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Surgery Finals > Trauma > Flashcards

Trauma Flashcards

1
Q

How do you decide whether to use a nasopharyngeal or an oropharyngeal airway?

A

NPA if gag reflex is present, OPA if it isn’t (stop tongue swallowing)

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2
Q

Name 2 kinds of emergency surgical airways

A

Needle circothyroidotomy, surgical cric

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3
Q

What are the kinds of definitive airways and what is their advantage over non definitive airways?

A

No risk of aspiration.

Endotracheal tube or tracheostomy

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4
Q

What are the signs of a tension pneumothorax?

A
  • Respiratory distress
  • Raised JVP
  • Low BP
  • Tracheal deviation and displaced apex
  • Decreased air entry and decreased VR
  • Hyperresonant percussion
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5
Q

How do you treat a tension pneumothorax?

A
  • Immediate decompression
  • Large bore cannula into 2nd ICS, mid clavicular line
  • Insert ICD later
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6
Q

What is the immediate management for an open sucking chest wound?

A

Convert it to a closed wound by covering itwith damp occlusive dressing stuck down on 3 sides

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7
Q

Which images are seen in a trauma series?

A
  • C spine (lat and peg)
  • CXR
  • Pelvis
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8
Q

How do you assess C spine radiographs?

A
  • View
    • AP/lateral/open mouth peg view
  • Adequacy
    • Need to see C7-T1 junction
    • May need swimmer’s view with abducted arm
  • Alignment: 4 lines
    • Anterior vertebral bodies
    • Anterior vertebral canal
    • Posterior vertebral canal
    • Tips of spinous processes
  • Bones: shapes of bodies, laminae, processes
  • Cartilage: IV discs should be equal height
  • Soft tissue: width of soft tissue shadow anterior to upper vertebrae should be 50% of vertebral width
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9
Q

What are the indications for C spine clearance?

A

NEXUS criteria:

  • Fully alert and oriented
  • No head injury
  • No drugs or alcohol
  • No neck pain
  • No abnormal neurology
  • No distracting injury
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10
Q

How much of the body’s mass is circulating blood volume?

A

7%

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11
Q

What % of blood volume do you have to lose before the mental state changes or blood pressure changes?

A
  • 15-30% patient will be anxious but BP normal
  • 30-40% confused and BP drop
  • >40% patient will be lethargic and BP will have dropped a lot
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12
Q

What causes neurogenic shock?

A

Disruption of sympathetic nervous system

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13
Q

What are the causes of neurogenic shock?

A
  • Spinal anaesthesia
  • Hypoglycaemia
  • Cord injury above T5
  • Closed head injury
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14
Q

How does neurogenic shock present?

A

Hypotension, bradycardia, warm extremities

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15
Q

How do you manage neurogenic shock?

A
  • Vasopressors: vasopressin and noradrenaline
  • Atropine to reverse bradycardia
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16
Q

What causes spinal shock?

A
  • Acute spinal cord transection
  • Loss of all voluntary and reflex activity below the level of injury
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17
Q

How does spinal shock present?

A
  • Hypotonic paralysis
  • Areflexia
  • Loss of sensation
  • Bladder retention
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18
Q

Which chest injuries are life threatening?

A

ATOMIC:

  • Airway obstruction
  • Tension pneumothorax
  • Open pneumothorax (sucking)
  • Massive haemothorax
  • Intercostal disruption and pulmonary contusion
  • Cardiac tamponade
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19
Q

What counts as a massive haemothorax and what causes it?

A

>1.5L of blood in chest cavity, usually caused by disruption of hilar vessels

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20
Q

How does a massive haemothorax present?

A
  • Signs of chest wall trauma
  • Low BP
  • Reduced expansion
  • Reduced breath sounds and VR
  • Stony dull percussion
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21
Q

How do you treat a massive haemothorax?

A
  • Cross match 6 units
  • Large bore chest drain with heparin saline for autotransfusion
  • Thoracotomy if >1.5L or >200ml/hour
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22
Q

What is a flail chest?

A

Whee there are anterior or lateral #s of 2 or more adjacent ribs in 2 or more places. The flail segment moves paradoxically with respiration. Oxygenation decreases as a result of the underlying pulmonary contusion and decreased ventilation of the affected segment

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23
Q

What investigation findings indicate a flail chest?

A
  • CXR/CT chest: pulmonary contusion (white)
  • Serial ABGs: low PaO2:FiO2 ratio
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24
Q

How do you treat a flail chest?

