Trauma Flashcards
242 What is the role of a chest drain in treating a haemothorax?
Haemothorax = collection of blood in the pleural space, usually due to blunt or penetrating trauma
A haemothorax, however small, must always be drained because blood in the pleural cavity will clot if not evacuated, resulting in a trapped lung or an empyema
A chest drain is the first step in definitive management where a thoracostomy tube is inserted into the 5th IC space in the mid-axillary line.
The goals of tube thoracostomy in acute haemothorax include:
- Drainage of fresh blood
- Measurement of the rate of bleeding
- Evacuation of any co-existing pneumothorax (via the two-drain technique)
- Tamponade of the bleeding site by restoring apposition of the pleural surfaces
243 How can rib fractures cause the death of a patient?
Although rib fractures are often simple fractures that heal with conservative management, they can cause significant injuries and complications that can become life-threatening. 2+ # is associated with a higher incidence of internal injury.
The 4th and 9th ribs are most commonly involved → thoracic and abdominal injury, respectively
Immediate complications:
- PE (thrombus formation in venous system following trauma)
- ARDS (increases with number of ribs #)
- Fat emboli (often asymptomatic, fulminant fat embolism syndrome has a very nigh mortality)
- Intra-thoracic penetration → cardiac damage, tension pneumothorax, haemothorax, aortic rupture
- Intra-abdominal penetration → splenic laceration, hepatic injury
- Flail chest (segment of rib cage becomes detached from chest wall) → paradoxical breathing, respiratory and failure
Late complications:
- Pneumonia (pain preventing DB&C)
- Empyema (can result from residual haematoma)
244 DVT and PE are common in trauma patients. How can they be prevented?
Current recommendations: VTE prophylaxis should be initiated in all trauma patients
Mechanical = TEDS stockings, pneumocompression Pharmacological = LMWH (enoxaparin), UFH, fondaparinux, rivaroxaban (unless specifically contraindicated) Behavioural = early mobilisation, adequate hydration
Should be continued until the patient regains full mobility
245 Why do we use a simple mnenomic (ABCDE) when assessing trauma patients? What does it stand for?
Usefulness of the mnemonic:
- Addresses life-threatening injuries in order of priority
- Easy to recall in stressful situations
- Allows consistency between clinicians and centres
- Can start again and re-evaluate if something changes
A = airway and c-spine control
- C-spine injury until proven otherwise in trauma cases
- Talking? Changes in voice?
- Jaw thrust, chin lift
- Inspect neck before covering
B = breathing
- Measure respiratory rate and SpO2
- Assess respiratory fields (percussion, auscultation, tracheal deviation)
- “GCS 8, intubate”
- Intubation can exaggerate a tension pneumothorax
C = circulation with haemorrhage control
- Measure pulse rate, BP, cap refill, warmth of peripheries
- Systematically look for sources of bleeding
- 2 x 16G IV access (at least) for fluid resus
- Warm fluids
- Permissive hypotension
- Blood component ratio 1:1:1 (i.e. whole blood)
D = disability
- Measure AVPU or GCS
- Assess pupillary size and response, gross motor and sensory function of all limbs, check BSL
- Seizure control with midazolam and phenytoin
E = exposure and environmental control
- Remove clothing while maintaining thermostasis
- Consider log-roll if not already done
- Includes (e)x-rays (trauma series) and CT (for neck injury)
246 In a laparotomy for trauma, what are the surgical priorities?
There are two main indications for laparotomy in trauma:
1) Peritonitis (exploration in haemodynamically stable patient)
2) Haemorrhage (damage control)
Priorities of damage control laparotomy:
1) Identify injuries and source of haemorrhage
2) Achieve haemostasis - clamping, packing, shunting, ligation
3) Limit contamination - repair hollow viscus injuries, wash out peritoneum
247 What is a pneumothorax? How can it be treated?
A pneumothorax is air within the pleural space
Treatment:
1) Observation and supplemental oxygen
If small and no significant symptoms
2) Thoracocentesis (needle aspiration)
If > 2cm or dyspnoea or pleuritic chest pain
2nd ICS, mid-clavicular line
3) Chest drain
Patients who are unstable, have a haemothorax, failed simple aspiration
5th ICS, mid-clavicular line
248 What is a tension pneumothorax?
A pneumothorax is the presence of air in the pleural cavity (between the parietal and visceral pleural layers)
A tension pneumothorax is a severe variant of the condition, characterised by increasing pressures within the chest and cardiorespiratory compromise
Differentiating clinical features
- Tachycardia, hypotension, severe dyspnoea (most indicative)
- Contralateral shift of the trachea and mediastinum, splaying of the ribs, flattening of the ipsilateral diaphragm (traditional teaching)
