Trauma Flashcards
What are the percentages for different mechanisms of injury?
- Fall < 2m = 59%
- Falls > = 11%
- RTA = 15%
- Assault = 5%
- Other = 10%
Describe what is trauma
-Any external force applied to the body which results in injury
-High amount of morbidity in working age and the elderly
=Loss of income, pain, prolonged bed rest etc.
-Leading cause of death and disability in first 4 decades of life
-50% of Orthopaedics is dealing with consequences of trauma
What is a fracture?
A disruption in bone continuity
What is a dislocation?
Complete loss of continuity of 2 bones forming a joint
What is subluxation?
Partial loss of continuity of 2 bones forming a joint
What is comminution?
Multiple fragments
What does antra-articular mean?
Fracture extends into a joint
What is a fracture dislocation?
A dislocated joint with associated fracture
What causes a fracture?
- Injury mechanism that exceeds maximum force the bone can withstand leading to a fracture (normal bone, abnormal force)
- Comorbidity that increase risk of fracture after injury
- Comorbidity that increases risk of injury
Describe comorbidity that increases risk of fracture after injury
-Congenital =Osteogenesis imperfecta (brittle bones) -Acquired =Metabolic (Rickets/osteomalacia) =Degenerative (Osteoporosis) =Tumour Abnormal bone, normal force
Describe comorbidity that increases risk of injury
-Visual impairment
-Alcohol/drug use
-Neuropathy
-Balance disorder
-Epilepsy
Normal bone, abnormal force, increased risk of trauma
Which fractures need fixed?
-Only the minority
=Anything which would cause suffering and prolonged bed rest e.g. hip fracture, femur, tibia
=To prevent long term complications or loss of function e.g. malunion or nonunion
-Major trauma patients with open fractures or long bone injuries need early intervention
What is the assessment map?
A Airway (+ C-spin control) B Breathing C Circulation D Disability E Exposure
What do we look for in Airways?
-Talking?
-Noises
=Snoring
=Stridor
=No noise…
-Physical blockage
=Food, blood, vomit, tongue= at risk
-Evidence of injury
=Face, oropharynx, neck
How do we treat airway obstruction?
-Suction
-Remove foreign body
-High flow O2
-Basic manoeuvres
+ C-spine control
-Airway adjuncts
-Definitive airway
– don’t forget the neck
ATLS teaches the ‘live long and prosper sign’ either side of the patient’s ears
What do we look for in Breathing?
- Colour of patient – pink, blue…
- Work of breathing – hard, shallow
- Evidence of injury – bruising, wound
- Observations – SpO2, RR, pulse, BP
- Chest symmetry
- Air entry
- Percussion note
How is thoracic cavity different in trauma from health?
- In health – thoracic cavity full of lung
- In trauma – thoracic cavity full of something else
- OR a disrupted ‘shell’/ rib cage
What is Tension Pneumothorax?
- Internal ‘one-way valve’
- Pressure on mediastinum= decreased venous return to the heart= cardiac arrest
Describe the presentation of a tension pneumothorax
- Decreased breath sounds on affected side
- Increased percussion note (hyper-resonant)
- Engorged neck veins
- Reduced lung expansion
- Deviation of trachea to opposite side
How do we treat tension pneumothorax?
- High flow oxygen, needle decompression in 2nd intercoastal space
- Definitive chest drain
- Sternal angle, 2nd intercostal space
Describe an open pneumothorax
- ‘sucking chest wound’
- External ‘one-way valve’
- Air passes into the cavity through path of least resistance
- Treat with oxygen and three-sided dressing
- Definitive chest drain – 4th or 5th intercostal space, mid-clavicular line
What is Flail Chest?
- 2 or more ribs fractured in 2 or more places
- Separation of a segment of the thoracic cage that is then unable to contribute to lung expansion
- Paradoxical movement of a segment of the chest wall
- Indrawing on inspiration
- Moving outwards on expiration
What do we look for in Circulation?
- Colour of patient – pink, blue…
- Work of breathing – hard, shallow
- Evidence of injury – wound, blood loss
- Observations – SpO2, RR, pulse, BP
- Heart sounds
- Pulses
- Peripheral circulation - CRT
- Mental state – cerebral perfusion?
What is Cardiac tamponade?
- Pericardium is a ‘fixed’ sac (like the skull)
- Small pressure increase (from blood) has big effect
- Pericardiocentesis
- Under ultrasound guidance
What is Beck’s Triad?
- Hypotension: decreased stroke volume
- Jugular venous distension: impaired venous return to the heart
- Muffled heart sounds: fluid inside the pericardium
What is a massive haemothorax?
