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General surgery > Trauma > Flashcards

Trauma Flashcards

1
Q

Goals of assessment and management in trauma

A
  1. Minimise the time from injury to definitive care 2. Don’t let the obvious injury distract you 3. No patient to leave resuscitation bay without a clear management plan 4. No need for guesswork after 2 hours
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2
Q

Causes of death from injury at the scene

A

Brain stem death High spinal cord transection Decapitation Major thoracic vascular/trancheobronchial disruption Liver avulsion Cardiac rupture

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3
Q

Causes of death within minutes

A

Hypoxia ++Bleed Tamponade Tentorial herniation

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4
Q

Causes of death within hours

A

Hypoxia Sepsis Bleeding Brain

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5
Q

Causes of death over days

A

+ICP, -ve perfusion Respiratory failure Renal failure Coagulopathy GIT failure Sepsis Ischemia MI PE

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6
Q

Primary survey and resuscitation

A

Airway with C spine control Breathing with ventilation Circulation with hemorrhage control Disability with prevention of secondary traumatic brain injury Exposure/Environment with temperature control

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7
Q

Problems of airway

A

Direct trauma Obstruction Deteriorating consciousness C spine- unstable fracture

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8
Q

Assessment of airway

A

Ascertain patency->talk to patient Inspect for foreign bodies Assess for: Cyanosis Tachypnea Voice Stridor Confusion Respiratory distress Assume C spine injury if->unconscious, head/face injury

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9
Q

Airway interventions

A

Gloved finger->feel for FB etc Light and suction Oxygen Chin lift/jaw thrust OP (unconscious)/NP mask (conscious) ETT Crycothyroidectomy Tracheostomy

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10
Q

Problems of breathing

A

Tension pneumothorax Massive hemopneumothorax Open pneumothorax Flail chest High spinal cord injury

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11
Q

Assessment of breathing

A

Expose the chest Cyanosis, tachyp, confusion resp distress Shallow, accessory muscle use Poor expansion Assymetric, hyperInflation Breath sounds, tracheal shift Feel for expired air 1. Work of breathing 2. Effectiveness->chest expansion, air entry 3. Distal effects->cyanosis, pulse, mentation

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12
Q

Interventions in breathing

A

Oxygen Ventilation Needle thoracocentesis Tubal thoracocentesis ETT Cover open wounds 1. High flow oxygen 2. Ventilator support 3. Intubation

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13
Q

Problems in circulation

A

Bleeding- external Chest (CXR), abdomen (FAST/DPL) Pelvis (Xray) Femurs Combination Heart->tension, tamponade, contusion, infarction

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14
Q

Assessment of circulation

A

Peripheral perfusion Cyanosis, pallor Cool, clammy TachyC Low volume pulse CRT + Neck veins Heart sounds

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15
Q

Interventions in circulation

A

O2, IV access Fluid resus Control hemorrhage Pressure infuions, blood warming gastric tube surgery Catheter Pericardiocentesis

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16
Q

Problems in disability

A

Secondary brain injury Intrcranial hematoma Brain- compresison, contusion, laceration, swelling

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17
Q

Assessment and management of disability

A

AVPULP (Alert, responds to voice, responds to pain, unresponsive, pupils, posture) AB, C, protect C spine Hyperventilation Adequate ventilation, circulation, consider mannitol, surgery

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18
Q

Problems in exposure/environment

A

Concealed injuries Hypothermia

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19
Q

Assessment of exposure/environement

A

Prepare for secondary survey Remove all clothes Warm fluids Blankets Heating mattress

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20
Q

What is the secondary survery

A

Identify anatomical injuries Provide clinical information to determine if xrays/special investigations are required

21
Q

Process of secondary survery

A

Look, listen, feel. Head to toe assessment GCS->scalp->ears->eyes-> Facial bones->mouth->neck->clavicles Chest wall/moveM/lungs/heart->Abdomen ->pelvis->hips->thighs->knees->Legs, ankle, feet Upper-arms, elbows, forearms, wrists hands, fingers Bank/flanks->need log roll Perineum, genitalia, Rectal, Urinalysis

22
Q

During the secondary survey what features are attempting to be elicited

A

Tenderness Lacerations Swelling Structure Discolouration Crepitus Evidence of ischemia Functional MSK Neurology

23
Q

How to proceed with findings on secondary survey

A

Digital photo of wounds Sterile wound dressing Pressure on bleed Splint fractures Traction when needed Pelvic fracture splinting Pain Tetanus Antibiotics

24
Q

What is the tertiary assessment

A

Reassess and re-examine

25
Q

What to do when patients have recordable vitals but deteriorate

A

Cardiac arrest is imminent–> ETT w/ 100% 02, bilateral large calibre intercostal catheters w/ underwater seal drainage 2-3 large bore cannulas high volumes colloid/uncrossed matched 0 -ve blood Direct pressure on bleed

26
Q

Causes of instability following blunt chest wall trauma

A

Tension pneumothorax Aortic dissection Hemothorax Blunt cardiac injury Damage to main vessels Cardiac tamponade Air emboli

27
Q

What to consider If the lung fails to reexpand after chest tube placement and significant air leakage is noted, one should consider the possibility of a major tracheobronchial injury.

