Trauma and minor injuries Flashcards
What is an ISS?
Injury severity score
What ISS score classifies a severe trauma?
Above or equal to 16
How do you calculate an ISS?
By scoring the injury to each section of the body from 1-6 (minor to unsurvivable) and adding the squares of three highest scores
By convention what score on any part of the body on an ISS will result in a maximum score?
6 - unsurvivable
What is the maximum ISS?
75
What regions of the body are assessed in an ISS?
Head
Face
Neck
Thorax
Abdomen
Spine
Upper extremity
Lower extremity
External and other
What demographic are most at risk of major trauma?
Males over the age of 64
What percentage of trauma patients are over 75?
25%
Why is shock difficult to diagnose in elderly patients?
Poor ability for systemic compensation -
Existing insufficient cardiac output causes a chronic state of hypoperfusion.
Maximum heart rate is lower whilst peripheral vascular resistance is higher.
The cardiovascular system reserve is inable to respond.
What is CATMIST-E?
Trauma pre-alert
Callsign
Age
Time of injury
Mechanism
Injuries found and/or suspected
Signs/vitals
Treatment given/required
-
ETA
What is REBOA?
Resuscitative Endovascular Balloon Occlusion of the Artery
What is the difference between primary and secondary head injuries?
Primary head injuries are immediate brain damage caused upon impact.
Secondary head injuries are progressive after the point of injury - e.g. progressive oedema, contusion, ischemia all leading to increased ICP, herniation and death.
How can pre-hospital care prevent secondary head injury?
Reducing hypotension, hypoxaemia, hypocapnia, hypoglycaemia and hyperglycaemia.
What are the types of skull fracture?
Compound/open
Hairline
Depression
Base of skull
What are typical visual signs of base of skull fracture?
Peri-orbital ecchymosis (racoon eyes)
Mastoid ecchymosis (battle signs)
What are other symptoms of increased ICP other than Cushing’s Triad?
Reduced GCS
Papiloedema
Dialated poorly reactive pupils
Decerebrate posturing
Palsy of 6th cranial nerve
How does increased ICP lead to presention of Cushing’s Triad?
-When ICP exceeds the Mean Arterial Blood Pressure the arteries in the brain will be compressed causing ischemia.
-Sympathetic response causes peripheral vasoconstriction and hypertension and initial tachycardia.
-HTN stimulates baroreceptors that stimulates a parasympathetic response via muscarinic receptors causing bradycardia.
-HTN and increased ICP will press on the resp. centre of the brain stem causing irregular or slowed breathing
In which section of the spine do most injuries occur?
Cervical ≈ 55%
What is the difference between primary and secondary spinal injuries?
Primary is immediate damage caused upon impact
Secondary are progressive injury from cord oedema, cord hypoperfusion and extension of primary injury
How can pre-hospital care limit secondary spinal cord injuries?
Preventing hypoxia, hypoperfusion and mechanical disturbance of the spine
What is neurogenic shock?
A distributive shock resulting in malfunction of the sympathetic nervous system.
What injuries usually cause neurogenic shock?
Acute spinal chord injuries above T6
What does neurogenic shock cause?
Disruption/malfunction of the SNS with a loss of catcholamines causing parasympathetic affects such as: -bradycardia
-vasodilation/hypotension
-respiratory effects (lung collapse, pneumonia, respiratory failure)
What is spinal shock?
Spinal cord ischemia and hypoxia in a specific area after injury often leading to paralysis and loss of sensation below the area of injury
What causes spinal shock after injury to the spinal cord?
Damage to the spinal cord causes bleeding and an inflammatory response. Chemical mediators are released causing vasoconstriction leading to ischemia and hypoxia
What neurogenic treatment can be given after spinal injuries?
Fluid/vasopressors to restore sympathetic function.
How long can spinal shock last?
Up to 5/6 weeks
What is the main difference between neurogenic and spinal shock?
Neurogenic is cirulatory and haemodynamic in nature whereas spinal is not
How long can neurogenic shock last?
4/5 weeks
How quickly can spinal shock set in?
From around 30 minutes after injury
What is the difference between pneumothorax and tension pneumothorax?
A simple pneumothorax is non-expanding. In a tension pneumothorax a “one-way valve” is created allowing air in but not out. Increasing pressure starts to collapse vascular structures within the mediastinum.
What is cardiac tamponade?
Compression or pressure on the heart caused by build up of fluid in the pericardium
What can cardiac tamponade cause?
Reduced filling of the heart and reduced output leading to hypoperfusion.
