Trauma AS Flashcards
Primary survey of a patient?
ADDRESS PROBLEMS IN 1st SURVEY IN THE ABCDE ORDER
What to look for in Airway and C-spine?
Check for airway compromise
- Ask patient a question
- Stridor
- Orofacial injury or burns
- Visualise airway and use section if necessary
Manoeuvres to open airway
- Jaw thrust
What adjuncts are available if compromised or potentially compromised airway?
Adjunct if compromise/potential compromised
- NPA: gag reflex present
- OPA: no gag reflex (Stop tongue swallowing)
What are the emergency airways?
Emergency airways
- Needle cricothyroidotomy or surgical cric
What are the definitive airways (no risk of aspiration)
Endotracheal tube
Tracheostomy
What is a C-spine?
Maintain in-line cervical support to keep neck stable
Place pt in hard-collar and sandbags with tape
How to assess for breathing?
Start 15L O2 via non-rebreathe mask
Assessment of breathing?
- SpO2
- Inspection of chest
- Position of trachea
- RR and chest expansion
- Breath sounds, vocal resonance
- Percussion
- ABG
What are the signs of a tension pneumothorax and what’s the management?
- Respiratory distress
- Increased JVP and Decreased BP
- Tracheal deviation + displaced apex
- Decreased air entry and decreased vocal resonance
- Hyperresonant percussion
Management
- INsert large-bore venflon into 2nd ICS, mid clavicular line
- Insert ICD later.
Circulation management?
Two-large bore cannulae (14/16 G) In each ACF
FBC, U+E, x-match, GU, clotting, VBG.
Assessment of circulation?
Inspection: pale, sweaty, active bleeding
Vascular status: BP, HR, JVP, heart sounds, cardiac mon.
End-organ: Consciousness, UO.
If bleeding - packing is perferred for haemorrhage control.
Sites of haemorrhage in circulation?
Chest
Abdomen
Pelvis: use pelvic binder
Floor
Management of circulation compromise
Give 2L warmed Hartmann’s stat (if haemodynamically compromise)
Consider further colloid/blood
Insert CVP and catheter (After PR) to guide resus
Assess response to fluids using UO, Lactate, BP.
If there is a transient or no improvement in circulation - there is inadequate resuscitation. If there is no improvement - exsanguiating haemorrhage which requires theatre, and consider non-haemorrhagic shock (tamponade, pneumothorax).
What to assess in disability?
- Assess consciousness using AVPU or GCS
- Pupil responses
What to assess in exposure?
Completely undress PT
Perform log-role and PR
- Feel for high riding prostate (urethral rupture)
- Look for bleeding
Prevent hypothermia.
DON’T FORGET TO REPEAT PRIMARY SURVEY AGAIN
What does the Secondary Survey involve?
History
Examination
Investigations
Clearing the C spine
History in Secondary Survey
History
- Allergies
- Medication
- PMH
- Last ate/drunk
- Events
Examination in Secondary survey?
Examine every system
Remember
- Following trauma there is a trimodal death distribution:
Immediately following injury.
- Typically as result of brain or high spinal injuries, cardiac or great vessel damage. Salvage rate is low.
- In early hours following injury. In this group deaths are due to phenomena such as splenic rupture, sub dural haematomas and haemopneumothoraces
- In the days following injury. Usually due to sepsis or multi organ failure.
Investigations for secondary survey?
trauma series
- C-spine: lat + peg
- CXR
- Pelvis
FAST scan (Focussed Assessment with Songraphy in trauma)
CT: when patient is stable
Assessing C-spine radiographs?
Views
- Lateral
- AP
- Open-mouth Peg view
Adequacy
- Must see C7-T1 junction
- May need swimmer’s view with abducted arm
Alignment: 4 lines
- Anterior vertebral bodies
- Anterior vertebral canal
- Posterior vertebral canal
- Tips of spinous processes
Bones: shapes of bodies, laminae, processes
Cartilage: IV discs should be equal height
Soft tissue
- Width of soft tissue shadow anterior to upper vertebrae should be 50% of vertebral width.
