Trauma Flashcards
Sterility is a luxury in trauma and other pearls of wisdom
Traumatic Brain Injury (TBI) classification
TBI an be classified by both severity and cause
Severity
- Mild
- GCS 13-15
- Also:
- LOC <30mins
- PTA <1 day
- Moderate
- GCS 9-12
- Also:
- PTA 1-7 days
- LOC 0.5-24 hours
- Severe
- GCS 3-8
- Also:
- PTA >7 days
- LOC >24 hours
Cause
- Primary
- fracture
- haemorrhage
- DAI
- Secondary
- hypoperfusion and hypoxia
Management of ICP
Needs to be below 20mmHg
nursing at 30 degrees
check collar (or remove)
EVD
Mannitol
Hyperventillation to PaCO2 of 30-35mmHg
Decompressive craniectomy
Anatomy of an underwater sealed drain
Considerations of extent of trauma in animal bites
May represent blunt and penetrating trauma
- Blunt
- Animals limbs
- Crushing with jaws
- Body weight
- Rotational distortion injuries
- Penetrating
- Amputation
- Penetration of body cavities
- Transmisable disease
- Bacterial
- Rabies (Rhabdovirus)
- Viral
Dog bite management
TRAUMA and EMST management, ABCDE approach
Tetanus
Antibiotics with Augmentin
- or cefoxitin
- consider pip-taz in severe infection
Wound care- the most important intervention for both bacterial and zoonotic infections e.g rabies
- clean
- debride
- healing by primary, delayed primary or secondary intention depending on wound and site
Fight bite
Human bite injury to the extensor surface of the metacarpophalangeal joint.
- due to striking closed fist against teeth
- high risk injuries
- NB: often appear minor
- tendon and joint are often involved
- secondary infection can be devastating to hand function.
Mammalian bite bacteriology
Pasteurella (most common esp canine and feline)
Staph species
Strep species
Humans: Eikenella corrodens
Name the key organism in human bite infections
Eikenella corrodens
Neck trauma zones
AAST liver injury grading:
Grade I
- Haematoma: subcapsular, <10% surface area
- Laceration: capsular tear, <1 cm parenchymal depth
AAST renal injury grading
Grade I
grade I
- subcapsular hematoma or contusion, without laceration
AAST renal injury grading
Grade II
grade II
- superficial laceration ≤1 cm depth not involving the collecting system (no evidence of urine extravasation)
- perirenal hematoma confined within the perirenal fascia
AAST renal injury grading
Grade III
grade III
- laceration >1 cm not involving the collecting system (no evidence of urine extravasation)
- vascular injury or active bleeding confined within the perirenal fascia
AAST renal injury grading
IV
grade IV
- laceration involving the collecting system with urinary extravasation
- laceration of the renal pelvis and/or complete ureteropelvic disruption
- vascular injury to segmental renal artery or vein
- segmental infarctions without associated active bleeding (i.e. due to vessel thrombosis)
- active bleeding extending beyond the perirenal fascia (i.e. into the retroperitoneum or peritoneum)
AAST renal injury grading
Grade V
grade V
- shattered kidney
- avulsion of renal hilum or laceration of the main renal artery or vein: devascularisation of a kidney due to hilar injury
- devascularised kidney with active bleeding
AAST splenic injury grading
All grades
grade I
- subcapsular hematoma <10% of surface area
- parenchymal laceration <1 cm depth
- capsular tear
grade II
- subcapsular hematoma 10-50% of surface area
- intraparenchymal hematoma <5 cm
- parenchymal laceration 1-3 cm in depth
grade III
- subcapsular hematoma >50% of surface area
- ruptured subcapsular or intraparenchymal hematoma ≥5 cm
- parenchymal laceration >3 cm in depth
grade IV
- any injury in the presence of a splenic vascular injury* or active bleeding confined within splenic capsule
- parenchymal laceration involving segmental or hilar vessels producing >25% devascularisation
grade V
- shattered spleen
- any injury in the presence of splenic vascular injury* with active bleeding extending beyond the spleen into the peritoneum
AAST splenic injury grading
Grade I
grade I
- subcapsular haematoma <10% of surface area
- parenchymal laceration <1 cm depth
- capsular tear
AAST splenic injury grading
Grade II
Grade II
- subcapsular haematoma 10-50% of surface area
- intraparenchymal haematoma <5 cm
- parenchymal laceration 1-3 cm in depth
AAST splenic injury grading
Grade III
Grade III
- subcapsular haematoma >50% of surface area
- ruptured subcapsular or intraparenchymal haematoma ≥5 cm
- parenchymal laceration >3 cm in depth
AAST splenic injury grading
Grade IV
Grade IV
- any injury in the presence of a splenic vascular injury or active bleeding confined within splenic capsule
- parenchymal laceration involving segmental or hilar vessels producing >25% devascularisation
AAST splenic injury grading
Grade V
Grade V
- shattered spleen
- any injury in the presence of splenic vascular injury with active bleeding extending beyond the spleen into the peritoneum
AAST pancreatic injury grading
grade 1:
- haematoma with minor contusion/laceration but without duct injury
grade 2:
- major contusion/laceration but without duct injury
grade 3:
- distal laceration or parenchymal injury with duct injury
grade 4:
- proximal (i.e. to the right of the superior mesenteric vein) laceration or parenchymal injury with an injury to bile duct/ampulla
grade 5:
- massive disruption of the pancreatic head
Injury Severity Score (ISS) score
Score is intended primarily for research but does correlate with LOS, ICU days so may have wider uses esp in ICU for prognostication
Score 0-75 points
Calculated mathematically from simple parameters
- 6 body regions
- Head and Neck
- Facial
- Chest
- Abdomen
- Extremity
- External
- Graded:
- No injury
- Minor
- Moderate
- Serious
- Severe
- Critical
- Unsurvivable
How can blast injuries be classified?