249 What are the symptoms and signs of a simple pneumothorax?
Symptoms:
- Sudden onset pleuritic chest pain
- Sudden onset dyspnoea
- Sudden deterioration of patients with asthma and COPD
- Cough
NB: may be asymptomatic if small and in a young, fit person
Unilateral signs
- Hyperexpanded hemithorax (loss of chest movement)
- Hyper-resonant on percussion
- Decreased/absent breath sounds
- Mediastinal shift TOWARDS affected side
250 What are the symptoms and signs of a tension pneumothorax?
Symptoms:
- Chest pain
- Dyspnoea
- Anxiety
- Fatigue
Signs
- Vitals: respiratory distress, tachycardia, hypotension
- Tracheal deviation AWAY from affected side
- Distended neck veins (due to great vein compression)
- Ipsilateral decreased chest movement, hyper-resonance, absent breath sounds
251 What is the treatment for a suspected tension pneumothorax?
Diagnosis is clinical, no time for CXR
1) Immediate decompression with 12G cannula into 2nd ICS mid-clavicular
- Gush of air confirms diagnosis
Immediately followed by:
2) Connection of thoracostomy tube into the 5th ICS between mid-axillary and anterior
- Attach to underwater seal - hydrostatic pressure of fluid column counteracts negative pleural pressure to prevent air being sucked back into the pleural space
252 What is shock, and what is the most common cause of shock in trauma patients?
Shock is a life-threatenining failure of adequte tissue perfusion
The most common type of shock in trauma patients is hypovolemic shock
253 What is permissive hypotension and what is haemostatic resuscitation?
Permissive hypotension (SBP 80-90 mmHg) is a strategy of deferring or restricting fluid administration until haemorrhage is controlled while accepting a period of suboptimal end-organ perfusion. The theory is that when a patient is haemorrhaging, the body is trying to gain haemostasis and excessive fluid resuscitation impedes this by dislodging the thrombus and diluting the coagulation factors.
Permissive hypotension is part of damage control resuscitation, aiming to correct hypotension without creating higher blood pressure that could disrupt unstable clots
Haemostatic resuscitation refers to resuscitation with blood components resembling whole blood. It aims to avoid exacerbation of coagulopathy which is associated with trauma and can be exacerbated by fluid resuscitation
JHH guidelines suggest 1:1:1
National Blood Authority guidelines suggest a ratio of 4:2:1 (RBC:FFP:platelets)
254 What is the difference between spinal shock and neurogenic shock?
Spinal shock - loss of all spinal cord function caudal to the level of injury
- Lasts hours to weeks
- Can be thought of as a “concussion” of the spinal cord
- Possibly due to loss K+ within injured cells and accumulation within the extracellular space, wearing off as K+ normalises
Neurogenic shock - damage to a significant proportion of the sympathetic nervous system following severe traumatic brain injury or spinal cord injury
- Loss of sympathetic tone → hypotension, bradycardia, peripheral vasodilation
- May occur with lesions at T6 level or higher
- Can be described as a type of “distributive” shock
255 What are the 5 sources of hypovolaemic life threatening bleeding, and how do you identify/diagnose them?
PLACE
P - Pelvis
L - Long bone
A - Abdomen
C - Chest
E - External
Pelvis - x-ray, FAST scan, pelvic CT
Long bones - physical examination, x-ray
Abdomen - physical examination, FAST scan, CT abdomen, emergency laparotomy
Chest - auscultation, CXR, FAST scan, CT
External - examination
256 What is the treatment for a trauma patient who has bleeding from an open wound identified as their immediate life threatening injury?
1) Primary Survey
- Organise trauma team
- Call surgeon
- Notify blood bank
A = Airway
- Protect airway, secure if unstable
- Control c-spine (neck brace)
B = Breathing
- Definitive control of airway
- Oxygen, bag and mask if necessary
C = Circulation
- IV access and fluid/blood resuscitation as required (activate MTP if necessary)
- Assess for shock
- Control external bleeding (consider tourniquet control on limbs), reverse anticoagulation
- Bloods: group and save, FBC (esp. Hb & HCT), UEC, coags, ABG (note lactate level and base deficit)
- Allow permissive hypotension if necessary
- Beware the lethal triad: hypothermia + acidosis + coagulopathy
D = Disability
- Full neurological evaluation (cranial nerves and limbs)
- AVPU or GCS
E = Exposure/Environment
- Full exposure of patient to check for additional trauma
- Maintain temperature
- Consider log-roll
- Trauma series X-ray (CXR, pelvis, lateral C-spine)
2) Definitive management
- Control bleeding with firm pressure on gauze over wound
- Stop bleeding: sutures, cautery, interventional radiology, damage control surgery