>1500 mls of blood in pleural cavity -decreased breath sounds, respiratory compromise (=‘B’) -large volume loss (= ‘C’) -needs a chest drain (B) AND fluid resuscitation due to SHOCK (C)
What is Shock?
-End-organ dysfunction
=due to inadequate oxygen availability for tissues (perfusion)
=cardiac, GI, neurology, renal…
-Demand for O2 increased as delivery decreases
What are the types of shock?
- Anaphylactic
- Cardiogenic
- Haemorrhagic
- Neurogenic
- Septic
Which types of shock affect supply and demand of oxygen?
Decrease delivery: anaphylactic, cardiogenic, haemorrhagic, neurogenic
Increase demand: septic
Describe haemorrhagic shock
- Most common in trauma
- Body’s balance between blood loss and compensation
- Four classes based on blood volume (70kg person has circulating volume of 5L= 70ml/kg)
Describe the 4 classes of haemorrhagic shock
- <15% blood loss (<750ml), pulse <100, normal BP, >30 ml/hr urine output
- 15-30% (750-1500), 100-120, normal BP, 20-30 ml/hr
- 30-40% (1500-2000), 120-140, decreased BP, 5-15 ml/hr
- > 40% (>2000), >140, decreased BP, neg
What trends develop in haemorrhagic shock?
-Through classes 1 to 3, the body compensates, but trends develop:
RESPIRATORY RATE – increases as lactic acid rises
PULSE – tachycardia; heart rate increases to compensate for falling stroke volume
BLOOD PRESSURE – remains fairly constant
URINE OUTPUT – falls with renal vasoconstriction
PERIPHERIES – cool with vasoconstriction
MENTAL STATE – increasing confusion / agitation with reduced cerebral perfusion
What happens to compensation in class 4?
By class 4, compensation reaches ‘overload’
RESPIRATORY RATE – falls with fatigue
PULSE – tachycardia reaches maximum, chest pain due to myocardial ischaemia
BLOOD PRESSURE – drops dramatically
URINE OUTPUT –negligible
PERIPHERIES – cold, mottled
MENTAL STATE – confused, comatose
Describe fluid resuscitation
STOP THE BLEEDING =haemostasis is the most effective resuscitation -Initial fluid bolus (10-20ml / kg) -Low thresh-hold for blood products= RBC, platelets, FFP -Tranexamic acid promotes clotting -Assess the response -Permissive hypotension =low BP is better in trauma =just enough to keep cerebral perfusion =not enough to start bleeding again =roughly 80mmHg systolic
What do we look for in Disability?
-GCS =best response in eye opening, verbal responses and motor, total out of 15 -AVPU scale =alert, verbal, pain or unresponsive -Temperature -Blood Glucose
What do we look for in Exposure?
-Full examination of the patient
-While keeping them warm
=clotting is temperature dependent
-Common sites to miss injuries:
=Back of head
=Back
=Buttocks
=Perineum
=Axillae
=Skin folds
What are the life threatening conditions in trauma?
Airway Obstruction Tension Pneumothorax Open Pneumothorax Massive Haemothorax Flail Chest Cardiac Tamponade
What occurs during secondary survey?
-Patient ABC stabilized - any change = review
-Systematic ‘top to toe’ examination with log roll
=Head, face, eyes, ears, nose and throat
=Neck
=Chest
=Abdomen
=Pelvis
=Back
=Extremities
=All wounds
What occurs during tertiary survey?
- Repetition of the secondary survey
- Over several days
- Broken pinky may be missed initially but still important!
What questions are to be considered when examining peripheral injuries?
- Where is it?
- What side?
- Which bone?
- Open or closed?
- Blood supply to leg?
- Nerve supply?
- What was the environment?
Describe open fractures
-Bone penetrates skin =Bone can go back in! -Skin penetrated from outside -Prompt management is imperative -Increased risk of infection
How do you treat any fracture?
-4 ‘R’s of fracture management =Resuscitate =Reduce =Restrict =Rehabilitate
Describe A and E management
-IV antibiotics =Early as possible =Cefuroxime 1.5g TDS =Clindamycin (pen allergy) =Gentamicin if heavy contamination -Anti Tetanus =No tetanus within 5yrs- give booster -Splint or Cast =Correct length and alignment =Get the bone back in =Tamponade bleeding vessels -Sterile saline soaked dressing
Describe surgical management
Within 24 hours or sooner… -Primary =Wound debridement (Dead tissue = culture for bacteria) =Skeletal stabilisation (IM nailing) (External fixation) - +/- Secondary =Tissue inspection and further debridement =Wound closure
Overview of open fracture assessment and treatment
- Fracture with break of dermis in same area
- Carefully examine the wound
- Sterile saline dressing
- Realign and splint wound
- IV abx and Tetanus
- Surgical referral