A
  • O2
  • Good analgesia: PCA or epidural
  • Persistent respiratory failure: PPV
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25
Q

How does cardiac tamponade occur from a trauma?

A

Usually from penetrating trauma. Disruption of myocardium or great vessels leads to blood in the pericardium, decreased filling and contraction, and therefore shock.

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26
Q

How does cardiac tamponade present?

A
  • Beck’s triad
    • Raised JVP/distended neck veins
    • Low BP
    • Muffled heart sounds
  • Pulsus paradoxus: SBP fall of >10mmHg on inspiration
  • Kussmaul’s sign: raised JVP on inspiration
  • Intensely restless
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27
Q

What investigation findings indicate cardiac tamponade?

A
  • US: FAST or transthoracic echo
  • CXR: enlarged pericardium
  • Raised CVP >12mmHg
  • ECG: low voltage QRS ± electrical alternans
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28
Q

How do you manage cardiac tamponade?

A

Pericardiocentesis: spinal needle in R subxiphoid space aiming at 45 degrees towards the R tip of the left scapula. May need thoracotomy

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29
Q

Which ribs most commonly fracture?

A

5-9

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30
Q

What is the usual mechanism of injury if there is a fracture of the upper 4 ribs?

A

A high energy trauma

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31
Q

What are the possible complications of rib fractures?

A

Pneumothorax, lacteration of thoracic or abdominal viscera

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32
Q

How do you treat rib fractures?

A

Good analgesia:

  • NSAIDs + opioids
  • Intrapleural analgesia
  • Intercostal block
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33
Q

What is the usual mechanism of injury for a sternal fracture?

A

Driver vs steering wheel

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34
Q

What is the risk with a sternal fracture?

A

Mediastinal injury

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35
Q

How do you treat sternal fractures?

A
  • Analgesia, admit, observe
  • Cardiac monitor
  • Troponin: rule out myocardial contusion
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36
Q

What is the usual mechanism of injury for a pulmonary contusion?

A

Rapid deceleration injury or shock waves

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37
Q

What is the possible complication with a pulmonary contusion?

A

ARDS

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38
Q

How does a pulmonary contusion present?

A

Dyspnoea, haemoptysis, respiratory failure

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39
Q

What investigation findings are consistent with a pulmonary contusion?

A

Opacification on CXR and low PaO2:FiO2 ratio on serial ABGs

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40
Q

How do you treat a pulmonary contusion?

A

Oxygen, ventilate if necessary

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41
Q

What causes a myocardial contusion?

A

Direct blunt trauma over the praecordium

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42
Q

What investigation findings are consistent with a myocardial contusion?

A

Abnormal ECG e.g. arrhythmias. Raised trop.

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43
Q

How do you treat a myocardial contusion?

A

Bed rest, cardiac monitoring, treat arrhythmias

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44
Q

What causes a contained aortic disruption?

A

Rapid deceleration injury (80% are immediately fatal)

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45
Q

How does a contained aortic disruption present?

A

Initially stable but becomes hypotensive

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46
Q

What investigations should you do in a suspected contained aortic disruption?

A

CXR: wide mediastinum, deviation of NGT

CT

47
Q

Who should you refer to if you suspect a contained aortic disruption?

A

Cardiothoracics

48
Q

When should you consider a diaphragmatic injury?

A

Penetrating injuries below the 5th rib or high energy compression

49
Q

Which investigations will show a diaphragmatic injury?

A

CXR (visceral herniation), CT

50
Q

What causes an oesophageal disruption?

A

Penetrating trauma

51
Q

What is the important complication of oesophageal disruption

A

Mediastinitis

52
Q

Which investigations will show an oesophageal disruption?

A

CXR: pneumomediastinum, surgical emphysema

CT

53
Q

How does tracheobronchial disruption present?

A
  • Persistent pneumothorax
  • Pneumomediastinum
54
Q

How do you treat tracheobronchial disruption?

A

Thoracotomy

55
Q

Which mechanisms of abdominal injury need surgical exploration?

A

Penetrating all need exploration because the tract may be deeper than it looks.

Blunt traumas should still invoke a high index of suspicion for taking the theatre

56
Q

Which investigations should you consider in an abdominal trauma?

A
  • Urine dip
  • FAST scan
  • Diagnostic peritoneal lavage
57
Q

What is the point of doing a urine dip in an abdominal trauma?

