Trauma

Question 1

What size cannulas are used for needle thoracostomy in adults? At what age do we switch?

Answer 1

Adults (pts >=13yrs) -10g x 8cm ARS Needle
Decompression Kit
Pediatrics (< 13yrs) - 14g x 5cm InSyte Cannula

Question 2

What are the indications for needle thoracostomy?

Answer 2

• Traumatic cardiac arrest (with torso
  involvement).
• Suspected pneumothorax with significant
  respiratory or haemodynamic compromise

Cardiovascular compromise may be a late sign, often preceded by respiratory failure and hypoxia.

Question 3

What are the signs of a tension pneumothorax?

Answer 3

Tension pneumothorax should be considered in a patient with significant trauma who is exhibiting signs of severe respiratory distress, diminished unilateral lung sounds, hypoxia and/or shock.

Signs such as jugular venous distension, tracheal deviation or subcutaneous emphysema may be difficult to observe and are unreliable indicators of tension pneumothorax

Question 4

What site is used for needle decompression?

Answer 4

2nd intercostal space, mid-clavicular line.

Question 5

In tension pneumothorax, what is the location for secondary/subsequent needle decompression(s) if the first catheter fails?

Answer 5

If catheter failure is suspected (i.e. catheter blocked) and/or if clinical deterioration suggests redevelopment of tension symptoms, reswab, allow to dry and insert another needle-catheter, approximately 1cm lateral to the previously inserted catheter.

Question 6

What size syringe is placed at the end of the NT cannula?
How much fluid should be in the syringe?

Answer 6

10ml Luer-lok syringe
2-4ml saline in syringe.

Question 7

How is correct placement of the cannula confirmed in a NT?

Answer 7

Advance needle/cannula until initial resistance overcome.
Draw back on syringe - bubble in fluid confirms correct placement into the pleural space.
If no bubbles, advance needle/cannula 1-2cm and reattempt aspiration.

Question 8

What is the guideline for managment of an amputated part?

Answer 8

Seal body part in water-tight bag.
Place bag in ice-cooled water if possible.
Body part should not be in direct contact with ice.

Question 9

When is an arterial tourniquet indicated?

Answer 9

Life-threatening haemorrhage not controlled by direct pressure.

Question 10

What are the 3 “dont’s” of arterial tourniquets?

Answer 10

Don’t
* Place over a joint or wound
* Cover with clothing
* Remove in the field

Question 11

When should clinical support be called in burns?

Answer 11

Significant burns
Airway burns
Uncontrolled pain

Question 12

What is the treatment in suspected airway burns?

Answer 12

In airway burns, airway managment and urgent transport take priority over cooling.

Treatment:
* Universal care
* Request Clinical support
* Consult EOC clinician
* Rapid transport with notification

Question 13

How long should thermal burns be cooled with running water in adults? Pediatrics? Neonates?

Answer 13

All 20 min.

Question 14

If water is not available, how long should thermal burns be cooled with hydrogels in adults? Pediatrics? Neonates?

Answer 14

Adults and pediatrics - 20 min.
Neonates - max 10min

Question 15

When is fluid indicated in burns patients? How much is given?

Answer 15

Indicated for burns patients with signs of poor central perfusion.
All patients - 10ml/kg (max 250ml) aliquots up to 20ml/kg
In pediatrics we’re targeting lower range of normal SBP for age.

Clinical consult if fluid > 20ml/kg required

Question 16

In which patients should pulmonary contusion be suspected?

Answer 16

Chest trauma patients who are hypoxic without obvious cause.

Most common thoracic injury in children due to the elastic properties of the paediatric ribcage and may occur in the absence of obvious chest wall injury

Question 17

In severe haemorrhage, what are the components of the lethal triad?

Answer 17

Coagulopathy - Catastrophic haemorrhage can lead to extensive loss of clotting factors as well as accelerated consumption of clotting factors and excessive clot breakdown (hyperfibrinolysis). Haemodilution can increase coagulopathy by diluting clotting factors.

Acidosis causes multiple negative impacts on the clotting cascade and coagulation

Hypothermia impacts coagulation by reducing platelet function as well as reducing the activity of clotting cascade enzymes

Question 18

What are the principles of damage control resuscitation?

Answer 18

• Haemorrhage control
• Temperature management
• Movement minimisation
• Access to early blood product administration (TXA)
• Targeted fluid resuscitation
• Rapid transport to definitive care

Question 19

In damage control resuscitation, when should fluid be administered? What is the target / fluid endpoint?

Answer 19

Fluids indicated when pt has inappropriate response to verbal commands.
Administer 10 mL/kg aliquots (max 250 mL) up to 20 mL/kg.

Target - minimum fluid to retain alertness such that patient responds to verbal commands.
If pt unresponsive for other reasons, target radial pulse.

