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
What are the indications for a resusitative thoracotomy?
1) Penetrating thoracic trauma
- HD abnormal despite resus and cardiac arrest < 15 mins
2) Blunt thoracic trauma
- Cardiac arrest in transit < 10 mins or in ED and have no obvious non survivable injury or cardiac tamponade
3) Penetrating abdominal trauma and loss of output
(Only if appropriately trained surgeon available and operating room available for definitive repair)
Not indicated if blunt trauma with no signs of life, asystole, pulllselessness > 15 mins, massive non survivable injuries
What is the AAST grading sysmtom for liver trauma?
What are the determinants of management of liver trauma?
1) Disease factors
- HD status - abonormal then straight to theatre
-Extent of injury - active bleeding but stable then needs IR
- Type of injury - OT more likely versus blunt
- Presence of other injuries - may need OT
2) Patient factors
- medical comorbidities
3) Institutional factors
Availablity o f IR or HDU/ICU
What is the sequence of events for every trauma operation?
Access and exposure -> bleeding and contamination control -> exploration -> decision of damage control or definitive repair
What factors are taken into account when deciding on damage control versus definitive repair?
1) Injury pattern - severity of trauma
2) Trauma burden - number of organs affected, head trauma
3) Physiology - CUMULATIVE insults (lethal triad and intr op cues (bowel oedema, midgut distension, dusky serosa)
4) Setting - regional or tretiary setting and is there ICU available
If choosing definitive repair, choose option that fails well.
What are the boundaries and contents of the neck zones?
Zone 1 - Cricoid cartilage to sernla notch
Vessels:
- arteries -> carotid, brachiocephalic, subclavian, vertebral
- veins -> IJV, subclavian
- lymph -> thoracic duct
Nerves:
- RLN, vagus, phrenic n, brachial plexus, SNS, spinal cord
Organs:
Thyroid, apices of lungs, trachea and oesophagus
Zone 2 - Angle of mandible to cricoid cartilage
Vessels:
- vertebral, common carotid, internal and external, IJV, EJV
Nerves:
- CNs - marginal mandibular, IX, X, XI, XII, SNS, spinal cord
Organs :
- trachea, oesophagus, larynx, pharynx
Zone 3 - base of skull to angle of mandible
Vessels:
- Internal and external carotid, vertebral, IJV
Nerves:
- CN VII, IX-XII, spinal cord
Organs:
Parotid and pharynx
What are neck hard signs?
Neurovascular:
- Severe/uncontrolled bleeding
- Expanding/pulsatile haematoma
- HD unstable
- No or diminised pulse
- Thrill/bruit
- Neurological signs
Aerodigestive:
- Bubbling from wound
- Massive haemoptysis or haematemesis
- Resp distress
What are the steps required to access the carotid when concerned for carotid injury in neck trauma?
- Anterior border of SCM
- Ligate middle thyroid and common facial vein
- Retract IJV laterally with SCM
Note - vagus is posterior in sheath and hypoglossal is anterior - Dissect cranially to posterior belly of digastric, divided behind angle of mandible, to access carotid bifurcation
- Internal carotid accessed by dividing SCM near origin at mastoid (accessory nerve is 3cm distal to mastoid bone, posterior to SCM AND glossopharyngeal is anterior to internal carotid)
- Proximal aspect of carotid can be accessed by dividing omohyoid
What are the steps required to access the root of the neck?
- Extend incision laterally above clavicle so clavicular head of SCM can be divided
- Expose scalenes anterior and phrenic nerve (pass from lateral to medial)
- Divide scalenus anterior and preserve phrenic nerve, allows access to second part of subclavian artery
Access to distal subclavian is by dividing clavicle at mid point and dissecting away subclavius and fascia
What is the clinical significance of spinal cord level injury?
T1 - above is quadraplegia and below is paraplegia
Discrepancy between bony and neurological level (spinal nerves enter spinal canal through foramina and ascend or descend inside spinal canal before entering spinal cord (This difference is more pronounced with more caudal injury)
What is the Monro-Kellie doctrine?
Total volume of the intracranial contents must remain constant
- CSF and venous blood becomes displaced to compensate for IC mass or blood
- Once compensation exhausted, exponential rise in ICP for small additional increase in volume
- Cerebral perfursion pressure = MAP - ICP (once ICP rises to arterial pressure, cerebral perfusion ceases)
- Leads to CUSHING REACTION -> decreased blood flow to vasomotor centre in brainstem -> activation of SNS -> vasoconstriction to increase perfusion -> HTN -> PNS activation -> bradycardia -> respiratory centre -> irregular breathing
What are the aims of management of severe traumatic brain injury?
1) Reducing elevated ICP
2) Maintain normal intravascular volume
3) Maintain normal MAP
4) Restore normal oxygenation and normocapnoea
What are the different patterns of brain injury?