What causes flail chest?
Almost always blunt trauma, very rarely bone deterioration due to disease/age.
What are the main causes of cardiac tamponade?
Cancers (mainly advanced lung but also breast cancer, melanoma, leukaemia and lymphoma)
Injury to the myocardium, aorta or cornary vessels (trauma, surgery, MI)
Pericarditis
What are the classifications of pelvic fractures?
Anterio-posterior (‘open book’)
Lateral compression
Vertical shear
What is the main danger with pelvic fractures?
Severe haemorrhage
How much blood can the retroperitoneal cavity hold?
Up to 4L (The human body usually has around 5L of circulating blood)
What type of fractures are perpendicular across the bone?
Transverse
What type of fractures are diagonal across the bone?
Oblique
What type of fractures result from a twisting force?
Spiral
What type of fracture involves a section of bone broken into many pieces?
Comminuted
What type of fracture involves small pieces of bone being pulled away by tendons or ligaments?
Avulsions
What type of fractures arise from a longitudinal compression?
Impacted fracture
What type of fractures involve longitudinal cracks?
Fissure fractures
What type of fracture is caused by a bone bending and cracking?
Greenstick
How much blood can be losses to a closed and an open femur fracture?
1-1.5 for a closed, 2-3 for an open
How much blood can be lost from a closed and an open tibia fracture?
0.5-1L for closed, 1-2L for open
What is neurovascular compromise?
Compromised blood flow or nerve damage following injury/surgery
What are the 6 P’s of a neurovascular assessment?
Pain
Poikilothermia
Paresthesia (tingling)
Paralysis
Pulselessness
Pallor
What is sequelae?
Long term chronic complications/affects of an acute condition/injury
What amount of blood loss defines a major haemorrhage?
More than 150ml/min or more than 50% of total volume in less that 3 hours
What is the body’s initial compensation response to a major haemorrhage?
Initial compensation:
- Vasoconstriction
- Increased HR
- Increased RR
What is the Barcroft-Edholm reflex?
A parasympathetic cardiac response of bradycardia, systemic vasodilation and hypotension.
What is the Barcroft-Edholm response’s role in major haemorrhage?
Triggered by a reduction in right atrial pressure, it attempts to slow blood loss
What is the arterial-baroreceptor reflex during major haemorrhage?
An initial increase in heart rate and peripheral resistance due to baroreceptors in the aortic and carotid sinuses triggering the medulla to send action potentials to the smooth muscle in the peripheral blood vessels and to the heart to increase contractility and heart rate
What is the terminal sympathetic storm?
With severe blood loss, the vagal reflex is overcome by a massive sympathetic response i.e. increased heart rate and systemic vascular resistance. This attempt to increase cardiac output aims to preserve organ perfusion.
What is exsanguination?
Loss of entire blood volume - ‘bleeding out/to death’
What is the triad of death?
Coagulopathy
Hypothermia
Metabolic Acidosis
How does haemorrhage lead to metabolic acidosis?
Haemorrhage causes hypoperfusion leading to cellular hypoxia. Anaerobic metabolism ensues releasing lactic acid
How does metabolic acidosis affect coagulopathy
Acidosis accelerates fibrinogen consumption with no effect on production, resulting in a deficit in fibrinogen availability.
The underlying contributing mechanisms are unclear.
What can cause hypothermia in trauma patients?
Alcohol/drugs
Environment
CNS injury
Hypovolaemia
Metabolic acidosis
How does alcohol lead to hypothermia?
Vasodilation - losing heat via skin radiation but feeling warm
Shivering response impaired
Impaired decision making in response to dangerous environments
Are anti-coagulants or pro-coagulants more dominant in normal haemostasis?
Anti-coagulants
How does major trauma disrupt normal coagulation?
Activation of protein C - widespread anticoagulation
Depletion of fibrinogen - normally used in clot formation
Hyperfibrinolysis - existing clots break down
Platelets become unresponsive - no longer ‘sticky’
What is fibrinolysis?
The enzymatic breakdown of the fibrin in blood clots
What neurological signs show in the body’s decompensation response to a major haemorrhage, what is the main cause of this?
Reduced cerebral perfusion
- Reduced GCS
- Confusion, agitation, coma, arrest
What does bright red, frothy blood coughed up through the trachea and airways signify?
Bleeding in the lungs
What does coffee ground vomit indicate?
Old blood in the stomach (not always caused by bleeding to the stomach directly)
What can urine discoloration ranging from smoky grey to bright red indicate?
