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1. Fellowship Written - SAQ > Trauma > Flashcards

Trauma Flashcards

1
Q

blunt force trauma
most obvious findings

A

haemoperitoneum
liver laceration
active haemorrhage

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2
Q

blunt force trauma with active intra abdominal bleed

A
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3
Q

blunt force trauma with intra abdominal bleed

A
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4
Q
A
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5
Q

what are the contraindications for FAST scan in trauma?

A
  • presence of more critical problem eg airway obstruction
  • clear indication for emergency laparotomy eg penetrating trauma with shocked patient
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6
Q

What are the classical CT findings with a seatbelt sign?

A

perforation with leakage of contrast
mural haematoma/thickening
abdo bowel wall enhancement (ischaemia)
fat stranding

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7
Q

blunt force injury
what are the major findings?

A
  • renal parynchymal laceration
  • devascularisation of part of kidney (hypodense)
  • large perinephric haematoma
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8
Q

what are the complications of a traumatic renal injury

A

hypertension
haemorrhagic shock
death
abscess
delayed bleeding

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9
Q

abnormalities

A
  1. teeth malocclusion
  2. fracture body of manible
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10
Q

what needs to be documented with a mandible fracture

A
  1. degree of mouth opening
  2. missing/occlusion of teeth
  3. ?open fracture to mouth
  4. ?haematoma to floor of mouth
  5. brusing/bleeding
  6. other injuries
  7. ?inferior alveolar nerve parasthesia
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11
Q

how do you manage mandible fracture in ED?

A
  1. ADT
  2. abx eg cefzolin 2g IV OD
  3. analgesia - be specific
  4. NBM and iv fluids
  5. mouth washes - QID hydrogen peroxide
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12
Q

?facial burn
what clinical signs must you look for?

A
  1. facial or oral burns
  2. singed nasal hair
  3. swollen lips
  4. singed eyebrows or lashes
  5. oedema - facia;
  6. tachypnoea
  7. wheeze
  8. stridor
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13
Q

?facial burn
Investigations?

A
  1. carboxyhaemoglobin level
  2. CK
  3. ABG
  4. glucose
  5. U+E
  6. ECG
  7. CXR
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14
Q

What is the modifeid parkland formula for burns?

A

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

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15
Q

whar are the criteria for transferring to specialist burns unit?

A
  1. mid to deep dermal burns over 10% TBSA
  2. Full thickness over 5% TBSA
  3. burns to face/feet/hands/genitalia or major joints
  4. chemical burns
  5. electrical burns eg lightning
  6. burns with associated inhalation
  7. burns with significant other trauma
  8. pregnancy with cutaneous burns
  9. any mid - deep over 5% in kids
  10. burns at extremes of age
  11. NAI
  12. significant co-morbidities eg diabetes
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16
Q

rule of 9s in burns

A
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17
Q

when methods are used for calculating burns

A

rule of 9s
ludlow and browder chart

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18
Q

what are the five different depths of burns?

A
  • Epidermal
    • Superficial dermal
    • Mid dermal
    • Deep dermal
    • Full thickness
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19
Q

when do patients with burns need fluids?

A
  1. electrical burns
  2. delayed presentation
  3. inhalation injury
  4. over 10% tbsa for adults
  5. coexistant traumatic injuries
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20
Q

what are the most common findings with central cord syndrome (central cervical cord syndrome) ?

A
  • Incomplete paralysis (upper over lower)
  • Incomplete sensory loss (upper over lower)
  • Urinary retention
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21
Q

what is the immediate plan for central cord syndrome

A
  • apply C-spine precautions
  • transfer to centre with MRI if MRI not available
  • refer to neurosurgery
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22
Q

what is the prognosis for central cord syndrome?

A

Good
most people will ambulate and have return of hand movement

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23
Q

what are the common causes of central cord syndrome?

A
  1. Trauma
  2. tumour
  3. cervical spondylosis
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24
Q

what life threatening injuries are associated with a chest stabbing?

