Trauma Flashcards
Stages of damage control surgery / orthopaedics
The stages of DCO are:
- Resuscitation
- Haemorrhage control
- Decompression
- Decontamination
- Fracture splintage
The aim is to avoid a second physiology hit from early surgical fixation of fractures in major trauma (i.e. delaying plating of a pelvis for 4 days)
Where physiological impact isn’t severe, Early Total Care of fractures is beneficial (i.e. complete fixation within 36 hurs)
Criteria for damage control sugery and not ETC`
Hypothermia <34
Acidosis, pH <7.2
Serum lactate >5
Coagulopathy
Blood pressure <70mmHg
Transfusion of 15 units
Injury severity score >36
Permissive hypotension in major trauma
Aim is to maintain tissue perfusion not achieve normotension
Target 70-90 mmHg
If head injury, target >90mmHg
Fluid resuscitation in mjaor trauma
Aim to use bolus of blood e.g. 250ml
Excessive intravenous crystalloid or colloid
solutions should be avoided because they cause haemodilution, increase coagulopathy and increase the risk of adult
respiratory distress syndrome (ARDS)
Aim is to maintain tissue perfusion not achieve normotension
Massive transfusion protocol
Adminster:
- Packed red cells
- Fresh frozen plasma
- Platelets
in a 1:1:1 ratio
Use of tranexamic acid in major trauma
1g is given intravenously over 10 minutes,
followed by a further 1 g dose over 8 hours
Tranexamic acid should be given to all trauma patients suspected to have significant haemorrhage, including those with a systolic blood pressure of <110 mmHg or a pulse of over 110 per minute
It needs to be administered within 3 hours of injury
Whole boydy CT in major trauma
WBCT from the head to pelvis with IV contrast is the gold standard investigation of the severely injured adult blunt trauma patient
There is no role for selective scanning of body systems in these patients
WBCT scan is a time-critical investigation and should be
obtained as early as possible in resuscitation of the severely injured patient
Any patient undergoing immediate trauma laparotomy after blunt trauma without a WBCT scan should have a pelvic binder applied and not removed until a pelvic fracture is excluded
Such patients should have an immediate pelvic radiograph either in the emergency department, or as they arrive in the operating room
Log-rolling ?pelvic fratcure
Log-rolling should not occur until a pelvic fracture has been radiographically excluded
Disturbs hamatomas –> re-bleeding
Formal log-rolling of the blunt trauma patient to examine the back during the primary survey adds minimal useful clinical information, delays the WBCT scan and may cause harm to a patient with a pelvic fracture.
Goals of resuscitation
HR <100
BP: normotensive
UO >30ml/hr
Avoid hypothermia (<35)
Normal pH i.e. not acidotic
Early total care
Early total care describes the definitive management of a patient’s injuries within 36 hours of injury after a period of initial resuscitation
Allows early mobilisation
Reduced pulmonary complications
Enahnced recovery
Lactate and decision for ETC or DCS
<2 mmol/L – Early total care
2–3 mmol/L – Look at the trend (increasing or decreasing)
> 3 mmol/L – May be under-resuscitated; should either have further resuscitation or damage control surgery (DCS) if surgery is urgent
> 5 mmol/L – DCS
Ischaemic cerebral blood flow
Normally 55ml / min /100g of brain parenchyma
Ischaemia results when flow drops <20ml / min / 100g
Normal cerebral perfusion pressure
~75-105mmHg
CPP (75–105 mmHg) =
MAP (90–110 mmHg) – ICP (5–15 mmHg)
Herniation during raised ICP
If laterally placed lesion causing mess effect
Subfalcine herniation under falx cerebri
–> If frontal lobe trapped a clinical picture of stroke appears
Uncal herniation: uncus of temporal lobe under tentorium cerebeli
- -> Third nerve compressed innitially –> blown pupil
- -> Dropping GCS
Central herniation and tonsillar herniation
- -> result in brainstem compromise
- -> manifesting as Cushing’s triad and dropping GCS
Classification of head injury severity
Using the GCS
GCS 15 with no LOC = minor head injury
GCS 15 or 14 with LOC = mild head injury
GCS 9-13 = moderate head injury
GCS 3-8 = sevre head injury
Discharge criteria for minor head injuries
Minor = GCS 15 with no LOC
Criteria:
- GCS 15/15 with no focal neurology
- Normal CT if they have had one
- Patient not under influence of drugs or alcohol
- Patient accompanied by responsible adult
- Verbal and written safety netting re. vomiting, developing focal neurology
Indications for CT head as per NICE within 1 HOUR
CT head within 1 hour
- GCS <13 at any point
- GCS <15 at hours post injury
- Focal neurology present
- Suspected skull fracture
- > 1 episode of vomiting
- Post-traumatic seizure
Indications for CT head as per NICE within 8 HOURS
CT head within 8 hours
- Age >65 years
- Coagulopathy (warfarin, aspirin, DOAC)
- Dangerous mechanism i.e. fall from height
- Retrograde amnesia >30 minutes
Management of extradural haematoma
Extradural haematoma mandates urgent transfer to the most accessible neurosurgical facility, for immediate evacuation in deteriorating or comatose patients or those with large bleeds
Close observation with serial imaging in other cases
The prognosis for promptly evacuated extradural haematoma, without associated primary brain injury, is excellent.
