TRAUMA Flashcards
Outline the trimodal death distribution after trauma?
Highest chance of death…
• immediately following the injury as a result of brain or high spinal injuries, cardiac or great vessel damage
• Early hours following injury due to splenic rupture, subdural haematomas and haemopneumothoraces
• Days following - sepsis or multi organ failure
Which simple airway manoeuvre should you not do on trauma patients and why?
Dont do head tilt due to high risk of c-spine injury
What do we use to assess the risk of a c-spine injury following trauma?
The Canadian C-spine rules
What are the Canadian C-spine rules?
Pt is considered high risk if they meet 1 or more of the following criteria…
• ages 65 or older
• Dangerous mechanism of injury
• Paraesthesia in any limbs
Pt is low risk if they meet none of the high risk criteria and 1 or more of the following:
• involved in a minor rear-end motor vehicle collision
• Comfortable sitting
• Ambulatory since the injury
• No midline cervical spine tenderness
• Delayed onset of neck pain
Pt is at no risk if no high risk factors, 1 or more low-risk factors and can rotate their head 45 degrees actively to the L and R
Investigation for c-spine injury?
CT
Interventions for C-spine injury?
Hard board and collar with head blocks
What are the 6 widely recognised life-threatening chest injuries following trauma?
TOM CAT
Tension pneumothorax
Open pneumothorax
Massive Haemothorax
Cardiac tamponade
Airway injury
Tracheobronchial injury
What does “on the floor, and four more” refer to?
Locating a haemorrhage - on the floor refers to the visible blood loss from an external wound and four more refers to 4 potential spaces inside the body where a large volume of blood may be lost: chest, abdomen, pelvis and long bones
Which groups of patients should you be cautious about relying on their observations in trauma?
Young people and athletes can compensate very well
Elderly dont compensate well at all
Imagine in trauma?
Whole body CT scan
FAST US can be done if CT not available or pt not stable enough
What is done in a secondary survey?
Once pt is haemodynamically stable:
AMPLE history
Head, maxillofacial, neck, abdomen, pelvis, perineum, genital, rectum neurological, spine, MSK exam
Pathophysiology of tension pneumothorax?
air enters the pleural space and is unable to escape, creating a one-way valve effect e.g. due to a flap of tissue. The continous accumulation of air leads to increased intrapleural pressure which exceeds atmospheric pressure throughout the resp cycle.
This compresses the affected lung leading to a decrease in functional residual capacity and impaired gas exchange, medistanial shift which can compress the opposing lung and compress the great veins reducing venous return to the heart and the direct pressure on the heart impairs cardiac filling which leads to a lower CO and systemic BP.
Causes of a tension pneumothorax?
Penetrating or blunt chest trauma
Iatrogenic - thoracdentesis, central venous catheter etc
Spontaneous - may have underlying lung disease or lung blebs
Clinical features of tension pneumothorax?
Acute onset dyspnoea
Pleuritic chest pain
Tachypnoea
Hyperresonance on percussion
Diminished breath sounds on affected side
Tracheal deviation away from affected side
Signs of shock
How is tension pneumothorax diagnosed?
Clinically - treatment should not await confirmation on imaging
Portable CXR is recommended if easily available??
Management of a tension pneumothorax?
Finger or needle thoracostomy initially
Placement of a chest drain in the safe triangle of the chest
What are the borders of the triangle of safety
Lateral border of pectoralis major anterior, mid-axillary line posterior, level of nipple inferior
What is a simple pneumothoraces?
The accumulation of air in the pleural space resulting in the partial or complete collapse of the affected lung
What are the types of simple pneurmothoaces?
Spontaneous - primary or secondary to underlying lung disease
Traumatic
Iatrogenic
What is a catamenial pneumothorax?
recurrent spontaneous pneumothorax occurring within 72 hours before or after onset of menstruation
Thought to be caused by endometriosis within the thorax
Features of simple pnuemothoraces?
Dyspnoea
Pleuritic chest pain
Hyperresonant lung percussion
Reduced breath sounds
Reduced lung expansion
Tachypnoea
Tachycardia
Management of a simple pneumothoraces if no significant symptoms or physiological compromise?