A

Haematuria suggests the renal tract has been damaged

58
Q

What is the advantage of a FAST scan and what is it replacing?

A
  • Replaces DPL
  • Checks for fluid in the abdo, pelvis and pericardium - 90% sensitive for free fluid
  • Can be extended to look for pneumothoraces
59
Q

What are the pros and cons of diagnostic peritoneal lavage in abdominal trauma?

A
  • 98% sensitive for intra abdo haemorrhage
  • Useful if can’t do a FAST
  • May be better for identifying injury to hollow viscus
  • Unable to identify retroperitoneal injury
60
Q

How do you do a diagnostic peritoneal lavage?

A
  1. Insert urinary catheter and NGT (decompression to minimise risk of injury)
  2. Midline incision through skin and fascia at 1/3 distance from umbilicus to pubic symphysis (arcuate line)
  3. Carefully dissect to the peritoneum and insert a urinary catheter
  4. Instil 10ml/kg warmed Hartmann’s
  5. Drain fluid back into bag and send sample to lab
  6. Positive = >100,000 RBCs/mm3, bile/intestinal contents
61
Q

What are the indications for a laparotomy in abdominal trauma?

A
  • Unexplained shock
  • Peritonism: rigid silent abdomen
  • Evisceration: bowel or omentum
  • Radiological evidenc eof intraperitoneal gas
  • Radiological evidence of ruptured diaphragm
  • Gunshot wounds
  • Positive DPL or CT
62
Q

What are the aims of damage control surgery in abdominal trauma?

A
  • Limit physiological stress
  • Controll haemorrhage: ligation and packing
  • Control contamination
  • Stabilise in ITU
63
Q

What is Kehr’s sign?

A

Shoulder tip pain secondary to blood in the peritoneal cavity. Left Kehr sign is a classic symptom of ruptured spleen

64
Q

How do you classify spleen ruptures?

A
  1. Capsular tear
  2. Tear + parenchymal injury
  3. Tear up to the hilum
  4. Complete fracture
65
Q

How do you manage a ruptured spleen?

A
  • Haemodynamically unstable -> laparotomy
  • Stable 1-3: observe in HDU
  • Stable 4: consider laparotomy
    • Suture the laceration or partial/complete splenectomy
66
Q

How do you manage liver trauma?

A
  • Conservative if capsule is intact
  • Suture laceration
  • Partial hepatectomy
  • Packing
67
Q

How do you manage bladder trauma and what normally causes it?

A
  • Assoc with pelvic injuries
  • Intraperitoneal rupture needs laparoscopic repair with urethral and suprapubic drainage
  • Extraperitoneal rupture can be treated conservatively with urethral drainage
  • Give prophylactic antibiotics
68
Q

How do you classify urethral injuries and what are the mechanisms for them?

A
  • Anterior
    • Spongy urethre (penile and bulbar)
    • Occur from straddling injuries or instrumentation
  • Posterior
    • Membranous urethra
    • Pelvic fractures
69
Q

How do urethral injuries present?

A
  • Associated pelvic fracture
  • Blood in urethral meatus or scrotum
  • Perineal bruising
  • High riding prostate
  • Inability to micturate and palpable bladder
70
Q

How do you investigate a suspected urethral injury?

A

Retrograde urethrogram

71
Q

How do you manage a urethral injury?

A

Suprapubic catheter, surgical repair

72
Q

What is the commonest cause of trauma death?

A

Head injury (alone or in combination with other injuries) - 50%

73
Q

What is the difference between a primary and secondary brain injury?

A

Primary - occurs at the time of injury and is a result of direct or indirect injury to the brain tissue.

Secondary - occurs after the primary injury

74
Q

What are the types of primary brain injury?

A
  • Diffuse
    • Concussion/mild traumatic brain injury
    • Diffuse axonal injury
  • Focal
    • Contusion
    • Intracranial haemorrhage
75
Q

What are the features of concussion?

A
  • Temporary decrease in brain function
  • Headache
  • Confusion
  • Visual symptoms
  • Amnesia
  • Nausea
76
Q

What are the features of diffuse axonal injury?

A
  • Shearing forces disrupt axons
  • May lead to coma and persistent vegetative state
  • Autonomic dysfunction -> fever, hypertension, sweating
77
Q

What are the features of brain contusions?

A

Can be coup or contra coup. May have a focal neurological deficit

78
Q

What are the types of intracranial haemorrhage?

