Trauma Flashcards
1
Q
- What is the role of a chest drain in treating a haemothorax?
A
Haemothorax is a collection of blood in the pleural space most commonly caused by trauma.
The role of a chest drain:
- Tube thoracostomy is used as definitive treatment for haemothorax
- Drainage of fresh blood – allows re-expansion of the lung and reduces any tension
- Measurement of the rate of bleeding – if massive haemothorax is present (>1500mL or 200mL/hour for 2-4 hours) then surgical thoracotomy should be performed
- Evacuation of any coexisting pneumothorax
- Tamponade the bleeding site by apposition of the pleural surfaces
2
Q
- How can rib fractures cause the death of a patient?
A
High mortality rate associated with chest wall injuries 10-20% stems from pain-induced splinting with resultant poor pulmonary hygiene
Rib fractures are often simple fractures that heal while managed conservatively with analgesia and physiotherapy
Rib fractures sustained as a result of more serious trauma may result in serious internal injury and death
Immediate complications:
- Intra-thoracic penetration
- Cardiac damage and haemopericardium
- Tension pneumothorax
- Haemothorax
- Pulmonary contusion
- Thoracic aortic injury
- Intra-abdominal penetration
- Splenic laceration
- Hepatic injury
- Flail chest – 3 or more adjacent ribs are fractured in 2 places creating a floating segment
- Impair ventilation and increased work of breathing
Late complications:
- Pneumonia and sepsis – pain preventing adequate ventilation, which leads to atelectasis and ultimately pneumonia
- Pulmonary embolism – due to reduce mobility
- Empyema – due to residual haematoma
3
Q
- DVT and PE are common in trauma patients. How can they be prevented?
A
VTE prophylaxis should be indicated for all trauma patients where primary haemostasis has been achieved.
Non-pharmocologic:
- Early mobilisation
- Adequate hydration
- Compression stockings (TEDs stockings
- Pneumoatic compression devices
- IVC filter
Pharmacological
- LMWH> UFH
- UFH in patients with renal failures
- Contraindicated in head trauma
Factors predisposing trauma patients to VTE:
- Reduced venous flow in the lower limbs
- Immobilisation
- Release of tissue factor
- Diminished fibrinolysis
- Depletion of endogenous anticoagulants
- Spinal cord injury
- Lower extremity/ pelvic fractures
- Need for surgical procedures
- Insertion of femoral venous lines
- Increasing age
- Delayed initiation of thromboprophylaxis
4
Q
- Why do we use a simple mneumonic (ABCDE) when assessing trauma patients? what does it stand for?
A
- ABCDE is an organised approach to assessing and addressing most life-threatening issues.
- Having a simple structure approach:
- Is easier to recall in a stressful situation
- Breaks down complex clinical situations into manageable parts
- Structures the priorities in trauma
- Establishes common situation awareness for the treating team and avoids confusion
- Can be simply repeated as the situation changes
- Increases the speed and quality of care
A – Airway & C-spine protection
- Assess for airway patency, obstruction and protective reflexes
- Employ simple airway manoeuvres – jaw thrust and chin lift
- Use suction and airway adjuncts (oropharyngeal [Guedel], nasopharyngeal or laryngeal mask airway [LMA])
- Endotracheal intubation should only be done by experienced staff
- Major trauma patient should be suspected of having cervical spine injuries. Until the C-spine is cleared, spinal precautions should be employed:
- Control the c-spine with manual immobilisation, hard collar, sandbags and tape
B – Breathing and Ventilation
- Assess for work and efficacy of breathing, including pulse oximetry (RR and SpO2)
- Give high flow oxygen (15L/min) via a non-rebreather mask on arrival
- Expose the patient for inspection, palpation and auscultation (percussion is difficult in a noisy ED and often omitted)
- Expansion, symmetry, wounds
- Assess the neck for life-threatening injuries to the neck or thorax (TWELVE):
- T – Tracheal deviation
- W – Wounds
- E – External markings
- L – Laryngeal disruption
- V – Venous distension
- E – Emphysema (surgical)
- May be appropriate to log roll at this point if concerned about posterior chest injury
- Identify and treat life-threatening conditions – tension pneumothorax, open pneumothorax, flail chest with pulmonary contusion, massive haemothorax
C – Circulation with Haemorrhage control
- Check HR, BP, capillary refill and the warmth of peripheries
- Systematically look for evidence of bleeding (RePLACE):
- Re – Retroperitoneum
- P – Pelvis
- L – Long Bones
- A – Abdomen
- C – Chest
- E – Externally
- Insert 2 large bore IV cannulas (at least 16 gauge – Grey) – intraosseous if unable to gain access, venous cut down if intraosseous unsuccessful
- Haemorrhage control with direct pressure, tourniquets, tying vessels, consider surgical control
- Commence IV fluids 1 – 2L stat of Normal Saline or Hartmann’s Solution.