How to clear the c-spine?
Clinical clearance - Indication: NEXUS Criteria Fully alert and orientated No head injury No drugs or alcohol No neck pain No abnormal neurology No distracting injury
- Method
Examine for bruising or deformity
Palpate for deformity and tenderness
Ensure pain-free active movement
Where would you want to use radiological clearance for C-spine?
Where Pt doesn’t met criteria for clinical clearance
- Radiograph initially
Clear if normal radiograph and clinical exam - CT c-spine if abnormal radiograph or clinical exam.
What is haemorrhagic shock?
Circulating blood volume = 7% body mass.
Blood loss of 750ml = 0-15% loss
Loss of 750-1500 = 15-30% loss.
1500-2000 = 30-40% loss
>2000 = 40% loss.
BP drops at 30-40%
HR >100 at 15-30%.
Decreasing urine output.
May be confused at Class III.
In order to generate a palpable femoral pulse an arterial pressure of >65 mmHg is required.
Class 1 = completely compensated for
Class II = tachycardia
Class III = tachycardia and hypotension as well as confusion
Class IV = causes loss of consciousness as well as severe hypotension
Neurogenic shock
Disruption of the sympathetic nervous system.
Spinal cord transection.
Causes
- Spinal anaesthesia
- Hypoglycaemia
- Cord compression above T5
- Closed head injuries
Presentation
- hypotension
- bradycardia
- Warm extremities
Management of neurogenic shock?
Vasopressors: vasopressin and noradrenaline
Atropine: reverse the bradycardia
Spinal shock
- Acute spinal cord transection
- Loss of all voluntary and reflex activity below the level of injury
Presentation of spinal shock?
Hypotonic paralysis
Areflexia
Loss of sensation
Bladder retention
What are the life-threatening chest injuries?
- Airway obstruction
- Tension pneumothorax
- Open pneumothorax
- Massive haemothorax
- Intercostal disruption and pulmonary contusions
- Cardiac Tamponade
Massive haemothorax presentation and management?
Accumulation of >1.5L of blood in chest cavity
Usually caused by disruption of hilar vessels
- Presents with signs of chest wall trauma
- Decreased BP
- Decreased expansion
- Decreased breath sounds and decreased vesicular breathing
- Stony dull percussion
Management
- X-match 6u
- Large-bore chest drain with hep saline for autotransfusions
- Thoractomy is >1.5L or >200ml/h
What is a flail chest and how do you manage it?
Anterior or lateral fracture of more than 2 adjacent ribs in >2 places.
Can lead to pneumothorax created by intubation and ventilation.
Associated with pulmonary contusion.
Flail segment moves paradoxically with respiration
- Decreased oxygenation
Underlying pulmonary contusion
Decreased ventilation of affected segment.
Inx
- CXR/CT chest: pulmonary contusion (white)
- Serial ABGs: Decreased PaO2:FiO2 ratio
Management
- O2
- Good analgesia: PCA, epidural
- Persistent resp failure: PPV
What is cardiac tamponade and how do you manage it?
Disruption of myocardium or great vessels –> blood in the pericardium –> decrease filling and contraction –> shock.
- Usually results from penetrating trauma.
Presentations
= Beck’s Triad (increased JVP, decreased BP, Muffled heart sounds). Pulsus Paradoxus: SBP fall of >10mmHg on inspiration.
Kussmaul’s sign: Increased JVP on inspiration
Inx
- US: FAST (Focussed assessment of Sonography for Trauma) or transthoracic echo
- CXR: enlarged pericardium
- Increased CVP >12mmhg
- ECG: low voltage QRS ± electrical alternans
Management
- Pericardiocentesis: spinal needle in R subxiphoid space aiming at 45 degree towards the R tip of left scapula.
2ndry survey chest injuries?
- Rib fracture
- Sternal fracture
- Pulmonary contusion
- Myocardial contusion (with cardiac arrhythmias). Overlying sternal fracture. Do Echo to exclude tamponade.
