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DipIMC > Trauma > Flashcards

Trauma Flashcards

1
Q

We are the liver and spleen so susceptible to injury via blunt forces? (3)

A
  1. Heavy and relatively free to move which leads to tearing
  2. Soft so when starts bleeding it is propagated
  3. Very vascular
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2
Q

How much of traumatic pelvic bleeding is venous?

A

Around 80%

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3
Q

What is the mortality of an open pelvic fracture?

A

50%

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4
Q

Which patients does the FPHC consensus statement suggest may not need a binder?

A
  1. Mechanism no suggestive of pelvic injury
  2. Haemodynamically stable (HR<100, SBP >90) patients with GCS >13 and no distracting injury and no pain in pelvis
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5
Q

What does FPHC consensus statement say about type of pelvic binder used? (2)

A
  1. No good evidence for one device over another
  2. Best evidence currently is for SAM Splint or T-POD device
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6
Q

What is the FPHC consensus statement with regards to femoral fractures and suspected unstable pelvic fractures and haemodynamically unstable patients?

A
  • if traction of legs will delay transfer +/- worsen instability of patient (via pelvic disruption), they should be pulled to length and then tied together at knees and a figure of 8 around ankle
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7
Q

What does JRCALC recommend with regards to transporting the distal part of of an amputation? (4)

A
  1. Remove any gross contamination
  2. Cover the part with a moist dressing
  3. Secure in plastic bag
  4. place bag in a container with ice
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8
Q

What are the protective layers of the skull from outer layer inwards

A
  1. Skull
  2. Dura mater
  3. Arachnoid mater
  4. Pia mater
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9
Q

What is the Monro-Kellie Doctrine?

A

The sum of the volumes of brain/CSF/blood is constant. A rise in 1 will therefore precipitate a drop in 1 or both of the others.

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10
Q

What 2 syndromes are associated with hyperacute head injury?

A
  1. Neuroventilatory syndrome
  2. Neuro-cardiac syndrome
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11
Q

What is neuroventilatory syndrome?

A

Impact brain apnoea

Concussive force to Pre-Botzinger complex of medulla oblongata

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12
Q

What is neurocardiac syndrome?

A
  • Cardiogenic failure secondary to locally released noradrenaline from myocardial sympathetic nerve terminals leading to neurogenic stunned myocardium.
  • creates reverse-Takusubo picture (intact apical contraction/ impaired heart base contracticility)
  • pump failure may decrease further secondary to systemic cathecolamine induced afterload +/- impact brain apnoea
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13
Q

How is coronary perfusion pressure calculated?

A

CPP = MAP - ICP

assume ICP >20cmH20 so aim MAP >80 mmHg

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14
Q

How much % decrease in effect does each 20mins delay in TXA cause?

A

10%

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15
Q

At what GCS does nice recommend giving TXA?

A

12 or less

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16
Q

What does JRCALC states about anti-platelet tx nd HI?

A

Should be conveyed unless aspirin monotherapy

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17
Q

What does JRCALC recommend for agitated head injuries?

A

Cautious use of midazolam

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18
Q
A
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19
Q

What are the indications for immediate CTH in children? (8)

A
  1. ? NAI
  2. Seizure
  3. GCS <14 at presentation
  4. GCS <15 at 2 hours
  5. ? skull # / tense fontanelle
  6. Basal skull # signs
  7. Focal neurological deficit
  8. Bruising/swelling >5cm in <1years
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20
Q

What are the risk factors that may require observation in paeds head injurys? (5)

A
  1. LOC >5mins
  2. Amnesia > 5 mins
  3. Abnormal drowsiness
  4. 3 or more vomits
  5. Dangerous MOI
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21
Q

If a child has one risk factor following head injury what should be their management?

A

4 hours observation

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22
Q

If a child has more than one risk factor following head injury what should be done?

