Trauma Flashcards
How should airway be assessed in the primary survey?
Airway
Check for airway compromise Ask pt. a question Stridor Orofacial injury or burns Visualise airway and use suction if necessary
Manoeuvres to open airway
Jaw thrust
Adjuncts if compromise / potential compromised
NPA: gag reflex present
OPA: no gag reflex (stop tongue swallowing)
Emergency Airways
Needle cricothyroidotomy or surgical cric
Definitive Airways (no risk of aspiration) Endotracheal tube Tracheostomy
How should C-spine be managed in primary survey?
Maintain in-line cervical support to keep neck stable
Place pt. in hard-collar and sandbags c¯ tape
How should breathing be assessed in primary survey?
SpO2 Inspection of chest Position of trachea RR and chest expansion Breath sounds, vocal resonance Percussion ABG
What are the signs of tension pneumothorax?
Respiratory distress JVP and BP Tracheal deviation + displaced apex air entry and VR Hyperresonant percussion
How is tension pneumothorax managed?
immediate decompression
Insert large-bore venflon into 2nd ICS, midclavicular
line.
Insert ICD later
How are open sucking chest wounds managed?
Convert to closed wounds by covering with damp
occlusive dressing stuck down on 3 sides.
What should be done under circulation in primary survey?
Two-large bore cannulae (14/16G) in each ACF
FBC, U+E, x-match (6U), clotting, VBG
How is circulation assessed in the primary survey?
Inspection: pale, sweaty, active bleeding
Vascular status: BP, HR, JVP, heart sounds, cardiac
mon
End-organ: consciousness, UO
how is disability assessed in the primary survey?
Assess consciousness using AVPU or GCS
Pupil responses
How is exposure assessed in the primary survey?
Completely undress pt.
Perform log-role and PR
Feel for high riding prostate (urethral rupture)
Look for bleeding
Prevent hypothermia
What should be covered under the history of the secondary survey?
AMPLE
Allergies Medication PMH Last ate / drunk Events
What investigations should form part of the secondary survey?
Trauma series
C-spine: lat + peg
CXR
Pelvis
FAST scan (Focussed Assessment c¯ Sonography in
Trauma)
CT: when pt. is stable.
How should c-spine radiographs be assessed?
Views
Lateral
AP
Open-mouth Peg view
Adequacy
Must see C7-T1 junction
May need swimmer’s view c¯ abducted arm
Alignment: 4 lines Ant. vertebral bodies Ant. vertebral canal Post. 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.
What is the indication for clinical clearance of the c-spine?
Indication: NEXUS Criteria Fully alert and orientated No head injury No drugs or alcohol No neck pain No abnormal neurology No distracting injury
How is the c-spine clinically cleared?
Examine for bruising or deformity
Palpate for deformity and tenderness
Ensure pain-free active movement
What is the indication for radiological clearance of the c-spine?
Pt. doesn’t meet criteria for clinical clearance
What are the modalities for radiological clearance of the c-spine?
Radiograph initially
- Clear if normal radiograph and clinical exam
CT C-spine if abnormal radiograph or clinical exam
What is neurogenic shock?
Disruption of sympathetic nervous system
What are the causes of neurogenic shock?
Spinal anaesthesia
Hypoglycaemia
Cord injury above T5
Closed head injuries
How does neurogenic shock present?
Hypotension
Bradycardia
Warm extremities
How is neurogenic shock managed?
Vasopressors: vasopressin and norad
Atropine: reverse the bradycardia
What is spinal shock?
Acute spinal cord transection
Loss of all voluntary and reflex activity below the level
of injury
How does spinal shock present?
Hypotonic paralysis
Areflexia
Loss of sensation
Bladder retention
What are the differentials in life-threatening chest injuries?
ATOMIC Airway obstruction Tension Pneumothorax Open pneumothorax (sucking) Massive haemothorax Intercostal disruption and pulmonary contusion Cardiac Tamponade
What is a massive haemothorax and what usually causes it?
Accumulation of >1.5L of blood in chest cavity
Usually caused by disruption of hilar vessels
How does massive haemothorax present?
Signs of chest wall trauma BP expansion breath sounds and VR Stony dull percussion
How is massive haemothorax managed?
X-match 6u
Large-bore chest drain c¯ hep saline for autotransfusion
Thoracotomy if >1.5L or >200ml/h
How does flail chest present?
Ant. or lat. # of >=2 adjacent ribs in >=2 places
Flail segment moves paradoxically c¯ respiration
decreased Oxygenation
Underlying pulmonary contusion
decreased Ventilation of affected segment
What investigations should be carried out in flail chest?
CXR / CT chest: pulmonary contusion (white)
Serial ABGs: decreased PaO2:FiO2 ratio
how is flail chest managed?
O2
Good analgesia: PCA, epidural
Persistent respiratory failure: PPV
What is cardiac tamponade and what usually causes it?
Disruption of myocardium or great vessels leading to blood in the
pericardium leading to decreased filling and contraction leading to shock
Usually results from penetrating trauma
how does cardiac tamponade present?
Beck’s Triad
increased JVP / distended neck veins
decreased BP
Muffled heart sounds
Pulsus paradoxus: SBP fall of >10mmHg on inspiration
Kussmaul’s sign: increased JVP on inspiration
Intensely restless pt.
how is cardiac tamponade investigated?
US: FAST or transthoracic echo
CXR: enlarged pericardium
increased CVP >12mmHg
ECG: low voltage QRS ± electrical alternans
how is cardiac tamponade managed?
Pericardiocentesis: spinal needle in R subxiphoid space
aiming at 45 degrees towards the R tip of left scapula
Thoracotomy may be needed
Which ribs are usually # and which suggest high energy trauma?
Usually 5th-9th ribs
# of upper 4 ribs = high energy trauma
What are the complications of rib #
Pneumothorax
Lacerate thoracic or abdominal viscera
how are rib # managed?
good analgesiaa
NSAIDs + opioids
Intrapleural analgesia
Intercostal block
How are sternal # usually obtained? What is the risk?
Usually MVA driver vs. steering wheel
risk of mediastinal injury
How are sternal # managed?
Analgesia, admit, observe
Cardiac monitor
Troponin: rule out myocardial contusion
How is pulmonary contusion usually caused?
Usually due to rapid deceleration injury or shock waves
how does pulmonary contusion usually present?
dyspnoea, haemoptysis, respiratory failure
How is pulmonary contusion investigated?
CXR: opacification
Serial ABGs: decreased PaO2:FiO2 ratio
How is pulmonary contusion managed?
O2, ventilate if necessary
What is the cause of myocardial contusion?
direct blunt trauma over precordium
how is myocardial contusion managed?
bed rest, cardiac monitoring, Rx arrhythmias
how is myocardial contusion investigated?
ECG: abnormal, arrhythmias
increased troponin
how is contained aortic disruption caused
Rapid deceleration injury (80% immediately fatal)
how does contained aortic disruption present
initially stable but become hypotensive
how is contained aortic disruption investigated
CXR: wide mediastinum, deviation of NGT
CT
how is contained aortic disruption managed?
cardiothoracic consult
What should raise suspicion of diaphramatic injury?
Consider in penetrating injuries below 5th rib or high
energy compression.
What investigations should be done in diaphramatic injury?
CXR (visceral herniation), CT
What should raise suspicion of oesophageal disruption?
Usually penetrating trauma
causing mediastinitis
What investigations should be done in oesophgeal disruption?
CXR: pneumomediastinum, surgical emphysema
CT
How does tracheobronchial disruption present?
Persistent pneumothorax
Pneumomediastinum
How is tracheobronchial disruption managed?
thoracotomy
