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Clinical Care > Trauma and minor injuries > Flashcards

Trauma and minor injuries Flashcards

1
Q

What is an ISS?

A

Injury severity score

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2
Q

What ISS score classifies a severe trauma?

A

Above or equal to 16

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3
Q

How do you calculate an ISS?

A

By scoring the injury to each section of the body from 1-6 (minor to unsurvivable) and adding the squares of three highest scores

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4
Q

By convention what score on any part of the body on an ISS will result in a maximum score?

A

6 - unsurvivable

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5
Q

What is the maximum ISS?

A

75

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6
Q

What regions of the body are assessed in an ISS?

A

Head
Face
Neck
Thorax
Abdomen
Spine
Upper extremity
Lower extremity
External and other

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7
Q

What demographic are most at risk of major trauma?

A

Males over the age of 64

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8
Q

What percentage of trauma patients are over 75?

A

25%

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9
Q

Why is shock difficult to diagnose in elderly patients?

A

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.

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10
Q

What is CATMIST-E?

A

Trauma pre-alert

Callsign
Age
Time of injury
Mechanism
Injuries found and/or suspected
Signs/vitals
Treatment given/required
-
ETA

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11
Q

What is REBOA?

A

Resuscitative Endovascular Balloon Occlusion of the Artery

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12
Q

What is the difference between primary and secondary head injuries?

A

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.

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13
Q

How can pre-hospital care prevent secondary head injury?

A

Reducing hypotension, hypoxaemia, hypocapnia, hypoglycaemia and hyperglycaemia.

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14
Q

What are the types of skull fracture?

A

Compound/open
Hairline
Depression
Base of skull

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15
Q

What are typical visual signs of base of skull fracture?

A

Peri-orbital ecchymosis (racoon eyes)
Mastoid ecchymosis (battle signs)

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16
Q

What are other symptoms of increased ICP other than Cushing’s Triad?

A

Reduced GCS
Papiloedema
Dialated poorly reactive pupils
Decerebrate posturing
Palsy of 6th cranial nerve

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17
Q

How does increased ICP lead to presention of Cushing’s Triad?

A

-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

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18
Q

In which section of the spine do most injuries occur?

A

Cervical ≈ 55%

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19
Q

What is the difference between primary and secondary spinal injuries?

A

Primary is immediate damage caused upon impact
Secondary are progressive injury from cord oedema, cord hypoperfusion and extension of primary injury

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20
Q

How can pre-hospital care limit secondary spinal cord injuries?

A

Preventing hypoxia, hypoperfusion and mechanical disturbance of the spine

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21
Q

What is neurogenic shock?

A

A distributive shock resulting in malfunction of the sympathetic nervous system.

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22
Q

What injuries usually cause neurogenic shock?

A

Acute spinal chord injuries above T6

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23
Q

What does neurogenic shock cause?

A

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)

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24
Q

What is spinal shock?

A

Spinal cord ischemia and hypoxia in a specific area after injury often leading to paralysis and loss of sensation below the area of injury

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25
Q

What causes spinal shock after injury to the spinal cord?

A

Damage to the spinal cord causes bleeding and an inflammatory response. Chemical mediators are released causing vasoconstriction leading to ischemia and hypoxia

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26
Q

What neurogenic treatment can be given after spinal injuries?

A

Fluid/vasopressors to restore sympathetic function.

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27
Q

How long can spinal shock last?

A

Up to 5/6 weeks

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28
Q

What is the main difference between neurogenic and spinal shock?

A

Neurogenic is cirulatory and haemodynamic in nature whereas spinal is not

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29
Q

How long can neurogenic shock last?

A

4/5 weeks

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30
Q

How quickly can spinal shock set in?

A

From around 30 minutes after injury

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31
Q

What is the difference between pneumothorax and tension pneumothorax?

A

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.

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32
Q

What is cardiac tamponade?

A

Compression or pressure on the heart caused by build up of fluid in the pericardium

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33
Q

What can cardiac tamponade cause?

A

Reduced filling of the heart and reduced output leading to hypoperfusion.

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34
Q

What causes flail chest?

A

Almost always blunt trauma, very rarely bone deterioration due to disease/age.

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35
Q

What are the main causes of cardiac tamponade?

A

Cancers (mainly advanced lung but also breast cancer, melanoma, leukaemia and lymphoma)
Injury to the myocardium, aorta or cornary vessels (trauma, surgery, MI)
Pericarditis

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36
Q

What are the classifications of pelvic fractures?

A

Anterio-posterior (‘open book’)
Lateral compression
Vertical shear

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37
Q

What is the main danger with pelvic fractures?

