Trauma: Canadian C Spine, Traumatic/Major Injury

Question 1

What is the Canadian C-spine Rule (CCR)?

Answer 1

A decision-making tool used to determine when radiography should be utilised in patients following trauma.

Question 2

Who is the Canadian C-Spine Rule applicable to?

Answer 2

Patients who are in an alert (GCS 15) and stable condition following trauma where cervical spine injury is a concern.

Question 3

When is the Canadian C-Spine Rule not applicable?

Answer 3

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

Question 4

According to the canadian c-spine rules, what criteria makes a patient ‘high risk’, resulting in a recommendation for imaging?

Answer 4

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

Question 5

What are some examples of dangerous mechanisms of injury for the c spine rules?

Answer 5

• fall from height >1 metre or 5 steps
• axial load to head e.g. diving, high-speed motor vehicle collision, horse riding accident

Question 6

According to the canadian c-spine rules, what are the ‘low risk’ criteria?

Answer 6

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

Question 7

According to the canadian c-spine rules, after assessing if patient has any low risk facotrs, what is the next step?

Answer 7

Is patient able to actively rotate their neck 45 degrees left and right?

If yes –> no risk

If no –> radiography

Question 8

According to the canadian c-spine rules, when does a patient have NO risk?

Answer 8

Have one of the low-risk factors AND are able to actively rotate their neck 45 degrees to the left and right.

Question 9

Steps of canadian c spine rules:

Answer 9

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

Question 10

What is the leading cause of death in people <45 y/o?

Answer 10

Major trauma

Question 11

Major trauma in older vs younger people?

Answer 11

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.

Question 12

What are the 2 options for c-spine immobilisation?

Answer 12

1) hard collar

2) head blocks

Question 13

What are the 6 widely recognised life-threatening chest injuries in trauma (TOM CAT)?

Answer 13

• T – tension pneumothorax
• O – open pneumothorax
• M – massive haemothorax
• C – cardiac tamponade
• A – airway injury
• T – tracheobronchial injury

Question 14

What is a flail chest?

Answer 14

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.

Question 15

What chest auscultation sounds may originate from a rib fracture?

Answer 15

Loud cracking, grinding, or popping sounds

Question 16

Acute management of haemothorax?

Answer 16

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.

Question 17

Acute management of flail chest?

Answer 17

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.

Question 18

Acute management of an open pneumothorax?

Answer 18

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.

Question 19

Define major haemorrhage

Answer 19

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

Question 20

For locating a haemorrhage, the phrase “on the floor, and four more” can be used.

What does this mean?

Answer 20

‘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

Question 21

What is Beck’s triad?

Answer 21

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.

Question 22

What ECG changes are seen in cardiac tamponade?

Answer 22

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)

Question 23

Management of cardiac tamponade?

Answer 23

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.

Question 24

How can raised ICP be managed in the acute setting?

Answer 24

IV mannitol or hypertonic saline

Question 25

What is the Monro-Kellie hypothesis?

Answer 25

Describes the relationship between the contents of the skull and intracranial pressure (ICP).

Question 26

What does the Monro-Kellie hypothesis state?

Answer 26

The skull is a closed rigid box with a fixed capacity (after the sutures have closed).

If the volume of one of these substances increases, to maintain a constant ICP, the volume of one of the others must decrease. Initially, this can be achieved through a process referred to as compliance.

An increase in the amount of blood in the skull leads to a compensatory decrease in the amount of CSF and normal ICP is maintained.

Once the compensatory compliance mechanism is overwhelmed, small increases in the volume of any one of the three substances will lead to dramatic increases in ICP. In head injuries, the volume of brain tissue or blood within the skull can increase secondary to swelling (i.e. oedema) or haemorrhage. If left untreated, rising ICP leads to a progressive reduction in cerebral perfusion, herniation of the brainstem and ultimately death.

Question 27

What is Cushing’s reflex?

Answer 27

A physiological response to raised ICP which attempts to improve perfusion.

It leads to a triad of:

1) hypertension
2) bradycardia
3) an irregular breathing pattern

Question 28

What is eFAST?

Answer 28

The Extended Focused Assessment using Sonography in Trauma (eFAST) is a sonographic examination that can be incorporated in the evaluation of patients with blunt or penetrating trauma to the torso.

Question 29

Give 3 indications for eFAST

Answer 29

1) Haemodynamically unstable blunt abdominal trauma

2) Haemodynamically stable blunt chest trauma

3) Any penetrating trauma to the chest

Question 30

What US views are there in eFAST?

Answer 30

1) Cardiac

2) RUQ

3) LUQ

4) Pelvic

5) Thoracic

Question 31

What are the criteria for a head CT within 1 hour in people aged ≥16?

Answer 31

1) GCS score of ≤12 on initial assessment

2) GCS score of ≤15 at 2 hours after the injury

3) Suspected open or depressed skull fracture

4) Any sign of basal skull fracture e.g. hhaemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign

5) Post-traumatic seizure

6) Focal neuro deficit

7) More than 1 episode of vomiting