Primary
- Wounding of air filled viscera as a result of blast wave
Secondary
- Penetrating trauma from bomb fragments and other projectiles
Tertiary
- Casualties propelled by blast- usual blunt injury mechanisms
Quaternary
- Crush from structural collapse
- Burns
- Other mechanisms not classed as primary, secondary, tertiary
What is the most common injury in underwater blast injuries
Bowel perforation
- often delayed presentation with developing peritonitis 24-48 hours later
Techniques used to control bleeding in liver trauma
Pack, Pringle, Angio
Juxtahepatic caval injuries- sternotomy
Balloon tamponade of missile tracts
Haemostatic agents
In trauma the pancreas is like a lobster
Bite the Tail
Suck the Head
Top knife includes the distal pancreas in “the take-outables”
What is the lethal triad
The triad is:
- Acidosis
- Coagulopathy
- Hypothermia
This triad is a late sign of severe trauma which, if develops, almost certainly heralds death
- avoid it developing, get out fast where possible.
What are the options for major traumatic vascular injury
Temporary
- Pressure
- Finger
- Packing
- Clamping
- Balloon occulsion
- REBOA
- Shunt
Definitive
- Ligation
- Almost anything can be ligated
- Even the portal vein if necessary
- Almost anything can be ligated
- Repair
- Interposition
- Primary
The Mattox maneouvre
Left sided medial visceral rotation
- Useful for access to the midline supramesocolic retroperitoneus
- Especially great vessels
- An expanding haematoma will often do most of the dissection for you
- Mobilise left colon
- Incise the white line of Toldt,
- continue it posteriorly around the kidney if you want to access the aorta well or
- Infront of the kidney if you want to access the kidney to remove it
- and superiorly around the spleen
- Roll the viscera to the midline
- Incise the white line of Toldt,
- Provides access to the non paired visceral aortic branches
- Division of the left crus superiorly can facilitate aortic access as high as T6 for clamping
AAST liver injury grading:
Grade II
Haematoma: subcapsular, 10-50% surface area
Haematoma: intraparenchymal <10 cm diameter
Laceration: capsular tear 1-3 cm parenchymal depth, <10 cm length
AAST liver injury grading:
Grade III
Haematoma: subcapsular, >50% surface area or ruptured subcapsular or parenchymal hematoma
Haematoma: intraparenchymal >10 cm
Laceration: capsular tear >3 cm parenchymal depth
Vascular injury with active bleeding contained within liver parenchyma
AAST liver injury grading:
Grade IV
Laceration: parenchymal disruption involving 25-75% hepatic lobe or involves 1-3 Couinaud segments
Vascular injury with active bleeding breaching the liver parenchyma into the peritoneum
AAST liver injury grading:
Grade V
Laceration: parenchymal disruption involving >75% of hepatic lobe
Vascular: juxtahepatic venous injuries (retrohepatic vena cava / central major hepatic veins)
What is the AAST liver trauma grading system
What are the elements
What is the range of grades given
A standardised radiological grading system for severity of liver injury
Elements include
- Haematoma
- Capsular
- Parenchymal
- Laceration
- Vascular
- Arterial and minor venous
- Juxtahepatic great veins
Graded in severity from grade I to grade V
In median sternotomy for access to the great vessels, which 2 structures will usually need to be divided
The remnant thymus
The left innominate vein
Landmarks for an anterolateral thoracotomy
4th or 5th intercostal space
In women use the inframammary fold
In men go below pec major ideally as it simplifies the entry
Explain the concept of damage control in trauma
What are the key principles of damage control resuscitation
- Permissive hypotension
- the aim is to achieve end organ perfusion while minimising blood loss
- systolic of 80mmHg
- MAP of 80mmHg in severe head injury
- the aim is to achieve end organ perfusion while minimising blood loss
- Minimise the use of crystalloid in early trauma
- switch to the use of blood products early
- Use an MTP with balanced RBC, platelets and FFP
- Targeting coagulopathy with use of TEG/RoTEM
- Restore normothermia