- Trauma bloods: X-match, VBG, FBC, UEC, Glucose, Coagulation studies, Lipase
- Place ECG
- Place Urinary Catheter for urine output
D – Disability (Neurological status)
- Assess level of consciousness (AVPU and/or GCS – document GCS in components e.g. E4, V5, M6 = GCS 15)
- Check pupil size and responsiveness
- Gross motor and sensory function in all 4 limbs
- If spinal injury suspected – check for priapism, loss of anal sphincter tone and the bulbocavernous reflex
- Check glucose
- Seizure control – midazolam, followed by phenytoin
- Treat raised intracranial pressure (head up, analgesia and sedation, NM blockade, mannitol or hypertonic saline, urgent surgical decompression)
E – Exposure and Environment control
- Completely undress the patient but keep the patient warm and check areas where life-threatening injuries could be missed (back of the head, back, buttocks, perineum, axillae, skin folds)
- If not done yet, consider log-rolling the patient now
- lengthy procedures and instead only controlling the life-threatening injuries
5
Q
- In a laparotomy for trauma, what are surgical priorities?
A
Indications in trauma:
- Peritonitis
- Exploratory laparotomy in hemodynamically stable patient
- Due to perforation of a hollow viscus, pancreatic injury, retroperitoneal bleed
- Haemorrhage (damage control)
In trauma patients avoidance of the lethal triad (hypothermia, acidosis, coagulopathy) is a priority.
This means avoiding lengthy procedures and instead only controlling the life-threatening injuries
Priorities
- Packing and exploration
- Immediately after opening the abdomen is packed in all 4 quadrants – start with quadrants where bleeding appears most significant
- Remove the packs in reverse order to explore and address any active bleeding when encountered.
- Control haemorrhage
- Resect severely damaged nonessential organs (e.g. spleen), leaving severely damaged essential organs packed (e.g. liver)
- Ligate or shunt transected intra-abdominal vessels
- Control contamination
* Seal (oversew and staple) or resect perforated hollow viscus - Provide temporary abdominal closure to prevent abdominal compartment syndrome
- Negative pressure dressings are commonly used
- A second look laparotomy may be needed if the patient remains severely haemodynamically unstable or hypothermic
6
Q
- What is a pneumothorax? How can it be treated?
A
Pneumothorax: presence of air between the parietal and visceral pleura
- Normally the intrapleural pressure is less than both the atmospheric pressure and alveolar pressure
- If there is a communication between the intrapleural space and either the alveoli or the atmosphere, air will follow the pressure gradient and flow into the pleural space
Classification
- Spontaneous
- Occurs without preceding trauma/ precipitating event
- Primary – no evidence of underlying lung disease
- Secondary – complication where lung disease is present, most commonly COPD, asthma, ILD, cystic fibrosis, HIV-associated infection
- Traumatic
- ‘open’ pneumothorax due to penetrating or blunt chest injury
- Could be iatrogenic
- Tension
- Intrapleural pressure exceeds atmospheric pressure throughout the respiratory cycle
- One way valve mechanism promotes accumulation of more pleural air during inspiration leading to hypoxaemia and respiratory failure as well as mediastinal compression and haemodynamic compromise
Treatment:
- O2 supplementation
- Observation – small stable spontaneous pneumothorax (repeat CXR)
- Needle decompression if signs of tension are present
- 14G needle in MCL at 2nd or 3rd intercostal space (alternatively the 4th or 5th space can be used if the length of the cannula is too short)
- Percutaneous needle aspiration for larger spontaneous pneumothorax
- As for needle decompression but a syringe is used to withdraw air
- Sealing of chest wound with impermeable dressing – used for sucking chest wounds
- Intercostal drain with underwater seal – tube thoracostomy (4th or 5th ICS in MAL)
- Surgical intervention may be required for persistent or recurrent pneumothorax
7
Q
- What is a tension pneumothorax?