A

CTH < 1hour

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23
Q

What are the increased risk factors needing imagine in the Canadian c-spine rules? (3)

A
  1. Over 65years
  2. Dangerous MOI
  3. Parasthesia in the extremities
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24
Q

What constitutes a dangerous MOI in the Canadian C-spine rules? (5)

A
  1. Fall over 3 foot or 5 stairs
  2. Axial load to head
  3. High speed MVC (>100kmph)/rollover/ejection
  4. Motorised recreational vehicles
  5. Bicycle collision
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25
Q

What are the low risk factors in the Canadian C-Spine rules? (5)

A
  1. Simple rear end shunt
  2. Sitting position in ED
  3. Walking at any point
  4. Delayed onset neck pain
  5. Absence of midline tenderness
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26
Q

How many low risk factors do you need to avoid imaging in the Canadian C-spine rules?

A

1

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27
Q

What is the final step in the Canadian C-Spine rules?

A

Can they rotate their neck 45 degrees left to right

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28
Q

What are the indications for immediate CTH in adults? (7)

A
  1. GCS <13
  2. GCS <15 after 2 hours
  3. Open/suspected skull #
  4. Signs basal skill #
  5. Seizure
  6. Focal neurology
  7. More than 1 vomit
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29
Q

Within what period should patients on anticoagulation have a CTH according to NICE?

A

8 hours

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30
Q

If an adult patient has no indication for CTH immediately and is not on anticoagulation, what is the next question to be asked?

A

Any LOC or amnesia - if no then no imaging
If yes move onto risk factors

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31
Q

What are the risk factors used to determine whether a patient needs a CTH within 8 hours who have had a LOC or amnesia? (4)

A
  1. Over 65years
  2. Hx bleeding/clotting disorder
  3. Dangerous MOI
  4. > 30mins retrograde amnesia (events before injury)
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32
Q

Describes the myotomes in the upper limb (6)

A

C5 - deltoid
C5/6 - biceps jerk
C6 - wrist extensors
C7 - elbow extensor/triceps jerk
C8 - finger flexors
T1 - little finger abductors

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33
Q

Describe the lower limb myotomes (5)

A

L2 - hip flexors
L4 - knee extensors
L5 - ankle dorseflexors
S1 - ankle plantar flexors
S5 - anal reflex

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34
Q

What dermatome is the thumb?

A

C6

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35
Q

Where is the dermatone C7?

A

Middle finger

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36
Q

What dermatone is the little finger?

A

C8

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37
Q

What dermatone is the:
1. nipple
2. xyphoid process
3. Umbilicus

A
  1. T4
  2. T6
  3. T10
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38
Q

Describe the dermatomes of the lower limbs (4)

A
  1. L3 = medial knee
  2. L4 = lateral knee
  3. L5 = dorsum foot + 1st-3rd toes
  4. S1 = lateral malleolus
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39
Q

What spinal levels to the sympathetic fibres extend from?

A

T1 - L3

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40
Q

What spinal levels do the parasympathetic fibres extend from?

A

S2-4

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41
Q

At what spinal level can a SCI lead to neurogenic shock?

A

T6 or below

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42
Q

What causes neurogenic shock?

A

Loss of sympathetic autonomic outflow

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43
Q

What neurology is associated with central cord syndrome?

A

Arms weaker than legs

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44
Q

What neurology is associated with anterior cord syndrome? (4)

A
  1. Complete motor loss below lesion
  2. Loss of pain/temp below lession
  3. Preserved sensation/vibration
  4. Autonomic dysfunction
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45
Q

What neurology is associated with Brown-Sequard syndrome?

A
  1. Weakness/paralysis on 1 side
  2. Loss on sensation on the other
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46
Q

What is the mechanism for acid burns?

A

Coagulative necrosis

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47
Q

What is the mechanism for alkali burns?

A

Liquefactive necrosis

48
Q

What are alkali burns worse than acid?

A

Acid burns form a barrier which prevents deep penetration into the skin, alkalis cause liquefactive necrosis which means it can penetrate deeper into the skin

49
Q

What is are the voltage cut off of:
- low voltage
- high voltage

A
  1. <1000V
  2. > 1000V
50
Q

What type of current is normal low voltage and can it lead to?