Bleeding kidneys
What can black sticky tarry stools signify?
Large intestine bleed
What can blood leaking through the ears, nose and eye orbits signify?
Cerebral insult/bleed
What can bruising to left hypocondrium signify?
Spleen damage
What makes the spleen more vulnerable after trauma?
The spleen cannot heal itself and will bleed profusely internally, causing hypovolaemia.
What can abdominal distention signify?
Blood, fluid, intestinal perforation or acute gastric distension. 6 Fs must be considered.
When is abdominal tenderness especially significant?
If over the liver, spleen or renal angles.
What does generalised abdominal guarding signify?
Peritonitis, usually a sign of massive bleeding or perforation.
What is Grey Turner’s sign and what does it signify?
Ecchymosis or discoloration of the flanks, generally accepted as a sign of pancreatic rupture.
What is Cullen’s sign and what does it signify?
Periumbilical ecchymosis, related to acute pancreatitis or various causes of abominal bleeding
What are the main aims of traction splints?
To establish patient comfort and better fracture alignment.
What are contraindications of traction splints?
Injury to connection points or other risks of worsening injuries:
Fractures of ankle or foot
Partial amputation or avulsion with bone separation while only marginal tissue connects the distal limb
When is packing a wound used?
For central wounds or wounds at bodily junctions where a tourniquet cannot be applied
At what points during hypovolaemia does low BP occur?
Low BP is an immediate (pre-compensatory) or late (decompensateory/refractory) sign
What are the four main principles of trauma management?
COMA
Clothes off
Oxygen on
Monitoring
Access (cannulas/IO)
What % of traumatic brain injuries (TBI) have associated C-spine injury?
10%
What is TWELVE?
T - Tracheal deviation
W - Wounds/bleeding/bruising
E - surgical Emphysema
L - Laryngeal crepitus / injury
V - distended neck Veins
E - Exclude pneumothorax, flail segment.
What is DCAP-BTLS
Deformity
Contusion
Abrasion
Penetration
-
Burns
Tenderness
Laceration
Swelling
Why can the spleen not be operated on?
It is similar in consistency to jelly in a muslin cloth and requires a splenectomy.
What is the leading cause of death in thoraxic trauma?
Hypoxia
Thoracic trauma accounts for what percentage of traumatic death?
25%
What is pleuritic pain?
Pain on breathing
What dressing should be used on a tension pneumothorax?
A russel chest seal (semi-occlusive dressing)
What ribs in adults are most commonly fractured?
4th-10th
What is commotio cordis?
Blunt force to the chest causing immediate cardiac arrest
What is permissible hypotension in trauma?
An acceptable drop in blood pressure during bleeding
Why don’t we treat permissible hypotension in trauma?
An increased blood pressure would cause more bleeding
When are fluids indicated for trauma?
Trauma:
BP<90 with signs of impaired organ function/reduced perfusion
Pentrating chest trauma:
BP<60: Aim to maintain a palpable radial pressure or BP>60
What is GLADSHIP?
Gunshot
Lacerations
Abrasions
Degloving
Skin tears
Haematoma
Incision
Puncture
What are the most common sites of internal bleeding?
Chest
Abdomen and retroperitoneum
Pelvis
Long bone fractures
What paralysis is caused by C4 injuries?
Quadriplegia/tetraplegia: Complete paralysis below the neck
What paralysis is caused by C6 injuries?
Partial or full paralysis of hands and arms, full lower body paralysis
What paralysis is caused by T6 spinal injuries?
Paraplegia, paralysis below the chest
What paralysis is caused by L5 spinal injuries?
Paraplegia below the waist
What kind of bone fracture patients will always require O2?
Long bone fractures
What are superficial (1st degree) burns and their symptoms?
Epidermis surface burns:
Red, painful but skin intact with no blisters
What are superficial partial (2nd superficial degree) burns and their symptoms?
Epidermis/dermis burns
Red/pink, may look moist, painful, superficial blisters
What are deep partial (2nd deep degree) burns and their symptoms?
Dermis burns
White with some red/pink mottled areas, limited pain, thick walled blisters
What are full (3rd degree) burns and their symptoms?
Subcutaneous fat burns:
White, leathery/charred, no sensation
What is the rule of nines for calculating burn TBSA?
What is the palmar method for TBSA?
Patient’s whole hand ≈ 1% TBSA
What burns would you not use cling film for?
Chemical burns
What’s the maximum time a patient should spend on a rigid board?
30 mins
Which parts of the spine give rise to the phrenic nerve and what would happen if these areas were to be damaged?
