Trauma Flashcards
Trimodal distribution of death
Three major times death occurs after an accident/trauma
Instant - 1hr –> laceration or trauma to the brain/brainstem, aorta, spinal cord, heart
3 - 5hrs –> Epidural, subdural, haemopneumothorax, open-book pelvic #, long bone #, abdominal trauma, blood loss and shock
2 - 4wks –> Sepsis or MOF
Golden Hour
The first hour following a trauma - need to recognise threats to life and treat them - massive influence on later mortality and morbidity
Principles of early trauma care
Do no harm - Cervical spine control
Adequate oxygen delivery to organs - Patent airway
- Functioning lung
- Additional high flow oxygen
- Organ perfusion - preserve and replace blood volume
Primary Survey
A - Airway + C spine control B - Breathing & ventilation + oxygen C - Circulation + Haemorrhage control (consider analgesia) D - Disability + CNS E - Exposure + Environment
Timeline of trauma care
Primary survey –> Resuscitation (re-evaluate) –> secondary survey (Re-evaluate primary survey) –> Definitive Care
Principles of Pre-hospital care
Safety first –> yourself, others and patient
Make the best use of the ‘Golden Hour’
Swoop and scoop Vs Stay and play
Treat immediate threats to life and transport to nearest appropriate facility
Way to protect the patient during transport
Spinal board
Cervical collar/blocks and straps
Limb splints and pelvic binder
Pressure on external haemorrhages
Preparations while awaiting the patient
Anticipate injuries and assemble team members
Define the roles and prepare the kit
Universal safety precautions
Roles of the trauma team
Simultaneous ABCDE management
Rapid critical and definitive interventions
Rapid test results allow for directed management
Senior multidisciplinary input immediately avaliable
C-spine control
Collar and blocks & straps for in-line immobilisation
Can be done manually
Use Jaw thrust to open the airway but not head tilt
Airway protection
Clear airway with suction (vomit, teeth, blood, FB etc)
Airway adjunct - Nasopharyngeal / Oropharyngeal airway
Definitive airways - an endotracheal tube - required if GCS is below 8
Guedel
An Oropharyngeal airway adjunct - not a definitive airway
Measure by incisors to the angle of the jaw
Insert upside down and once in the mouth rotate and fully insert - use a tongue depressor and no turn with children
Definitive airway
Cuffed Oro-endotracheal tube (COETT) - Oro/nasal tracheal airways or combitube
Surgical airways - Cricothyroidotomy & Tracheostomy
Others - LMA or jet insufflation (Not definitive)
Emergency respiratory assessment
Rapid exam - RR & inspect, palpate, percuss, auscultate
Investigate with X-ray if concern of trauma
Pulse oximetry, ABG
Thoracic Trauma
Major cause of mortality
Blunt: less than 10% require operation
Penetrating: 15-30% require surgical treatment
Can be life threatening and should be identified in primary survey – most require only simple procedures
Traumatic injuries which may impair breathing
Airway obstruction or Tracheobronchial tree injury
Tension, open or haem- pneumothorax
Flail chest
Laryngeal injuries causing airway obstruction
Rare but serious and will cause hoarseness
May be signs of subcutaneous emphysema
Treat with cautious intubation and possible tracheostomy
Tension pneumothorax
Respiratory distress with distended neck veins and unilaterally absent breath sounds –> BP drops. Tracheal deviation is a later sign
Needle aspiration through the 2nd intercostal space, mid-clavicular line
Flail chest
Where multiple rib fractures have produced a flail segment which will move paradoxically with breathing
Tx - re-expand lung and give oxygen. cautious use of intubation, analgesia and fluids
Cardiac Tamponade
Often found after penetrating chest injury - Drop in arterial pressure, distended neck veins and muffled heart sounds - May develop PEA
Potentially lethal cardiac injuries
Cardiac tamponade
Blunt cardiac injury
Traumatic aortic disruption
Mediastinal traversing wound
Circulation and haemorrhagic control
Identify site of bleeding - open wounds or internal (thorax, abdomen, pelvis, retroperitoneal, long bones)
Control haemorrhage –> Direct pressure, splint/realign long bones, emergency surgery, reduce pelvic/3rd space volume
Replace volume and RBCs (warmed crystalloid or blood)
Assessing Disability in the primary survey