Management of traumatic SAH
Very different to primary SAH
Traumatic SAH tends not to result in vasospasm
Usually managed conservatively with neuro-observations and management of parallel trauma
Sites of brain contusion
Tend to occur at sites of roughening within the skull
e.g. inferior frontal lobes
inferior temporal poles
Diagnosis of diffuse axonal injury
Confirmation is only at post-mortem histologically
Clinical diagnosis made in consideration with mechanism of injury and clinical picture
CT findings of haemorrhagic foci at carpos callosum and dorsolateral rostral brainstem are indicative
Traumatic intra-cranial and extra-cranial arterial dissection
Dissection of carotid extra-cranially:
- Headache
- Neck pain
- Focal ischaemic deficits
Intracranial dissection often affects the vertebral
artery
–> result in subarachnoid bleeding.
Key therapeutic goals in severe head injury
pCO2 = 4.5–5.0 kPa
pO2>11 kPa
MAP = 80–90 mmHg
ICP <20 mmHg
CPP >60 mmHg
[Na+] >140 mmol/L
[K+] >4 mmol/L
Post TBI Seixures
60% in severe TBI
-Started on prophylactic phenytoin
Feeding in TBI
Enteral feeding started within 72 hours
Give metoclopramide or erythromycin as pro-kinetic
Glasgow outcome score (GOS)
Used to grade outcome
5 - Independent and working
4- Moderate disability
3 - Severe disability
2- Vegetative state
1- Dead
Stability of spinal injuries
Three column theory
Anterior
Middle
Posterior
If two of the three columns are injured = unstable
End of the spinal cord
L1/L2 where it continues as the conus medullaris then to the cauda equina
ASIA scoring levels
A: complete spinal cord injury
B: sensation present but motor function absent
C: sensation present, motor present but not functional MRC garde 3/5)
D: Sensation and motor present MRC grade >3/5
E: Normal function
A= absolutely nothing can be done E= excellent news
Absolute indication for surgical fixation in spinal trauma
Deteorating neurological function
Neurological deficit determines management
Deteriorating neurological status requires surgical intervention
Corticosteroids are ineffective
Occipital condyle fracture Mx
Relatively stable fracture
Mx: Hard collar 6-8 weeks
Occipitoatlanto dislocation Mx
Caused by high-energy trauma
Often fatal
Can dislocate anterior, posterior or vertical
Power’s ratio is used to assess skull translation.
Treatment is with a halo brace or occipitocervical fixation.
Atlas fracture (Jefferson #) Mx
Fracture of C1, Atlas
Associated with axial loading
Some are stable and some are unstable depending on displacement and assoicated transverse ligament injury
Mx: most treated with halo-brace
Power’s ratio
Used in occipitoatlanto dislocation
Power’s ratio
BC/OA ≥1 indicates anterior translation
≤0.75 indicates posterior translation.
Atlantoaxial instability
Non-physiological movement between atlas and axis
It can be translational or rotatory
Resolves either spontaneously or with traction followed by a cervical collar.