Cervical plexus, particularly C3, C4 and part of C5.
Injury above C3 would lead to death by suffocation
What does the phrenic nerve do?
Innovates the diaphragm
What are the dangers of complete immobilisation and why isn’t it always necessary?
Discomfort
Raised ICP
Risk of aspiration
Potential to reduce airway opening
Conscious c-spine # patients self immobilise anyway
What are the hateful 8 of major haemorhage/exsanguination?
ALPHA PVC
A-Air hunger
L-Low/falling CO2
P-Pale
H-Hypotension
A-Abnormal sensorium
P-Pulse fast or slow
V-Venous collapse
C-Clammy
Do paramedics clean up contaminated fractures with saline?
Only clean up gross contamination.
DO NOT squirt saline with pressure onto open fractures, it will only drive contaminants in further and loosen blood clots
Which trauma patients will always require antibiotics?
Open fracture patients
What is critical skin?
Ischaemic skin under pressure from segments of bone after a closed fracture causing a reduction in blood flow
What is “reduction” and when is it done?
Pulling/positioning/manipulating closed fracture bones back into place. It must be done for patients with closed fractures and critical skin as soon as possible to prevent further damage.
What is a simple fracture?
A fracture where both ends of bone remain in place. Can be transverese, oblique or spiral providing there is no dissplacement
What is the difference between segmented and comminuted fractures?
Segmental is when one or several large segments of bone separate from the main body of fractured bone.
Comminuted is a break with multiple small pieces separated from the main body of bone.
What are compression fractures and where are they most commonly found?
Where the bone is crushed or collapses into small pieces. Most commonly found in the vertebrae
Why is acute lower back pain a red flag for cancer patients?
They might have spinal cord compression from a metastasised tumour
What non-clinical feature must be considered about the mechanism of injury for fractures or trauma in young children and infants?
Safeguarding - especially if baby is not yet mobile
How do impacted fractures occur and where are they more common?
When one end of a bone is forced into the adjacent bone. Also known as telescopic. Common in distal phalanges and more at risk in patients with degenerative bone diseases or patients taking long term steroid therapy
What are pathological fractures?
Fractures caused by existing weaknesses e.g. disease. Can be trauma related or spontaneous
What is osteogenesis imperfecta?
“Brittle bone disease”
An inherited disorder characterized by extreme fragility of the bones.
What is a greenstick fracture?
A bending of a bone with minimal calcification. Often heals quickly
What is Colles #?
A break in the distal radius at the wrist. Commonly occurs in people that fall and try and catch themselves with their hands. The ulna may be damaged too.
FOOSH = Fall On Outstretch Hand
What is Potts’ #?
A lower fibula fracture due to excessive force on the ankle i.e. stepping down or falling flat on feet from height. The tibia may also be damaged.
Do paramedics relocate dislocations?
No, unless patella dislocation and cardiovascular compromise - consult with senior clinician first.
Patella’s can relocate on their own as the leg is straightened to splint correctly. However, we are not straightening to relocate but to splint.
What assesmment and management should be undertaken for dislocations?
Consider the MOI and complete thorough MSK assessment including above and below affected joint.
Inspect for:
Bruising, swelling, deformity, colour, tone, wounds, scars, erythema. How is the patient holding the injured limb?
Palpate for:
Bony tenderness and deformity, oedema, pain, pulses, temperature (compared to uninjured).
Movement:
Does the patient have any range of motion? Have they moved the limb since the injury?
Sensation:
Any absence of sensation? Tingling, pins and needles, neurovascular compromise, compared to uninjured.
Analgesia – early administration, maintain comfort, consider easy access analgesia e.g., Entonox as first line and then escalate as required – ensuring observations are taken (especially BP if considering morphine).
Splinting – Box or vacuum will be effective or slings to maintain positions of comfort. Patient usually place themselves into comfortable positions to relieve symptoms.
What referral option do paramedics have for dislocations, and what’s the rationale behind each?
A&E;
X-ray, MRI, CT, ultrasound
Analgesia, Abx
Splinting and setting of dislocation in a controlled environment (NICE guidance)
Surgery and orthopaedic referrals
Admittance if unstable or urgent surgical intervention required
UCH;
X-ray
Splinting
Ortho referrals - e.g., fracture clinic (for onward management and surgical intervention if required).
MTU/MTC;
Local guidance to dictate this however briefly, pt will require MTC if open book pelvis, depressed skull fracture, severe neurological changes (e.g., paralysis, decreased motor score).