- Contained aortic disruption
- Diaphragmatic injury
- Oesophageal disruption
- tracheobronchial disruption
What is a rib fracture and how do you manage it?
Usually 5th-9th ribs
Fracture of upper 4 ribs = high energy trauma
Complications
- Pneumothorax
- Lacerate thoracic or abdominal viscera
Management
- Good analgesia
- NSAIDS + opioids
- Intrapleural analgesia
- Intercostal block
How do you get a sternal fracture?
- Usually MVA driver vs steering wheel
- Risk of mediastinal injury
- Management
Analgesia, admit, observe
Cardiac monitor
Troponin: rule out myocardial contusion
How do you get a pulmonary contusion?
Usually due to rapid deceleration injury or shock waves
May lead to ARDS
Presentation: dyspnoea, haemoptysis, resp failure
Investigations
- CXR: opacification
- Serial ABGs: decreased PAO2:FiO2 ratio
Management: Oxygen, ventilate if necessary.
How do you get a myocardial contusion?
Direct blunt tauma over precordium
Investigations
- ECG: abnormal, arrhythmias
- Increased troponin
Management: bed rest, cardiac monitoring, management of arrhythmias.
Contained aortic disruption?
- Rapid deceleration injury (80% immediately fatal)
- Presentation: initially stable but –> hypotension
Survivors have a contained haematoma.
Invx: CXR: wide mediastinum, deviation of NGT
CT
Management: Cardiothoracic consult
Diaphragmatic injury management?
Consider in penetrating injuries below 5th rib or high energy compression
Lateral blunt injury during a road traffic accident is a common cause. XR changes show non-visible diaphragm, bowel loops in the hemithorax and displacement of the mediastinum. Most cases direct surgical repair is the best option.
Inx: CXR (visceral herniation), CT.
Oesophageal disruption
Usually penetrating trauma - mediastinitis
- CXR: pneumomediastinum, surgical emphysema
CT
Tracheobronchial disruption
Presents with persistent pneuomothorax/pneumomediastinum.
Management: Thoracotomy
What are the mechanisms of abdominal trauma?
Penetrating - all require exploration as rtact may be deeper than it appears
Blunt - Have a higher index of suspicion for taking to theatre
What investigations are used in abdominal trauma?
urine dip
- haematuria suggests injury in renal tract
FAST Scan -Focussed Assessment with Sonography for Trauma (FAST)
- replacing GPL in most centres
- Check for fluid in abdomen, pelvis and pericardium
(90% sensitive for free fluid).
- Can be extended to look for pneumothoracies
Abdo CT if normotensive
- Most specific for localising injury of organs.
- takes time
US - document fluid if hypotensive
Diagnostic peritoneal lavage?
- 98% sensitive for intra-abdominal haemorrhage. Early diagnosis.
- Indicated to document bleeding if hypotensive.
- Useful if FAST unavailable
- May be better for identifying injury to hollow viscus.
- Unable to identify retroperitoneal injury.
Insert urinary catheter and NGT - decompression to minimise risk of injury.
Midline incision through skin and fascia. Dissect to the peritoneum and insert a urinary catheter.
Instil 10ml/kg warm Hartmann’s
Drain fluid back into bag and send sample to lab.
+ve = >100,000 RBC/mm3, bile or intestinal contents.
Invasive + may miss retroperitoneal and diaphragmatic injury.
Indications for laparotomy in abdominal trauma?
If a patient has intra-abdominal bleeding without haemodynamic compromise - this does not warrant a laparatomy.
- Unexplained shock
- Peritonism: rigid silent abdomen
- Evisceration: Bowel or omentum
- Radiological evidence of intraperitoneal gas
- Radiological evidence of ruptured diaphragm
- Gunshot wounds
- +ve DPL or CT.