Isolated, traumatic transverse ligament rupture leading to C1/2 instability is uncommon and is treated with posterior C1/2 fusion
Odontoid fractures
Three types of peg fractures
Neurological injury is relatively rare and the majority are treated with hard collar/ halo jacket for 3 months
Mx: if unstable –> surgical fixation with anterior compression screw
stable –> halo jacket / hard collar
Posterior C1/2 fusion is considered in cases of
non-union
Types of odontoid fractures
Type 1: Chipped the top
Type 2: base of adentoid fracture
Type 3: Involved the lamellar/ vetrebral body
Traumatic sponylolisthesis of the axis
= Hangman;s fracture
Traumatic spondylolisthesis of C2 on C3
4 types
Significant displacement / facet dislocation –> posterio rstabilisation surgical fixation
Types of subaxial cervical spine injury (i.e. C3 and below)
C3 - C7
Compression fractures: flexion injuries
Burst fractures: axial loading injuries
Facet dislocation: distraction - flexion injuries
Tear-drop fractures: hyper-extension injuries
Fractures of spine in ank spond
Usually require operative fixation
Sometimes collar contra-indicated so specialist advice required
Classifying thoracic and thoracolumbar spinal fractures
Arbeitsgemeinschaft für Osteosynthesefragen classification
Three main types A - C with increasing instability and risk of neurological injury
Type A: vertical body compression fractures
Type B: Involve distraction of the anterior or posterior elements
Type C: rotational injurt that often is in association with A or B
B and C –> surgical fixation
Duodenal, pancreatic and/or aortic ruptures are also
associated with these injuries
Chance fractures are flexion-distraction injuries of the thoracolumbar spine
Assoc with lap belt injury
Lumbar spinal injuries
Less likely to cause neurological compromise
More capacious
Lumbar lordosis means kyphosis less likely to develop
Mx: usually non-operative
Increase in interpedicular distance
= burst fracture
Types of incomplete spinal cord injury
= peri-anal sensation remains intact
- some functioning cord
Types: Central cord syndrome Brown-Séquard syndrome (hemisection) Anterior spinal syndrome Posterior cord syndrome Cauda equina syndrome
Later complications of spinal cord injury
Pressure ulcers
Neurogenic pain
Spasticity
Autonomic dysreflexia: paroxysmal syndrome of hypertension, hyperhyderosis, bradycardia, flushing and headache
–> most comonly due to bladder distension or faecal loading
Neurological deterioration: Post traumatoc syringomyelia (PTS ) may occur in up to 28% of SCI patients
DVT / PE
Osteoporosis
Heterotopic ossification may affect the hips, knees, shoulders and elbows
Fractures of the mandible
Neck of the condyle is the most common site
Also angle of the mandible and canine region
Numbness over mental nerve is common
Tx: ORIF with sloppy diet for 2 weeks
Zygomatico-orbit complex fractures
4-legged stool
With exception of isololated zygomatic process and infra-orbital rim fractures –> all involve orbit
Altered sensation over infra-orbital nerve is common
Mx: ORIF at one of the for legs
+/- double/triple point fixation
Classification of maxillary fractures
Type 1:
Transverse fracture through the maxillary sinuses, lower nasal septum, pterygoid plates
Type 2:
Oblique fracture crossing zygomaticomaxillary suture, inferior orbital rim, nasal bridge
Type 3
Fracture above the zygomatic arch, through the lateral and medial orbital walls and nasofrontal suture
Diplopia ir orbital injuries
Monocular = eye damage
- Dislocated lens
- Retinal detachment / damage
Binocular diplopia = motility issue
-Rectust muscles
Diplopia ir orbital injuries
Monocular = eye damage
- Dislocated lens
- Retinal detachment / damage
Binocular diplopia = motility issue
-Rectus muscles
Diplopia in orbital floor fracture
Indictaes entrapment of inferior rectus / inferior oblique
Diplopia on up-gaze
On imaging may appear undisplaced = trap-door deformity
Mx: surgical emergency as pressure necrosis causing irreversible damage
Retrobulbar haemorrhage
= surgical emergency as leads to blindess
Decreasing visual acuity
Pain
Loss of pupillary response
Tense proptosis
Medical management:
Acetazolamide, mannitol and steroids
Surgical Mx:
Lateral canthotomy and cantholysyis
CSF leaks from carniofacial trauma
Fracture of frontal or ethmoidal sinuses creating communication between cranial cavity and nasal cavity
Dural tear needed for CSF to leak
Most common site of injury is the posterior wall of the frontal sinus, however fractures of the ethmoid and sphenoid sinus can also cause CSF leaks
Initial CSF leaks are not treated
Persistent CSF leaks >10 days –> dural repair using open anterior fossa repair (necessitating a frontal craniotomy
The Deadly Dozen
6 immediately life-threatening
- Airway obstruction
- Tension pneumothorax
- Pericardial effusion
- Open pneumothorax
- Massive haemothorax
- Flail chest
6 life-threatening
- Aortic injuries
- Tracheobronchial injuries
- Myocardial contusion
- Rupture of the diaphragm
- Oesophageal injuries
- Pulmonary contusion
Closure of open chest wounds
MUST have remote chest drain in first if wounds are sucking
Temporary closure with three sided dressing
If chest drian isn’t inserted one could convert a leaking pneumothoax into a closed pneumothorax –> tension
Indications for urgent thoracotomy
Initial drainage of more than 1500 mL of blood
OR
Ongoing haemorrhage of more than 200 mL/h over 3–4 hours
Clamping a chest drain to tamponade a massive haemothorax is not helpful.
Flail chest
On inspiration, the loose segment of the chest wall is
displaced inwards and therefore less air moves into the lungs
On expiration, the segment moves outwards (paradoxical respiration).
Mx of flail chest
Oxygen administration, adequate analgesia (including opiates) and physiotherapy.
