Trauma Flashcards
What are common causes of head trauma?
Crushing injuries
(need to consider bony & soft tissue structures impacted by this)
What are the considerations in head trauma assessments?
- Can the animal breathe?
- bony structures: crushed nasal bones
- soft tissue: oral bleeding (tongue) & aspiration risk, damaged airway/larynx - is there evidence of traumatic brain injury?
- bony structures: depressed skull fracture
- soft tissue: direct concussive trauma to brain - any other injuries that are not immediately life threatening?
- broken jaw
- proptosis of eye
How do you check if a patient with head trauma can breathe?
Assess resp rate, effort, signs of cyanosis, pulse oximetry
If concerned instigate emergency therapy
How can you manage airway obstruction in head trauma?
Oxygen therapy is airway is patent
If not, then rapid induction & intubation
- Have suction available to clear airway (machine or urinary catheter & big syringe)
If intubation fails, emergency tracheostomy (rare)
Give examples of primary injuries in traumatic brain injury (TBI)
Concussion (no histopathological changes, self limiting)
Contusion, haematoma & laceration
What is a contusion (traumatic brain injury)?
Bruising & oedema of brain, leading to increase in intracranial pressure (ICP)
What is a haematoma (traumatic brain injury)?
Collection of blood in cerebral, subdural, or epidural spaces, all contributing to increased ICP
What is a laceration (traumatic brain injury)?
tear in parenchyma (functional tissue) of brain, which can lead to severe neurological damage
Give examples of secondary injuries in traumatic brain injury
Huge excitation of neurological tissues –> depletes ATP & energy stores –> neuronal damage
Pro-inflammatory state –> neuronal damage & generation of free radicals
Disruption of BBB & loss of brains capability to regulate cerebral perfusion
All result in brain being sensitive to changes in peripheral BP, ischaemic injury & further neuronal death
How can you sport traumatic brain injury?
Mentation neurological assessment:
- patient obtunded + history of head trauma –> strongly consider TBI
Eyes neurological assessment:
- bilateral miosis with reduced PLR (variable prognosis)
- unilateral mydriasis with reduced PLR (guarded prognosis)
- Bilateral mydriasis or normal size pupils with no PLR (poor prognosis)
Cushings reflex (cerebral response to ischaemia) - Severe!
- increase in MAP (hypertension) with bradycardia
Lab results:
- glucose elevated (catecholamine release)
- severity of hyperglycaemia may correlate with prognosis
How do we treat traumatic brain injury?
Reduce ICP with hypertonic fluids
- Hypertonic Saline or Mannitol
Normalise perfusion
How can perfusion be normalised in traumatic brain injury?
Maintain BP at normal MAP:
- hypotension: fluid therapy +- vasopressor
- hypertension: pain relief, anti-hypertensive medication
Maintain CO2 at normal values
- hypercapnia causes cerebral vasodilation & worsens ICP
- hypocapnia causes cerebral vasoconstriction reducing perfusion
-If this isn’t normalised with restoration of BP, consider intubation & ventilation to control
What are the 2 main types of thoracic injury
Blunt trauma (concussive)
Penetrating (more devastating)
Give examples of thoracic trauma caused by blunt trauma
Bruising/contusions
Swelling/oedema
Lung rupture from acute increase in pressure
Diaphragm rupture & subsequent herniation of abdominal contents
Orthopaedic (e.g. rib fractures –> secondary penetrating injury)
Give examples of thoracic trauma caused by penetrating injuries
Direct injury of lungs/airways
Direct injury of major vessels of heart
External contamination of thorax
Oesophageal injury
What are the key priorities when assessing thoracic trauma?
Triage baseline parameters, perform POCUS, secure IV access, and provide pain relief
What does a normal lung ultrasound look like?
What is going on in this lung ultrasound
What can you see in this lung ultrasound?
Pulmonary contusions (B-lines)
What can you see in this lung ultrasound?
Pleural effusion
How do you diagnose pleural effusions?
Perform thoracocentesis, check PCV to confirm blood & consider blood gas analysis for oxygen therapy
If BP is normal, what else is a good marker for needing oxygen therapy?
Lactate (elevates with anaerobic respiration)
Why is a tension pneumothorax life threatening?
Pressure from pneumothorax exceeds right sided filling pressure of heart –> venous return drops –> cardiac output drops –> death
How can tension pneumothorax be diagnosed?
on POCUS with signs of obstructive shock
Radiography is dramatic but don’t always have time to confirm
How is a tension pneumothorax treated?
Immediate thoracocentesis (butterfly catheter or needle with extension line, 3 way tap & syringe)
Outcome should be immediate restoration of thoracic output (also confirms that you were correct)
How do you stabilise a persistent pneumothorax?
Chest drain placement
How do you stabilise a traumatic haemothorax?
Drain until ventilation improves
Consider transfusion/autotransfusion (PCV won’t change in acute setting so use clinical signs & sudden drop in total protein to judge need)
Surgery
How do you stabilise a chylothorax?
Chest drain as required to maintain ventilation
Surgery (e.g. thoracic duct ligation)
How do you stabilise a diaphragmatic hernia?