A
An expanding pneumothorax causing progressive mediastinal shift to the contralateral side (a pushing force), leading to contralateral lung compression, mediastinal compression/ shift and tracheal deviation.
This is a clinical diagnosis (i.e. not time for CXR) and medical emergency requiring immediate management
- Intrapleural pressure exceeds atmospheric pressure throughout the respiratory cycle
- One way valve mechanism promotes accumulation of more pleural air during inspiration leading to hypoxaemia and respiratory failure as well as mediastinal shift and haemodynamic compromise
8
Q
- What are the symptoms and signs of a simple pneumothorax?
A
Clinical features:
- Pleuritic chest pain
- Dyspnoea – proportionate to volume of air in pleural space
- May be a cough
- Decreased chest expansion on the affected side
- Reduced vocal resonance on the affected side
- May be tracheal shift towards the affected side
- Hyper-resonance to percussion on the affected side
- Diminished breath sounds on the affected side
9
Q
- What are the symptoms and signs of a tension pneumothorax?
A
Clinical features:
- Pleuritic chest pain
- Dyspnoea – significant (respiratory distress)
- Tachypnoea
- Anxiety
- Fatigue
- Decreased chest expansion on the affected side
- Reduced vocal resonance on the affected side
- May be tracheal shift away from affected side
- Hyper-resonance to percussion on the affected side
- Diminished breath sounds on the affected side
- Hypotension
- May be cyanosis
- Distended neck veins
10
Q
- What is the treatment for a suspected tension pneumothorax?
A
Immediate decompression (medical emergency):
- Needle decompression with a 12G or 14G cannula in the 2nd or 3rd ICS in MCL
- A gush of air released confirmed the diagnosis
- Followed by tube thoracostomy – upper edge of the rib in the 4th or 5th ICS in MAL or AAL
11
Q
- What is shock, and what is the most common cause of shock in trauma patients?
A
Definition of shock:
- State of cellular and tissues hypoxia due to reduced O2 delivery and/or increased O2 consumption or inadequate O2 utilisation – if untreated proceeds to irreversible organ damage and death of the patient
Pathophysiology:
- Cellular hypoxia causes cell membrane ion pump dysfunction, intracellular oedema, leakage of intracellular contents into the extracellular space, and inadequate regulation of intracellular pH
- This process progresses to a systemic level resulting in acidosis, endothelial dysfunction and further stimulation of inflammatory and anti-inflammatory cascades
- This is further compounded by complex humoural and microcirculatory processes that reduce regional blood flow
- Serum lactate levels have traditionally been used as surrogates for hypoperfusion and tissue hypoxia, however lactate flux is more complex than this and other causes may increase lactate
- The major determinants of tissue perfusion
- BP = CO x TPR
- CO = HR x SV
- SV is determined by
- Preload
- Myocardial contractility
- Afterload
- TPR is determined by
- Vessel diameter (predominantly)
- Vessel length
- Blood viscosity
- Most forms of shock are either diminished CO and/or TPR
- Generally, hypovolaemic shock and late stage obstructive shock are characterised by a low CO with a compulsory increase in TPR to maintain perfusion to vital organs
- In contrast, distributive shock is generally associated with reduced TPR and a compensatory increase in CO
Stages of shock
- Pre-shock
- Aka compensated shock or cryptic shock
- Compensatory responses to diminished tissue perfusion e.g. tachycardia or peripheral vasoconstriction
- HR, BP, and mild to moderate increase in serum lactate may be the only signs
- Shock:
- The compensatory mechanisms have become overwhelmed and signs and symptoms of organ dysfunction appear: symptomatic tachycardia, dyspnoea, restlessness, sweating, metabolic acidosis, hypotension, oliguria, cool, clammy skin
- End-Organ Dysfunction:
- Progressive shock leading to irreversible organ damage, multiple organ dysfunction (MODS) and death.
