Trauma

Question 1

What are the types of Brain Injury?

Answer 1

Primary injury - injury sustained to brain at time of impact

• Diffuse axonal injury
  
  • Shearing force - sits in pool of CSF fluid -
  • decelerates and smacks into the edge of skull (whiplash)
• Types of brain bleeds:
  
  • Subdural
  • Epidural
  • Subarachnoid
  • Intraventricular

Secondary injury - what you’re trying to prevent

• From bleeds exerting pressure on the brain
• Brain hypoxia (Provide oxygen)
  
  • Hypotension (blood pressure low)
  • anaemia
  • Cerebral oedema
• Hypoglycemia and hyperglycemia
• Seizures

Question 2

Head injury primary assessment?

Answer 2

A

• GCS - airway patency

B

• cushings reflex (bradycardia and hypotension) - ICP

C

• haemorrhage

D

• GCS /AVPU
  
  • minor (13-15)
    
    • no LOC
    • up to one episode vomiting
    • stable, alery conciousness
  • moderate (9-12)
    
    • visible external
  • severe (3-8)
• not all patients get a head CT
• Absolute:
  
  • respiratory irregularity
  • unresponsive
  • <8 persistently
  • focal neurology
  • signs of base of skull fracture
  • suspiscion of open skull fracture
• relative
  
  • amnesia etc.. etc..

Question 3

Secondary Assessment from Base of Skill fracture?

Answer 3

• Scalp (lacerations, bruises, boggy swelling, Battle’s sign)
• Eyes (raccoon eyes, pupillary reaction, fundoscopy
• Ears (CSF leak
• etc… etc…

avoid NGT as it can go in brain - mouth to decompress stomach rather than stomach.

Question 4

What GCS means for prognosis?

Answer 4

• GCS:
  
  • eye opening (1-4 nil, to pain, to speech, spontaneous)
  • verbal response (1-5 nil, incomprehensible, inappropriate, confused, orientated)
  • motor response (1-6 nil, extensor, abnormal flexion, withdraws to stimulus, localise to stimulus, obeys commands)
• brief LOC (<5mins) can be sent home after initial 4hour observation.
  
  • information given about deterioration (unconcious, convulsions, headache, vomiting, bleeding ear)
• LOC >5mins, severe headache, deterioration, neuro deficits
  
  • minimum 48hr observation

Question 5

What sort of treatment whould patient recieve?

Question 6

What are the mechanisms of Abdominal injury and death?

Answer 6

• 2nd most common cause of paediatric injury
• 3rd most common cause of paediatric death
  
  • spleen, liver, kidney bad
• mechanism: (make bad decisions)
  
  • MVA
  • Car vs. kid
  • Fall from height
  • Lap seat belt (in some cars in middle seat, not as good)
    
    • force is concentrated onto smaller area
    • Lap Seatbelt syndrome (top of hips but in kids runs across stomach)
      
      • fold over belt
      • high risk of bowel injury and L1/L2 vertebrae (fracture)
      • Chance fracture
      • eccyhmosis
      • bowel injury
      • intraabdominal bladder
  • Handle bar (ride bikes)
    
    • land on handlebar, force distributed over one point
    • handlebare bruise
      
      • solid organ liver/spleen injury
  • MBA
• blunt > penetrating, knifes/guns not common

Question 7

Primary Survey for an abdomen injury?

Answer 7

• A - c-spine
• B - oxygen
• C: - haemorrhage control
  
  • tenderness
  • eccymoses
  • abrasions
  • femoral fracture (high OR)
• D (neuro)
  
  • GCS <13
• E - environment

secondary and tertiary survey

Question 8

What are some problems with children with abdominal injury?

Answer 8

• exposed organs more
• decreased protective habitus (fat)
• smaller torso (smaller SA for force distribution

Question 9

Why do you put in Oro-gastric tube?

Answer 9

• fear of NG going into brain with BOS fracture
  
  • prevents gastric dilation
  • prevents vomiting and aspiration
  • improves imaging quality
  • improves ventilation

Question 10

What are some problems with abdominal CT in Kids?

Answer 10

• Doesn’t need a scan criteria? (see slides)
• haemodynamically stable with penetrating trauma

Question 11

Treatment of abdo injury

Answer 11

• spleen has changed
  
  • used to take it out now rarely
• non-operative management normal
  
  • come to trauma centre, may need operation
• surgical Mg: (rare)
  
  • perforation
  • ruptured bladder
  • pancreas
  • avulsion of renal artery
  • penetrating injuries

Question 12

Decorticate vs Decerebrate signs? Which has a poorer prognosis?

Answer 12

• decorticate posturing - upper extremity flexion with lower extremity extension (above midbrain)
• decerebrate posturing - arm extension and internal rotation with wrist flexion (brainstem injury, poor predictor)

Question 13

What investigations would you consider for a head injury? When would you consider them?

Answer 13

• Cervical spine XR:
  
  • c-spine injury (all patients with mod-severe head injuries)
• CT:
  
  • all patients with significant head injuries
  • especially if intracranial haematoma (vomiting, headache, GCS, focal signs)
• MRI
  
  • spinal cord injury or vascular injury/anomaly suspected

Question 14

A 10 year old with spiral fracture of humerus. Team notices an admission 5mths ago for broken femur. Neurovascular assessment is normal.

What is the best management?

1. discharge
2. review in 6 weeks
3. immobilisation with splint
4. open reduction and internal fixation
5. bone scan and social work consult

Answer 14

c - immobilisation

• transverse and oblique humerus fractures are from direct trauma, whereas spiral fractures are indirect twisting (with a fall)
  
  • in infants and toddlers its more likely to be NAI not in 10 year olds, more likely a fall
  • femoral fractures are common in older children in high energy trauma (MVA), younger due to falls.
• reduction - not often required, collar and cuff with 10 degrees axial alignment
  
  • ortho if open, neurovascular injuries, pathological
  • radial nerve injury do not manipulate
• follow up is generally in 1 week