Trauma Flashcards
1
Q
Major trauma is suspected in…
A
- 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
2
Q
Phases of ATLS…
A
- Primary survey: AcBCDE assessment
- Resuscitation phase (continuing to treat the findings from primary survey)
- Secondary survey
- Definitive care phase
3
Q
What happens in the primary survey?
A
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
4
Q
What are the main sources of bleeding?
A
On the floor and four more On the floor= external bleeding Four more = internal bleeding: - Thorax - Abdomen - Pelvis - Long bones
5
Q
How is catastrophic haemorrhage managed acutely?
A
Extreme pressure should be applied over the site of bleeding - to stem the blood flow
CAT tourniquet at single bone proximal to the wound.
6
Q
What does Airway management consist of?
A
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
7
Q
What does Breathing management consist of?
A
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
8
Q
What does Circulation management consist of?
A
- 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
9
Q
What does Disability management consist of?
A
- GCS/ AVPU
- Pupil reactivity and size
- BM
10
Q
What does Exposure management consist of?
A
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
11
Q
What factors may indicate C-spine injury?
A
- Mechanism of injury
- Neck pain, or inability to move neck
- Neurological deficit
12
Q
Why are large volumes of IV fluids not given in bleeding trauma patients?
A
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.
13
Q
What are the important details in the patient history to ascertain?
A
AMPLE: Allergies Medications Past illnesses Last oral intake (may require surgery) Events leading to the injury
14
Q
What is the structure of a trauma handover to ED?
A
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
15
Q
What takes place in the secondary survey?
A
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
16
Q
What does a FAST scan involve?
A
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
17
Q
What is diagnostic peritoneal lavage?
A
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.
18
Q
What are the two types of brain injury?
A
- 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
19
Q
Role of intracranial pressure in head injury..
A
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
20
Q
What is Cushing’s response?
A
Raised ICP causes compensatory hypertension to try increase MAP but this leads to reflex bradycardia
21
Q
Why is controlling pCO2 important?
A
Cerebral arterioles remain sensitive to pCO2, which results in cerebral vasodilation and unwanted increase in intracranial pressure.
22
Q
Important points from a head injury history…
A
- Mechanism of injury
- Time of injury
- LoC
- Other symptoms: headache, N+V, amnesia, weakness, diplopia
23
Q
Indications for head CT scan within one hour…
A
- 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
24
Q
What are the signs of a basal skull fracture?
A
- 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
25
Why is it important to admit patients with basal skull fractures?
Risk of meningitis infection - IV antibiotic prophylaxis is required
26
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
27
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
28
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
29
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
30
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
31
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)
32
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.
33
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.
34
How does a subdural hameorrhage occcur ?
Tearing of the bridging veins in the subdural space between the dura and arachnoid mater - leads to collection of venous blood.
35
How does subdural haemorrhage present?
- Acute subdural: immediate LoC, then progressive decline in GCS
- Chronic subdural: gradual evolution of headache, cognitive decline, ataxia, hemiparesis, impaired GCS
36
What does CT scan of subdural haemorrhage show...
Crescenteric hyperdense mass (banana shaped)
37
Management of subdural hameorrhage...
Severe subdural = emergency craniotomy and haematoma evacuation
Less severe= burr hole drilling and insertion of subdural drain
38
How does an extradural haemorrhage occur?
Usually caused by tear of the middle meningeal artery due to pterion fracture - leads to collection of arterial blood between dura and the bone.
39
How does an extradural haemorrhage present?
Traumatic head injury leading to sudden loss of consciousness, followed by lucid period over which the patient will deteriorate.
Signs will show drop in GCS and neurological deficit
40
What does CT scan of extradural haemorrhage show?
Biconvex lenticular high density extra-axial mass - (lemon shaped)
41
Management of extradural haemorrhage?
Neurosurgical emergency - needs burr hole drilling with craniotomy and evacuation of haematoma.
42
What is spasticity?
Increased muscle tone leading to stiffness/ tightness of the muscle
43
How is spasticity treated?
Physical therapy to improve range of motion and coordination.