- Anuria and acute renal failure develop, acidaemia further depresses CO, hypotension becomes severe and resistant to treatment, lactate continues to increase and restlessness becomes obtundation and coma
- Death is common
Classification:
- Distributive Shock
- Cardiogenic Shock
- Hypovolaemic Shock
- Obstructive Shock
- In trauma patients, shock is most commonly hypovolaemic, due to haemorrhage
- Occasionally trauma related shock is obstructive (e.g. tension pneumothorax, cardiac tamponade) or distributive (e.g. neurogenic)
12
Q
- Wat is permissive hypotension and what is haemostatic resuscitation?
A
- Damage control resuscitation is an approach to managing hypovolaemic shock due to major trauma that involves:
- Permissive hypotension
- Haemostatic resuscitation
- Damage control surgery
Permissive hypotension
- This is low volume resuscitation
- The approach
- Let the SBP fall low enough to avoid exsanguination but keep high enough to maintain perfusion (target MAP 65mmHg)
- The goal is to avoid disruption of an unstable clot by higher pressures and worsening of bleeding
- Avoids cyclic over-resuscitation that can lead to re-bleeding and paradoxically exacerbate hypotension despite increased fluid resuscitation and subsequent complications
- Low BP is not the target, it is a compromise pending emergency surgical intervention
- Haemorrhage control is the goal, once this is achieved normalisation of haemodynamics is appropriate
Haemostatic resuscitation:
- Resuscitation with blood components resembling whole blood
- Aims to avoid or ameliorate acute coagulopathy of trauma and the complications of aggressive crystalloid fluid resuscitation while maintaining circulating volume
- It involves blood component ratios of 1 or 2 RBCs: 1 FFP: 1 platelets
13
Q
- What is the difference between spinal shock and neurogenic shock?
A
Spinal shock (not a true form of shock)
- This is a temporary loss or depression of spinal reflex activity that occurs below a complete or incomplete spinal cord injury
- There may be physiological loss of all spinal cord function distal to the level of injury (flaccid paralysis, anaesthesia, absent bowel and bladder control, loss of reflex activity, priapism may also develop in men)
- Spinal shock may last hours to several weeks
- The loss of function may be caused by the loss of potassium within the injured cells in the cord and its accumulation in the ECF, causing reduced axonal transmission
- As the potassium level normalises within the ICF and ECF, the spinal shock wears off
Neurogenic shock (true form of shock – distributive):
- Loss of sympathetic tone occurring in severe traumatic brain injury or spinal cord injury
- Neurogenic shock is true shock – where there is end-organ hypoperfusion
- Generally occurs with spinal cord injuries at the thoracic or cervical level
- Loss of sympathetic tone leads to bradycardia, vasodilation and hypotension (bradycardia is characteristic)
- Loss of the T1-T4 sympathetic nerves to the heart leaves the Vagus nerve unopposed
- Loss of sympathetic nerves to the peripheral vasculature results in a decreased in SVR and BP
- Treatment: IV crystalloids (aim for a MAP 85-90mmHg) and monitor for heart failure and pulmonary oedema
14
Q
- What are the 5 sources of hypovolaemic life threatening bleeding, and how do you idenify/ diagnose them?