A
  • 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
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25
Q

how would you prepare the ED with a chest stabbing pre alert

A
  1. team - allocate roles, ask skill set, alert specialty teams (anaesthetics/gen surg/radiology) - trauma call
  2. equipment - intubation, thoracotomy. IV access, USS
  3. blood products, rapid infuser, warmer
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26
Q

what are the indications for thoracotomy in ED?

Thoracostomy

A

Thorocotomy

  1. penetrating chest trauma and witnessed arrest
  2. severe shoick with signs of tamponade
  3. 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

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27
Q
A
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28
Q

MVA, tubed, hypotensive
findings?

A
  • 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
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29
Q

MVA, tubed, hypotensive
Differentials in order of severity

A
  1. aortic dissection
  2. diaphragm rupture
  3. blunt cardiac injury
  4. lung contuison
  5. splenic injury
  6. bony injuries
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30
Q

high speen MVA
injuries present on x ray and radiograpghic evidence

A

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

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31
Q

how do you improve oxygenation in trauma and bilateral significant pneumothoraces?

A

bilateral thoracotomy
increase fio2
increase peep

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32
Q
A

barcode sign
pneumothorax

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33
Q

management prioritoes

A
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34
Q
A
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35
Q
A
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36
Q

what is a paeds CT head calculator?

A

PECARN
CATCH

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37
Q

What does PECARN say the indications for ct head in kids is?

A
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38
Q

how do you safely prepare child for CT head in trauma

A
  1. consent
  2. access and sedation - 0.5-1mg/kg ketamine
  3. anti emetic eg 0.15mg/kg ondansetron
  4. monitoring - sats/BP/HR
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39
Q

how could you anaethetise these teeth?

A
  • 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
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40
Q

delay to dentist - describe ED management

A

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

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41
Q

what are the adverts events associated with severe dental injury

A
  • dental abscess
  • pulp necrosis
  • root resorption
  • need for root canal
  • tooth colour change
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42
Q

describe injury

A

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

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43
Q

goals of treatment for this injury

A
  • stablise to prevent aspiration
  • approximate anatomical position to aid healing
  • see dentist for definitive management**
  • analgesia
  • exclude other injuries
    *
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44
Q

advers effects of ketamine for sedation

A
  • Laryngospasm
  • x Emergence reactions
  • x Transient Apnea
  • x Emesis
  • x Allergy
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45
Q

abnormalities

A
  • right maxillary intrusion and luxation
  • left maxillary horizontal fracture involving pulp
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46
Q

dental trauma terminology

A
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47
Q
A
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48
Q
A
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49
Q

collapse onto heater and facial burn (severe)
what issues need to be considered

A

cardiac monitoring for cause of syncope
airway assessment
signs of head trauma
ADT status

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50
Q

how would you describe this burn?

A

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

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51
Q

fall with trauma and bleeding with hypotension.
What patient meds may be important in this situation?

A

anticoagulants
anti platelets
anti hypetensives
diabetic meds
opioids
sedatives

52
Q

fall with trauma and bleeding with hypotension.
four causes and ways to confirm the hypotension in resus room

A
  1. haemothorax - CXR
  2. tension pneumothorax - clinical exam
  3. tamponade - efast
  4. intraperitoneal haemorrhage - efast
  5. long bone fracture - x ray
  6. pelvic fracture. x ray
53
Q

what are the common components of a massive haemorrhage pack

A
  • PRBC
  • FFP
  • Platelets
  • cryoprecipitate
  • TXA
  • calcium gluconate
54
Q

other than normal INR what are the anticoag targets in massive haemorrhage

A
55
Q

fall from roof
main pathology

A

mediastinal haematoma - likely large vessel injury

Why:
widened mediastinum
loss of aortic knob
depressed left main bronchus
left apical pleural cap

56
Q

trauma with hypotension but normal scans. what is the other cause?

A

neurogenic shock

57
Q

what are the early complications of head injury and their signs

A
58
Q

what are the high risk features on canadian head CT tool

A
  • 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
59
Q

what are the medium risk features on canadian head CT tool

A
  • amnesia before impact >30min
  • dangerous mechanism (pedestrian v. MVA, ejection from vehicle, fall from height >3ft or 5
    stairs)
60
Q

what are the neuroprotective measures for head injury

A
  • 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

61
Q

how do you manage ICP in head injury

A

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

62
Q

what are the indications for CT head in child with trauma

A

Pecarn criteria

63
Q

positive findings

A
  1. left frontal extradural haematoma
  2. left frontal lobe compressed
  3. fluid in left frontal sinus
  4. external soft tissue swelling
64
Q

child deteriorates
what are the priorities?