GP;
Consider if pt has chronic condition which causes dislocations and patient stable, comfortable and no signs of current dislocation (e.g., joint relocated without intervention).
What are red flags of shoulder dislocations?
Sudden loss of ability to actively raise the arm (with or without trauma) – suspect acute rotator cuff tear.
Suspect malignancy – ANY shoulder mass or swelling
Red skin, painful joint, fever or if the person is systemically unwell – suspect septic arthritis.
Trauma leading to loss of rotation and abnormal shape.
Suspected inflammatory arthritis
New symptoms of inflammation in several joints
What are red flags of knee dislocations?
Septic arthritis
Cannot exclude fracture
Evidence of neurovascular compromise - e.g. absent pulses, significantly delayed CRT
Rupture quadricep or patellar tendon - Inability to straight leg raise, loss of tone, ‘floating’ patella, swelling, deformity, pain
First time traumatic patella dislocation
Soft tissue injury with gross instability - e.g. ruptured ACL/MCL/PCL/LCL
What considerations must you account for in holistic plans for minor injuries?
Long term management plans – consider anticipatory care docs, RESPECT forms, Pt wishes and best interest planning.
MOI - (crucial if concerns over non-accidental injury in vulnerable patient groups, (e.g., older adults, frailty, disability, paediatric pts etc.)
Ensure adequate provisions are brought – things like phone/phone charger, spare clothing if soiled/torn, chaperone.
Appropriateness of home referral - e.g. is pt is a carer for relative, who will look after the other person whilst the pt receive treatment? Can we call in family, neighbours, emergency care, discuss with care providers extra visit (consent as may charge) etc.
What hospital treatment will minor MSK injury patients recieve?
Diagnostics (E.G., X-ray, CT, MRI, Ultrasound)
Ongoing Analgesia
Longer term splinting e.g., slings, braces, crutches
Referral to fracture clinic for orthopaedic support
Possible surgery
What at home post discharge treatment will minor MSK injury patients recieve?
Fracture clinic assessment
Physiotherapy – NHS or private
Short term analgesia
At home management
What long term complications can come from minor injuries?
Long term analgesia use:
-Addiction
-Gastric complications
Increased risk of falls
Chronic pain
Chronic conditions
What is the difference between a sprain and a strain?
Sprains are stretches or tears of ligaments
Strains are stretches or tears of muscle fibres and or tendons
What are the symptoms of a sprain?
Pain or tenderness
Swelling
Bruising
Decreased functioning
Joint instability
What are the symptoms of strains?
Muscle pain
Cramping or spasming
Muscle weakness
Inflammation
Bruising
What are the risk factors for both sprains and strains?
Athletes/sportspeople
Age
Falls
Previous injuries
Instability/hyper-mobility
Balance issues
Neuropathy
Alcohol and drugs
High/low BMI
Which ankle ligaments are commonly affected by sprains?
Antero talofibular ligament (ATFL)
Posterior talofibular ligament (PTFL)
Which knee ligaments are commonly affected by sprains?
Anterior cruciate ligament (ACL)
Medial/lateral collateral ligament (MCL/LCL)
Which wrist sprain is most common?
Scapholunate ligament
Which thumb ligament is commonly sprained?
Ulnar collateral ligament (UCL)
What is the most prevalent MSK injury in active populations?
Lateral ankle sprains
What are the red flags for sprains and strains?
Possible fracture
Neurovascular compromise
Underlying pathophysiology/concerning medical conditions
Disability indicative of ligament rupture
Acute inflammation or infection (?septic arthritis)
Concerning MOI (medical or safeguarding)
Tendon rupture
Complete tear (or more than half of the muscle body)
Large intramuscular haematoma
What are the PRICE guidelines for self care of sprains/strains?
Prevent further injury - hazards/causes
Rest - 2/3 days
Ice - indirect contact every 2-3 hours for 10-15 mins
Compression - not overnight and not too tight
Elevation
What should you advise home discharge sprain/strain patients?
OTC analgesia
PRICE
Review in 5-7 days
Safe and gentle return to activity
Other than red flags, why might you convey a sprain/strain patient?
Need for splinting and support (also UCH/walk-in)
Safeguarding/welfare
Need for imaging (also UCH/walk-in)
Onward referalls (also UCH/walk-in)
What are the 3 grades of strains and sprains?
Grade 1 - mild, will heal
Grade 2 - moderate, some instability, requires support (tendond injured on both side of the muscle)
Grade 3 - Complete rupture, unstable, requires surgery
