Trauma Flashcards
Major trauma is suspected in…
- Major road traffic accidents - especially where an individual has died in the same collision
- Being thrown up/ ran over by a car
- Crush injury
- Falls of >2m
Phases of ATLS…
- Primary survey: AcBCDE assessment
- Resuscitation phase (continuing to treat the findings from primary survey)
- Secondary survey
- Definitive care phase
What happens in the primary survey?
CAcBCDE:
C= catastrophic haemorrhage- any major trauma which is causing significant active bleeding
A= maintaining a good airway - may need to use manoeuvres / adjuncts
c= when carrying out airway assessment, check for c-spine injury - this needs to be stabilised
B=breathing
C= circulation - haemodynamic stability is important, identifying sites of bleeding (floor and four more)
D= GCS, BM
E= exposure for any other injuries, temp
What are the main sources of bleeding?
On the floor and four more On the floor= external bleeding Four more = internal bleeding: - Thorax - Abdomen - Pelvis - Long bones
How is catastrophic haemorrhage managed acutely?
Extreme pressure should be applied over the site of bleeding - to stem the blood flow
CAT tourniquet at single bone proximal to the wound.
What does Airway management consist of?
All patients should be assumed to have C-spine injury unless proven otherwise.
1. Immediate manual cervical immobilisation -can be achieved by placing one hand on either side of patient’s head without traction
2.In the meantime, colleague should find appropriately sized cervical collar
3. Place towels/ blocks either side of collar
Airway needs to be assessed:
- Best way is to speak to patient
- Listen for breath sounds, feel against cheek and look for chest movement
- Removal of foreign bodies
- Airway manoeuvres - jaw thrust NOT head tilt
- Airway adjuncts e.g. guedel
What does Breathing management consist of?
Breathing assessment may follow
Look: RR, breathing pattern, bruising/ injury
Feel: tracheal deviation, chest expansion, surgical emphysema (bubble wrap feeling under the skin)
Percussion:dullness/ hyper-resonance
Auscultation: breath sounds, added sounds
Search: back, shoulders and sides of chest
What does Circulation management consist of?
- Two large bore cannulae into ACF of both arms - take bloods for FBC, U&E, cloting and X match
- Appropriate fluid resuscitation - no more than 1L saline, then need to switch to blood
- 1g TXA IV can be given for major haemorrhage
- Identify any obvious sources of bleeding
What does Disability management consist of?
- GCS/ AVPU
- Pupil reactivity and size
- BM
What does Exposure management consist of?
Whole body of the patient must be exposed - may need to cut clothes off
Need to check the patient’s temp - should be covered and kept warm
What factors may indicate C-spine injury?
- Mechanism of injury
- Neck pain, or inability to move neck
- Neurological deficit
Why are large volumes of IV fluids not given in bleeding trauma patients?
Has been shown to increase mortality.
Patient is already in hypercoaguable state but with increased circulating volume, these remaining clotting factors become diluted and their action is impeded, therefore preventing them from stopping any bleeding.
What are the important details in the patient history to ascertain?
AMPLE: Allergies Medications Past illnesses Last oral intake (may require surgery) Events leading to the injury
What is the structure of a trauma handover to ED?
AT MIST: Age of the patient Time of the incident, and estimated time of arrival to ED Mechanism of injury Injuries found or suspected Signs (vitals) and symptoms Treatments given
What takes place in the secondary survey?
A focussed head to toe examination with relevant investigations
- Urinalysis - microscopic haematuria is useful marker of intrabdominal haemorrhage
- ECG scan
- Chest x-ray - only if you are not going to do CT scan anyway
- FAST scan - identify free fluid in abdo, pelvis or pericardium
- CT scan - good for assessing internal injuries, patient needs to be stable
What does a FAST scan involve?
Focused Assessment with Sonography for Trauma (FAST) scan
Looks at four specific areas for collection of free fluid:
- Hepatorenal recess
- Splenorenal recess
- Pouch of Douglas (behind bladder in pelvis)
- Pericardium
Carried out by ED doctor/ radiologist using portable USS scanner
Positive FAST can identfy free fluid in the abdomen or in the pericardium - usually means there is at least 500ml
Negative FAST does not rule out internal bleeding i.e. not very sensitive
What is diagnostic peritoneal lavage?