Damage control surgery? - Aims
Early management of abdominal trauma should focus on damage control to limit physiological stress
- Control haemorrhage: ligation and packing
- Control contamination
- Stabilise in ITU
What is Kehr’s sign
- Shoulder tip pain 2ndry to blood in the peritoneal cavity
- Left Kehr sign is classical symptoms of ruptured spleen.
Classification of spleen damage?
1: Capsular tear
2: Tear + parenchymal injury
3: Tear up to the hilum
4: Complete fracture
Management of spleen damage?
Haemodynamically unstable: Laparotomy
Stable 1-3: observation in HDU
stable 4: consider laparotomy
- Suture lac or partial /complete splenectomy
Management of liver damage?
- Conservative if capsule is intact
- Suture laceration
- Partial hepatectomy
- Packing
Damage to bowel?
Resection may be required
Damage to bladder - associated with pelvic injury?
- Intraperitoneal rupture requires laparoscopic repair with urethral and suprapubic drainage
- Extraperitoneal rupture can be treated conservatively with urethral drainage
- Give prophylactic Abx.
Management + Classification of urethra damage?
Classification
- anterior (spongy urethra) = penile + bulbar. Occur following straddling injuries or instrumentation.
- Posterior = Membranous urethra, occur following pelvic fracture.
Presentation
- Often assoc with pelvic fracture
- Blood in the urethral meatus or scrotum
- Perineal bruising
- High-riding prostate
- Inability to micturate + palpable bladder.
Investigation
- Retrograde urethrogram
Management
- Suprapubic catheter
- Surgical repair
What is primary brain injury?
Occurs at the time of injury and is the result of direct or indirect injury to brain tissue.
What are the types of brain injury?
Diffuse
- Concussion/Mild traumatic brain injury: Temporary decreased in brain function, with headache, confusion, visual symptoms and amnesia/nausea.
- Diffuse axonal injury
Shearing forces disrupt axons
May –> coma and persistent vegetative state. Autonomic dysfunction –> fever, HTN, sweating.
Focal - Contusion = coup and contra-coup May have focal neurological deficit. - Intracranial haemorrhage Extradural Subdural Subarachnoid Parenchymal haemorrhage and laceration
What is the secondary brain injury?
Occurs after primary injury
Causes of Secondary brain injury?
Hypoxia Hypercapnoea Hypotension Increased ICP Infection
What is the Monroe-Kelly doctrine?
Cranium is a rigid box therefore total volume of intracranial contents must remain constant if ICP is not to change.
Increased in volume of one constituent –> compensatory decreased in another.
- CSF
- Blood (venous)
These manchaism can compensation for a volume of ~100ml before ICP increases
As autoregulation fail, ICP increased rapidly –> herniation.
What is the cushing reflex (imminent herniation)
Hypertension
Bradycardia
Irregular breathing
History of head injury?
- LOC
- Amnesia: Anterograde worse
- Nausea/vomiting
- Fits
- Focal neurology
- Mechanism
- Drugs: e.g antiplatelets, warfarin
Examination of head injury?
GCS: E4, V5, M6
3-8 = coma 9-12 = moderate head injury 13-15 = mild head injury
Scalp lacerations
Signs of a basal skull fracture?
CSF rhinorrhoea or otorrhoea
Battle sign: bruised mastoid
Pando sign: Bilateral orbital bruising
Haemotypmanim
Investigations for head injury?
C-spine CT head indications - Basal or other skull fracture - Amnesia: >30 mins retrograde (Before event) Neurological deficit: e.g seizures GCS: <13 @ scene, <15 2hs later. Sick: vomiting >1
Bloods: FBC, U+E, glucose, clotting, ETOH, ABG.
Management of head injury?
Neurosurgical consult if +Ve CT. Admit if - LOC >5 mins - 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 #
When to intubate due to head injury?
GCS <8
PaO2 <9KPa on air
<13kPa on o2 or PCO2 >6kPA.
Spontaneous hyperventilation: PCO2 <4kPa.
Respiratory irregularity.
Management of raised ICP?
Elevate bed
Good sedation, analgesia ± NM block
Neuroprotective venilation
Mannitol or hypertonic saline
Discharge advice for head injury?