Further imaging (radiography) to confirm diagnosis
Delay surgical repair for 24h until patient is stable
If unstable (unable to ventilate adequately, will need to intubate & ventilate so surgery makes sense at this point)
How do you stabilise a penetrating injury in thoracic trauma?
Anaesthesia probably necessary to ventilate patient until wound closure
Wound management
- clip, clean, flush (use saline, not hibiscrub (causes irritation & inflammation if it enters thoracic cavity))
- radiography for foreign material
- close wound opposing each layer
- place chest drain via separate opening
- lavage & drain chest
Antibiotics
- broad spectrum cover with good penetration (amoxicillin/clavulanate good starting point & should cover for clostridium)
- submit fluid samples from chest for culture & sensitivity
What are the 2 main types of injuries in abdominal trauma?
Blunt trauma
Penetrating injury
Give examples of blunt traumas in abdominal trauma
Bruising/contusions
Swelling/oedema of all organs
Small lacerations to spleen & liver from internal aspect of ribs
Rupture of spleen, GIT or bladder
Orthopaedic (e.g. hip fractures)
Give examples of penetrating injuries in abdominal trauma
Direct injury of abdominal organ
Direct injury of major vessels
External contamination of abdomen
How do you differentiate between blood & urine in free abdominal fluid?
Abdominocentesis
Blood: Centrifuge → PCV similar to peripheral blood, low TP
Urine: Centrifuge → Biochemistry (Creatinine >2x blood, K⁺ >1.4x blood in dogs, >1.9x in cats
How is a blunt trauma haemoabdomen managed in abdominal trauma?
Usually non-surgical (rarely has organ ruptured)
Managed with fluid therapy, blood products if necessary (e.g. persistent tachycardia & tachypnoea), abdominal wrap & tranexamic acid
Large animals may need hypertonic saline to achieve improvement in BP
What is Tranexamic Acid, and how does it help in trauma?
Anti-fibrinolytic that helps stabilise clot formation
Used for neoplastic & idiopathic bleeds, trauma cases & spinal surgery (reduces intraoperative bleeding)
How is a penetrating trauma haemoabdomen managed in abdominal trauma?
Usually surgical
Initial stabilisation with fluid therapy +- blood products/autotransfusion
Aim to restore perfusion (BP, lactate & clinical signs are primary measures)
Anaesthesia might be complicated (cardiac arrythmias)
- myocardial hypoxia may have occurred (exacerbated by anaesthesia)
- Lidocaine pre drawn up or CRI
Tranexamic acid
Exploratory laparotomy (staged approach)
Why is a staged approach recommended for exploratory laparotomy?
Finding exact source of bleeding can be difficult
Consider harvesting blood for autotransfusion
If bleeding can’t be stopped, pack & close abdomen
Re-operate in 24–48 hours
What is pneumoperitoneum, and why is it serious?
Free gas in abdomen indicating GIT damage, which can lead to sepsis & distributive shock
How is pneumoperitoneum diagnosed and treated?
Diagnosis: POCUS (air interference), confirmed by radiography
Treatment: Exploratory laparotomy, GI repair, broad-spectrum antibiotics (amoxicillin/clavulanate)
What is the main life-threatening consequence of uroabdomen?
Hyperkalemia, which slows cardiac conduction, causing bradycardia, atrial standstill & death
How is uroabdomen treated?
Usually surgical
Hyperkalaemia:
- Glucose + insulin, alkalinizing fluids (Hartmann’s)
Abdominal drainage & lavage with saline
Urinary catheter placement
- urine will drain via this instead of leaking into abdomen, allowing bladder/urethral tear to heal before surgery
- allows instillation of contrast to look for location of damage
- if no leak, may need intravenous ureterography to assess ureters for leak
Why can spinal trauma be hard to diagnose in the initial triage?
Patient may present collapsed from other injuries (e.g., haemoabdomen), delaying neurological assessment
Treat what you can see initially but important to perform full neuro assessment in stages of triage
What can spinal cord transection lead to?
Loss of autonomic control & loss of vascular tone –> Neurogenic shock (type of distributive shock)
What are the signs of neurogenic shock?
Lack of response to fluid therapy alone to improve BP
Requirement of vasopressor therapy
Neurological deficits
What exam should you do if you are suspicious of spinal trauma?
Survey radiography
Always take orthogonal views
Spinal manipulation to obtain these views must be extremely careful
Sedation may be indicated if patient still has movement in forelimbs (thrashing around) but beware, loss of muscle tone may make destabilisation worse
What are the UMN vs LMN signs in spinal trauma?
UMN (Upper Motor Neuron) → Increased/normal reflexes & tone
LMN (Lower Motor Neuron) → Decreased/absent reflexes & tone
When should you refer spinal traumas?
Always if possible
CT preferred for absolute diagnosis & to allow for surgical planning
Some fractures/subluxations not obvious on routine radiography
Some cases may have contusions without fractures & recover with supportive care
What is the prognosis for large animals with spinal trauma?
Poor; euthanasia often best outcome
However, surgical stabilisation is possible for neck fractures in adult horse if neurological deficits are mild
