Trauma

Question 1

What are the aims of the primary and secondary surveys?

Answer 1

Primary survey = identify and correct any immediately life threatening conditions
Secondary survey= once patient stable identify all injuries no matter how minor

Question 2

What is C ABCDE?

Answer 2

used in trauma where before the normal ABCDE assessment you need to address catastrophic external haemorrhage

Question 3

History needed in a trauma?

Answer 3

mechanism of the injury, energy and transfer
then AMPLE history

Question 4

Order of interventions in airway?

Answer 4

look for obvious obstructions and remove, suction if appropriate
then head tilt chin lift/ jaw thrust

if that does not work or patient obstructs again when you let go of manoeuvre you need an airway adjunct

1. guedel
2. nasopharyngeal
3. LMA

definitive airway management would be with ET tube

If patient cannot be intubated or ventilated they need a surgical airway

Question 5

When are guedel/ oropharyngeal airways not well tolerated?

Answer 5

when a patient is not unconscious

Question 6

Who should you not use a NP airway in?

Answer 6

people with base of skull fractures
signs of base of skull fractures include: battle sign (bruising behind ear), raccoon eyes, clear fluid (CSF) or blood running from ears or nose

Question 7

Explain what paradoxical breathing is and what it may be a sign of?

Answer 7

when the chest moves in on inspiration and out on expiration (opposite to what it usually does)

may be a sign of flail chest where two or more ribs become detached from the rib cage

Question 8

Explain 4 types of shock?

Answer 8

hypovolaemic - loss of blood or fluid in burns
Obstructive - physical obstructive to flow e.g. tamponade or tension pneumothorax
distributive - massive vasodilation e.g. neurogenic, septic or anaphylactic shock
Cardiogenic - pump failure

Question 9

Neurogenic vs spinal shock?

Answer 9

neurogenic shock is when you get loss of sympathetic outflow in trauma and massive vasodilation- clue in a question - people with neurogenic shock appear flushed

spinal shock is the initial flacid paralysis and arreflexia you get in spinal injury - eventually these people if spinal injury complete will then get paralysis with UMN signs

Question 10

Aim when resuscitation of someone with massive haemorrhage?

Answer 10

presence of radial pulse (systolic 80-90)
NOT normotension

Question 11

What is sent in massive haemorrhage?

Answer 11

4 packed red cells and 4 frozen plasma plus a pool of platelets
red cells are universal o neg
given in ratio of 1 RCC: 1 FFP

Question 12

List GCS scoring?

Answer 12

Eyes:
spontaneous - 4
verbal - 3
pain - 2
none - 1

Verbal:
oriented - 5
confused - 4
inappropriate words - 3
incomprehensible sounds- 2
none - 1

Motor:
obeys - 6
localises to pain - 5
withdraws from pain - 4
decorticate - 3
decerebrate -2
none - 1

Question 13

Decorticate vs decerebrate posturing?

Answer 13

decorticate posturing you have abnormally bent arms
decerebrate it is abnormal extension of whole body

Question 14

During initial assessment of the airway all major trauma patients should receive?

Answer 14

high flow oxygen 15l/ min through a non-rebreather mask

Question 15

Gold standard investigation for patients with thoracic trauma?

Answer 15

CT
CXR can be done initially to pick up life threatening trauma and check tube placement though

Question 16

Signs of a tension pneumothorax?

Answer 16

patient likely to be shocked
tracheal deviation away from side of injury - late sign
hyper resonance to percussion
bony crepitus
surgical emphysema - air in the chest wall (seen as abnormal black spaces in subcutaneous layer on CXR)
flail chest

Question 17

Emergency and definitive management of a tension pneumothorax?

Answer 17

emergency management - large bore cannula in 2nd intercostal space mid clavicular line - go just above the rib below to avoid the neurovascular bundle which runs on the underside of each rib

definitive management = insertion of a chest drain
5th intercostal space mid axillary line - lateral border of the pectoralis major, anterior border or latissimus dorsi and axial border just superior to the nipple

Question 18

Management of an open pneumothorax?