A

Severe haemorrhage

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38
Q

How much blood can the retroperitoneal cavity hold?

A

Up to 4L (The human body usually has around 5L of circulating blood)

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39
Q

What type of fractures are perpendicular across the bone?

A

Transverse

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40
Q

What type of fractures are diagonal across the bone?

A

Oblique

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41
Q

What type of fractures result from a twisting force?

A

Spiral

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42
Q

What type of fracture involves a section of bone broken into many pieces?

A

Comminuted

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43
Q

What type of fracture involves small pieces of bone being pulled away by tendons or ligaments?

A

Avulsions

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44
Q

What type of fractures arise from a longitudinal compression?

A

Impacted fracture

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45
Q

What type of fractures involve longitudinal cracks?

A

Fissure fractures

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46
Q

What type of fracture is caused by a bone bending and cracking?

A

Greenstick

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47
Q

How much blood can be losses to a closed and an open femur fracture?

A

1-1.5 for a closed, 2-3 for an open

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48
Q

How much blood can be lost from a closed and an open tibia fracture?

A

0.5-1L for closed, 1-2L for open

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49
Q

What is neurovascular compromise?

A

Compromised blood flow or nerve damage following injury/surgery

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50
Q

What are the 6 P’s of a neurovascular assessment?

A

Pain
Poikilothermia
Paresthesia (tingling)
Paralysis
Pulselessness
Pallor

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51
Q

What is sequelae?

A

Long term chronic complications/affects of an acute condition/injury

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52
Q

What amount of blood loss defines a major haemorrhage?

A

More than 150ml/min or more than 50% of total volume in less that 3 hours

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53
Q

What is the body’s initial compensation response to a major haemorrhage?

A

Initial compensation:
- Vasoconstriction
- Increased HR
- Increased RR

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54
Q

What is the Barcroft-Edholm reflex?

A

A parasympathetic cardiac response of bradycardia, systemic vasodilation and hypotension.

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55
Q

What is the Barcroft-Edholm response’s role in major haemorrhage?

A

Triggered by a reduction in right atrial pressure, it attempts to slow blood loss

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56
Q

What is the arterial-baroreceptor reflex during major haemorrhage?

A

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

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57
Q

What is the terminal sympathetic storm?

A

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.

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58
Q

What is exsanguination?

A

Loss of entire blood volume - ‘bleeding out/to death’

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59
Q

What is the triad of death?

A

Coagulopathy
Hypothermia
Metabolic Acidosis

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60
Q

How does haemorrhage lead to metabolic acidosis?

A

Haemorrhage causes hypoperfusion leading to cellular hypoxia. Anaerobic metabolism ensues releasing lactic acid

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61
Q

How does metabolic acidosis affect coagulopathy

A

Acidosis accelerates fibrinogen consumption with no effect on production, resulting in a deficit in fibrinogen availability.

The underlying contributing mechanisms are unclear.

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62
Q

What can cause hypothermia in trauma patients?

A

Alcohol/drugs
Environment
CNS injury
Hypovolaemia
Metabolic acidosis

63
Q

How does alcohol lead to hypothermia?

A

Vasodilation - losing heat via skin radiation but feeling warm
Shivering response impaired
Impaired decision making in response to dangerous environments

64
Q

Are anti-coagulants or pro-coagulants more dominant in normal haemostasis?

A

Anti-coagulants

65
Q

How does major trauma disrupt normal coagulation?

A

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’

66
Q

What is fibrinolysis?

A

The enzymatic breakdown of the fibrin in blood clots

67
Q

What neurological signs show in the body’s decompensation response to a major haemorrhage, what is the main cause of this?

A

Reduced cerebral perfusion
- Reduced GCS
- Confusion, agitation, coma, arrest

68
Q

What does bright red, frothy blood coughed up through the trachea and airways signify?

A

Bleeding in the lungs

69
Q

What does coffee ground vomit indicate?

A

Old blood in the stomach (not always caused by bleeding to the stomach directly)

70
Q

What can urine discoloration ranging from smoky grey to bright red indicate?

A

Bleeding kidneys

71
Q

What can black sticky tarry stools signify?

A

Large intestine bleed

72
Q

What can blood leaking through the ears, nose and eye orbits signify?

A

Cerebral insult/bleed

73
Q

What can bruising to left hypocondrium signify?

A

Spleen damage

74
Q

What makes the spleen more vulnerable after trauma?

A

The spleen cannot heal itself and will bleed profusely internally, causing hypovolaemia.

75
Q

What can abdominal distention signify?

A

Blood, fluid, intestinal perforation or acute gastric distension. 6 Fs must be considered.

