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BPs Decks > TRAUMA, RETRIEVAL & EMST- B (59) > Flashcards

TRAUMA, RETRIEVAL & EMST- B (59) Flashcards

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1
Q

CLINICAL DIFFERENTIATION OF PNEUMO AND HAEMO THORAX

A
  • Both cause resp distress and decr BS, but PT percusses resonant, and haemothorax dull
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2
Q

THE FIRST RIB YOU CAN FEEL BELOW THE CLAVICLE IS…..

A

The First Rib

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3
Q

PHYSIOLOGICAL IMPACT OF SIMPLE vs TENSION PT

A
  • the main effect of a SIMPLE PT is hypoxia due to lung collapse and SHUNTING
  • TENSION PT adds haemodynamic compromise as well, by raising ITP, which impairs venous return
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4
Q

TREATMENT OF SIMPLE, TENSION AND OPEN PT

A
  • SIMPLE PT = 4*ICSMAL tube
  • TENSION PT = 2ICS needle then 4ICSMAL tube (or finger alone if IPPV)
  • OPEN PT = seal, then 4ICSMAL tube

* EMST states 4th or 5th, going higher reduces risk of being below diaphragm. The 4th interspace is about the nipple level in males, go higher if anything.

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5
Q

WHAT IS RE-EXPANSION PULMONARY OEDEMA?

A
  • = sudden onset of Ipsilateral, bilateral or even contralateral PULMONARY OEDEMA after drainage of a large PNEUMOTHORAX or EFFUSION
  • it is a rare (1%) but life threatening (20%) complication, the risk of which can be reduced by
    • limiting initial effusion drainage to 1500mls, and
    • not using suction to re-expand PT
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6
Q

TREATMENT OF PULMONARY CONTUSION

A

Supportive, with:

  • Oxygen
  • Analgesia
  • Judicious IVT
  • Ventilatory support as needed
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7
Q

MANAGEMENT OF HAEMOTHORAX

A
  • bleeding in haemothorax is usually self limiting and manageable with a 4ICSMAL tube
  • surgery only if:
    • large initial drainage (>1500ml*) or
    • ongoing loss requiring transfusion

* note: both needles AND CHEST TUBES block easily with clot, so neither reliably estimate loss

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8
Q

MEDSTAR EMERGENCY CLAMSHELL THORACOTOMY: INTENT AND METHOD

A

INTENT:

  • To find and fix a Tamponade in a penetrating chest trauma pt who has been down <10m

METHOD

  1. do bilateral 4ICSM*AL f_in_ger thoracostomies first (excludes PT)
  2. join up across the midline with knife & trauma shears in the ICS & GIGLI saw for the sternum**
  3. spread and look for (dark) blood of tamponade, and if found:
  • slit pericardium widely
  • plug hole with finger then foley (small holes tend to self seal)
  • refill circn
  • restart (flick with a finger/ext defib if VF)
  • perform 2 handed ICM if indicated
  • consider aortic compression above or below the diaphragm
  • * go well posterior to maximise chest exposure*
  • ** keep the hands well spread so the saw is not describing an acute loop around the bone: this causes jamming*
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9
Q

WHAT IS A RESUSCITATIVE THORACOTOMY

A
  • this is a L anterior thoracotomy performed as part of a trauma resus
  • it has modest success (~10%) if performed within 10m of loss of vitals in patients with penetrating chest injury*, esp tamponade from cardiac stab wounds, but is usually futile in blunt trauma
  • it has 6 potential benefits:
  1. find and fix a cardiac tamponade
  2. control exanguinating upper limb junctional bleeding
  3. control lung bleeding, eg by hilar twist/clamp
  4. perform ICM, which is much more effective than ECM
  5. gain IV access directly into the RA
  6. Aortic cross clamp to control any bleeding below

* or for exanguinating subdiaphragmatic bleeding from blast/gsw

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10
Q

PERICARDIOCENTESIS LANDMARKS

A
  • insert the needle in subxiphoid space and advance toward tip of L scapula
  • NOTE: the myocardium has a tendency to self seal and blood often wont reaccumulate after initial evacuation
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11
Q

EFFICIENCY OF ICM vs ECM

A
  • Internal Cardiac Massage is much more effective, producing outputs of up to 66% of normal, vs 25% for ECM
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12
Q

ICM SHOULD BE DONE HOW?…….

