Trauma Flashcards
blunt force trauma
most obvious findings
haemoperitoneum
liver laceration
active haemorrhage
blunt force trauma with active intra abdominal bleed
blunt force trauma with intra abdominal bleed
what are the contraindications for FAST scan in trauma?
- presence of more critical problem eg airway obstruction
- clear indication for emergency laparotomy eg penetrating trauma with shocked patient
What are the classical CT findings with a seatbelt sign?
perforation with leakage of contrast
mural haematoma/thickening
abdo bowel wall enhancement (ischaemia)
fat stranding
blunt force injury
what are the major findings?
- renal parynchymal laceration
- devascularisation of part of kidney (hypodense)
- large perinephric haematoma
what are the complications of a traumatic renal injury
hypertension
haemorrhagic shock
death
abscess
delayed bleeding
abnormalities
- teeth malocclusion
- fracture body of manible
what needs to be documented with a mandible fracture
- degree of mouth opening
- missing/occlusion of teeth
- ?open fracture to mouth
- ?haematoma to floor of mouth
- brusing/bleeding
- other injuries
- ?inferior alveolar nerve parasthesia
how do you manage mandible fracture in ED?
- ADT
- abx eg cefzolin 2g IV OD
- analgesia - be specific
- NBM and iv fluids
- mouth washes - QID hydrogen peroxide
?facial burn
what clinical signs must you look for?
- facial or oral burns
- singed nasal hair
- swollen lips
- singed eyebrows or lashes
- oedema - facia;
- tachypnoea
- wheeze
- stridor
?facial burn
Investigations?
- carboxyhaemoglobin level
- CK
- ABG
- glucose
- U+E
- ECG
- CXR
What is the modifeid parkland formula for burns?
how much fluid to give over 24 hours (crystalloid)
Adults
4ml X tbsa burnt x kg
Paeds
3ml x tbsa burnt x kg
Give half in first 8 hours and then the rest over 16 hours
whar are the criteria for transferring to specialist burns unit?
- mid to deep dermal burns over 10% TBSA
- Full thickness over 5% TBSA
- burns to face/feet/hands/genitalia or major joints
- chemical burns
- electrical burns eg lightning
- burns with associated inhalation
- burns with significant other trauma
- pregnancy with cutaneous burns
- any mid - deep over 5% in kids
- burns at extremes of age
- NAI
- significant co-morbidities eg diabetes
rule of 9s in burns
when methods are used for calculating burns
rule of 9s
ludlow and browder chart
what are the five different depths of burns?
- Epidermal
- Superficial dermal
- Mid dermal
- Deep dermal
- Full thickness
when do patients with burns need fluids?
- electrical burns
- delayed presentation
- inhalation injury
- over 10% tbsa for adults
- coexistant traumatic injuries
what are the most common findings with central cord syndrome (central cervical cord syndrome) ?
- Incomplete paralysis (upper over lower)
- Incomplete sensory loss (upper over lower)
- Urinary retention
what is the immediate plan for central cord syndrome
- apply C-spine precautions
- transfer to centre with MRI if MRI not available
- refer to neurosurgery
what is the prognosis for central cord syndrome?
Good
most people will ambulate and have return of hand movement
what are the common causes of central cord syndrome?
- Trauma
- tumour
- cervical spondylosis
what life threatening injuries are associated with a chest stabbing?
- cardiac - tampanade, STEMI, rupture, contusion
- Lung - haemothorax, pneumothorax, hilum injury
- vessels - aorta, SVC, pulmonary artery or vein damage
- organs - diaphragm, spleen, liver
- nerve - phrenic nerve
how would you prepare the ED with a chest stabbing pre alert
- team - allocate roles, ask skill set, alert specialty teams (anaesthetics/gen surg/radiology) - trauma call
- equipment - intubation, thoracotomy. IV access, USS
- blood products, rapid infuser, warmer
what are the indications for thoracotomy in ED?
Thoracostomy
Thorocotomy
- penetrating chest trauma and witnessed arrest
- severe shoick with signs of tamponade
- blunt thoracic trauma with rapid exanguanation or persistant hypotension
Thorocostomy
Widely accepted
o Penetrating chest injury with cardiac arrest/ peri-arrest non-responsive to resus
measures and signs of life within previous 10 minutes
Controversial:
penetrating non thoracic trauma with cardiac arrest
MVA, tubed, hypotensive
findings?