76
Q

When is abdominal tenderness especially significant?

A

If over the liver, spleen or renal angles.

77
Q

What does generalised abdominal guarding signify?

A

Peritonitis, usually a sign of massive bleeding or perforation.

78
Q

What is Grey Turner’s sign and what does it signify?

A

Ecchymosis or discoloration of the flanks, generally accepted as a sign of pancreatic rupture.

79
Q

What is Cullen’s sign and what does it signify?

A

Periumbilical ecchymosis, related to acute pancreatitis or various causes of abominal bleeding

80
Q

What are the main aims of traction splints?

A

To establish patient comfort and better fracture alignment.

81
Q

What are contraindications of traction splints?

A

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

82
Q

When is packing a wound used?

A

For central wounds or wounds at bodily junctions where a tourniquet cannot be applied

83
Q

At what points during hypovolaemia does low BP occur?

A

Low BP is an immediate (pre-compensatory) or late (decompensateory/refractory) sign

84
Q

What are the four main principles of trauma management?

A

COMA
Clothes off
Oxygen on
Monitoring
Access (cannulas/IO)

85
Q

What % of traumatic brain injuries (TBI) have associated C-spine injury?

A

10%

86
Q

What is TWELVE?

A

T - Tracheal deviation
W - Wounds/bleeding/bruising
E - surgical Emphysema
L - Laryngeal crepitus / injury
V - distended neck Veins
E - Exclude pneumothorax, flail segment.

87
Q

What is DCAP-BTLS

A

Deformity
Contusion
Abrasion
Penetration
-
Burns
Tenderness
Laceration
Swelling

88
Q

Why can the spleen not be operated on?

A

It is similar in consistency to jelly in a muslin cloth and requires a splenectomy.

89
Q

What is the leading cause of death in thoraxic trauma?

A

Hypoxia

90
Q

Thoracic trauma accounts for what percentage of traumatic death?

A

25%

91
Q

What is pleuritic pain?

A

Pain on breathing

92
Q

What dressing should be used on a tension pneumothorax?

A

A russel chest seal (semi-occlusive dressing)

93
Q

What ribs in adults are most commonly fractured?

A

4th-10th

94
Q

What is commotio cordis?

A

Blunt force to the chest causing immediate cardiac arrest

95
Q

What is permissible hypotension in trauma?

A

An acceptable drop in blood pressure during bleeding

96
Q

Why don’t we treat permissible hypotension in trauma?

A

An increased blood pressure would cause more bleeding

97
Q

When are fluids indicated for trauma?

A

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

98
Q

What is GLADSHIP?

A

Gunshot
Lacerations
Abrasions
Degloving
Skin tears
Haematoma
Incision
Puncture

99
Q

What are the most common sites of internal bleeding?

A

Chest
Abdomen and retroperitoneum
Pelvis
Long bone fractures

100
Q

What paralysis is caused by C4 injuries?

A

Quadriplegia/tetraplegia: Complete paralysis below the neck

101
Q

What paralysis is caused by C6 injuries?

A

Partial or full paralysis of hands and arms, full lower body paralysis

102
Q

What paralysis is caused by T6 spinal injuries?

A

Paraplegia, paralysis below the chest

103
Q

What paralysis is caused by L5 spinal injuries?

A

Paraplegia below the waist

104
Q

What kind of bone fracture patients will always require O2?

A

Long bone fractures

105
Q

What are superficial (1st degree) burns and their symptoms?

A

Epidermis surface burns:
Red, painful but skin intact with no blisters

106
Q

What are superficial partial (2nd superficial degree) burns and their symptoms?

A

Epidermis/dermis burns
Red/pink, may look moist, painful, superficial blisters

107
Q

What are deep partial (2nd deep degree) burns and their symptoms?

A

Dermis burns
White with some red/pink mottled areas, limited pain, thick walled blisters

108
Q

What are full (3rd degree) burns and their symptoms?

A

Subcutaneous fat burns:
White, leathery/charred, no sensation

109
Q

What is the rule of nines for calculating burn TBSA?

A
110
Q

What is the palmar method for TBSA?

A

Patient’s whole hand ≈ 1% TBSA

111
Q

What burns would you not use cling film for?

A

Chemical burns

112
Q

What’s the maximum time a patient should spend on a rigid board?

A

30 mins

113
Q

Which parts of the spine give rise to the phrenic nerve and what would happen if these areas were to be damaged?

A

Cervical plexus, particularly C3, C4 and part of C5.
Injury above C3 would lead to death by suffocation

114
Q

What does the phrenic nerve do?