A
  • Extradural
  • Subdural
  • Subarachnoid
  • Parenchymal haemorrhage and laceration
79
Q

What are the causes of secondary brain injury?

A
  • Hypoxia
  • Hypercapnoea
  • Hypotension
  • Raised ICP
  • Infection
80
Q

Explain the Monroe-Kelly doctrine

A

The cranium is a rigid box so the volume of its contents must remain constant if ICP is not to change. An increase in the volume of one constituent leads to a compensatory decrease in another (CSF, blood - especially venous). These mechanisms can compensate for a volume change of ~100ml before ICP raises. As autoregulation fails, ICP increases rapidly leading to herniation

81
Q

What determines cerebral blood flow and cerebral perfusion pressure?

A

CBF is proportional to CPP x radius of vessels.

CPP = MABP - ICP

82
Q

What happens to CPP and CBF when ICP increases?

A
  • Raised ICP -> decreased CPP -> decreased CBF
  • Autoregulation -> vasodilatation -> increased volume -> increased ICP
83
Q

What can you do to attenuate the vicious cycle of raised ICP causing reduced CPP and CBF and therefore raising ICP?

A
  • Ventilate to normocapnoea: 4.5kPa
  • IV fluid to normovolaemia
  • Mannitol bolus acutely
84
Q

What is the Cushing reflex and what does it mean?

A
  • Hypertension, bradycardia, irregular breathing
  • Indicates immediate herniation
85
Q

How do you classify head injuries by GCS?

A
  • 3-8 = coma
  • 9-12 = moderate head injury
  • 13-15 = mild head injury
86
Q

What are the signs of a basal skull fracture?

A
  • CSF rhinorrhoea or otorrhoea
  • Battle sign: bruised mastoid
  • Panda sign: bilateral orbital bruising
  • Haemotympanum
87
Q

What investigations should you do in a head injury?

A
  • C spine
  • Consider CT head
  • Bloods: FBC, U+E, glucose, clotting, EtOH level, ABG
88
Q

What are the indications for doing a CT head in a head injury?

A
  • Basal or other skull fracture
  • Amnesia >30 min retrograde (before event)
  • Neurological deficit e.g. seizures
  • GCS <13 at the scene, or <15 2 hours later
  • Vomiting more than once
89
Q

How do you manage a head injury?

A
  • Neurosurgical consult if positive CT
  • Admit if:
    • LOC >5 min
    • Abnormalities on imaging
    • Difficult to assess: alcohol, post ictal
    • Not returned to GCS 15 after imaging
    • CNS signs: persistent vomiting, severe headache
  • NEuro obs half hourly until GCS 15 (GCS, pupils, TPR, BP)
  • Analgesia: codeien phosphate 30-60mg PO/IM QDS
  • Suture scalp lacs
  • Antibiotics if open/base of skull fracture
90
Q

What are the indications for intubation in a head injury?

A
  • GCS ≤8
  • PaO2 <9kPa on air/<13kPa on O2 or PCO2>6kPa
  • SPontaneous hyperventilation: PCO2<4kPa
  • Respiratory irregularity
91
Q

How do you treat raised ICP?

A
  • Elevate bed
  • Good sedation, analgesia ± NM block
  • Neuroprotective ventilation
  • Mannitol or hypertonic saline
92
Q

What discharge advice should you give in head injury?

A
  • Stay with someone for the first 48 hours
  • Give advice card telling them to come back if:
    • Confusion, drowsiness, unconsciousness, fits
    • Visual problems
    • Very painful headache that won’t go away
    • Vomiting
93
Q

What are the risk factors for burns?

A
  • Age: children and elderly
  • Comorbidities: epilepsy, CVA, dementia, mental illness
  • Occupation
94
Q

How are burns classified?

A
  • Superficial
  • Partial thickness
  • Full thickness
95
Q

What are the features of superficial burns?

A

Erythematous and painful e.g. sunburn

96
Q

What are the 2 kinds of partial thickness burns and how long do they take to heal?

A
  • Heal in 2-3 weeks if not complicated
  • Superficial
    • No loss of dermis
    • Painful
    • Blisters
  • Deep
    • Loss of dermis but adnexae remain
    • Healing from adnexae e.g. follicles
    • V painful
97
Q

What are the features of full thickness burns?

A
  • Complete loss of dermis
  • Charred, waxy, white skin
  • Anaesthetic
  • Heal from the edges leading to a scar
98
Q

What are the complications of burns?