- ETT just above the level of his clavicles
- NG tube in situ that migrates below the level of the right hemidiaphragm and curls
around to the left above the level of the right hemidiaphragm - Deviation of the NG tube to the right
- Elevation of the left hemidiaphragm
- Fracture left scapula(subtle)
- Left lung basal collapse/consolidation
- Left apical capping
- Widened mediastinum
MVA, tubed, hypotensive
Differentials in order of severity
- aortic dissection
- diaphragm rupture
- blunt cardiac injury
- lung contuison
- splenic injury
- bony injuries
high speen MVA
injuries present on x ray and radiograpghic evidence
Multiple displaced Rib Fractures – displaced rib fractures seen posteriorly
Rt TENSION Pneumothorax – expansion Rt hemithorax, deviation NGT to left, visible lung edge,subcut emphysema
Rt Pulmonary Contusion – Increased opacification throughout Rt lung field
Lt Pneumothorax – subcutaneous emphysema
Left Clavicle fracture – comminution of mid-clavicle
how do you improve oxygenation in trauma and bilateral significant pneumothoraces?
bilateral thoracotomy
increase fio2
increase peep
barcode sign
pneumothorax
management prioritoes
what is a paeds CT head calculator?
PECARN
CATCH
What does PECARN say the indications for ct head in kids is?
how do you safely prepare child for CT head in trauma
- consent
- access and sedation - 0.5-1mg/kg ketamine
- anti emetic eg 0.15mg/kg ondansetron
- monitoring - sats/BP/HR
how could you anaethetise these teeth?
- infra orbital nerve block - 2ml lidnocaine below infra orbtial notch
- local infiltration - supraperiostial infiltration with 2ml lidocaine into deepest part of sulcus formed by trauma
delay to dentist - describe ED management
Ideally need OPG to assess fracture of alveolar bone
* Local anaesthetic analgesia
* Reinsert tooth into normal position (mould alveolar bone if needed, check occlusion)
* Splint to adjacent teeth with Glass Ionomer Cement (GIC). If no GIC available need
alternate splint – e.g. “blue tac” and a mouth guard
* Cover exposed fracture surface (dentine) with GIC
* If no GIC available needs relatively urgent (< 24h) f/u with dentist
* Will need splinting for 2-4 weeks
* adt
* abx
what are the adverts events associated with severe dental injury
- dental abscess
- pulp necrosis
- root resorption
- need for root canal
- tooth colour change
describe injury
x Subluxed 1:1 (R upper 1st incisor)
x Extruded or Lateral luxation 2:1 (Lt upper 1st incisor)
x Lip contusion
x Alveolar Fracture
goals of treatment for this injury
- stablise to prevent aspiration
- approximate anatomical position to aid healing
- see dentist for definitive management**
- analgesia
- exclude other injuries
*
advers effects of ketamine for sedation
- Laryngospasm
- x Emergence reactions
- x Transient Apnea
- x Emesis
- x Allergy
abnormalities
- right maxillary intrusion and luxation
- left maxillary horizontal fracture involving pulp
dental trauma terminology
collapse onto heater and facial burn (severe)
what issues need to be considered
cardiac monitoring for cause of syncope
airway assessment
signs of head trauma
ADT status
how would you describe this burn?
Burn involves approx. 2% TBSA
* Central area of full thickness burn (approx. 1% TBSA) with white/leathery appearance of
skin and no capillary refill
* Surrounded by partial thickness burn with evidence of deroofed blisters
* Area extends from the patients left ear (involving the inferior 2 thirds of their helix,
antihelix and the tragus), the majority of the patients left maxillary, mandibular and
zygomatic areas, to the patient’s chin.
* Left eye, lips and airway appear to be spared
fall with trauma and bleeding with hypotension.