Stay with someone for first 48hrs Give advice card advising return on - Confusion, drowsiness, unconsciousness, fits - Visual problems - V.painful headache that won't go away - Vomiting.
Risk factors for burns?
Age: children and elderly
Comorbidities: epilepsy, CVA, dementia, mental illness
Occupation
Classification of burns?
Superficial
Partial Thickness
Full thickness
What indicates a superficial burn?
Erythema
Painful (sunburn)
What is a partial thickness burn?
Heals in 2-3 weeks if not complications
- Superficial = no loss of dermis, painful and blisters.
- Deep = loss of dermis, byt adnexae remain. Healing from adnexae: e.g follicles.
Very painful
What is a full thickness burn?
- Complete loss of dermis
- Charred, waxy, white skin.
- Anaesthetic
- Heal from the edges –> Scar.
Early complications of burns?
Infection - SIRS, necrotic tissue
Hypovolaemia - loss of fluid in skin + increased cap permeability
Metabolic disturbances - increased K, increased myoglobin, increased Hb –> AKI
Compartment syndrome: circumferential burns
Peptic ulcers: Curling’s ulcers (stress in stomach from traumatic burns).
Pulmonary: laryngeal oedema, CO poisoning, ARDs.
Intermediate = VTE + pressure sores
Late
- Scarring, contractures, psychological problem.s
Management of burns?
Based on ATLS principles
- Secure airway
- Manage fluid loss
- prevent infection
Airway management in burns?
Examine for respiratory burns
- Soot in oral or nasal cavity
- Burnt nasal hairs
- Hoarse voice, stridor
Flexible laryngoscopy can be helpful
Consider early intubation + dexamethasone (reduce inflammation).
Breathing in burns management?
100% O2 Exclude constricting burns Signs of CO poisoning - Headache - n/v - confusion - Cherry red appearance
ABG
- COHb level
- SpO2 unreliable if CO poisoning
Circulation management in burns?
- Fluid loss may be huge
- 2x large-bore cannulae in each ACF
- Bloods: FBC, U+E, G+S/XM
Start with 2L warmed Hartmanns immediately
Indication for fluid resus burns
- > 15% total body area burns in adults
- Main aim of resus is to prevent burn deepening
- Use Parkland formula
- Total fluid requirement in 24hrs - 50% given in first 8hrs.
After 24hrs - colloid infusion at rate of 0.5ml x total burn surface area x body weight.
Parkland formula for the total fluid requirement in 24 hours is as follows: 4ml x TBSA (%) x body weight (kg); 50% given in first eight hours; 50% given in next 16 hours.
Formula to guide replacement in 1st 24hrs
Parkland
- Give half in 1st 8hrs
- Next half in next 16hrs.
Total fluid requirement in 24hrs
= 4ml x( total burn surface areas x body weight kg)
Resus endpoint: UO 0.5-1ml/kg/hr.
Wallace’s Rule of Nines - Extent of burns = 9%, 9% for everything.
Lund and Browder chart.
Burns management?
Burns caused by heat: remove the person from source. Within 20 mins of the injury irrigate the burn with cool water for between 10-30mins. Cover with cling film, layered rather than wrapped around limb.
Referral to secondary care
- All deep dermal and full-thickness burns
- Superficial dermal burns of more than 3% TBSA in adults, or more than 2% TBSA in children.
- If it involves the face, hands, feet, perineum, genitalia, flexure, circumferential burns.
Analgesia: Morphine Dress partial thickness burns - Biological: cadaveric skin - Synthetic - Cream (Flamazine) - silver sulp
Full thickness burns
- Tangential excision debridement
- Split-thickness skin graft
Once patient is resuscitated transfer to specialist management burns centre.
- Circumferential burns may require escharotomy to prevent compartment syndrome. Patients that are having impaired ventilation require escharotomy as division of encasing band of burn tissue will improve ventilation or relieve compartment syndrome.