A
  • 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
65
Q

abnormalities

A
  • 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
66
Q

treatment priorties of ICH in in ED

A

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

67
Q

findings

A
  • Acute on subacute subdural haematoma / haemorrhage
  • High attenuation anterior – acute blood
  • Iso-attenuation – subacute blood
  • Loss of sulci left hemisphere – raised ICP
68
Q

MVA, intubated
list the findings and radiological evidence

A
69
Q

what does this show?

A

fluid in hepatorenal angle

70
Q

what is the blood ratio given in trauma

A

1:1:1
PRBC:platelets:FFP

71
Q

MVA
findinds and radiological evidence

A

**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

72
Q

MVA
main abnormalities and why

A

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

73
Q

how do you minimise chance of coagulopathy post trauma

A
  1. normothermia
  2. correct any acidosis
  3. 1:1:1 blood resus
  4. Rotem to target
  5. calcium
74
Q

trauma
pertinent findings

A

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

75
Q

what are the clinical features of neurogenic shock

A
  1. warm peripheries
  2. normotensive
  3. bradycardia
  4. poikilothermia
76
Q

what are the management priorties for neurogenic shock

A
77
Q
A
78
Q

describe injury

A

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)

79
Q

complications of this injury

A

pneumothorax
tension pneumothorax
haemothorax
hepatic injury
vascular injury
bowel injury
infection

80
Q

how do you conduct wound irrigation

A
  • local with lidocaine
  • wash with normal saline with pressure
  • 100-300ml
81
Q

what wounds are candidates for delayed primary closure?

How do you do delayed primary closure

A

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

82
Q

when do you give abx prophylaxis in wounds?

A

bites
heavily containated
seawater
deeper structures
delated presentation
penetrating wounds

83
Q

post head injury the pupils are differnte sizes
what would you do?

A

500ml IV hypertonic saline to lower ICP

plus usual neuroprotective

84
Q

1.describe injury

2.What are the next steps in assessing patient

  1. management priorities
A
  • 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

85
Q

Detail the main differences between research evidence behind the PECARN, CHALICE and CATCH clinical decision rules.

A
  • C and C are rule in, pecarn rule out
  • Pecarn has highest sensitivity and prospectively validated
86
Q

key things to explain in parent demanding CT head

A
  • 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
87
Q

what are the contraindications to thoracotomy

A

unwitnessed cardiac arrest
severe head injury
penetrating abdo injury
no cardithoracics available

88
Q

what measures can be performed post thoractomy

A
  • cardiac massage
  • clamp aorta
  • ventricular repair
89
Q

steps in thorocostomy

A
90
Q

what is this

A

pericardial effusion

91
Q

steps in thorocotomy

A
92
Q
A
93
Q

what clinical features suggest critical vascular injury

A
  • pulsatile
  • rapidly expanding haematoma
  • thrill
  • bruit
94
Q

what are the four acute cord syndromes

A
95
Q

trauma

A

calcium chloride 10mls 10% IV

96
Q

BP target in ICH and why?

A
97
Q

pregnancy and MVA
what ar the pregancy specific trauma conditions you want to excluce

A
  1. fetal distress
  2. placental abruption
  3. amniotic fluid embolism
  4. uterine rupture
  5. laceration of placenta
  6. premature labour
  7. premature rupture of membranes
  8. fetomaternal haemorrhage
  9. direct fetal injury
98
Q

pregnancy, MVA, heavy bleed
what are the initial steps

A
  1. resusciate mother MAP over 60
  2. check fetal heartrate with CTG/US
  3. notify OG
  4. large cannula
  5. URgent US
  6. +/- steroids for fetal lung maturation
99
Q

punch to face
abnormalities

what are the important components of exam and what pathology are you looking for

A
  • Inferiorly displaced left orbital floor fracture
  • Fluid (blood) in left maxillary sinus
  • Inferior rectus is displaced in to fracture segment –
100
Q

what x ray featurs suggest inferior orbital wall fracture

A

fluid in maxillary sinus
orbital emohysema
teardrop sign - herniation of fat inferiorly

