anterior tibiotalar, posterior tibiotalar, tibiocalcaneal, tibionavicular,
Structure damaged on lateral ankle twist
Anterior talofibular
Posterior talofibular
Calcaneofiubular
Cardiac tamponade effect on CVP, PAP and JVP
CVP PAP elevated
Increased JVP on inspiration- Kussmaul sign
Pulsus paradoxis- drop in systolic on inspiration
Penetrating abdo injuries usually involved
Small bowel
Then colon
then liver
Mx of colles fracture
Manipulation if significant displacement
Reduction
Dorsal back slab
Distal fragment in palmar flexion and ulnar deviation
Mx of hypothermia
Slow rewarming 1C per hour
AS may cause pul/cerebral oedema
Warming with IV fluid, blankets and bear hugger
Types of odontoid fracture
1- tip of peg
2- base of dens, commonest, extension
3- base of dens- extend into body of axis
Mx of odontoid fracture
1- usually stable
2- surgical reduction and halo and body cast
If no fusion by 12w - may need fusion
Hangman fracture and mx
From hyperextension
Peduncles of C2
External immobilisation
Jefferson fracture
Ant and post arches of C1
Caused by blow to back of the head
Le fort 3 fracture with unstable airway mx
Cricothyroidotomy
Most important thing to check with circumferential burns
Peripheral pulses and cap refill
Ix after sternal and rib fracture
CT
If concerned about cardio contusion- serial trops and ECG
Normal CVP range
3-8cmH20
Hypertrophic scar features
Normally regresses with time
Confined to margin Respond to steroids, compression therapy
Occur with deep dermal burns
Wounds by secondary intention
Crossing flexor or tension lines
Main function of menisci
Shock absorbers
Main cause of hypoxia with flail chest
Pulmonary contusion
Physiological response to shock
Vasoconsritciton
Haemodilution
Tachycardia
Supracondylar fracture, unable to flex thumb and do ok sign, no sensory defect
AIN damage
Types of joints
Synovial- hylaine capsule with synovial fluid
Fibrous- a fixed joint where collagenous fibrous connective tissue connects two bones. Fibrous joints (synarthroses) are usually immovable and have no joint cavity
Cranial suture, between ulnar and radius, tibia and fibular
Cartilaginous- bone meets cartilage
Primary- ribs and epiphyses
Secondary- union of bones with thin lamina of hyaline cartilage
Most common salter Harris
2
Ix for haematocele
US
Signs of teste rupture on US
Hetegeneous pattern of testicular parenchyma and disruption fo tunica albuingea
Control of poorly controlled diabetes with infected burn
VRII until infection improves
What should an amputated digit be kept in
Wrapped in saline soaked gauge
Plastic bag chilled in ice water
Specific placing of chest drain
Use US
4th 5th ICS
In between anterior and mid axillary below axilla
Abdo trauma, pregnant, no free fluid on FAST scan, what next
CT
BSA of perineum and arms
Arms- front 4.5% back 4.5%
Perineum 1%
ml required for fluid resuscitations in electrical burns
4ml x BSA x weight
Open fracture, severe bleeding, HR 220 what should you do
Apply direct pressure to control bleeding
Which shoulder dislocation causes axillary nerve damage
Anterior
What does Le fort 3 fracture go through
Nasofrontal suture
Maxilla frontal suture
Orbital wall
Zygomatic arch
Irrigation amount for open fracture
3L guistillo 1
6L for 2
9L for 3
What should be monitored in electrical burns
Myoglobin
Renal failure- urinary output
If myoglobin detected- fluid resuscitations to aim for 100ml/h of urine
Hydrofluroic acid burn effects on electrolytes
Hypocalcaemia
Blow to lateral knee can cause
Unhappy triad
ACL, MCL, MM
MM as attaches to Mcl
Primary intention process
Occurs when wound is closed between 12-24 hrs
Wound edges meet
Epithelisaition occurs within 48 hrs
Immediate inflammatory
Prolif phase- migration of fibroblast and capillaries into wound lasting 3w
Collagen detected day 4
Main cells involved in soft callus formation
Osteoblasts and fibroblasts
Most common fracture in direct blow to patella
Stellate
Comminuted
Mx of patella fracture
Undisplaced - cylinder cast
Displaced transverse- internal fixation
X ray signs for aortic injury
Wide mediastinum
Obliteraated aortic knuckle
Depressed left bronchus
Large left haemothorax
Plerural cap
Depressed right bronchus
Best method for monitoring fluid requirements in trauma and what it should be kept at
Urine output
>0.5ml/kg/hr
Fat embolism feeatures
Hypoxic
Petechial rash on trunk axilla and conjunctiva
Confusion
Excessive crystalloids in trauma patients can cause
ARDS
Structure most likely damaged in tracheostomy
Thyroid ima
Anterior jugular retracted laterally
Area of incision for trachy
Midway from cricoid to sternum
Fluids used in hypovolaemic shock
Hartman for 1 or 2 may be enough
Hartmann plus blood products for 3
Symptoms and signs of orbital floor fracture
Structure may herniate through ethmoidal or maxillary sinus
Trapdoor appearance on x ray
Occular injury- enopthalmos and diplopia especially on upward gaze
Burn types and symptoms
Superficial- red and painful no blister
Superficial partial thickness- superficial dermis- blisters, painful- papillary dermis
