trauma Flashcards
what is the leading cause of death in the developed world for 1-44yo?
trauma and injury
why is a systematic approach important when dealing with trauma?
- allows pts to be sent to correct centres after triage and stabilisation
- higher quality care and improved outcomes
what is the “golden hour”?
concept that pts suffering critical injuries should start receiving care in the first hour following injury to reduce mortality and morbidity
what is the general structure for managing a patient with trauma?
1 primary survey
2 resuscitation
3 secondary survey
4 initiation of definitive care
5 reassessment of pt at regular intervals
describe the primary survey for a pt with trauma
1 Airway with spine protection (prevent further harm to neck/spinal cord) = cervical in-line stabilisation or positioning upright and forwards
2 Breathing
3 Circulation
4 Disability = AVPU, GCS (≤8 significant)
+/- some assessment of injury at this stage
what is the Glasgow Coma Scale and what is assessed?
- objectively assesses extent of impaired consciousness
- rated 3-15 with ≤8 indicating significant deficit (should be intubated)
- eyes /4
- motor /6
- voice /5
describe what is assessed in the secondary survey for a pt with trauma (9)
- full history, also mechanism and time of injury, esp head injury, safeguarding, alcohol or drugs
- inspection of H&N = injuries, symmetry, Battle’s sign, etc
- palpation for tenderness, step deformities, swelling
- eyes = pupil reflex, visual acuity, range of movement, diplopia, haemorrhage, swelling, exophthalmos
- ears = gross abnormalities, tympanic membrane, fluid leakage
- nose = bridge (nas-ethmoidal complex), airflow, bleeding, fluid leakage
- full CN examination (short = 3/4/5/6/7)
- mouth opening
- IO = occlusion, dental trauma and fragments, bleeding, lacerations, haematoma, fractures
what is Battle’s sign?
bruising seen behind the ear (over mastoid process) which may indicate a skull base fracture
if a patient has clear fluid leakage from ear/nose, what should you test for and what does this confirm?
- beta 2 transferrin
- only found in CSF
for visual acuity, should you test the injured or uninjured eye first?
- injured first
- to prevent memory bias
what types of haemorrhage may affect the eye post-trauma? (2)
- subconjunctival haemorrhage
- retrobulbar haemorrhage
what is exophthalmos?
abnormal protrusion of the eyeball(s)
(AKA proptosis)
describe retrobulbar haemorrhage (what, s/s, immediate and definitive management)
- seen with some orbital fractures
- bleeding –> compartment syndrome, increased orbital pressure
- impaired vision + 4 Ps = pain, paralysis, poor visual acuity, proptosis
- urgent surgical management to prevent blindness = lateral canthotomy and inferior cantholysis
- +/- medical management = eye drops (timolol, mannitol), diuretics, carbonic anhydrase inhibitors, corticosteroids
- definitive management = remove any haematoma, decompression if needed
4Ps of retrobulbar haemorrhage
consider retrobulbar haemorrhage if impaired vision with any of the following:
- Pain
- Paralysis of ocular movement
- Poor visual acuity
- Proptosis
septal haematoma management
urgent aspiration and nasal packing (prevent reaccumulation)
what IO feature indicates mandibular fracture?
sublingual haematoma
describe epidemiology of mandible fractures (demographic, cause, location)
- 20-30yo, males
- mostly interpersonal violence
- most commonly angle and ramus, parasymphysis, condylar region
what immediate management would be involved in mandibular fracture? (3)
- primary survey
- bridle wire to reapproximate displaced fragment with rest of bone under LA (comfort, improved tongue control, decreased sublingual bleeding)
- secondary survey
what treatment is ideal for simple fractures of the ramus, body, angle and parasymphysis of mandible?
open reduction and internal fixation (ORIF)
what may be prescribed with open fractures?
antibiotics (peri-operative period)
describe what is involved in ORIF
- open reduction = relocate segments with direct vision
- place fixation (semirigid plates and screws) onto bony fragments = stabilise, allow osteosynthesis
what is intermaxillary fixation? (3)
- treatment of fractures involving maxillomandibular complex (esp condylar and panfacial fractures)
- facilitates healing (~6 weeks)
- upper and lower arches splinted together, eg with wires and archbars or elastics
what is external fixation used for? (4)
- grossly comminuted fractures
- significant bone loss
- infection
- pathology
describe the two different types of plates used in ORIF
- miniplates 2mm Ti system (transoral approach) - load-sharing so need 6 weeks soft diet
- thicker plates (EO approach) - load-bearing for bone loss, comminution, poor buttressing on either side of fracture
what are two risks with extraoral access for fixing condylar fractures?
