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 THIS HAS CHANGED
- 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