Trauma: Canadian C Spine, Traumatic/Major Injury Flashcards
What is the Canadian C-spine Rule (CCR)?
A decision-making tool used to determine when radiography should be utilised in patients following trauma.
Who is the Canadian C-Spine Rule applicable to?
Patients who are in an alert (GCS 15) and stable condition following trauma where cervical spine injury is a concern.
When is the Canadian C-Spine Rule not applicable?
1) non-trauma cases
2) if the patient has unstable vital signs
3) known vertebral disease
4) previous history of cervical spine surgery
5) age <16 years
6) pregnant
7) acute paralysis
8) GCS <15
According to the canadian c-spine rules, what criteria makes a patient ‘high risk’, resulting in a recommendation for imaging?
The person is at high risk if they have at least one of the following high-risk:
1) Age ≥65
or
2) Dangerous mechanism of injury
or
3) Paresthesias in upper or lower limbs
What are some examples of dangerous mechanisms of injury for the c spine rules?
- fall from height >1 metre or 5 steps
- axial load to head e.g. diving, high-speed motor vehicle collision, horse riding accident
According to the canadian c-spine rules, what are the ‘low risk’ criteria?
The person is at low risk if they have at least one of the following low-risk:
1) involved in a minor rear-end motor vehicle collision
2) comfortable in a sitting position
3) ambulatory at any time since the injury
4) no midline cervical spine tenderness
5) delayed onset of neck pain
According to the canadian c-spine rules, after assessing if patient has any low risk facotrs, what is the next step?
Is patient able to actively rotate their neck 45 degrees left and right?
If yes –> no risk
If no –> radiography
According to the canadian c-spine rules, when does a patient have NO risk?
Have one of the low-risk factors AND are able to actively rotate their neck 45 degrees to the left and right.
Steps of canadian c spine rules:
1) Any high risk factors?
If yes –> radiography
If no –> go to 2)
2) Any low risk factors?
If no –> radiography
If yes –> go to 3)
3) Are they able to actively rotate their neck?
If yes –> no radiography
If no –> radiography
What is the leading cause of death in people <45 y/o?
Major trauma
Major trauma in older vs younger people?
It is important to consider frailty and comorbidity. Smaller traumas, such as falls from standing height, may not cause significant trauma in young healthy patients but can cause significant injury to older, more frail patients with multiple comorbidities.
What are the 2 options for c-spine immobilisation?
1) hard collar
2) head blocks
What are the 6 widely recognised life-threatening chest injuries in trauma (TOM CAT)?
- T – tension pneumothorax
- O – open pneumothorax
- M – massive haemothorax
- C – cardiac tamponade
- A – airway injury
- T – tracheobronchial injury
What is a flail chest?
Where multiple adjacent ribs are fractured in multiple places, a chest section becomes “detached” from the chest wall and moves paradoxically during respiration.
While the rest of the chest is expanding during inspiration, decreased pressure pulls the flail segment inwards, and vice versa during expiration. This can cause significant pain, further injury to the lung, and difficulty breathing.
What chest auscultation sounds may originate from a rib fracture?
Loud cracking, grinding, or popping sounds
Acute management of haemothorax?
Insertion of a chest drain.
Larger volumes of blood loss (>1.5L from the chest drain being considered a “massive haemothorax”) may necessitate surgical intervention.
Acute management of flail chest?
This increases work of breathing significantly and can often lead to respiratory failure. Early intubation and ventilation are sometimes required, and later discussion with surgeons for repair.
Acute management of an open pneumothorax?
When a penetrating chest injury results in a pneumothorax, it creates a “sucking chest wound.”
Acutely, this is managed by covering the wound with a sterile dressing, securely taped on 3 sides. The open side creates a valve, allowing air to exit but not enter the chest cavity.
Once stabilised, a chest tube can be inserted, and surgery may be considered later.
Define major haemorrhage
1) Loss of more than one blood volume within 24 hours
or
2) 50% of total blood volume lost in less than 3 hours
or
3) Bleeding in excess of 150 mL/minute
However, in an acute scenario, it cab be considered as bleeding (visible or presumed) which results:
1) A blood pressure <90mmHg systolic
or
2) A heart rate >110bpm
For locating a haemorrhage, the phrase “on the floor, and four more” can be used.
What does this mean?
‘On the floor’ –> refers to visible blood loss from an external wound.
‘Four more’ –> refers to four potential spaces inside the body, where a large volume of blood may be lost:
1) chest cavity e.g. rib fracture causing damage to the intercostal blood vessels
2) abdominal cavity
3) pelvic
4) long bones e.g. fractured femur
What is Beck’s triad?
Indicates cardiac tamponade:
1) Jugular venous distension
2) Quiet heart sounds
3) Hypotension
Note - Beck’s triad is not always uniformly present in trauma. Hypovolaemia may prevent jugular venous distension, and it can be difficult to assess with a collar in place.
What ECG changes are seen in cardiac tamponade?
1) Low voltage QRS complexes
2) Tachycardia
3) Electrical alternans (where the QRS complexes alternate in height, due to the swinging motion of the heart within the pericardium)
Management of cardiac tamponade?
Pericardiocentesis – inserting a needle and aspirating the fluid, either using surgical landmarks or under ultrasound guidance.
Note - if pericardiocentesis is indicated, then the patient is likely to require cardiothoracic surgery and should be discussed with the cardiothoracic team.
How can raised ICP be managed in the acute setting?
IV mannitol or hypertonic saline