A
  • 2 handed
  • gently
  • with the flats of the fingers, not the tips: they can perforate the myocardium
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13
Q

BLOOD VOLUMES, ADULT V CHILD

A
  • Adult = 70ml/kg
  • Child = 80-90 ml/kg
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14
Q

SHOCK =

A
  • Any condition characterized by inadequate tissue perfusion
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15
Q

TYPES OF SHOCK IN TRAUMA

A
  • is usually HYPOVOLAEMIC, with clear sympathetic responses: pallor and tachycardia

but may also be:

  • CARDIOGENIC (includes Contusion, Rupture, Tamponade or Tension)
  • NEUROGENIC (warm, slow hypotension)
  • SEPTIC (late)
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16
Q

NEUROGENIC v SPINAL SHOCK

A
  • NEUROGENIC SHOCK = warm slow hypotension due to loss of SNS tone after cord injury
  • SPINAL SHOCK = widespread flaccid skeletal muscle paralysis seen immediately after cord injury
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17
Q

CARDIAC OUTPUT FORMULA ?

A

CO = HR X SV where SV is determined by:

  • PRELOAD (which is a volume)
  • CONTRACTILITY (which is a %)
  • AFTERLOAD (which is a resistance)
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18
Q

SIGNIFICANCE OF A NARROW PULSE PRESSURE in TRAUMA?

A
  • = raised diastolic pressure compared to systolic
  • in trauma, it indicates significant SNS compensation for Hypovolaemia
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19
Q

DIAGNOSIS OF OESOPHAGEAL RUPTURE?

A
  • Epigastric trauma
  • Severe abdominal pain
  • Shock
  • widened or pneumo-mediastinum
  • Left pleural effusion/food in chest drain
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20
Q

5 CAUSES OF RETRO-PERITONEAL HAEMATOMA

A

BLEEDING FROM:

  1. Duodenum or pancreas
  2. Aorta or IVC
  3. Kidney
  4. Ascending or Descending Colon
  5. tracking up from the pelvis
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21
Q

5 MAJOR SITES OF OCCULT BLOOD LOSS IN TRAUMA

A
  1. chest
  2. abdomen
  3. pelvis
  4. long bones
  5. retro-peritoneum

(and, in children, from the scalp)

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22
Q

XRAY SIGNS OF AORTIC INJURY ?

A
  • wide mediastinum
  • L pleural effusion/cap
  • NGT or trachea displaced to the R
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23
Q

HOW/WHEN TO ASSESS PELVIC STABILITY IN TRAUMA

A

It should be done:

  • once only
  • by the most experienced clinician
  • by stressing the iliac crests in then out
  • and avoided entirely where pelvic injury is obvious (to avoid disrupting the clot)
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24
Q

BLOOD AT THE (MALE) URETHRAL MEATUS IS…..

A
  • An ABSOLUTE C/I to IDC (as likely urethral injury)
25
Q

WHICH PELVIC FRACTURES BLEED MORE?

A

Fractures which ‘open’ the pelvic ring, like AP COMPRESSION or VERTICAL SHEAR fractures bleed more then those which close it, eg LATERAL COMPRESSION fractures.

26
Q

FIRST AID FOR PELVIC FRACTURES

A

CLOSE the pelvic ring with

  • Pelvic binder (or sheet)
  • Internal rotation of the legs + knee and ankle bandages
27
Q

CAN THE PELVIC BINDER BE USED CO-INCIDENT WITH A FEMORAL SPLINT?

A
  • Yes it can
28
Q

A BETTER TERM THAN ‘HAEMODYNAMICALLY STABLE’ is….

A
  • ‘CURRENT haemodynamics are NORMAL’
29
Q

WHEN TO DO THE LOG ROLL IN EMST?

A
  • as early as possible in SHARP trauma (its part of C & B in C-ABCDE), preferrably at initial transfer onto the resus gurney, and certainly before D
  • at leisure in blunt trauma, usually as part of the secondary survey
30
Q

ROLE OF FAST IN EMST?

A
  • FAST is now part of the primary survey to look for pneumothorax or bleeding into the abdomen or chest
31
Q

REMOVAL OF CLOTHES IN EMST?

A

all clothes should be cut off as soon as possible in:

  • all penetrating trauma
  • any SERIOUS blunt trauma, preferably in parallel with the ABCs
32
Q

HOW NEGATIVE IS INTRATHORACIC PRESSURE IN RESPIRATION?