A
  • Early
    • Infection: loss of barrier, necrotic tissue, SIRS
    • Hypovolaemia: loss of fluid in skin + increased capillary permeability
    • Metabolic disturbance (raised K, raised myoglobin, raised Hb -> AKI)
    • Compartment syndrome if circumferential burns
    • Peptic ulcers (Curling’s)
    • Pulmonary (laryngeal oedema, CO poisoning, ARDS)
    • Renal and hepatic impairment
  • Intermediate
    • VTE
    • Pressure sores
  • Late
    • Scarring
    • Contractures
    • Psychological problems
99
Q

What is the Wallace rule?

A

9s - % body surface area burnt:

  • Head and neck = 9%
  • Arms = 9% each
  • Torso = 18% front and back
  • Legs = 18% each
  • Perineum = 1%
  • Palm = 1%
100
Q

What are the specific concerns in management of burns?

A
  • Secure airway
  • Manage fluid loss
  • Prevent infection
101
Q

What are the signs of CO poisoning?

A
  • Headache
  • Nausea + vomiting
  • Confusion
  • Cherry red appearance
102
Q

What is the Parkland formula?

A

To guide fluid replacement in first 24 hours after a burn:

  • 4 x weight (kg) x % burn = mL of Hartmann’s in first 24h
  • Replace fluid from time of burn
  • Give half in the first 8h
  • Best guide is UO - aim for 30-50ml/h
103
Q

What is the Muir and Barclay formula?

A

To guide fluid replacement in burns:

  • (weight x % burn)/2 = ml of colloid per unit time
  • Time units: 4, 4, 4, 6, 6, 12 = 36 hours total
  • May need to use blood
104
Q

How do you treat burns?

A
  • Analgesia: morphine
  • Dress partial thickenss burns
    • Biological, synthetic, cream e.g. flamazine (silver sulfadiazine) + sterile film
  • Full thickness burns: tangential excision debridement or split thickness skin grafts
  • Circumferential burns may require escharotomy to prevent compartment syndrome
  • Anti-tetanus toxoid (0.5ml ATT)
  • Consider prophylactic antibiotics espcially anti-pseudomonal
105
Q

What is the definition of hypothermia?

A

Core (rectal) temp <35C

106
Q

How does the body lose heat?

A
  • Radiation: 60%
    • Infra red emissions
  • Conduction: 15%
    • Direct contact
    • Primary means in cold water immersion
  • Convection: 15%
    • Removes warmed air from the body
    • Moreso in windy environments
  • Evaporation: 10%
    • Removal of warmed water
    • Moreso in dry, windy environments
107
Q

How is hypothermia classified aetiologically?

A
  • Primary - environmental exposure
  • Secondary: change in temperature set point
    • E.g. age related, hypothyroidism, autonomic neuropathy
108
Q

How is hypothermia classified by severity?

A
  • Mild - 32-35C
  • Moderate - 28-32C
  • Severe - <28C
109
Q

What are the features of mild hypothermia?

A

Shivering, tachycardia, vasoconstriction, apathy

110
Q

What are the features of moderate hypothermia?

A

Dysrhythmia, bradycardia, hypotension, J waves, reduced reflexes, dialted pupils, reduced GCS

111
Q

What are the features of severe hypothermia?

A

VT->VF->cardiogenic shock

Apnoea, non reactive pupils, coagulopathy, oliguria, pulmonary oedema

112
Q

Which investigations should be done in hypothermia?

A
  • Rectal/ear temperature
  • FBC, U+E, glucose
  • TFTs, blood gas
  • ECG
    • J waves: between QRS and T Wave
    • Arrhythmias
113
Q

How should you manage hypothermia?

A
  • Cardiac monitor
  • Warm IVI 0.9% NS
  • Urinary catheter
  • Consider antibiotics for prevention of pneumonia
    • Routine if temp <32 and >65 years
  • Slowly rewarm
    • Reheating too quickly -> peripheral vasodilatation and shock
    • Aim for 0.5C/hour
    • Passive external: blankets, warm drinks
    • Active external: warm water or warmed air
    • Active internal: mediastinal lavage and CPB (severe hypothermia only)
114
Q

What are the complications associated with hypothermia?

A
  • Arrhythmias
  • Pneumonia
  • Coagulopathy
  • Acute renal failure

Surgery Finals (12 decks)

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