Conseervative care regardless of size
If primary it must be reviewed every 2-4 days as an outpatient
If secondary they must be monitored as an inpatient
What are the high risk characteristics of simple pnuemothroaces?
Haemodynamic compromise
Significant hypoxia
Bilateral
Underlying lung disease
>=50
Significant smoking history
Haemotgorax
Management of a traumatic simple pneumothoraces with high-risk characteristics?
Chest drain with inpatient family review
Management of a traumatic simple pneumothoraces but without any high-risk characteristics?
Conservative management or ambulatory or needle aspiration
When must all pmeumothoraces be followed up?
Must have FU 2-4 weeks after as an outpatient
How are recurrent pneumothoraces managed?
Video-assisted thoracoscopic surgery should be considered to allow for pleurodesis and a bullectomy
Discharge advice after a pneumothorax?
• avoid smoking
• Generally you can fly 2 weeks after resolution but normally recommended to =wait for a CXR confirming resolution
• Scuba diving should be permenantly avoided unless pt has undergone bilateral surgical pleurectomy and has normal lung function and chest CT post op
How can you tell a chest drain is lying within the chest cavity?
Look for fogging of the tube and swinging of the chest drain with respiration
What is an open pneumothorax and what usually causes it?
This is a hole on the chest that competes with the normal airway for delivery of air
Very rare and most commonly caused by a shot gun injury
Management of an open pneumothorax?
Cover wound and tape only 3 sides to allow for a 1 way valve where air can escape
Definitive diagnosis is surgical
What is a massive haemothorax?
A haemothorax with >1500ml or >1/3rd of the pt’s blood volume
Management of a massive haemothroax?
Patients should all have a wide bore 36F chest drain.
May require blood
Indications for thoracotomy include loss of more than 1.5L blood initially or ongoing losses of >200ml per hour for >2 hours.
What usually cause a massive haemothroax?
laceration of lung vessel or internal mammary artery by rib fracture.
What is becks triad?
The 3 signs of cardiac tamponade: hypotension, raised JVP, muffled heart sounds
How do we diagnose a cardiac tamponade?
eFAST (Extended Focused Assessment using Sonography in Trauma)
Tx of cardiac tamponade?
Fluid resuscitation
Pericardiocentesis
Some say thoracotomy is indicated
What is flail chest>?
When 2 or more rib fractures along 3 or more consecutive ribs occur and this makes the flail segment move paradoxically during respiration, impairing ventilation of the lung on the side of injury
Can cause serious contusional injury to the underlying lung if not treated
How is flail chest diagnosed?
CXR
Management of flail chest?
intubation and ventilation IPPV, address pain, fluid resuscitation and definitive surgery to prevent complications
Important investigations for pulmonary contusions?q
ABG
Pulse oximetry
CXR - look for associated rib fracture and haemo/pneumothorax
Management of pulmonary contusions?
Intubation and ventilation within 1 hour if significant hypoxia
Whats the risk of pulmonary contusion?
can cause parts of the lung to consolidate, alveoli to collapse, and atelectasis to occur
Can cause significant hypoxia
Why are myocardial contusions so dangerous?
They often cause unexplained tachycardia and arrhythmias
Management of myocardial contusions
Resuscitation
Cardiac monitoring
Manage any arrhythmias expectantly - risk of arrhythmias fall aftr 24 hours
What traumas tend to cause aortic injuries?
Rapid deceleration injuries e.g. RTAs
Presentation of aortic injury?
Hypertension
Weak femoral pulses
Harsh systolic murmur
Management of aortic injur?
Sugrical repair or endovascular stenting
Labetalol to control acute hypertension
Where does diaphragmatic injury most commonly occur and why?
Left posterolaterally - weakest point and not protected by the liver
Management of diaphragmatic injury?
NGT to drain stomach
Chest drain
Direct surgical repair
What causes tracheobronchial injury?
Very rare
Caused by significant deceleration injuries
Most die at the scene of the accident
Features of tracheobronchial injury?
Haemoptyasis
Surgical emphysema
Tension pneumothorax
Vigorously bubbling chest drain that fails to alleviate respiratory compromise
Whats the most commonly injured organ in abdominal trauma?