A
  • approx -5cm H2O in normal respiration
  • up to -30cm H2O at a maximum
33
Q

WHAT ARE THE 6 PARTS OF A ‘6 PACK’ CT

A

The ‘6 pack’ is an initial trauma pan-scan which images:

  1. Head with contrast
  2. Head without contrast
  3. Entire spine
  4. Chest
  5. Abdomen
  6. Pelvis to mid femur
34
Q

10% OF PATIENTS WITH A C-SPINE FRACTURE……

A
  • will have a second, non contiguous vertebral #
35
Q

HOW DO FEMORAL TRACTION SPLINTS REDUCE BLEEDING?

A
  1. by reducing movement (which disrupts clot) at the site
  2. by converting the thigh space from a sphere to a cylinder, reducing its volume
36
Q

OPEN FRACTURES AND COMPARTMENT SYNDROME

A
  • A fracture being open does not prevent compartment syndrome
37
Q

HOW TO SECURE A CHEST TUBE

A
  1. close the skin incision each side of the tube with interupteds
  2. use a large suture through the skin adjacent to secure the tube itself
  3. no purse strings: seal with an occlusive dressing on removal
38
Q

NASAL FENTANYL DOSE & TECHNIQUE

A
  • 1.5 mcg/kg, atomised only via a MAD, 27g needle does not work
  • NOTE
    • prime MAD prior
    • use neat with 1ml LUER LOCK syringe (or blows off)
    • administer as fast as possible to get best atomisation
39
Q

GENERIC FEATURES OF POISONING AND OD, AND INITIAL Rx

A

Generic features of poisonings and ODs include:

  • LOC
  • Seizures
  • Airway/Respiratory depression
  • Arrhythmias and hypotension
  • Nausea/vomiting

General Treatment Plan:

  • Assess/secure airway and ventilation
  • For ingestions, consider warm water lavage (only if within 1h), and Activated Charcoal 50g O/NGT
  • Give IV fluids and vasoconstrictors for Hypotension, not adrenergics lest prolonged QT
  • Consider pacing for bradycardia
  • Specific antidotes if available, eg ACETYL CYSTEINE for Paracetamol or ETHANOL for Methanol
40
Q

TREATMENT OF PARACETAMOL OD

A
  • PARACETAMOL is mostly metabolised harmlessly in the liver, but a secondary pathway exists with hepatotoxic metabolites.
  • These are normally mopped up by Hepatic GLUTATHIONE, but this depletes in OD (>10g/20 tabs).
  • ACETYL-CYSTEINE (PARVOLEX) can be hepatoprotective in OD by regenerating GLUTATHIONE

Management of OD

  • general measures, plus:
  • check Paracetamol levels after 4h and consult risk nomogram: if at risk, or unknown, and within 12h, give ACETYL CYSTEINE per the protocol
41
Q

SPECIFIC TREATMENT OF METHANOL POISONING

A
  • METHANOL is not toxic per se, but is metabolised to FORMALDEHYDE which is, producing a severe METABOLIC ACIDOSIS, and neuro toxicity after 12-18h.
  • ETHANOL may be used as a competetitive substrate to block the metabolism of Methanol
  • DOSE: give 50g of Ethanol as either
    • ORAL/NGT : give 5 std drinks, diluted to 1000mls with water
    • IV : give 50 mls of 100% Ethanol slowly via CVC, or diluted to 1000mls with NS and given peripherally
    • repeat 4/24 for several days, titrated to a BAC of 0.10-0.15%
42
Q

PARAQUAT POISONING

A
  • PARAQUAT is a common herbicide, and occasional suicide agent
  • Ingestion of as little as a mouthful can kill, even if immediately spat out, and despite patients initially appearing quite well: they subsequently develop lethal ARDS.
  • Treatment is supportive, there is no specific antidote, although FULLERS EARTH absorbs it
43
Q

GIVING INOTROPES VIA PERIPHERAL IVT

A
  • ADREN up to ~10mcg/min into a large free flowing vein is OK but NORAD less so: it causes severe vasospasm
  • IO may be a better option
44
Q

NGT AFTER TRAUMA RSI IN CHILDREN

A
  • children are very prone to acute gastric dilatation in trauma, so should always have a stomach tube passed after trauma RSI (as should adults really)
45
Q

HOW TO DO A SUPRAPUBIC CATHETER

A
  • confirm bladder is full clinically or by U/S
  • go in vertically, just above symphysis with large IV cannula or proprietary kit
  • aspirate as you go to confirm placement
46
Q

