Trauma

Question 1

Goals of assessment and management in trauma

Answer 1

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

Question 2

Causes of death from injury at the scene

Answer 2

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

Question 3

Causes of death within minutes

Answer 3

Hypoxia ++Bleed Tamponade Tentorial herniation

Question 4

Causes of death within hours

Answer 4

Hypoxia Sepsis Bleeding Brain

Question 5

Causes of death over days

Answer 5

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

Question 6

Primary survey and resuscitation

Answer 6

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

Question 7

Problems of airway

Answer 7

Direct trauma Obstruction Deteriorating consciousness C spine- unstable fracture

Question 8

Assessment of airway

Answer 8

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

Question 9

Airway interventions

Answer 9

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

Question 10

Problems of breathing

Answer 10

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

Question 11

Assessment of breathing

Answer 11

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

Question 12

Interventions in breathing

Answer 12

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

Question 13

Problems in circulation

Answer 13

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

Question 14

Assessment of circulation

Answer 14

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

Question 15

Interventions in circulation

Answer 15

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

Question 16

Problems in disability

Answer 16

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

Question 17

Assessment and management of disability

Answer 17

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

Question 18

Problems in exposure/environment

Answer 18

Concealed injuries Hypothermia

Question 19

Assessment of exposure/environement

Answer 19

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

Question 20

What is the secondary survery

Answer 20

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

Question 21

Process of secondary survery

Answer 21

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

Question 22

During the secondary survey what features are attempting to be elicited

Answer 22

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

Question 23

How to proceed with findings on secondary survey

Answer 23

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

Question 24

What is the tertiary assessment

Answer 24

Reassess and re-examine

Question 25

What to do when patients have recordable vitals but deteriorate

Answer 25

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

Question 26

Causes of instability following blunt chest wall trauma

Answer 26

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

Question 27

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.

Answer 27

Possible tracheobronchial damage

Question 28

In rib fractures, important management and why

Answer 28

Adequate pain control Chest splinting To avoid hypoventilation and associated atelectasis

Question 29

Most common diagnostic study for Traumatic rupture of aorta

Answer 29

CT angiography Also consider TOE

Question 30

Who may form part of the trauma team

Answer 30

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)

Question 31

How to handover a trauma patient

Answer 31

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

Question 32

Principles of trauma management (14)

Answer 32

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

Question 33

3 traumatic conditions that most often compromise ventilation are and management

Answer 33

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

Question 34

Triad of death and bloody vicious cycle

Answer 34

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

Question 35

Coagulopathy of trauma

Answer 35

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.

Question 36

What is a FAST scan and purpose

Answer 36

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

Question 37

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

Answer 37

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

Question 38

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

Answer 38

Grades

Question 39

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

Answer 39

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’

Question 40

IV boluses, max

Answer 40

250ml Crystalloid boluses, 2L max crystalloid

Question 41

Are Hb, PT, ApTT helpful when still bleeding

Answer 41

No-\>cannot correct rewarm and acidosis when still bleeding

Question 42

Valuable blood tests in hemorrhage

Answer 42

Base deficit Lactate pH PLT count Fibrnogen INR

Question 43

Management of hemorrhage

Answer 43

• 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

Question 44

Glasgow coma scale

Answer 44

Includes

Question 45

Degree of brain injury corresponding to GCS

Answer 45

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

Question 46

AMPLE history

Answer 46

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

Question 47

Investigations, procedures and standard XR

Answer 47

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

Question 48

Two hit model

Answer 48

Involves