101
Q

with trauma, what are the causes of optin neuropathy

A
  1. compressive optic neuropathy eg haemorrhage, foreign body
  2. optic nerve sheath haematoma
  3. optic nerve head avulsion
  4. optic nerve laceration
102
Q

what are the indications for intercostal cathether post rib fractures

A
  1. hypoxia
  2. ventilatiry failure needed positive pressure
  3. need for operative intervention
  4. progressive pneunothorax or presence of haemothorax
103
Q

patient is GCS 15 wth no motor function below C5. wht are the managmenet priorities

A

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

104
Q
A
105
Q

what US features suggest cardiac tamponade

A
  • pericardial effusion
  • right sided collapse in diastole
106
Q

what are the potential complications of resuscitave thoracotomy

A
  • Coronary artery injury/ligation
  • Phrenic Nerve laceration
  • Diaphragmatic injury
  • Chest wall vascular injury (intercostals, internal mammary)
  • Infection
  • Health care worker body fluid exposure
107
Q

trauma and rapid deterioration

A
108
Q

what are the three goals of resus in trauma

A
  1. maintain perfusion to organs eg MAP over 65 and BP over 100 depending on head injury
  2. correct or prevent coagulopaty - 1:1:1 and rotem based tx
  3. avoid hypothermia and acidosis
109
Q

what is the triad of death in trauma

A

coagulopathy
hypothermia
acidosis

110
Q
A
111
Q

acute complications of head injuries

A
  • raised ICP
  • impact apnoea
  • ICH
  • CSF leaf
  • diffuse axonal injury
  • C spine injury
  • cranial nerve injury
  • seizures
  • haemorrhagic shock
  • aspiraiton pneumonia
112
Q

MVA
initial priorities

A

primary and seconday survery
analgesia
pressure dressing to miminise haeatoma
imaging for bony and vascular injury

113
Q

what are the potential consequences of rapid release of prolonged crush injury?

How could you mitigate this

A
  1. washout of ‘bad blood’ - cold, acidotic and K ridden
  2. arrhythmias

Mitigate:
IV access and saline pre load
IV bicarb
IV calcium

114
Q

how do you measure compatment pressures?
What figure suggests CS?

A
  • Stryker needle and insert into muscle of concern post prepping skin
  • Clinical suspicion trumps measurement

Over 35mmHg

115
Q

with a high CK and trauma, what are the risks of starting mannitol for renal protection?

A
  • lack of evidence it is more effective than NaCl
  • fluid shifts causing hypotension and hypovolaemia
  • increased blood viscosity
  • allergy
116
Q

interpretation and why

A

normal swischuk line

117
Q

what is the Nexus criteria to clinically rule out c spine fracgure

A
  • No midline tenderness
  • No neurological abnormalities
  • No distracting injury
  • Not intoxicated
  • No altered consciousness
118
Q

abnormalities

A
  • Soft tissue swelling in front of C6/7
  • Antero-superior corner fracture C7
  • Disruption of posterior spinal line
  • Widening between spinous processes C6 – C7
119
Q

what are the C-spine lines

A
120
Q
A
121
Q
A
122
Q

investigations and why post C spine injury

A
123
Q

classify pelvic injury
what is the classification system

A

antero posterior

classification system
Young-Burgess

124
Q

list complications, assessment findings and management of associared pelvic fractures

A
125
Q

classify injury and why

A

vertical shear:
* Superior and inferior pubi rami fracture
* fracture left iliac wing

126
Q

abnormalities

A

Pubic diastasis
Widened R Sacro-Iliac Joint
Widened L Sacro-Iliac Joint

127
Q

what is the treament for open book pelvic fracture

A

pelvic binder to close pelvic diastasis

+/- IR for vascular injury

1. Fellowship Written - SAQ (27 decks)

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