HOW TO RELOCATE THE RECALCITRANT OPEN ANKLE #

A
  1. _Bend i_t: flex the knee: dont pull on a straight leg
  2. Over bend it: exaggerate the deformity to hook the bone ends together
47
Q

INTRA ARTICULAR BLOCK FOR DISLOCATED SHOULDER

A
  • this can be a useful technique when anaesthesia/sedn is not desired
  • puncture the skin 2cm inf to the acromion directly lateral with a long needle (eg spinal)*
  • advance 45 degrees down until blood aspirated**
  • inject 20mls 1% lignocaine
  • works in 5-10m

  • * its deeper than you think*
  • ** if you dont get blood, you are not in*
48
Q

STIMSONS (HANGING) METHOD FOR SHOULDER REDUCTION

A
  • this is an old technique suitable for simple analgesia or intra-artic block
  • pt lies prone on a table with the arm hanging down with a 5-10kg wt on the wrist
  • may take 10-15m
49
Q

ETOMIDATE FOR RSI (US)

A
  • Until recently, ETOMIDATE was a popular IV Induction agent for trauma RSI in US circles for its ability to support the circulation, without raising ICP
  • Its now falling from favour, particularly for compromised ICU patients, due to recognition that even a single dose can cause long term Adrenocortical Suppression
  • DOSE :
    • 0.3 mg/kg
50
Q

WHAT ARE THE THREE “10mm” COMPARTMENT PRESSURES?

A

Normal pressures inside the:

  1. head
  2. abdomen and
  3. muscle compartments

do not exceed 10mmHg

51
Q

10 CAUSES OF ACUTE SOB IN MEDICAL PATIENTS

A
  1. bronchospasm
  2. PT
  3. PE
  4. effusion
  5. ischaemia
  6. arryhthmia
  7. failure
  8. anaemia
  9. infection
  10. exacc COAD
52
Q

HOW TO DO EXTERNAL PACING

A
  • Consider pharmacological pacing
  • Consider sedation
  • Apply dots (reqd as well as pads)
  • Apply PADS (AP over L central chest)
  • Select Pace mode on DEFIB
  • Commence pacing at 20mA and 100 BPM
  • increase until capture, typically ~50mA
  • Confirm palpable pulse accompanies electrical capture
  • If hiccups occur, move pads cranially, away from diaphragm
53
Q

HOW TO DO A CARDIOVERSION

A
  • check anticoagulation/TOE
  • Apply PADS AP over L central chest
  • consider sedation
  • CHARGE to 100 then 150J (1 then 2 J/kg)
  • SYNC on ALWAYS (on R wave)
  • Press and HOLD the SHOCK button (there may be a short delay for sync)
54
Q

CARDIOVERSION AND DEFIBRILLATION DOSES?

A
  • CARDIOVERSION (AF/SVT/VT)
    • = (sync) 100 then 150J (kids 1 then 2 J/kg)
  • DEFIBRILLATION (V__F)
    • = 200J (kids 4J/kg)
55
Q

MANAGING SEVERE MAXILLOFACIAL BLEEDING

A
  1. Secure airway with ETT
  2. Insert DENTAL PROPS bilaterally
  3. Ensure C-Collar on to support jaw
  4. insert EPISTATS bilaterally
    • Inflate each posterior balloon with 10mls NS & pull forwards
    • SEQUENTIALLY* inflate each anterior balloon with 20-30mls NS, a few mls at a time

* to avoid # displacement

56
Q

PUPILLARY HIPPUS

A
  • = rhythmically oscillating* pupillary size sometimes seen in fitting patients. This may be the only sign that a paralysed, anaesthetised patient is still seizing

* as on the back of a galloping horse

57
Q

FIXED DILATED PUPILS IN STATUS EPILEPTICUS

A
  • are NOT indicative of cerebral herniation unless otherwise suspected
58
Q

WHAT ARE ‘DIAGNOSTIC’ ECG CHANGES IN MI?

A

STEMI consists of:

  • >1mm elevation in 2 contiguous limb leads or
  • >2mm elevation in 2 anterior chest leads*

* T Inversion does not count, nor does ST Depression, unless in the anterior chest leads, when it can represent the reciprocal changes of Posterior MI

59
Q

TREATMENT OF ALKALINE BURNS TO THE EYE

A
  • = 8 hours continuous irrigatin with water, eg with a small cannula affixed to the eyebrow

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