A
  1. AC domestic current
  2. Arrhythmia
51
Q

What does high voltage electricity normally cause? (3)

A
  1. Full thickness burns at both entry and exit sites (internal damage can be far worse than appears externally)
    - Tissue damage secondary to heat generated by resistance of tissues
  2. Muscle spasms/secondary trauma from being thrown causing bony/SCI
  3. Arrhythmia particularly if chest involved
52
Q

What type of tissue leads to the most damage when conducting high voltage electricity and why?

A

Bone because it has the highest resistance, it is the resistance that causes heat and bone can therefore become very hot and lead to further damage once the current has stopped.

53
Q

What surgical interventions might be require of high voltage burns?

A
  • may need aggressive surgical intervention inc. fasciotomy and amputation
54
Q

What can muscle damage related to high voltage burns lead to?

A

Myonecrosis, compartment syndrome and rhabdo with renal failure

55
Q

What does a lightening strike lead to and what might be a protective factor?

A

Death unless it has already passed throught another object

56
Q

Describe the palm method of assessing burns size and in what are the weakness of using it

A
  1. Palm INC. adducted fingers = around 1% TBSA (patients hand, not clinicians)
  2. Some debate as to the accuracy, particularly in small kids and obese patients
57
Q

What burns assessment does the FPHC consensus statement recommend? (2)

A
  1. Lund and Browder chart
  2. Mersey burns app (or similar)
58
Q

Describe superfical burns?

A

Erythema only,not included in burns calculation

59
Q

What differentiates superficial burns from superficial dermal/superficial partial?

A

Blisters - fluid lifts dead epidermis off dermis

60
Q

What is the difference between deep dermal/ partial and superficial dermal/partial? (3)

A

Extends into dermis

  1. Decreased sensation secondary to damage to nerve endings
  2. Hallmaark = increase CRT due to damage of dermal vascular plexus
  3. Can be ‘blotchy’ pink/red colour secondary to extravasation of the Hb from damaged vessels
61
Q

Describe full thickness burns

A

Can include fat/fascia/muscle/bone

  • ‘charred’ or ‘leathery’
  • ‘woody’ feel
  • insensitive (but surrounding non full thickness burns with be painful)
  • non blanching
62
Q

What questions should be asked to any burns patient? (4)

A
  1. Were they trapped and if so for how long?
  2. Did clothes catch fire?
  3. Any cooling?
  4. Any explosion/ were they thrown?
63
Q

What level of CO is classed as severe?

A

> 30%

64
Q

Why does CO lead to hypoxia?

A

CO x 240 more affinitity to Hb than oxygen which shifts 02 dissociation curve to the left

65
Q

What will pulse oximetry be like with CO poisoning and why?

A

Normal as unable to differentiate between carboxyhaemoglobin and haemoglobin

66
Q

What is a normal value of COHB in:
1. non-smokers
2. smokers
3. heavy smokers

A
  1. < 3%
  2. <5%
  3. <9%
67
Q

What is the treatment (initially) for CO poisoning and why does it help?

A

High flow oxygen because it reduces the half life of COHb from 320mins to 80mins

68
Q

What is the mechanism of cyanide poisoning?

A

Usually from burning plastic

Poisons mitochondria and prevents further cellular oyxgen use leading to anaerobic metabolism

69
Q

What are 2 treatments available for cyanide poisoning?

A
  1. Hydroxycobalamin (Cyanokit)
  2. Dicobalt edetate (Kelocyanor)
70
Q

To what depth should an escharotomy incision be?

A

Down to unburnt skin

71
Q

What 3 lines should be made in a breast plate escharotomy?

A
  1. Mid clavicular to ant axillary line to costal margin bilaterally
  2. Transverse subcostal
  3. Transverse infraclavicular
72
Q

What are the % burn thresholds for:
1. Adults
2. Kids
3. < 18months old

A
  1. 15%
  2. 10%
  3. 8 %
73
Q

What is the Parkland formula?