What patient meds may be important in this situation?
anticoagulants
anti platelets
anti hypetensives
diabetic meds
opioids
sedatives
fall with trauma and bleeding with hypotension.
four causes and ways to confirm the hypotension in resus room
- haemothorax - CXR
- tension pneumothorax - clinical exam
- tamponade - efast
- intraperitoneal haemorrhage - efast
- long bone fracture - x ray
- pelvic fracture. x ray
what are the common components of a massive haemorrhage pack
- PRBC
- FFP
- Platelets
- cryoprecipitate
- TXA
- calcium gluconate
other than normal INR what are the anticoag targets in massive haemorrhage
fall from roof
main pathology
mediastinal haematoma - likely large vessel injury
Why:
widened mediastinum
loss of aortic knob
depressed left main bronchus
left apical pleural cap
trauma with hypotension but normal scans. what is the other cause?
neurogenic shock
what are the early complications of head injury and their signs
what are the high risk features on canadian head CT tool
- GCS <15 at 2h after injury
- suspected open or depressed skull #
- any sign of basal skull #: haemotympanum, ‘racoon’ eyes, CSF otorrohoea/rhinorrhoea, Battle’s sign
- vomiting > or +2 episodes
- age >65yo
what are the medium risk features on canadian head CT tool
- amnesia before impact >30min
- dangerous mechanism (pedestrian v. MVA, ejection from vehicle, fall from height >3ft or 5
stairs)
what are the neuroprotective measures for head injury
- Normoxia: keep the PaO2 above 60 mmHg
- low normocapnia: keep the PaCO2 between 35-40 mmHg
- Normotension: measure the MAP, and keep the systolic above 90mmHg
*** Intracranial Pressure monitoring: **keep it under 20mmHg
- Cerebral perfusion pressure: keep it 50-70mmHg
* Cerebral oxygenation monitoring:keep the SjO2 >50%, and PbrO2 >55mmHg
Manage ICP
how do you manage ICP in head injury
o Draining the EVD ( about 20ml/hr, max)
o Head up 30 degrees
o Positioning the head straight
o Removing the C-spine collar
o Sedation :
▪ Propofol sedation to decrease distress and thus decrease ICP
▪ Barbiturate coma if other methods of lowering ICP have failed
▪ Analgesia to prevent increased ICP in response to suctioning and routine care
o Paralysis
what are the indications for CT head in child with trauma
Pecarn criteria
positive findings
- left frontal extradural haematoma
- left frontal lobe compressed
- fluid in left frontal sinus
- external soft tissue swelling
child deteriorates
what are the priorities?
- Resuscitate: Move to RR/Team Leader. Delegate Roles. Resus Equipment/Monitoring
- RSI/Ventilation. Maintain BP/avoid Hypotension and hypoxia. Appropriate drugsketamine. Ongoing sedation and paralysis.
- CPP: Avoid Hypotension/hypoxia. Aim PaO2 100mmHg or more, low normal CO2. Headup. Avoid tight tapes. Mannitol/Hypertonic saline
- Mobilise Surgeon (Burr holes/EVACUATION)/Retrieval team. Tertiary referral centre andNeurosurgery.
- Inform parents/NOK/SW
abnormalities
- Large extradural haematoma – high density bi convex lesion left temporal region
- Hyperacute extradural with “swirl sign” mixed density
- Large scalp haematoma left temporal region
- Parietal cerebral contusion left
- Significant midline shift to right
- Loss of sulci and gyri consistent with raised intracranial pressure
treatment priorties of ICH in in ED
Immediate neurosurgical referral for surgical drainage of haematoma
Intubation for airway control and management of CO2
Maintain MAP >80 (accept approx.) mmHg with IV N/S +/- noradrenaline infusion
Maintain oxygenation sats >95%
Ventilate for low normal CO2 (35 – 40)
Other neuroprotective measures (max 4 marks)
Well sedated, paralysed
Slightly head-up position
Loosen ties / restriction to venous return
Na high normal range
Normothermia
normoglycaemia
findings
- Acute on subacute subdural haematoma / haemorrhage
- High attenuation anterior – acute blood
- Iso-attenuation – subacute blood
- Loss of sulci left hemisphere – raised ICP
MVA, intubated
list the findings and radiological evidence
what does this show?