Antispasmodics - baclofen and dantrolene
Botulinum toxin injection - injected specifically into affected muscle groups and therefore paralysing spastic muscles.
44
How should uncomplicated rib fractures be treated?
Simple analgesia - co-codamol and NSAIDs
Advise patient the area may remain tender for 3 weeks
Advise patient to take deep breaths every so often to aerate the lower alveoli
45
What can flail segments cause?
Can lead to pulmonary contusions i.e. bruising of the lung parenchyma - this limits the effectiveness of respiration and is usually associated with respiratory distress (cyanosis and tachypnoea)
46
What is the management of flail chest?
- Provide high flow oxygen and treat any associated life-threatening problems
- Contact ICU and consider need for urgent tracheal intubation with IPPV
- Require careful monitoring and observation in HDU
47
What investigations are necessary for sternal fractures?
- Cardiac monitor and 12 lead ECG: look for changes consistent with myocardial contusion (ST elevation)
- Check troponins
- CXR and lateral sternal XR: looking for spinal injury
48
How does sternal fracture present?
Anterior chest pain with localised tenderness over the sternum.
49
What is the definition of massive haemothorax?
Collection of blood in the pleural space that is enough to cause hypovolaemic shock.
50
How will haemothorax differ from pneumothorax clinically?
- Signs of shock present with massive haemothorax
- Dullness on percussion over the affected side (fluid not air)
- Evidence of chest wall trauma e.g. external bruising, lacerations, palpable crepitus
51
How is haemothorax managed?
- High flow oxygen
- Two wide bore cannulae with X-match for blood products
- IV fluid resuscitation
- Wide bore chest drain insertion - >1500ml of blood needs urgent referral to thoracic surgeon for thoracotomy
52
Key features of assessment of abdominal/ pelvic trauma?
- Look for abdominal bruising
- Feel for tenderness and evidence of peritonism
- Check femoral pulses
- Examine perineum and perform PR (boggy prostate or impalpable prostate may indicate urethral injury)
53
Treatment of abdominal trauma...
Management is dependent on clinical situation:
- If patient is haemodynamically unstable- need urgent referral to senior surgeon for emergency laparotomy (damage control surgery)
- If patient has clinical peritonism - needs urgent laparotomy and IV antibiotics
- Haemodynamically stable and no signs of peritonism: FAST and CT scan , then refer to surgery.
54
What investigations are important for ?splenic rupture ?
- FAST scanning = 1 st line imaging
- CT scanning if patient is stable: used to grade splenic injury from I to V dependent on size, depth, vessel involvement
55
Management of splenic rupture...
- Conservative management used in younger patients with low grade injury (I/II)
- Interventional radiology with angioembolisation
- Surgery: emergency laparotomy with splenic removal
56
What are the signs and symptoms of a pelvic fracture?
- Tenderness, bruising and crepitus of pelvic bones
- Haematuria or PR bleeding
- Perineal and/ or loin bruising
- High riding, boggy prostate on PR
57
What are the different classifications of pelvic fractures?
- Type A= stable injury - single fracture along pelvic ring
- Type B= rotationally unstable but vertically stable
- Type C= rotationally unstable and vertically unstable- pelvic ring completely disrupted at 2 or more points
58
Management of pelvic fractures...
- Type A fractures= usually stable, require bed rest and analgesia for 3-6 weeks before mobilising again
- Type B and Type C = orthopaedic emergency:
>Resuscitation like any trauma - correct hypovolaemia and ensure blood is ready for massive transfusion
>Minimise movement - stabilise pelvis with pelvic binder -AVOID LOG ROLLING
>If pelvic binder stablises pt haemodynamically - refer to ICU for definitive fixation with surgery
>If pelvic binder does not stabilise pt haemodynamically - will require damage control surgery or endovascular embolisation (to prevent further bleeding of vessels)
59
Why can spinal injury lead to breathing problems?
- Thoracic spinal injury will lead to reduced innervation of the intercostal muscles below the level of the injury impairing ventilation
- C3-C5 injury can result in diaphragmatic paralysis- as these are the nerve roots to the phrenic nerve. This can lead to respiratory arrest.