The spleen
What causes bladder injuries?
Mostly blunt trauma with 85% associated with pelvis fractures
Presentation of bladder injury?
Haematuria
Suprapubic pain
Inability to void
Investigating bladder injuries?
IV urography or cystogram
Who do urethral injuries typically occur in and how do they present?
In males
Blood at the meatus in 50% of cases. Urinary retention, perineal oedema/haemotoma. Displaced prostate on PR
How are urethral injuries managed?
With surgically placed suprapubic catheters
What is the deadly dozen?
The lethal six = immediate, life-threatening injuries that require evaluation and treatment during the primary survey. It includes airway obstruction, tension pneumothorax, cardiac tamponade, open pneumothorax, massive haemothorax and flail chest.
The hidden six = potentially life-threatening injuries that should be detected during the secondary survey. It includes thoracic aortic disruption, tracheobronchial disruption, myocardial contusion, traumatic diaphragmatic tear, oesophageal disruption and pulmonary contusion.
What are examples of systemic complications of poly trauma?
Coagulation disorders
Fat embolisms
Crush syndrome
PE
ARDS
Outline how poly trauma can cause coagulation disorders?
In the early hours, hypocoagulability is typically present, resulting in bleeding, whereas later there is a hypercoagulable state associated with venous thromboembolism and multiple organ failure.
Remmeber the lethal triad of coagulopathy, hypothermia and acidosis!
What is the pathophysiology behind fat embolisms?
2 theories: fatty tissue is directly released into the vascular circulation as a result or trauma or the inflammatory response to the trauma causes release of free fatty acids into the venous system from the bone marrow.
The fatty emboli cause a severe inflamamtory response in the local tissue which increases vessel permeability and can lead to cerebral oedema and ARDS.
What causes fatty emboli?
Normally associated with long bone fractures
Presentation of fat emboli?
24-72 hours after trauma with worsening SOB. May also be confusion, drowsiness, and an impalpable petechial rash. To will be tachypnoeic, tachycardia, hypoxic, may have neurological signs and low grade fever.
What diagnostic tool can be used to diagnose fat embolism syndrome?
Gurd and williams criteira
Outline gurd and williams criteria for fat emboli?
The presence of 2 Major or 1 Major + 4 Minor criteria is deemed diagnostic
Major criteria = Petechial Rash, Respiratory Insufficiency, Cerebral Involvement
Minor criteria = Tachycardia, Pyrexial, Retinal Changes, Jaundice Thrombocytopaenia, Anaemia, Raised ESR, Fat macroglobulinaemia
What will lung CT show in fat embolism?
May show a ground glass appearance at the peripheries of the lung
Management of fat emboli?
Fix fractures ASAP
DVT prophylaxis
Supportive care
Mortality rates in fat emboli?
5-15%
What is crush syndrome?
Systemic manifestations resulting from a crush injury which can result in organ dysfunction or death
What is crush syndrome characterised by?
Hypovolaemic shock
Hyperkalaemia
Metabolic acidosis
AKI
DIC
Why is crush syndrome known as “smiling death”?
the victim smiling after being released from the crush injury cause suddenly arrests from V fib due to efflux of K+, phosphate and myoglobin from the areas of injury.
What is silver trauma?
major trauma in a patient ≥ 65 years old.
Different patterns of injury e.g. falling from own height can be major trauma
These pt likely to have underlyign hypertension and on HR controlling meds so increased potential for devastating haemorrhage and they have a reduced physiological reserve
What is the leading cause of death in people under 45?
Major trauma
Outline the configuration of trauma services in England?
Major trauma care is delivered through an inclusive trauma network delivery model. This includes all providers of trauma care e.g. pre-hospital services, trauma units and rehabilitation centres.
Major trauma centres are the centres of excellence providing multi-speciality hospital care to seriously injured patients; they are the focus of the trauma network and provide consultant-level care and access to tertiary and specialised level services.
Trauma networks compromise 1 or more major trauma centres and a number of trauma units. Some patients will need training in trauma units before being transferred to a major trauma centre.