A
The mnemonic is PLACE (extended to 6 it is RePLACE)
- Re – Retroperitoneum
- May not be detectable on FAST scan, so CT scan may be required
- P – Pelvis
- Pelvic XR looking for bony or ligamentous injury/ instability
- May need to use CT to diagnose bleeding
- Treat by externally stabilising the pelvis with a pelvic binder
- Emergency angiography with coiling may need to be used
- L – Long Bones
- Exposure and inspection +/- XR to identify #
- Treat with splinting +/- reduction
- A – Abdomen
- FAST scan may detect bleeding
- Diagnostic peritoneal aspiration may also be used
- Treat with emergency laparotomy
- C – Chest
- Clinical examination, CXR and FAST to detect bleeding
- Treat with a chest drain
- E – Externally
- Clinical examination with exposure and inspection, including log roll to detect bleeding
- Treat with direct pressure or suturing lacerations
15
Q
- What is the treatment for a trauma patient who has bleeding from an open wound identified as their immediate life threatening injury?
A
A – Airway & C-spine protection
- Assess for airway patency, obstruction and protective reflexes
- Employ simple airway manoeuvres – jaw thrust and chin lift
- Use suction and airway adjuncts (oropharyngeal [Guedel], nasopharyngeal or laryngeal mask airway [LMA])
- Endotracheal intubation should only be done by experienced staff
- Major trauma patient should be suspected of having cervical spine injuries. Until the C-spine is cleared, spinal precautions should be employed:
- Control the c-spine with manual immobilisation, hard collar, sandbags and tape
B – Breathing and Ventilation
- Assess for work and efficacy of breathing, including pulse oximetry (RR and SpO2)
- Give high flow oxygen (15L/min) via a non-rebreather mask on arrival
- Expose the patient for inspection, palpation and auscultation (percussion is difficult in a noisy ED and often omitted)
- Expansion, symmetry, wounds
- Assess the neck for life-threatening injuries to the neck or thorax (TWELVE):
- T – Tracheal deviation
- W – Wounds
- E – External markings
- L – Laryngeal disruption
- V – Venous distension
- E – Emphysema (surgical)
- May be appropriate to log roll at this point if concerned about posterior chest injury
- Identify and treat life-threatening conditions – tension pneumothorax, open pneumothorax, flail chest with pulmonary contusion, massive haemothorax
C – Circulation with Haemorrhage control
- Check HR, BP, capillary refill and the warmth of peripheries
- Systematically look for evidence of bleeding (RePLACE):
- Insert 2 large bore IV cannulas (at least 16 gauge – Grey) – intraosseous if unable to gain access, venous cut down if intraosseous unsuccessful
- Haemorrhage control with direct pressure, tourniquets, tying vessels, consider surgical control
- Commence IV fluids 1 – 2L stat of Normal Saline or Hartmann’s Solution.
- Trauma bloods: X-match, VBG, FBC, UEC, Glucose, Coagulation studies, Lipase
- Place ECG
- Place Urinary Catheter for urine output
D – Disability (Neurological status)
- Assess level of consciousness (AVPU and/or GCS – document GCS in components e.g. E4, V5, M6 = GCS 15)
- Check pupil size and responsiveness
- Gross motor and sensory function in all 4 limbs
- If spinal injury suspected – check for priapism, loss of anal sphincter tone and the bulbocavernous reflex
- Seizure control – midazolam, followed by phenytoin
- Treat raised intracranial pressure (head up, analgesia and sedation, NM blockade, mannitol or hypertonic saline, urgent surgical decompression)
E – Exposure and Environment control
- Completely undress the patient but keep the patient warm and check areas where life-threatening injuries could be missed (back of the head, back, buttocks, perineum, axillae, skin folds)
- If not done yet, consider log-rolling the patient now
Management of bleeding from open wound:
- Control bleeding with firm pressure on gauze over the wound
- Apply a tourniquet if direct pressure has failed to control the bleeding
- If bleeding continues, invasive management should be considered:
- Surgical management (vessel tying, suturing, cautery)
- Interventional radiology (angiographic embolisation)
