Trauma principles Flashcards
Components of airway assessment in primary survey
Listen: Patient talking? Quality? Airway noise (bubbling/stridor)
Look: Bleeding/soft tissue swelling, objectsin airway
Feel: Crepitus/emphysema, C-spine stepping
Immobilise if blunt trauma above clavicle or high-energy trauma
Resuscitate: C-spine immobilisation, airway adjunct, inform ITU
Components of breathing assessment in primary survey
Look: Bruising, injuries, chest movements (symmetry, paradoxicality), respiratory rate
Listen: Air entry throughout
Feel: Chest expansion, percussion, midline trachea
Investigate: Oximetry, CXR
Resuscitate: O2 if required
Components of circulation assessment in primary survey
Look: peripheral and central capillary refill, bleeding (external, abdomen, pelvis)
Feel: Pulse - rate, rhythm
Investigate: IV access, BP, ECG, ?echo, FAST scan, pelvic XR
Resuscitate: Warm colloid/blood/FFP, tranexamic acid, activate major haemmorhage protocol
Components of disability in primary survery
- Brainstem reflexes (esp pupils)
- GCS (incl unequal responses to pain indicating weakness)
- Plantars
- Blood glucose
Components of exposure in primary survey
Temperature - measure and treat accordingly
Expose patient + log-roll for other sources of injury
Sources of blood in trauma
On the floor and:
- Chest –> drain
- Abdomen –> surgery
- Long bones –> splint
- Pelvis –> binder
Life-threatening chest injuries
ATOM FC
Airway obstruction
Tension pneumothorax
Open pneumothorax
Massive haemothorax
Flail chest
Cardiac tamponade
Management of airway obstruction
Clear foreign objects, suction for aspiration, airway adjuncts, ITU
Management of tension pneumothorax/massive haemothorax
Finger thoracostomy + chest drain insertion in safe triangle
Anatomical borders of safe triangle
5th intercostal space
pec major
lat dorsi
Base of axilla
Management of open pneumothorax
Three-way dressing, chest drain insertion
Reversible causes of cardiac arrest
4Hs and 4Ts
Hypothermia
Hypo/hyperkalaemia
Hypovolaemia
Hypoxia
Tension pneumothorax
Tamponade
Thrombosis
Toxins
Management of cardiac tamponade
clamshell thoracotomy
Describe the major fracture patterns
System for describing a fracture
- Bone: Which bone(s)? Where in bone?
- Type of fracture: Spiral, oblique, etc…
- Displacement: Rotation, translation, angulation, shortening (refer to distal fragment)
- Joint: Intra- or extra-articular; dislocation/subluxation
- Neurovascular: O/E any compromise
- Soft tissues: Open/closed, compartment syndrome
AO classification for diaphyseal fractures
AO classification for metaphyseal fractures
Forms of fracture management
- No treatment (beware in neuropaths)
- Non-surgical immobilisation
- External surgical fixation
- Internal surgical fixation
- Intramedullary/extramedullary
- Replacement
Rule of 3s for fracture healing
Closed
Paediatric
Metaphyseal
Upper limb fracture
Takes 3 weeks. Any change = doubling of healing time
Risk factors for poor fracture healing
Older age
Co-morbidity (e.g. diabetes, malignancy)
Smoking
NSAIDs/steroids
Osteoporosis
Local infection/poor blood supply
Principles of fracture management
Reduction
Immobilisation
Rehabilitation
Aims of fracture reduction
- Anatomical position to promote union
- Maintain neurovascular supply
- Pain relief
- Stability
Indications/advantages of external fixation
Burns/skin loss/open fractures
Minimises soft tissue disruption + allows postoperative manipulation
Indications/advantages of internal fixation
2 #s in one limb
Unstable fractures
Intra-articular #s
allows early restoration of function
Forms of internal fixation for fractures
Plate and screws: Used for long bones, bu may hold apart
Intramedullary nail: For shaft fractures
Dynamic screws: Compression screw plate aka dynamic hip screw –> allows it to be forced together as NOF
K-wires: For small metaphyseal segments
Initial management of open fracture
- Assess neurovascular stuts
- Assess for compartment syndrome
- IV antibiotics
- Tetanus prophylaxis
- Irrigate
- Wound cover - saline-moistened sterile occlusive dressing
- Splintage and immobilisation
- X-ray and photograph
- Debride IN THEATRE
Gustillo grade I fracture definition
Open wound <1cm, clean, minimal soft tissue injury
Gustill-Anderson grade II open fracture
Wound >1cm, without extensive soft tissue damage
Gustillo-Anderson grade IIIa
Open wound, soft tissue damage (flaps, avulsions) but with adequate cover
Gustillo-Anderson grade IIIb
Bone exposure (extensive soft tissue damage
Definition of compartment syndrome
Raised pressure within a closed compartment (fascial, burns, plaster) resulting in tissue ischaemia and necrosis
Clinical presentation of compartment syndrome
Red, swollen, tender muscle
Very painful for passive stretch
Pain out of proportion to clinical appearance
Injuries with high index of suspicion for compartment syndrome
Crush
gunshot
burn
polytrauma (+ low GCS)
Tight plaster casts
Treatment of acid burns
ABC
Irrigation
Calcium gluconate
Treat hyperkalaemia + protect kidneys (fluids)
Analgesia in trauma settings
IV diamorphine up to 10mg titrated to effect
2nd line: Ketamine
Medication for major haemmorhage
1g TXA
GCS - Eye response
Spontaneously
Verbal command
Pain
None
GCS - motor response
Obeys commands
Localises pain
Flexion/withdrawal
Abnormal flexion
Extension
No response
GCS - vocal response
Oriented
Disoriented
Words
Sounds
None
CURB-65 scoring
>=2 –> admit
Confusion
Urea >7
RR >30
BP: <90/60
Age >65
Gold-standard treatment of traumatic pneumothorax
Bilateral finger thoracostomy + chest drain
Classes of haemmorhagic shock
I: 0-15% blood loss, pulse <100
II: 15-30% blood loss, pulse 100-120
III: 30-40% blood loss, pulse 120-140
IV: >40% blood loss, pulse >140
Complications of open fractures
Infection (esp gas gangrene from C. perfringens)
Compartment syndrome
Neurovascular damage
Ortho history taking components
Pain (esp night pain)
Loss of f(x) - ADL, occupation
Swelling - timing
Stiffness
Deformity
PMHx- esp ortho, hip replacements
Approach to MSK radiology - COPE
Check - right pt, right date, right side, right view
Old/other films - >1 view if necessary
Penetration - adequate?
Exposure - Full view given on film?
Approach to MSK radiology -ABCS
Alignment - check joint space, bone lines
Bone - Check for any jagged edges, colour change, density change, cysts, enlargement
Cartilage/cortex - Check for cartilaginous defect or breaks in bone cortical edge/periosteal reactions
Soft tissue - check for swelling, bleeding, hardware/foreign bodies
