Trauma Flashcards
primary survey - brief summary
process for dealing with acute trauma patient
- secure airway + c-spine
- put on high flow oxygen
- treat any tension pneumo
- close any open sucking 5. chest wounds (dressing)
- cannulas x2
- cross match, key bloods
- assess circulation
- examine for sites of haemorrahage
- consider fluids, catheter
- assess GCS/AVPU, pupil
- assess fluid response
- fully expose + survey
- log roll, PR
and repeat
trauma imaging
c spine 2x views CXR x ray pelvis FAST scan CT when stable enough
causes of neurogenic shock x 4
- Spinal anaesthesia
- Hypoglycaemia
- Cord injury above T5
- Closed head injuries
presents as:
Hypotension
• Bradycardia
• Warm extremities
treatment neurogenic shock
vasopressin, norad
atropine for brady
spinal shock
Acute spinal cord transection • Loss of all voluntary and reflex activity below the level of injury Presentation • Hypotonic paralysis • Areflexia • Loss of sensation • Urinary retention
life-threatening chest injuries
Airway obstruction • Tension Pneumothorax • Open pneumothorax (sucking) • Massive haemothorax • Intercostal disruption and pulmonary contusion • Cardiac Tamponade
define massive haemothorax
Accumulation of >1.5L of blood in chest cavity
• Usually caused by disruption of hilar vessels
signs and management massive haemothorax
reduced breath sounds
vitals off
stony percussion
reduced expansion
x match 6 units
large-bore chest drain (consider autotransfusion)
thoracotomy if 1.5L+, more than 200ml drained/hr
cardiac tamponade signs and management
usually penetrating trauma
Beck’s Triad § ↑ JVP / distended neck veins § ↓ BP § Muffled heart sounds • Pulsus paradoxus: SBP fall of >10mmHg on inspiration • Kussmaul’s sign: ↑ JVP on inspiration • Intensely restless pt. Ix • US: FAST or transthoracic echo • CXR: enlarged pericardium • ↑CVP >12mmHg • ECG: low voltage QRS ± electrical alternans Mx • Pericardiocentesis: spinal needle in R subxiphoid space aiming at 45O towards the R tip of left scapula • Thoracotomy may be needed
define flail chest
when adjacent ribs broken in multiple places so you have an independent segment of rib unsupported
rib fractures
usually lower ribs
key is good pain relief
consider subcostal block if extreme pain
can cause pneumothorax or organ injury
sternal fracture
nearly always driver hitting steering wheel
check troponins for cardiac contusion
what does FAST scan check for?
free fluid in the abdominal cavity, checks in multiple locations
indications for laparotomy
Unexplained shock
• Peritonism: rigid silent abdomen
• Evisceration: bowel or omentum
• Radiological evidence of intraperitoneal gas
• Radiological evidence of ruptured diaphragm
• Gunshot wounds
• +ve DPL (Iavage) or CT
sign of splenic rupture
Kehr’s Sign
§ Shoulder tip pain 2O to blood in the peritoneal
cavity.
§ Left Kehr sign is classic symptom of ruptured
spleen
signs of urethral injury
§ Often assoc. pelvic fracture
§ Blood in the urethral meatus or scrotum
§ Perineal bruising
§ High-riding prostate
§ Inability to micturate + palpable bladder
do retrograde urethrogram, suprapubic catheter, surgical repair
trauma and urine dip
if blood suggests renal injury / ureteric injury
Cushing reflex
Hypertension
• Bradycardia
• Irregular breathing
means herniation is imminent, very late and bad sign of raised ICP
GCS and head injury
3-8 = coma
§ 9-12 = moderate head injury
§ 13-15 = mild head injury
base of skull fracture signs
CSF rhinorrhoea or otorrhoea (Test: halo sign)
• Battle sign: bruised mastoid
• Pando sign: bilateral orbital bruising
• Haemotympanum
some indications for CT head
(head) trauma +
Basal or other skull fracture § Amnesia: > 30min retrograde (before event) § Neurological deficit: e.g. seizures § GCS: <13 @ scene, <15 2h later § Sick: vomiting > 1
managing head trauma post CT head
• Neurosurgical consult if +ve CT • Admit if § LOC >5min § Abnormalities on imaging § Difficult to assess: EtOH, post-ictal § Not returned to GCS 15 after imaging § CNS signs: persistent vomiting, severe headache • Neuro obs: half hrly until GCS 15/15 § GCS, pupils, TPR, BP • Analgesia: codeine phosphate 30-60mg PO/IM QDS • Suture scalp lacs • Abx: if open / base of skull #
head injury and when to intubate
GCS ≤ 8
• PaO2 <9KPa on air / <13KPa on O2 or PCO2 >6KPa
• Spontaneous hyperventilation: PCO2 <4KPa
• Respiratory irregularity
treating raised ICP
Elevate bed
• Good sedation, analgesia ± NM block
• Neuroprotective ventilation
• Mannitol or hypertonic saline
safety-netting discharging head injury
• Stay with someone for first 48hrs • Give advice card advising return on: § Confusion, drowsiness, LOC, fits § Visual problems § V. painful headache that won’t go away § Vomiting
classifying burns
Superficial • Erythema • Painful • E.g. sunburn Partial Thickness • Heal w/i 2-3wks if not complicated • Superficial § No loss of dermis § Painful § Blisters • Deep § Loss of dermis but adnexae remain § Healing from adnexae: e.g. follicles § V. painful Full Thickness • Complete loss of dermis • Charred, waxy, white, skin • Anaesthetic • Heal from the edges → scar
early medium late complications of burn
Early
• Infection: loss of barrier function, necrotic tissue, SIRS
• Hypovolaemia: loss of fluid in skin + ↑ cap permeability
• Metabolic disturbance: ↑↑K, ↑↑myoglobin, ↑Hb → AKI
• Compartment syndrome: circumferential burns
• Peptic ulcers: Curling’s ulcers
• Pulmonary: laryngeal oedema, CO poisoning, ARDS
• Renal and hepatic impairment
Intermediate
• VTE
• Pressure sores
Late
• Scarring
• Contractures
• Psychological problems
Wallace rule of 9s
Wallace Rule of 9s: % body surface area burnt • Head and neck: 9% • Arms: 9% each • Torso: 18% front and back • Legs: 18% each • Perineum: 1% • (Palm: 1%) NB. may also use Lund and Browder charts
key ATLS prinicples in managing severe burns
Secure airway
§ Manage fluid loss
§ Prevent infection
formulae for replacing fluid lost in burns patients
Parkland Formula to guide replacement in 1st 24hrs
• 4 x wt. (kg) x % burn = mL of Hartmann’s in 24h
• Replace fluid from time of burn
• Give half in 1st 8h
• Best guide is UO: 30-50mL/h
Muir and Barclay Formula to guide fluid replacement
• (wt. x % burn)/2 = mL of Colloid per unit time
• Time units: 4, 4, 4, 6, 6, 12 = 36hrs total
• May need to use blood
treating burns
grafts dressings creams abx prophylaxis tetanus booster prevent compartment syndrome
hypothermia ECG
J waves
treating hypothermia
cardiac monitor
warmed IV fluids
urinary catheter
Abx routinely if <32 and 65+
warm up slowly or they’ll get worse shock!
