Trauma - General

Question 1

ATLS. What are components?

Answer 1

A - airway with C spine protection. Blocked airway causes include: debris such as clots, fragments of teeth or bone;
Pharyngeal edema - direct tissue injury
Bilat mandibular fracture

Breathing - mechanical assisted ventilation
Circulation - massive hemorrhage from
Maxillary artery and pterygoid venous plexus in displaced maxillary fractures
Branches of carotid artery/ tributaries of IJV in penetrating neck injury
Disability - other massive injuries.
Including
Head injury - gcs assessment.
Sight threatening condition - orbital trauma -> ocular injury.

Question 2

Sight threatening conditions?

Answer 2

Loss of visual acuity.
Caused by orbital trauma such as Fracture of orbital bones leading to intraocular injury.
Primary optic nerve injury.
Increased pressure within the orbits causing secondary injury to optic nerve (eg. Retrobulbar hemorrhage)

Question 3

What are cause of massive hemorrhage jn facial injury?

Answer 3

Maxillary artery
Pterygoid venous plexus
-> grossly displaced maxillary fracture

Question 4

Cause if airway compromise in facial trauma

Answer 4

Debris from fracture of bones or teeth or foreign bodies
Pharyngeal edema
Bilateral mandibular fracture making the tongue and floor of mouth loss its support and falls back

Question 5

How to assess brain injury?

Answer 5

GCS level
AVPU for quick assessment
Must differentiate signs and symptoms of head injury with mass effects of alcoholism or drug addictions

Question 6

Who has priority over management in multidisciplinary injuries?

Answer 6

Life threatening
Sight threatening
Facial lacerations with active bleeding and unstable mandibular fracture (within 24H)
Midface and orbital fractures (24-48Hrs) or delayed after facial edema has subsided

Question 7

What are signs of hypoxia

Answer 7

Agitated
Varying level of consciousness
Inappropriate behaviour
Stridor/ sounds of obstruction

Question 8

Indications of CT in head injury

Answer 8

1. Deteriorating gcs
2. Moderate to severe head injuries
3. LOC
4. Amnesia
5. Focal neurological deficit
6. Suspected skull fracture or penetrating injury
7. Large scalp hematomas or laceration wound >10cm
8. CSF leak and other signs of base of skull frcature (battle sign)

Question 9

How to confirm presence of csf fluid

Answer 9

Halo sign

Beta 2 transferrin

Question 10

Usage of tetanus prophylaxis?

Answer 10

Depends on immunisation and status of wound

• immunization
  Last dose within 10yrs
  More than 10 yrs
  Never been immunized

- status of wound
Clean wound (clean incised superficial graze)
Tetanus prone (wound >6hrs, contact with soil and manure, puncture wound, infected wound, devitalized tissues, animal or human bite)

Question 11

When do u give tetanus shot?

Answer 11

Clean wounds
Within 10 yrs - no shots
More than 10yrs - reinforcing dose of adsorbed tetanus vaccine
Never - full course of adsorbed tetanus

Tetanus prone wounds
Within 10 yrs - human tetanus Ig
More than 10 yrs - reinforcement of adsorbed tetanus vaccine + human tetanus Ig
Never - full course of adsorbed tetanus + human tetanus Ig

Question 12

What is adsorbed tetanus vaccine

Answer 12

Tetanus toxoid - active
SC/IM 0.5ml
3 doses at 4 weeks interval

Question 13

What is human tetanus Ig

Answer 13

Passive type of vaccination

IM 250iu in 1ml

Question 14

If patient develop tetanus, how would u treat

Answer 14

Metronidazole
Bite injuries - co-amoxiclav
Antitoxin
Benzodiazepine (diazepam) to control muscle spasms

Question 15

What are signs of sight threatening injuries

Answer 15

Retrobulbar hemorrhage:
Tensed proptosed eyes
Ophthalmoplegic eyes
Orbital pain
Chemosis
Marcus gun pupil (RAPD)
Raised intraocular pressure
Signs of retinal injury - papilloedema, lack of central retinal artery pulsation, pale optic disc

Question 16

Emergency tx of retrobulbar hemorrhage

Answer 16

Medical decompression
IV Mannitol 20% 2g/kg over 5min
IV Dexamethasone 8mg
IV Acetazolamide 500mg (carbonic anhydrase inhibitor) ; 1000mg oral over 24H for maintenance

Surgical

• lateral canthotomy (to make a V of the canthal lig)
• cantholysis (to cut the inferior crus of the canthal lig - check if intraocular pressure reduced, if not cont with superior crus)

Question 17

Classification of hemorrhage

Answer 17

4 classes based on

• volume of blood loss
• % of blood loss
• pulse rate
• BP
• RR
• UO
• CNS

Question 18

Stage 1 hemorrhage (hypovolemic shock)

Answer 18

Volume loss - <750ml
% loss - 15%
PR - normal
BP - normal
RR - normal 
UO - normal
CNs - normal

Question 19

Stage 2 haemorrhage

Answer 19

Volume loss - 750-1500ml
% loss - 15-30%
PR - 100-120
BP - decreased
RR - increase 20-30
UO - decreasing 20-30
Cns - anxious

Question 20

Stage 3 hemorrhagic shock

Answer 20

Volume loss - 1500-2000ml
% loss - 30-40%
PR - 120-140
BP - decreased
RR - increased 30-40
UO - 5-15mls/hr
Cns - confused

Question 21

Stage 4 hemorrhagic shock

Answer 21

Volume loss >2000ml
% loss > 40%
PR - >140
BP - decreased
RR - >35
UO - negligible
Cns - lethargic

Question 22

How do u treat hemorrhagic shock

Answer 22

To restore volume and maintain intravascularly
Replace with whats loss

1. IV crystalloid NS or lactated Ringers (they leak from vascular space, with every L Of fluid, expands 20-30% of intravasc volume)
   - to restore 1L into intravasc - need 3L of NS
2. Transfuse 2 packed cells will increase 1g/dL hb
3. Colloids increase in 1:1 ratio (albumin, hypertonic saline-dextran)

Question 23

How do u manage hemorrhage

Answer 23

1. Stop the bleeding by direct pressure (nasal packing, pressure dressings, clamping of accessible hemorrhaging vessels)
2. Systemic - tranexamic acid (10-15mg/kg)
3. IV crystalloids if hemorrhagic shock
4. Transfusion with packed rbcs

Question 24

How do u protect and maintain the airway in emergency situation

Answer 24

Clear debris
Open airway - neck extension protecting c spine, jaw thrust
OPA cuffed to prevent blood clot/debris to escape to lungs
Cricothyroidotomy
Tracheostomy