60
What is neurogenic shock?
- Hypotension caused by CNS injury which leads to sudden loss of sympathetic tone --> vasodilation and reduced systemic vascular resistance -->reduced BP--> hypoperfusion to organs
61
What is secondary spinal cord injury?
Within minutes of the structural (primary) injury - there is blood vessel damage leading to haemorrhage in the central grey matter and spinal ischaemia. Leads to release of inflammatory cells which causes spinal cord oedema and therefore cord compression.
62
Signs and symptoms of spinal cord damage...
- Pain at the site of spinal injury
- Loss of sensation/ power below the level of injury
- Unconscious patients may have flaccid limbs, no pain response
- Signs of neurogenic shock e.g. hypotension
63
Pattern of anterior cord syndrome...
- Loss of pain and power
| - Preservation of touch and proprioception
64
Pattern of posterior cord syndrome...
- Loss of touch
| - Preservation of power
65
Pattern of Brown -Sequard syndrome...
Hemisection of the spinal cord - injuring lateral spinothalamic and lateral corticospinal tract on one side:
- Ipsilateral loss of motor function, touch and proprioception
- Contralateral loss of pain and temperature
66
What is a simple fracture?
Single fracture line with two bone fragments either side
67
What is a spiral fracture?
Twisting injury with two bone fragments
68
What is a comminuted fracture?
Complex fracture with > 2 fragments - usually caused from high impact/ force
69
What is a crush fracture?
Loss of bone volume due to compression of the bone
70
What is an avulsion fracture?
Pulling away of the ligament/ tendon with bony attachment
71
What is a hairline fracture?
Very minute fracture - barely visible with no displacement
72
What is a greenstick fracture?
Incomplete fracture of immature bone - normally only fractured on one side.
73
What is a stress fracture?
Repeated sub-clinical injury which leads to weakening of the bone until it is fractured. Usually presents with pain and x-ray finding of fracture but no hx of trauma.
74
What is crush syndrome?
Rhabdomyolysis caused by traumatic crush injury to a part of the body - this release of muscle breakdown products (myoglobin, phosphate...) can lead to major shock and kidney failure.
The sudden release of the pressure can lead to release of the electrolytes and consequent fluid shift.
There may be re-perfusion injury as blood flow returns to the limb.
75
How is crush syndrome managed?
Give high flow oxygen and fluid overload the patient before slowly releasing the pressure.
Fluids should run at 1.5L/hr and UO of 300ml/hr should be maintained with use of mannitol - clear the blood of toxic metabolites.
76
What is a compound fracture?
Fracture of the bone which leads to break through the skin which is open to the air.
77
Management of a compound fracture...
- Control obvious haemorrhage with manual pressure
- Analgesia in the form of incremental opioid increase
- Irrigate wound with saline then dress with sterile moist dressing
- IV antibiotics should be used
- Limb needs to be splinted
- Urgent referral to T&O for operative repair if required.
78
Early complications of fractures...
- Neurovascular damage
- Compartment syndrome - may require open fasciotomy for decompression
- Fat embolism - bone fracture may release fat embolus
- Fracture blisters - vesicles or bullae on the skin overlying a fracture
79
Late complications of fractures...
- Non-union: the frature does not heal - may present with pain over the site, or a palpable gap over the fracture line
- Malunion: the bone has healed but is misaligned
80
What is the purpose of fracture casting?
- Restore the structural anatomy
- Stabilise the fracture
- Preserve blood supply
81
What are the complications of casts?
- Disintegration of the cast if the material becomes damp
- Cast is too tight= circulatory compromise, needs cutting off
- Cast is too loose= the fracture may slip out of place
- Pressure ulcers
- Allergic dermatitis to the material used
82
What is the difference between dislocation and subluxation?
Dislocation is the complete loss of congruity between articular surfaces in a joint whereas subluxation is a partial dislocation where there is still some articular contact.
83
Most dislocations should be x-rayed before reduction, what are the exceptions?
- Dislocations with neurovascular compromise
- Uncomplicated patellar and mandibular dislocation
- Individual with recurrent dislocations e.g. EDS