Checking CNS function (5 P’s) - monitor for deterioration
Pernicketiness - GCS
Pupils - responsive? size and papilloedema
Planatars - normal reflexes
Power - Any focal weakness
Protruded tongue
Preventing secondary Brain injury
ABC is most important because it keeps blood going to the brain - MABP should be >60mmHg to maintain CPP
If a concern about ICP raise head 30 degrees - if there is a bleed refer for surgery if cerebral oedema - head up, diuretics, ventilate
Exposure and environment
Expose for primary and secondary survey but keep warm (warmed environment, fluids, blankets etc)
May be hypothermic on arrival and so will need warming
Additional monitoring after primary survey
Obs - RR, Stats, BP, ECG
ABG + bloods
Catheters and NG tube
Imaging - CT, CXR, Pelvic X-ray, C-spine X-ray, abdo USS
Secondary Survey
AMPLE history
Check for injuries - head to toe body check
Systems reveiw - neurological, musculoskeletal
AMPPLEE history
Allergies Medications Past medical History and Pregnancy Last Meal Events leading up and including the injury
Use of emergency C-spine X rays
An X-ray will not totally exclude a C-spine injury so it is not considered useful to have early in management - thus it is not an emergency measure
Easy and quick first assessment?
Ask the patient their name/get them to talk to you
Indicates they have a patent airway, enough air to speak and enough cerebral perfusion to think and enough senses to hear
Dangers when securing the airway
Occult airway injury
Progressive loss of airway patency - keep re-evaluating
Equipment failure
Inability to intubate
Dangers when securing breathing
Lower airway problems verses ventilation problems
Risks of iatrogenic pneumothorax
Ventilation/perfusion mismatching
Dangers when securing the circulation
Assess organ perfusion - level of consciousness - skin colour and temp and pulse rate and character
Beware of children, the elderly and athletes as they have weird CV systems anyway
When performing a secondary survey on the head
External exam - scalp palpation for skull fractures or lacerations - Check eyes and ears
Red Flags - continued unconsciousness, periorbital oedema (panda eyes) and occluded auditory canal
When performing a secondary survey on the face
Feel for bony crepitus, deformity or malocclusion (fucked up teeth)
Red Flags – Potential airway obstruction, Cribiform plate fractures, skull base fractures
When performing a secondary survey on the neck
Consider was the injury blunt or penetrating
Check for hoarseness or airway obstruction
Signs - crepitus, haematoma, stidor,
Red Flags –> delayed onset symptoms, occult injuries, airway obstructions
When performing a secondary survey on the pelvis
Possible injury if there is: pain on palpation, leg length inequalities, bony instability, leg/foot rotation – x-ray if needed
Be cautious about excessive pelvic manipulation or underestimating pelvic blood loss (its alot)
When performing a secondary survey on the limbs
Check for contusions and deformity - always check peripheral perfusion and neurological status
Red flags – missed fractures, ligamentous injury, compartment syndrome
When performing a secondary survey on the spine
Check the whole spine for tenderness and swelling
Complete motor and sensory exams with reflexes
Consider imaging if there is altered sensorium or inability to perform exam properly - refer or perform further investigations
Accidents in children
15-20% of children attending AnE are due to accidents. cause 1/3 of all childhood deaths and are the single commonest cause of death in children 1-15yrs old. Boys and lower social class children are at a higher risk and RTAs are the most common cause of fatal accidents
Primary Prevention
Preventing an accident from happening - stair guards, speed limits, teaching road safety, window safety catches
Secondary Prevention
Preventing or reducing injury from the accident - wearing seat belts, cycling helmets, smoke alarms, laminated safety glass
Tertiary Prevention
Limiting the impact of the injury - eg teaching parents first aid.
Disaster Triage
Can they walk? - if yes priority 3
Are they breathing? - if no dead
Is there RR abnormal or cap refill prolonged - yes priority 1
- if not priority 2
Process of Decontamination
Remove clothes - rinse - wash - rinse - dry.