Question 20

Considering damage control resuscitation, in which patients is permissive hypotension not appropriate?

Answer 20

Permissive hypotension not appropriate for patients with suspected traumatic brain injury - TBI takes priority over damage control resuscitation.

Question 21

Which trauma patients may receive TXA?

Answer 21

Patients with blunt or penetrating trauma.
Consider IV TXA 1 g bolus slow push over 2 - 3 mins if:
* ≥ 16 yrs and
* < 3 hrs of injury and
* HR > 120 and/or SBP < 90 mmHg

Question 22

Which patients are indicated for a chest seal?

Answer 22

Any patient with penetrating trauma to the thorax - very low threshold for application

Also consider for penetrating trauma to upper abdomen (i.e. diaphragm may be penetrated, creating channel between plural space, abdomen and open air

Question 23

If patient with chest seal begins to develop tension pneumothorax, what should be done (2 points)?

Answer 23

1) Check chest seal - if blocked with clots then replace
2) If seal not compromised, then decompress chest

Question 24

What gauge is the ARDS needle catheter used for chest decompression?
What age range is the ARDS needle indicated?
What should be used for patients outside this age range?

Answer 24

10G
Use ARDS for patients > 13yrs
For patients <=13yrs use 14G cannula

Question 25

In needle thoracostomy, what should be attached to the top of the needle/cannula? Why?
What should be done if bubbles don’t appear?

Answer 25

• Attach a 10ml syringe with 2-4 ml NaCl for injection
• Used to confirm cannula placement - after initial resistance overcome, aspirate syringe - bubbles in fluid indicate correct placement in the plural space
• If bubbles don’t appear, advance syringe 1-2cm and reaspirate

Question 26

When should a chest seal be removed?

Answer 26

Chest seal should be removed when IPPV is performed as it can create a tension pneumothorax

Question 27

What is the mechanism for neurogenic shock?
What symptoms would be expected?

Answer 27

Spinal cord injury to T6 or above - get unopposed parasympathetic drive as unable to mount sympathetic response -> bradycardia, vasodilation (flushed skin below injury, hypotension)

Question 28

How would you differentiate neurogenic and haemorrhagic shock?

Answer 28

Neurogenic - usually bradycardic
Haemorrhagic shock - usually tachycardic unless deteriorating

Question 29

What is the BP target for a patient in neurogenic shock? Why?

Answer 29

Target is MAP 80mmHg or SBP 100mmHg - need this to adequately perfuse spinal cord

Question 30

What are the components of the NEXUS criteria (i.e. first components of the C-spine clearance tool)? (5 points)

Answer 30

1. ALOC or intoxication (drugs/alcohol)
2. Focal neurological deficit
3. Thoracolumbar spinal pain
4. Previous Hx of spinal injury or disease
5. Significant distracting injuries

Question 31

What are the high-risk criteria in the C-spine decision tool? (6 points)

Answer 31

1. Age > 65yrs
2. Fall from > 1m / 5 stairs
3. High speed MCV / rollover / ejection
4. Fallen from a motorised vehicle
5. Involved in bicycle collision with object (i.e. car, post)
6. Axial load to head (i.e. diving)

Question 32

What are the low risk criteria in the C-spine decision tool? (4 points)

Answer 32

1. Involved in simple rear end MVC
2. Has been ambulatory at any time
3. Has delayed onset of neck pain
4. No midline C-spine tenderness on palpation

Question 33

What are the indications for external abdominal aortic compression?

Answer 33

• Life-threatening sub umbilical haemorrhage, characterised by deterioration observations and conscious state, which is unable to be managed by less invasive procedures.
• Patients in traumatic cardiac arrest where exsanguination from an uncontrollable haemorrhage below the umbilicus is suspected.

Question 34

What are the contraindications for external abdominal aortic compression (x2) ?

Answer 34

1. Foetus in utero
2. Suspected isolated splenic or hepatic haemorrhage

Question 35

What are the steps of applying external abdominal aortic compression (x4)?

Answer 35

1. Confirm decision to apply EAAC, gain consent if possible
2. Locate femoral pulse
3. Apply pressure just above + left of umbilicus. Confirm femoral pulse ceased.
4. Hold until definitive care.

Question 36

What are the contraindications for use of a semi-rigid spinal collar (x3)?

Answer 36

1. Compromised airway
2. Spinal deformities
3. Concerns about raised intra-cranial pressure

Question 37

What order are straps placed on the vacmat?

Answer 37

Green - yellow - red - blue shoulder straps, black arm strap optional.

Question 38

What is the weight limit for applying traction with a CT6?

Answer 38

23kg.
CT6 can be applied as a splint to any age, but traction should only be applied to pts 23kg and over.