Trauma Flashcards
What structures could be injured from a pelvic fracture?
Structures that cross the SI joint:
1) Iliac vessels (bleeding)
2) Sciatic nerve roots (nerve palsy)
3) Ureters
Describe a classification used for pelvic fractures?
Young and burgess
1) Anterior Posterior Compression
APCI - pubic symphyseal diastasis <2.5cm
APCII - pubic symphyseal diastasis >2.5cm
APCIII - hemopelvis separation with complete disruption of pubic symphysis and posterior ligament complexes
2) Lateral Compression
LC1 - posterior compression fo SI joint w/o ligament disruption
LCII - Posterior SI ligament rupture, sacral crush injury, or iliac wing fracture
LCIII - LCII with open book injury to contralateral pelvis
3) Vertical shear
Vertical fracture of pubic rami
Displaced fractures of anterior rami and posterior columns
What is your initial management in ED for a pelvic fracture?
ABCDE assessment as per the EMST principles
HD status will determine management
Examination
- Assess for lacerations and bruising to groin, perineum, sacral region
- Look for blood at meatus
- Assess for a high riding prostate
Imaging
- EFAST
- Pelvic Xray
- CT if stable
Consult orthopaedics
Resusitation including activcation of MTP
Place a binder (type c injuries need a traction on leg of side cranially dislocated)
HD stable -> active arterial bleed -> angioembolisation -> definitive fixation
HD unstable -> hybrid suite with extraperitoneal packing + laparotomy to treat exclude intra abdominal bleed -> stabilisation -> angiography + embolisation with external fixation
-> if exsanguinating will need aortic clamp
-> consider damage control
What are the principles of management for anorectal injuries?
1) Based on the degree of damage to sphincters and anorectal mucosa
2) Injuries superficial -> debridement and dressings
3) Injuries deep -> colostomy and drainage
4) Refer to colorectal surgeon for shoncter repair
What invesitgations for you request for a patient with possible genitourinary injury?
1) Urianlysis - microscopic or gross haematuria
2) Retrograde urethrogram - suspected urethral injuries. Insert foley catheter a few cm’s into urethra and partially inflate ballon so is snug.
3) CT scan with IV contrast and delayed phase (IVP)
What is shock and what are the causes?
Abonormality of the circulatory system that results in inadequate organ perfusion and tissue oxygenation
Haemorrhagic
Non haemorrhagic
- Cardiogenic from blunt cardiac injury, cardiac tamponade, MI, tension pneumothorax
- Neurogenic with spinal cord injury
- Distributive from sepsis or anaphylactix
Describe the classes of haemorrhagic shock
What are the criteria for activation of massive transfusion protocol?
ABC score > 2 or more
(PR > 120, systolic < 90, +ve eFAST, penetrating torso injury)
Persistent HD instability
Active bleeding requiring surgery or embolisation
Blood transfusion in the trauma bay
What is the massive transfusion protocol?
Institution based transfusion protocol that will faciliate timely and balanced use of RBC and other blood products (FFP, platelet, CCP) in patients with critical bleeding requiring or anticipating to require massive transfusion that will reduce morbidity and mortality.
What are the constituents of the products used in a massive transfusion protocol?
FFP - all coagulation factors (ABO grouping required)
Cryoprecipitate - ppt from FFP containing VIII, XIII, fibrinogen, von Willebrand factor
Prothrombinex - II, IX, X (not much factor VII) (25-50H/kg given
Recombinant factor V!!a - directly activates factor X and IX -> Xa and IXa complex with TF -> local haemostasis. NOTE - systemic activation of the coagulation system can occur in some patients.
Describe the massive transfusion protocol flow chart.
What are the indications for a thoracotomy?
1) Initial drainage of > 1500ml or 1/3 blood volume
2) Continuing output of >200ml/hr for 2-4 hrs
3) Persisting transfusion requirement or HD instability
What are the clinical signs of a tracheobronchial injury?
Massive haemoptysis
Airway obstruction
Progressive mediastinal air
Subcutaenous emhysema
Tension PTx
Significant **persistent air leak **
What is “Becks” Triad?
1) Distended neck veins
2) Hypotension
3) Muffled heart sounds
What features on CXR woyuld make you concerned for a aortic disruption?
Widened mediastinum
Obliterated aortic knuckle
Tracheal deviation
Left haemothorax
Fracture of 1st or 2nd rib / scapula
Usually located at the ligamentum arteriosum
Diagnosis confirmed with CT aortogram