A

Innovates the diaphragm

115
Q

What are the dangers of complete immobilisation and why isn’t it always necessary?

A

Discomfort
Raised ICP
Risk of aspiration
Potential to reduce airway opening

Conscious c-spine # patients self immobilise anyway

116
Q

What are the hateful 8 of major haemorhage/exsanguination?

A

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

117
Q

Do paramedics clean up contaminated fractures with saline?

A

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

118
Q

Which trauma patients will always require antibiotics?

A

Open fracture patients

119
Q

What is critical skin?

A

Ischaemic skin under pressure from segments of bone after a closed fracture causing a reduction in blood flow

120
Q

What is “reduction” and when is it done?

A

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.

121
Q

What is a simple fracture?

A

A fracture where both ends of bone remain in place. Can be transverese, oblique or spiral providing there is no dissplacement

122
Q

What is the difference between segmented and comminuted fractures?

A

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.

123
Q

What are compression fractures and where are they most commonly found?

A

Where the bone is crushed or collapses into small pieces. Most commonly found in the vertebrae

124
Q

Why is acute lower back pain a red flag for cancer patients?

A

They might have spinal cord compression from a metastasised tumour

125
Q

What non-clinical feature must be considered about the mechanism of injury for fractures or trauma in young children and infants?

A

Safeguarding - especially if baby is not yet mobile

126
Q

How do impacted fractures occur and where are they more common?

A

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

127
Q

What are pathological fractures?

A

Fractures caused by existing weaknesses e.g. disease. Can be trauma related or spontaneous

128
Q

What is osteogenesis imperfecta?

A

“Brittle bone disease”
An inherited disorder characterized by extreme fragility of the bones.

129
Q

What is a greenstick fracture?

A

A bending of a bone with minimal calcification. Often heals quickly

130
Q

What is Colles #?

A

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

131
Q

What is Potts’ #?

A

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.

132
Q

Do paramedics relocate dislocations?

A

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.

133
Q

What assesmment and management should be undertaken for dislocations?

A

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.

134
Q

What referral option do paramedics have for dislocations, and what’s the rationale behind each?

A

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).

135
Q

What are red flags of shoulder dislocations?

A

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

136
Q

What are red flags of knee dislocations?

A

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

137
Q

What considerations must you account for in holistic plans for minor injuries?

A

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.

138
Q

What hospital treatment will minor MSK injury patients recieve?

A

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

139
Q

What at home post discharge treatment will minor MSK injury patients recieve?

A

Fracture clinic assessment
Physiotherapy – NHS or private
Short term analgesia
At home management

140
Q

What long term complications can come from minor injuries?

A

Long term analgesia use:
-Addiction
-Gastric complications
Increased risk of falls
Chronic pain
Chronic conditions

141
Q

What is the difference between a sprain and a strain?

A

Sprains are stretches or tears of ligaments

Strains are stretches or tears of muscle fibres and or tendons

142
Q

What are the symptoms of a sprain?

A

Pain or tenderness
Swelling
Bruising
Decreased functioning
Joint instability

143
Q

What are the symptoms of strains?

A

Muscle pain
Cramping or spasming
Muscle weakness
Inflammation
Bruising

144
Q

What are the risk factors for both sprains and strains?

A

Athletes/sportspeople
Age
Falls
Previous injuries
Instability/hyper-mobility
Balance issues
Neuropathy
Alcohol and drugs
High/low BMI

145
Q

Which ankle ligaments are commonly affected by sprains?

A

Antero talofibular ligament (ATFL)
Posterior talofibular ligament (PTFL)

146
Q

Which knee ligaments are commonly affected by sprains?

A

Anterior cruciate ligament (ACL)
Medial/lateral collateral ligament (MCL/LCL)

147
Q

Which wrist sprain is most common?

A

Scapholunate ligament

148
Q

Which thumb ligament is commonly sprained?

A

Ulnar collateral ligament (UCL)

149
Q

What is the most prevalent MSK injury in active populations?

A

Lateral ankle sprains

150
Q

What are the red flags for sprains and strains?

A

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

151
Q

What are the PRICE guidelines for self care of sprains/strains?

A

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

152
Q

What should you advise home discharge sprain/strain patients?

A

OTC analgesia
PRICE
Review in 5-7 days
Safe and gentle return to activity

153
Q

Other than red flags, why might you convey a sprain/strain patient?

A

Need for splinting and support (also UCH/walk-in)
Safeguarding/welfare
Need for imaging (also UCH/walk-in)
Onward referalls (also UCH/walk-in)

154
Q

What are the 3 grades of strains and sprains?

A

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

Clinical Care (15 decks)

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