A

Possible tracheobronchial damage

28
Q

In rib fractures, important management and why

A

Adequate pain control Chest splinting To avoid hypoventilation and associated atelectasis

29
Q

Most common diagnostic study for Traumatic rupture of aorta

A

CT angiography Also consider TOE

30
Q

Who may form part of the trauma team

A

team leader ED reg/ED SMO airway doctor ED/ICU/anaesth reg/SMO procedure doctor surgical/ED reg/SMO airway nurse ED RN procedure nurse scribe nurse ortho reg/SMO ED wardie – runner and messenger radiographer paeds, gynae, social worker, bed manager (when needed)

31
Q

How to handover a trauma patient

A

N-MIST N = number of people injured M = Mechanism I = injuries suspected S = signs T = treatment

32
Q

Principles of trauma management (14)

A

ensure simultaneous (parallel) activity avoid sequential interventions – don’t just treat one thing, then another, than another, treat various things at one time! aim to provide meaningful interventions maximise oxygen delivery – number one rule! minimise work of breathing (early intubation if required) remove all clothes –CUT it off! identify immediate life threats preserve blood volume splint pelvis and reduce/splint limb #’s – pelvic binder minimise handling (co-ordinated and gentle) adequate analgesia early anaesthesia - often because of anticipated clinical course minimise any therapeutic vacuums

33
Q

3 traumatic conditions that most often compromise ventilation are and management

A
  1. tension pneumothorax • needle thoracocentesis->mid clavicular line, second intercostal space 2. open pneumothorax / sucking wound • occlusive flap dressing, surgery 3. large flail chest • paralysis, intubation & IPPV, chet drain 3rd and 5th intercostal midaxillary line
34
Q

Triad of death and bloody vicious cycle

A

Acidosis Hypothermia Coagulopathy –>hemorrhage, resuscitation, hypothermia, hemodilution, coagulopathy, and continued bleeding

35
Q

Coagulopathy of trauma

A

Hypoperfusion->systemic anticoagulation and hyperfibrinolysis Shock is the main driver of early coagulopathy, but requires tissue injury as an initiator. As shock progresses and intravenous therapy is initiated, hemodilution exacerbates the established hemostatic derangements. Where bleeding is unchecked, severe hypothermia and acidemia aggravate the established coagulopathy.

36
Q

What is a FAST scan and purpose

A

Focussed abdominal sonography in trauma Diagnosis of major bleed, not retroperitoneal, for bladder, spleen, kidneys, heart and liver

37
Q

How much blood can lose in 2 fractured femurs, 1L on the floor = how much in the chest, abdomen, pelvis and long bones

A

2 fractured femurs-> 3L of blood 1L on the floor = 4L in the chest, abdomen, pelvis

38
Q

Grades of hemorrhage %loss, vol/70kg, HR, BP, PP, CRT, RR, LOC, skin colour/temp, UP

A

Grades

39
Q

In what circumstance may people not develop tachyC, even when +hemorrhage

A
  1. penetrating trauma 2. intra-abdominal/pelvic trauma (↑ vagal tone) 3. spinal trauma (‘neurogenic shock’) – so heart rate wont increase, due to loss sympathetic innervation 4. heart rate limiting medication e.g. B-blockers 5. the elderly with ‘clapped out hearts’
40
Q

IV boluses, max

A

250ml Crystalloid boluses, 2L max crystalloid

41
Q

Are Hb, PT, ApTT helpful when still bleeding

A

No->cannot correct rewarm and acidosis when still bleeding

42
Q

Valuable blood tests in hemorrhage

A

Base deficit Lactate pH PLT count Fibrnogen INR

43
Q

Management of hemorrhage

A

• ABC airway protection to avoid hypoxia • IV X 2 large bore • 2L crystalloid • blood – they loose blood, so give blood • aim for BP 90 syst (radial pulse) stop the bleeding (still) MTP – RBC FFP platelets – mass transfusion protocol – patient needs 4 unit of blood or more RBCs don’t contain caogs so add fresh frozen plasma and platelets The MTP involves 1:1:1 ratio of FFP:Platelets:Blood after 4 units of blood has been given In extremis don’t waste time initial livesaving procedures stop diagnostics and the bleeding chest abdomen pelvis long bones direct pressure the finger is mightier than the clamp sterility is a luxury tourniquet - extremities pelvic binder - usually venous bleeds chest tube,thoracotomy ligature embolisation – interventional angiography

44
Q

Glasgow coma scale

A

Includes

45
Q

Degree of brain injury corresponding to GCS

A

13 or higher = mild brain injury 9 to 12 moderate injury,

46
Q

AMPLE history

A

Allergies Medications Past medical Last meal Events/environment Where do you hurt? Where else? Does your breathing feel normal?

47
Q

Investigations, procedures and standard XR

A

Investigations Bloods: • Hb • Cross match and hold • Electrolytes • Coags • Lactate • ABG • Pregnancy Procedures • Nasogastric tube • IDC- not in pelvic injury • Pulse oxy • ECG • FAST scan Standard Xrays • Chest • Cervical spine first • Pelvis Need a lateral Cervical spine CT

48
Q

Two hit model

A

Involves

General surgery (36 decks)

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