- facial nerve damage
- difficulty manipulating and reducing proximal segment
post-operative advice for jaw fracture surgery (5)
- reassurance - neuropraxia and paraesthesia often resolve over time (sometimes permanent but hard to tell)
- regular pain relief (paracetamol, NSAIDs +/- codeine)
- 6 weeks soft diet, avoid contact sports
- good OH - soft brush at least 2x/day, CHX or warm salt water rinse 3x/day
- show how to replace any elastics for IMF
possible complications following fracture surgeries (4)
- malunion (healing in wrong position) seen as malocclusion
- non-union (failure for osseous union to occur)
- infection
- ankylosis or limited mouth opening (fusion of condyle and glenoid fossa or scarring of muscles and soft tissue)
what may increase the risk of non-union of bone following fracture surgery? (3)
- lack of bone at fracture sites
- poor compliance or infection
- failed fixation
describe anatomy of the orbit
- pyramidal shape with base being the eyelids/tarsal plates
- medial wall = ethmoid and lacrimal bones
- inferior = orbital process of maxilla and palatine bones with infraorbital NV bundle running through
what is a tripod fracture?
fracture through:
- frontozygomatic suture
- maxillary process of the zygoma (inferior orbital floor, inferior orbital rim, lateral wall of the maxillary sinus)
- zygomatic arch
(AKA zygomaticomaxillary complex fracture)
signs of zygomaticomaxillary complex injury (up to 8)
- swelling, bruising
- subconjunctival haemorrhage, infraorbital haematoma
- infraorbital paraesthesia
- ipsilateral epistaxis
- trismus (zygomatic arch impinging on coronoid)
- flattening of cheek
- step deformity
- orbit fracture features - diplopia with upwards gaze, enophthalmos, hypoglobus
what are Campbell’s lines?
- imaginary lines traced across the face on an occipitomental view skull radiograph to assess for fractures of the middle third (especially) of the face
- supraorbital and infraorbital rims
- zygomatic arches
- occlusal plane
- border of mandible
what is a white-eyed blowout fracture? (age, what, management)
- children
- fracture where springy orbital floor bone is depressed and comes back up, trapping inferior rectus and periorbital fat (often vertical motility restriction)
- no subconjunctival haemorrhage
- needs immediate repair otherwise extraocular muscle necrosis, diplopia, oculocardiac reflex and neurogenic shock
what is the oculocardiac reflex?
- traction on extraocular muscles stimulates the parasympathetic nervous system via the vagus nerve
- leading to decreased heart rate, hypotension, nausea, vomiting
which 3 orbital fracture issues need immediate repair?
- white-eyed blowout fracture
- non-resolving oculocardiac reflex
- significant early exophthalmos or hypoglobus (visible even with traumatic swelling)
which 2 orbital fracture issues can have delayed repair (within 2 weeks)?
- symptomatic diplopia (restricted motility or evidence of entrapment on CT)
- large fractures of orbital floor (>50% of floor or floor and medial wall) that are likely to cause latent enophthalmos or hypoglobus
management of isolated fracture of zygomatic arch (3)
- 7-14 days post-injury (decrease in swelling helps assess correct positioning)
- transoral via upper vestibule = zygoma elevated with Ray’s elevator (cannot do direct fixation without bicoronal incision/transfacial approach)
- Gillies temporal approach (incision in hairline to temporalis fascia) - zygoma elevated
management of zygomaticomaxillary fracture (4)
- zygomatic portion = transoral or Gillies temporal approach
- ORIF before orbital floor fracture management - with thicker plates than mandibular
- bicoronal incision needed if comminuted fracture
- orbital fractures managed transcutaneous or transconjunctival with deeper dissection +/- synthetic/autogenous materials
describe Le Fort 1 fracture
palate and alveolus separated from the maxillary complex by a transverse fracture just above the floor of the nose and antrum
describe Le Fort 2 fracture
“pyramidal” fractures, passing through the anterior and lateral walls of the maxillary sinuses and continue up through the infraorbital margins to join across the nose bridge
describe Le Fort 3 fracture
high transverse fracture where the maxillary complex is separated from the cranium by fracturing the lateral walls of both orbits, orbital floors and crosses the cribriform plates of the ethmoid
describe Le Fort fractures (cause, 2 major effects)
- created by significant trauma, less common
- may posteriorly displace and occlude the airway needing immediate disimpaction
- may cause significant haemorrhage (maxillary artery)
signs of Le Fort fracture (5)
- dish deformity (retruded midfae)
- anterior open bite, gagging on back teeth
- bilateral black eyes
- palatal haematoma (midline fracture)
- mobility of maxilla
surgical approaches to manage Le Fort fractures
- Le Fort 1 = upper vestibular approach
- Le Fort 2 and 3 = bicoronal incision