1) Diffuse axonal injury
- 2nd to shearing mechanism or prolonged shock/apnoea
2) Focal cerebral contusion
- Basal frontal and temporal areas 2nd to direct impact on basal skull surface -> intracerebral haemorrhage
3) Epidural haematomas
- 2nd to torn dural vessels (middle meningeal artery), associated with skull fractures and lenticular shape on imaging
4) Subdural haematomas
- 2nd to damage of bridging veins and often associated with significant underlying cerebral injury. Cresent shape.
5) Subarachnoid haemorrhage
- 2nd to rupture of small pial vessels or extension of intraventricular /superficial intracerebral haemorrhage
6) Intraventricular haemorrhage
- 2nd to tearing of subepedymal veins or extension from adjacent intraparenchymal / SAH
What are the clinical signs of base of skull fracture?
Racoon eyes (periorbital)
Battle sign (retroauricular)
CSF leakage from nose/ears
CN VII or VIII injury (facial paralysis / hearing loss) may be delayed
How do you calculate GCS?
Eye opening (4)
4 -> spontaenous
3 -> Speech
2 -> Pain
1 -> None
Verbal response (5)
5 -> orientated
4 -> confused
3 -> Inappropriate words
2 -> Incomprehensible sounds
1 -> No response
Best motor repsonse (6)
6 -> obeys commands
5 -> localising to pain
4 -> withdrawal from pain
3 -> flexion response to pain (decorticate)
2 -> extension reponse to pain (decerebrate)
1 -> no response
What is the management of acute brain injury?
Based on GCS of the patient and medical therapy is used to reduce 2nd injury to neurons
**Mild (GCS 14-15) **
- consider CT if loss of consciousness, amnesia, severe headache, GCS <15, focal neurological deficit
**Moderate (GCS 9-13) **
- CT and neurosurgical review
- Admission for observation (maybe HDU)
- Repeat CT 12-24 hrs if initial CT scan abnormal or deterioration in neurological status
**Severe (GCS <8) **
- Early intubation to maintain oxygenation > 98% (make sure check GCS and pupillary reflex proir to intubation)
- Early sign of temporal lobe herniation is fixed dilated pupil on ipsilateral side (from pressure on CNIII)
- Fluid resus - aim for normovolaemia
- Urgent CT scan -> midline shift > 5mm (surgical decompression)
Medical therapy
1) IVFs (hartmanns or NS -> normovolaemia)
2) Hyperventilation (reduce PaCO2 -> cerebral vasoconstriction). Aim for PaCO2 >35mmHg. Use selectively for brief periods
3) Mannitol (reduces elevated IC pressure -> immediate effect in expanding plasma volume -> osmotic effect of drawing water out of neurons. NOT given to hypotensive patients given profound osmotic diuretic)
- bolus dose of 20% solution 1g/kg
4) Sedation and anaesthesia
What are the indications for surgery in the context of orbital fracture?
1) Large defect in orbital floor
2) Exophthalmos >2mm 2nd to herniation of obital contents into maxillary sinus
3) Diplopia 2nd to muscle entrapment
What are the LeFort fractures of the maxilla?
LeFort 1 - horizontal fracture across the inferior aspect, seperating alveolar process and hard palate from rest of maxilla
LeFort 2 - pyramidal fracture from nasal bone to ethmoid and lacrimal bones (zygomaticomaxillary suture)
LeFort 3 - seperation of facial bones from the cranial base with simultaneous fracture of zygoma, maxilla, and nasal bone
What are the indications for performing an emergency burrhole?
1) Imaging evidence of mid line shift and unequal pupils
2) GCS < 8
3) Neurosurgical help not available in a timely manner
Describe the steps in performing a Burrhole
Pre op
- Localisation - centerd above haematoma based on imaging (commonly temporal)
- Equipment - shave, scalpel, hudson brace or pneumatic
Operative
- shave, mark incision and prep
- Incise down to bone and elevate periosteum off bone with knife /swab
- Drill through skull (regular inspection so not to plung into brain)
- Evacuate extradural haematoma or if subdural, use sharp hook to tent dura up and make cruciate incision (more likely clotted and this is removed manually)
What is the pathophysiology of pericardial tamponade?
Accummulation of fluid in pericardial sac -> reduced venous return -> reduced cardiac output
Only requires 15-20ml of blood to cause this effect to interfere with cardiac filling.
Classic clinical triad of muffled heart sounds, hypotension and distended veins.
Kussmaul’s sign -> rise in venous pressure with inspiration when breathing spontaneously
What is the management of pericardial tamponade?
Immediate (if required) -> subxiphoid pericardiocentesis
Theatre transfer (urgent) -> thoracotomy
What is the AAST for kidney injury?