Answer 18

cover the defect but only three sides so there is still a small space for air to escape but the space is not as big meaning air will start going in and out again through the trachea

Question 19

What is the most commonly injured organ in blunt abdominal trauma?

Answer 19

spleen

Question 20

What is a deceleration injury?

Answer 20

occurs when you get difference in movement between fixed and non fixed body parts

Question 21

What is the most commonly injured organ in penetrating trauma?

Answer 21

the liver

Question 22

If a patient with abdominal trauma is too unstable for a CT scan?

Answer 22

send them straight to theatre for emergency laparotomy

Question 23

3 types of major pelvic fractures?

Answer 23

vertical shear - fall from height - one part moves up so leg shorter than other
anterior posterior compression - open book fracture
lateral compression fracture - force from side

Question 24

If in major trauma there are concerns of a pelvic fracture?

Answer 24

should stabilise early on with a pelvic binder

Question 25

What is the definitive management for patients with ongoing haemorrhage related to a pelvic fracture?

Answer 25

angiographic embolisation by the interventional radiologists

Question 26

A dilated pupil on the context of severe head trauma?

Answer 26

suggests rapidly rising ICP due to pressure on the third nerve

Question 27

Investigation of choice for head injuries?

Answer 27

CT scan (skull XR plays no role)
use NICE/ SIGN guidelines to decide if needed

Question 28

What is the cushing response?

Answer 28

terminal phase of raised ICP and suggests herniation is imminent

causes bradycardia, hypertension and respiratory depression - essentially you raise your BP to try and perfuse the brain but the baroreceptor reflex drops the HR because you dont need increased vascular resistance

Question 29

Usual cause of extradural haematoma?

Answer 29

arterial bleed
rupture of the middle meningeal artery secondary to trauma of the pterion

Question 30

Classic presentation of extradural haematoma?

Answer 30

brief loss of consciousness followed by a lucid interval then a deterioration

Question 31

Appearance of EDH on CT?

Answer 31

lens shaped appearance as bounded by sutures

Question 32

Usual cause of subdural haematoma?

Answer 32

venous bleed
rupture of the bridging veins
more common in elderly or alcoholics as there is cerebral atrophy meaning the bridging veins are more stretched so more likely to rupture

Question 33

Appearance of SDH on CT?

Answer 33

semilunar appearance as not bounded by sutures

Question 34

What is a cerebral contusion?

Answer 34

bleeding into the brain parenchyma from direct impact

Question 35

Cerebral contusion vs haemorrhage?

Answer 35

no distinct cut off but contusions generally smaller

Question 36

What is diffuse axonal injury?

Answer 36

Brain injury with damage in the form of extensive lesions to white matter tracts occurring over a widespread area
The result of shearing forces from rapid acceleration/deceleration of the head for example, in high speed RTCs
One of the most devastating head injuries and a major cause of unconsciousness/ persistent vegetative state post head trauma
Initial CT scan may be normal

Question 37

What is secondary brain injury?

Answer 37

this does not occur at the time of the trauma but afterwards due to hypoperfusion or increased ICP - it is important to try and prevent this !

Question 38

Initial management of burns?

Answer 38

cool the burn (beware of hypothermia, only attempt cooling if burns < 10% total body area)
cover the burn - helps with pain and keeps it clean

Question 39

Rule of 9s for burns?

Answer 39

Body surface area can be estimated on an adult using multiples of nines

Anterior head = 4.5%
Posterior head = 4.5%
Anterior arm = 4.5%
Posterior arm = 4.5%
Anterior torso = 18%
Posterior torso = 18%
Anterior leg = 9%
Posterior leg = 9%

Question 40

Giving fluids in burns?

Answer 40

Parkland formula: 4ml x %burn x Weight(kg)
This calculates the total volume of fluid required over a 24 hour period. 50% of this total should be administered over the first 8 hours of treatment from the time of the thermal insult. The remaining 50% should be administered over the next 16 hours.

Question 41

What is a CT pan-scan?

Answer 41

A whole body CT done in major trauma