Deep partial- most of dermis- pale some blisters, not much pain- reticular dermis
No eschar
Both can look lobster red with mottling
Full thickness- subcutaneous fascia, waxy, painless
Eschar
Most common organ damaged with blunt trauma
Spleen
Mortality of open pelvic fractures
50%
Traumatic AV fistula features
AV fistula forms after trauma to artery and vein
If large can cause ischamia, left to right shunt can cause heart failure
When to immobilise C spine and with what
Unconsious with traum a
Blunt injury above clavicle
Multi systemic trauma
Initially immobilised in line position - no traction- if resistance don’t
Use rigid collar, sandbags and tape
Hypovolaemic shock on pulse pressure
Narrows
Patient with neck wound- stable, mx
CT angio head and neck then theatre
Cause of absent left breath sounds after intubation
Intubation of right mainstream bronchus
Cushing response
Decreased HR
Increased BP
Increased PP
Decreased RR
Most common complication of urinary extravasation of kidney
Urinoma
Physiological effects of burns
Hyperthermia
Hypermetabolic state
Immunosuppression
Arms in supine position in surgery- which nerve at most risk of damage
Ulnar
Adequate urine output in children
1-2ml/kg/hr
Meds used in tx frostbite
Aspirin
Subaponeurotic haematoma symptoms
Between galea and pericranium
Large fluctuant mass
Gradually resolves by selfW
Which bones are difficult to break but if broken suggest high energy trauma and extensive soft tissue damage due to location
First rib
Sternum
Scapula
Mx of urethra trauma
Retrogrdae urethrography first
Then suprapubic cathete r
Mx of liver injury
If patient stable and low grade- conservative
Unstable- lapratoy and liver packing
What is a FAST scan likely to miss
Kidney injury as retroperitoneal
Ix for kidney injury
Delayed phase CT with contrast
Pain control of NOF
If uncontrollable on opioids and para
Fascia iliaca block
If elderly and non displaced NOF mx
If well- IF
If poor mobiliser, imapired- Hemi
When to intubate
Inadequate ventilation - ie RR >35 or low is asthma
Specific- head injury, GCS <8, raised ICP or burns
Chest injury- flail chest, pulmonary contusion
High spinal trauma
Mx of hip dislocations
Allis technique
flex knee to 90
Apply longitudinal traction
With someone applying counter traction at ASIS
Adduct and IR then extend
When may amputation by necessary
Uncontrollable haemorrhage in open fracture
Penile fracture
Break of tunica albuginea of penis (fibrous capsules of erectile bodies)
If bleeding in Bucks fascia- only in penis
If Bucks breaks- butterfly in perineum
Wound management of open pneumothorax
Wound dressing on 3 sides
Blocking entry when inhaling
Allowing exit when exhaling
Most effective preventative of fat embolisms
Early reduction
PP and peripheries in neurogenic shock
Warm peripheries
Widened pulse pressure
Types of blast injury
1- primary - direct pressure- damage to gas organs, tympanic
Secondary - fragments
Tertiary - impact With objects
Quaternary - related injuroes, illnesses not related to 1-3- burns
Mx of penile fracture
Surgical exploration
What burns are used in parkland formula
All part from superficial
Ie erythema without blisters
Chemical burns treatment, acid vs alkali
Flushed with large amounts of water
Of dry brushed first
Alkali penetrate deeper
Acid hurts more
Hydrofluric causes low calcium - require systemic Ca
Patient presents with hoarseness voice, subcutaneous emphysema, tender around neck - dx and mx
Laryngeal fracture
Endotracheal intubation with C spine immobilisation if unstable
Weber fracture
Fibular fracture
Look at level of syndesemosis where fibular joins tibia just above talus
How much of tibia should be kept for below knee amuptation
At least 8cm
15cm desirable
Flap vs graft
Graft only take on well vascularised surface- wouldn’t on bone
Split- no limit, full smaller
Flap- limited by territory blood supply
Most common bladder injury
Extraperitoneal perf by pelvic fracture
Signs of cervical cord injiry
Flaccid areflexia
Diaphragmatic breathing - loss of intercostal muscles
Flex but not extend the elbow
Hypotension with bradycardia
Priapism
Movements unable to do if common fibular damage
Inversion, eversion and dorsiflexion
Trauamatic amputation haemorrhage mx
Tourniquet
Which areas to look in FAST scan
Looks for fluid in 4 areas (hepatorenal, splenorenal, pelvic, and pericardial spaces)
Determining bladder vs urethral injury
Bladder- CT cystogram
Urethral- retrograde uretrogram
Rhabdomyolysis electrolytes
Fluid and electrolyte abnormalities
Hypovolemia
Acidemia
Hyperkalemia
Hyperphosphatemia and hypocalcemia
Tetanus prophylaxis
Tetanus-prone wound: >6 hrs postinjury; stellate or avulsion; >1 cm deep, projectile or crush-type injury; devitalized, contaminated, or ischemic tissue
Unknown status in general or < 3 adsorbed tetanus toxoid doses or >5-10 years since last dose: administer tetanus toxoid 0.5 cc IM
With tetanus-prone wounds and above, administer tetanus immune globulin 250 units IM.
Witnessed arrest, suspicious of tamponade tx
Thoracotomy