A

4 x wt (kg) x TBSA
3 x wt (kg) x TBSA (kids)

First half in initial 8 hours
Second half in following 16 hours

74
Q

What does JRCALC recommend for burns fluid resusitation?

A

1L warmed fluids / hr (adult)
10ml/kg/hr paeds

75
Q

What should the first steps be in with chemical burns?

A

Remove agent, removed contaminated clothes and if liquid, irrigate well

76
Q

What is the recommended to use in decontaminating both acids and alkalis?

A

Diphoterine (normalises PH more quickly)

77
Q

If Diphoterine is not available, what fluids should be use to decontaminate acids/alkalis?

A

Isotonic or hypertonic fluid because water can propagate chemical deeper into the skin

78
Q

How long should chemical burns be irrigated for?

A
  • until pain improved which is a useful crude sign that PH has improved
79
Q

How does hydrofluric acid lead to burns?

A
  • H+ ions dissociate on contact with skin and lead to liquefactive necrosis allowing acid to penetrate deeply
  • Free flouride ions bind to calcium and magnesium ions leading to systemic hypomagnesia and hypocalcaemia
80
Q

How should hydrofluric acid be treated? (4)

A
  1. Irrigate
  2. Calcium gluconate gel
  3. IV/intra-arterial calcium if extreme
  4. Specific agent = hexaflourine
81
Q

What is the specific agent for hydrofluric acid tx?

A

Hexaflourine

82
Q

How should tar/bitumen burns be treated?

A
  • they are heated to around 150 degrees and cause full thickness burns
  • cool with water to solidify and then remove with toluene or peanut/paraffin oil
83
Q

How does the FPHC consensus statement divide airways burns? (2)

A
  1. Supraglottic (nose/oropharynx and larynx) - most common
  2. Infraglottic
84
Q

How can infraglottic burns be caused?

A

Steam inhalation
Aspiration of scalding liquid
Blast injury
Flammable gas under pressure
Aerosolised chemicals

85
Q

What are the features of infraglottic burns? (5)

A
  1. Impaired ciliary activity
  2. Hypersecretion
  3. Oedema
  4. Mucosal ulceration
  5. Bronchial spasm
86
Q

What 3 considerations should be made with intubation in patients with airway burns?

A
  1. Largest size tube that will be placed (bronchoscopy on ITU)
  2. Uncut (airway will swell)
  3. Careful with tube tie
87
Q

What features have been shown to correlate with need for RSI (FPHC)? (6)

A
  1. Full thickness facial burns
  2. Stridor
  3. Resp distress
  4. Swelling on larygnoscopy
  5. Smoke inhalation
  6. Singed nasal hairs
88
Q

When does FPHC recommend using cyanide antidote?

A

Suspected smoke inhalation AND:
- altered mental status
- CV instability

89
Q

What 3 categories of burns severity does FPHC recommend using pre-hospital?

A

< 20%
20-50%
> 50 %

90
Q

What does FPHC say about water cooling of thermal burns? (3)

A
  1. Water < 20 degrees (12 ideal)
  2. 20 mins
  3. Not ice water secondary to risk of tissue necrosis
91
Q

What does FPHC recommend with regards to first aid for chemical burns? (3)

A

1.Treat any chemical burn ASAP regardless of delay to presentation

  1. Use amphoteric solution as first line
  2. Irrigate for as long as possible
92
Q

When does FPHC state fluid resus should be commenced pre-hospital in:-
- adults
- paeds

A

> 20%

93
Q

Describe the FPHC ‘threshold’ method for estimating pre-hospital fluid resusitation?

A
94
Q

What analgesia should be avoided in burns?

A

NSAIDs if requiring fluid resus

95
Q

When does FPHC recommend chest escharatotomy?

A

Circumferential or near circumferential eschar with imprending or established respiratory compromise to to thoraco-abdominal burns

96
Q

What is the definition of crush injury?