Intra-abdominal exploration carried out by as surgeon if CT and USS are not available.
Involves making an incision in peritoneum and aspirating free fluid for analysis –> positive DPL= indication for laparotomy.
What are the two types of brain injury?
- Primary injury= occuring at the same time as the head injury - may cause axonal shearing/ disruption or contusion
- Secondary injury - events that the acutely injured brain is now susceptible to e.g. hypoxia, hyperthermia, cerebral oedema, raised ICP
Role of intracranial pressure in head injury..
Cerebral perfusion pressure= MAP - ICP
- Increase in ICP will therefore lead to drop in cerebral perfusion pressure - caused by; cerebral oedema, space occupying lesion, intracerebral bleeding
- Decrease in MAP will therefore lead to drop in cerebral perfusion pressure - caused by; cardiogenic shock, hypovolaemia, peripheral vasodilation
What is Cushing’s response?
Raised ICP causes compensatory hypertension to try increase MAP but this leads to reflex bradycardia
Why is controlling pCO2 important?
Cerebral arterioles remain sensitive to pCO2, which results in cerebral vasodilation and unwanted increase in intracranial pressure.
Important points from a head injury history…
- Mechanism of injury
- Time of injury
- LoC
- Other symptoms: headache, N+V, amnesia, weakness, diplopia
Indications for head CT scan within one hour…
- GCS <13 in ED
- GCS <15 for more than 2 hours
- Suspicion of open/depressed fracture
- Signs of basal skull fracture
- Post-truamatic seizure
- Focal neurological deficit
- > 1 episode of vomiting
What are the signs of a basal skull fracture?
- Haemotympanum - blood in tympanic cavity
- Bruising around the eyes
- CSF leak from nose and ears
- Battle’s sign (bruising behind the ears)
- Pneumocranium - air in the cranial cavity
Why is it important to admit patients with basal skull fractures?
Risk of meningitis infection - IV antibiotic prophylaxis is required
What are the indications for head CT within 8 hours…
- Patient on DOAC
- LOC/ amnesia with: >65y/o, dangerous MoI, bleeding history, clotting disorder, retrograde amnesia
How can CPP be maintained…
- Elevate head of bed
- Close management of arterial O2 and CO2, therapeutic hyperventilation may be required to keep PCO2 low - causing vasoconstriction
- Avoidance of pyrexia
- Avoid hypotension (low MAP)
- If ICP is still high: Mannitol, intraventricular CSF drains, decompresisve craniotomy
Management of seizures post head injury…
- Post-traumatic seizures: give levetiracetam or phehnytoin prophylactically for one week
- Poist-traumatic epilepsy: late complication of brain trauma - caused by skull fragments irritating the cerebral tissue
What is cerebral salt wasting syndrome?
Rare endocrine condition where the kidneys function normally but they excrete excessive amounts of sodium.
Symptoms= polyuria, polydipsia, salt cravings
Signs= low blood Na, high urine Na
What is a concussion? What are the symptoms seen?
Brief neurological deficit following a minor traumatic brain injury.
Symptoms include: LoC, headache, amnesia, visual disturbance, confusion
Patient may be irritable and repeating questions
How to manage concussed patients…
- Serious head injury needs to be ruled out initially –> then patient is discharged
- Ask patient to be vigilant for any increasing drowsiness, worsening headaches
- Someone should stay with patient for first 48 hours
- Patient needs rest, simple analgesia PRN, avoid alcohol
- Need to avoid any risk of LoC for 3 weeks as this could cause second impact syndrome (another head injury following concussion)
What are coup and contrecoup injuries?
Coup = contusion occurring directly under the site of impact with an object.
Contrecoup = contusion occurring on opposite side of impact.
Usually coup injuries are seen when moving object hits stationary head
Contrecoup and coup injuries are seen simultaneously when moving head hits stationary object - due to movement of brain in cranium.
What is diffuse axonal injury?
Type of brain injury caused by multiple shearing forces acting on the head - both deceleration and acceleration which leads to shearing of the axons within brain matter.
Usually occurs at multiple sites across the brain - seen as hyper-intense lesions.
Very severe injury where over 90% of patients never regain consciousness - many remain in persistent vegetative state.