fluid in hepatorenal angle
what is the blood ratio given in trauma
1:1:1
PRBC:platelets:FFP
MVA
findinds and radiological evidence
**Left haemothorax **– veiled hemithorax, pleural cap
**Mediastinal haematoma **– wide mediastinum, rightward displacement NGT, paratracheal stripe,depressed left main bronchus
**Right pulmonary contusion **– right midzone opacities/consolidation
Right PTX – lucent right hemithorax, subcut emphysema
MVA
main abnormalities and why
Respiratory acidosis – underventilation, need to increase MV
HAGMA – mainly lactate due to tissue hypoperfusion
Hyperkalaemia – when corrected for acidosis is approx. 3.6
**Hypoxia **– due to lung pathologies V/Q mismatch – haemothorax, contusions, PTX
how do you minimise chance of coagulopathy post trauma
- normothermia
- correct any acidosis
- 1:1:1 blood resus
- Rotem to target
- calcium
trauma
pertinent findings
Displaced Chance type fracture of T12 vertebra
- Ventral displacement of distal vertebral column
- 3 column fracture (ie unstable)
- Likely retropulsion into spinal canal
- S3 fracture
what are the clinical features of neurogenic shock
- warm peripheries
- normotensive
- bradycardia
- poikilothermia
what are the management priorties for neurogenic shock
describe injury
Penetrating injury with ?knitting needle to right lower anterior chest (?9th-11th
interspace), line of nipple – knitting needle in situ, appears to be at right angle to
chest wall, with foreign material at entry point
Unable to assess depth
Child appears comfortable, not distressed, co-operative and well perfused
Chest appears equally expanded right vs left
(IV access in right cubital fossa)
complications of this injury
pneumothorax
tension pneumothorax
haemothorax
hepatic injury
vascular injury
bowel injury
infection
how do you conduct wound irrigation
- local with lidocaine
- wash with normal saline with pressure
- 100-300ml
what wounds are candidates for delayed primary closure?
How do you do delayed primary closure
bite wounds
heavily contaminated
late presentation
Process:
irrigated and debrided
packed with saline gauze and dressed
return in 4/5 days and close if not infected
when do you give abx prophylaxis in wounds?
bites
heavily containated
seawater
deeper structures
delated presentation
penetrating wounds
post head injury the pupils are differnte sizes
what would you do?
500ml IV hypertonic saline to lower ICP
plus usual neuroprotective
1.describe injury
2.What are the next steps in assessing patient
- management priorities
- open fracture/dislocation left ankle with profound angulation
- large wound
- minimal active bleeding
- calf flap
Next steps
* Primary survey to address life threatening injuries
* neurovascular status of limp
* AMPLE (allergies, medications, past history, last ate, event)
Management priorities
* analgesia
* abx
* gross decontamination
* reduction under sedation
* admit to orth/vasc
Detail the main differences between research evidence behind the PECARN, CHALICE and CATCH clinical decision rules.
- C and C are rule in, pecarn rule out
- Pecarn has highest sensitivity and prospectively validated
key things to explain in parent demanding CT head
- Not required as per best evidence
- CTB performed to diagnose injury that requires neurosurgical intervention
- Concussion managed conservatively
- Risk of radiation: lifetime cancer mortality risk from a single head CT is about
- 1 in 1,500 in a 1 year old; 1 in 10,000 in a 10 year old
- Risk related to sedation if required
what are the contraindications to thoracotomy
unwitnessed cardiac arrest
severe head injury
penetrating abdo injury
no cardithoracics available
what measures can be performed post thoractomy
- cardiac massage
- clamp aorta
- ventricular repair
steps in thorocostomy
what is this
pericardial effusion
steps in thorocotomy
what clinical features suggest critical vascular injury
- pulsatile
- rapidly expanding haematoma
- thrill
- bruit
what are the four acute cord syndromes
trauma
calcium chloride 10mls 10% IV
BP target in ICH and why?