A

Direct injury to a body part which has undergone a prolonged static compressive force sufficient to interfere with normal tissue metabolic function

97
Q

What is the definition of crush syndrome?

A

Systemic consequences of muscle + soft tissue trauma

98
Q

What 3 factors make crush syndrome more likely?

A
  1. Increased compressive force
  2. Increased muscle bulk
  3. Increased time
99
Q

What is suspension syncope?

A

Orthostatic hypovolaemia leads to syncope if trapped in vertical position -can lead to death

100
Q

Describe the two components that lead to progressive orthostatic shock in patients trapped vertically

  1. Orthostatic syncope
  2. Orthostatic hypovolaemia
A
  1. Orthostatic syncope
    Cerebral perfusion compromised as autonomic/humoural + local responses fail to preserve MAP. Process made worse by: pain (vagal tone), hypovolaemia, forced erect position
  2. Orthostatic hypovolaemia
    Entrapping force/harness acts a venous tourniquet and limb congests. This leads to loss local vascular tone and leaky capillaries leading to further swelling/ tightening harness. Can progress to limb ischaemia
101
Q

Describe rescue cardioplegia

A

Occurs on release of compressing force

  • cold ‘toxic’ blood released back into systemic circulation leading to a sudden and transient increased preload. Causes atrial stretch which can lead to asystole of AF
  • Simultaneous rapid drop in afterload + SVR as blood moves back into affected limb
  • both lead to acute hypotension when limb released
102
Q

What can make the affects of rescue cardioplegia worse?

A
  • blood released ‘ideal cardioplegic solution’ leading to arrhythmia
  • cold/hyptertonic/acidotic/ raised k+/ca2+/Mg2+/P04D
103
Q

Describe the pathophysiology of crush syndrome

A
  • Constant external mechanical force prevents cell wall integrity by forcing extracellular cations + fluid against normal electrochemical + osmotic gradient into
  • cell wall extrusion pumps become overhwhelmed allowing water with dissociated Na+/Cl-/Ca2+ into cell
  • ultimately leads to death
104
Q

When is irreversible cell death caused by crush syndrome?

A

<1 hour but no universally accepted ‘safe time’

105
Q

What is compartment syndrome?

A

Intramuscular compartment forces act continualy above DBP leading to comrpession and death of nerves/blood vessels/muscle

106
Q

Describe the pathophysiology of compartment syndrome

A

Integrity of muscle cell wall breached and intracellular components move extracellular and into damaged tissue

Cell content forced into vascular compartment lead to systemic affects

107
Q

How are kidneys damaged in compartment syndrome? (2)

A
  1. Direct damage of intracellular substances (proteases/purines)
  2. Indirect - attempt to filter acidotic plasma + myoglobin damage
108
Q

How does myoglobin damage kidney?

A
  • Myoglobin itself not nephrotoxic but when systemic acidosis lead to pH urine< 5.6 myoglobin converted to larger protein Ferrihaemate.
  • This is directly nephrotoxic and causes mechanical obstruction of nephron lumen
  • hypovolaemia and third space shift makes this worse
109
Q

What is the protein that myoglobin becomes when urine PH < 5.6

A

Ferrihaemate

110
Q

How should suspended patients be rescued?

A

ASAP and placed horizontally

111
Q

What has been shown to improved outcomes in trapped earthquake patients?

A

Systemic resus with sodium and potassium containing fluids (20ml/kg - 10ml/kg elderly)

112
Q

Describe the pain response in crush injury

A

Initially reduced due to endorphins and pressure neuropraxia but this will increase as limbs swell and endorphins wear off

113
Q

When should alkaline diuresis be considered in crush injury?

A

If evacuation time >4 hours

114
Q

How is alkaline diuresis performed?

A
  1. 50ml 8.4% soidum bicarbonate to each alternate 1L fluid
  2. If prolonged transfer alternate 5% dex to prevent sodium overload
  3. Aim urine PH >6.5

Really should be done in hospital

115
Q
A

DipIMC (3 decks)

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