If chest tube is in situ, topical intrapleural local analgesia introduced via the tube
Ventilation is reserved for cases developing respiratory failure despite adequate analgesia and oxygen
Internal fixation of the ribs may be useful in isolated or severe chest injury and pulmonary contusion
Diagnosis of oeosphageal perforation
Oesophagogram in the decubitus position
and
oesophagoscopy confirm the diagnosis in the great majority of casesa
Indications for a FUTILE EDT
CPR in the absence of endotracheal intubation for more than 5 minutes;
CPR for more than 10 minutes (despite endotracheal
intubation);
Blunt trauma when there have been no signs of life at the scene
Aims of ED thoracotomy
Internal cardiac massage;
Control of haemorrhage from injury to the heart or lung
Control of intrathoracic haemorrhage from other sources
Control of massive air leak
Clamping of the thoracic aorta to preserve the blood supply to the heart and brain, and cutting off the arterial supply distally, in a moribund patient with a major distal penetrating injury.
Management of liver injuries
Push
Pringle
Plug
Pack
Damage to hepatic artery
Can be tied off
One CANNOT tie off portal vein, must be repaired
= 50% mortality if it is tied off
-If bleeding cannot be controlled it should be stented and tranfserred to complex trauma HBP unit
Management of blunt pancreatic injuries
Pancreatic body (left is SMA) and tail --> closed suction drainage alone If duct involved --> distal pancreatectomy
Proximal injuries (right of SMA) are treated as conservatively as possible, although partial pancreatectomy may be necessary
–> pylorus can be temporarily closed (pyloric exclusion) in association with a gastric drainage procedure, to minimise pancreatic enzyme stimulation
Management of retropeitorneal bleeding
Haematomas split into three zones
Zone 1 (central): central haematomas = Always explored, proximal and distal vascular control
Zone 2 (lateral): lateral haematomas s
= Only be explored if they are expanding or pulsatile.
Renal in origin and can be managed non-operatively
Zone 3 (pelvic) =Only be explored if they are expanding or pulsatile. Pelvic haematomas are exceptionally difficult to control --> Compression or extraperitonea packing, and if the bleeding is arterial in origin, with angioembolisation.
Disruption of iliosacral joint is likely to damage which vessel
Iliac vessels
Tile classification of plevic fractures
Type A
- Stable
- Lateral compression, which causes ncompression fractures of the pubic rami or compression fracture of the sacrum posteriorly
Type B
-Partial stability, ORIF required
-Disruption of the anterior pelvis and partial disruption of the posterior pelvis.
-Pelvis can open and close ‘like a book’
-Sacroiliac ligaments remain intact, there is no vertical
displacement
Type C
- Completely unstable
- Both anterior pelvis and the entire posterior pelvic complexes are disrupted
- Free to displace horizontally and vertically.
Antibiotics in penetrating abdominal trauma
Prophylaxis antibiotics given if penetrating trauma
Ususally stat dose unless gross contamination then on-going abx may be required
Gustilo and Anderson Open fracture classification
I: <1cm and clean
II: >1cm without excessive soft tissue damage
III: Characterised by high energy injury irrespective of the size of the wound
-Soft tissue damage
-High degree of contamination
A: adequate soft tissue coverage post-repair
B: inaqdequate soft tissue coverage post repair
C: associated arterial injury
Salter Harris #s requiring surgery
III - V
Fixation of scaphoid fracture
Displaced >1mm or unstable
Use headless compression screw
If undisplaced –> below elbow casting not including thumb
Perilunate dislocation and lunate dislocation
Most common dislocation around capometacarpal joint
—> puts pressure on median nerve
Requires reduction, ligamentous repair and k-wire fixation
Fixation of Smith’s fracture
Most volar fractures of the radius are unstable
Standard treatment is volar plate on volar buttress of radius
If radial fracture is associated with splitting of the
lunate fossa fragment in the coronal plane and separation of the radial styloid
= failure
Intra-articular fracture that requires internal fixation with a plate
Neer Classification
Proximal humeral fractrures
4 parts to the proximal humerus:
- Articular head fragment
- Lesser tuberosity
- Greater tuberosity
- Shaft
If a fragment is displaced by more than 1 cm or angulated by more than 45 degrees in respect of another fragment, it is considered a part.
May be undisplaced, 2 part, 3 part or 4 part.
Greater the number of parts, the higher the chances of
interruption of the vascularity to the humeral head and the more complex the injury
Indications for surgical fixation of the clavicle
Displaced, comminuted fractures
2cm shortening
Ederly females
Indications for a gamma nail
Unstable extra-capsular femoral fractures
+ reverse oblique fracture –> unstable
Dynamic hip screws can sometiems still be used
Os calcis fractures
Fall from height
20% have associated lumbar spinal fracture
Talar neck fracture.
Most common fracture of the talus
Caused by forced dorsiflexion
Blood supplied interupted in displaced fractures
Anatomical reduction and stable fixation of the talar neck should be performed