- Anti-tetanus toxoid
- Consider prophylactic ABx: Esp anti-pseudomonal
Fluid management for burns?
Resus of patient = IV fluids for children with burns greater than 10%.
Adults with burns >15% need IV fluid.
IV fluids not required for first degree burns. Give IV to 2nd or 3rd degree burns that cover 15% body surface area.
Half of fluid is administered in first 8hrs.
Urinary catheter should be inserted.
What is the definition of hypothermia?
Core temperature <35 C
What is the pathophysiology of hypothermia?
Body heat is lost via 4 mechanisms
Radiation, conduction, convection, evaporation
Aetiological classification of hypothermia
- Primary: environmental exposure
- Secondary: change in temp set point - age-related, hypothyroidism, autonomic neuropathy
Presentation of mild hypothermia?
32-35C
- Shivering
- Tachycardia
- Vasoconstriction
- Apathy
Presentation of moderate hypothermia?
28-32C
- Dysrhythmia, bradycardia, hypotension
- J waves
- Decreased reflexes, dilated pupils, decreased GCS
Presentation of severe hypothermia?
<28C
- VT –> VF –> Cardiogenic shock
- Apnoea
- Non-reactive pupils
- Coagulopathy
- Oliguria
- Pulmonary oedema
Investigations of hypothermia?
Rectal/ear temp FBC, U+E, glucose TFTs, blood gas ECG - J waves: between QRS and T wave. Acute ST elevation . - Arrhythmias
Management of hypothermia ?
Cardiac monitor Warm IVI 0.9% NS Urinary catheter Consider ABx for prevention of pneumonia - Routine if temp <32 and >65.
Slowly rewarm
- reheating too quickly –> peripheral vasodilatation and shock
- Aim for 0.5C/hr
- Passive external: blankets, warm drinks
- Active external: warm water or warm air
- Active internal: Mediastinal lavage and CPB
- Severe hypothermia only
Complications of hypothermia?
Arrhythmias
Pneumonia
Coagulopathy
Acute renal failure
Be careful not to warm too quickly - peripheral vasodilation and shock. May have to do CPR.
Kerion
Fungal abscess
Diaphragm disruption?
Most due to motor vehicle accidents and blunt trauma causing large radial tears (laceration injuries result in small tears)
More common on left side
Insert gastric tube, which will pass into the thoracic cavity
Aorta disruption
Deceleration injuries
Contained haematoma
Widened mediastinum
Presence of persistent hypotension is more consistent with haematoma than a tension pneumothroax.
Duodeno-jejunal flexure disruption ?
Site of sudden deceleration injury. Given the large amount of free fluid, if it were blood there would be a much greater level of haemodynamically instability such as in a splenic rupture.
RTA involving passengers wearing seatbelts incorrectly
Laceration of the carotid artery.
Mediastinal traversing wounds
These result from situations like stabbings. Exit and entry wounds in separate hemithoraces. The presence of a mediastinal haematoma indicates the likelihood of a great vessel injury. All patients should undergo CT angiogram and oesophageal contrast swallow. Indications for thoracotomy are largely related to blood loss and will be addressed below.
High riding prostate on PR
Urethral disruption
Transfusion lung injury?
Occur after infusion of plasma components.
Leads to NORMAL CVP and bilateral pulmonary infiltrates.
Fluid overload has a raised CVP.
Complications of major haemorrhage? Hypothermia
Blood is refrigerated
Hypothermic blood impairs homeostasis
Shifts Bohr curve to the left
Complications of major haemorrhage? Hypocalcaemia?
Both FFP and platelets contain citrate anticoagulant - may chelate calcium
Complications of major haemorrhage? Hyperkalaemia?
PLasma of red cells stored for 4-5 weeks contains 5-10mmol K+
Abdominal wall haematoma?
Occur following trauma, either directly to abdo wall or iatrogenic from surgery.
Spontaneous following excessive straining of the rectus muscle.
During prolonged valsalva manoeuvres experienced with strenuous excesses.