pregnancy and MVA
what ar the pregancy specific trauma conditions you want to excluce
- fetal distress
- placental abruption
- amniotic fluid embolism
- uterine rupture
- laceration of placenta
- premature labour
- premature rupture of membranes
- fetomaternal haemorrhage
- direct fetal injury
pregnancy, MVA, heavy bleed
what are the initial steps
- resusciate mother MAP over 60
- check fetal heartrate with CTG/US
- notify OG
- large cannula
- URgent US
- +/- steroids for fetal lung maturation
punch to face
abnormalities
what are the important components of exam and what pathology are you looking for
- Inferiorly displaced left orbital floor fracture
- Fluid (blood) in left maxillary sinus
- Inferior rectus is displaced in to fracture segment –
what x ray featurs suggest inferior orbital wall fracture
fluid in maxillary sinus
orbital emohysema
teardrop sign - herniation of fat inferiorly
with trauma, what are the causes of optin neuropathy
- compressive optic neuropathy eg haemorrhage, foreign body
- optic nerve sheath haematoma
- optic nerve head avulsion
- optic nerve laceration
what are the indications for intercostal cathether post rib fractures
- hypoxia
- ventilatiry failure needed positive pressure
- need for operative intervention
- progressive pneunothorax or presence of haemothorax
patient is GCS 15 wth no motor function below C5. wht are the managmenet priorities
Manage ventilatory failure -
(Control of airway with intubation using MILS as ventilatory failure likely given
phrenic nerve involvement at this spinal level)
BP management - high risk of hypotension from neurogenic shock
- initially iv fluids +/- pressors
- consider concurrent hypovolaemia from bleeding and Ix as required
Maintain spinal immobilisation
Assess and manage concurrent injuries (eg chest, abdo, pelvis, limb fractures)
Temperature control
Methylprednisolone controversial- discuss with local spinal team
Refer to spinal team for definitive management once other injuries excluded
what US features suggest cardiac tamponade
- pericardial effusion
- right sided collapse in diastole
what are the potential complications of resuscitave thoracotomy
- Coronary artery injury/ligation
- Phrenic Nerve laceration
- Diaphragmatic injury
- Chest wall vascular injury (intercostals, internal mammary)
- Infection
- Health care worker body fluid exposure
trauma and rapid deterioration
what are the three goals of resus in trauma
- maintain perfusion to organs eg MAP over 65 and BP over 100 depending on head injury
- correct or prevent coagulopaty - 1:1:1 and rotem based tx
- avoid hypothermia and acidosis
what is the triad of death in trauma
coagulopathy
hypothermia
acidosis
acute complications of head injuries
- raised ICP
- impact apnoea
- ICH
- CSF leaf
- diffuse axonal injury
- C spine injury
- cranial nerve injury
- seizures
- haemorrhagic shock
- aspiraiton pneumonia
MVA
initial priorities
primary and seconday survery
analgesia
pressure dressing to miminise haeatoma
imaging for bony and vascular injury
what are the potential consequences of rapid release of prolonged crush injury?
How could you mitigate this
- washout of ‘bad blood’ - cold, acidotic and K ridden
- arrhythmias
Mitigate:
IV access and saline pre load
IV bicarb
IV calcium
how do you measure compatment pressures?
What figure suggests CS?
- Stryker needle and insert into muscle of concern post prepping skin
- Clinical suspicion trumps measurement
Over 35mmHg
with a high CK and trauma, what are the risks of starting mannitol for renal protection?
- lack of evidence it is more effective than NaCl
- fluid shifts causing hypotension and hypovolaemia
- increased blood viscosity
- allergy
interpretation and why
normal swischuk line
what is the Nexus criteria to clinically rule out c spine fracgure
- No midline tenderness
- No neurological abnormalities
- No distracting injury
- Not intoxicated
- No altered consciousness
abnormalities
- Soft tissue swelling in front of C6/7
- Antero-superior corner fracture C7
- Disruption of posterior spinal line
- Widening between spinous processes C6 – C7
what are the C-spine lines
investigations and why post C spine injury
classify pelvic injury
what is the classification system
antero posterior
classification system
Young-Burgess
list complications, assessment findings and management of associared pelvic fractures
classify injury and why
vertical shear:
* Superior and inferior pubi rami fracture
* fracture left iliac wing
abnormalities
Pubic diastasis
Widened R Sacro-Iliac Joint
Widened L Sacro-Iliac Joint
what is the treament for open book pelvic fracture
pelvic binder to close pelvic diastasis
+/- IR for vascular injury
