TRAUMA, RETRIEVAL & EMST- B (59) Flashcards
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CLINICAL DIFFERENTIATION OF PNEUMO AND HAEMO THORAX
- Both cause resp distress and decr BS, but PT percusses resonant, and haemothorax dull
THE FIRST RIB YOU CAN FEEL BELOW THE CLAVICLE IS…..
The First Rib
PHYSIOLOGICAL IMPACT OF SIMPLE vs TENSION PT
- 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
TREATMENT OF SIMPLE, TENSION AND OPEN PT
- 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.
WHAT IS RE-EXPANSION PULMONARY OEDEMA?
- = 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
TREATMENT OF PULMONARY CONTUSION
Supportive, with:
- Oxygen
- Analgesia
- Judicious IVT
- Ventilatory support as needed
MANAGEMENT OF HAEMOTHORAX
- 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
MEDSTAR EMERGENCY CLAMSHELL THORACOTOMY: INTENT AND METHOD
INTENT:
- To find and fix a Tamponade in a penetrating chest trauma pt who has been down <10m
METHOD
- do bilateral 4ICSM*AL f_in_ger thoracostomies first (excludes PT)
- join up across the midline with knife & trauma shears in the ICS & GIGLI saw for the sternum**
- 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*
WHAT IS A RESUSCITATIVE THORACOTOMY
- 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:
- find and fix a cardiac tamponade
- control exanguinating upper limb junctional bleeding
- control lung bleeding, eg by hilar twist/clamp
- perform ICM, which is much more effective than ECM
- gain IV access directly into the RA
- Aortic cross clamp to control any bleeding below
* or for exanguinating subdiaphragmatic bleeding from blast/gsw
PERICARDIOCENTESIS LANDMARKS
- 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
EFFICIENCY OF ICM vs ECM
- Internal Cardiac Massage is much more effective, producing outputs of up to 66% of normal, vs 25% for ECM
ICM SHOULD BE DONE HOW?…….
- 2 handed
- gently
- with the flats of the fingers, not the tips: they can perforate the myocardium
BLOOD VOLUMES, ADULT V CHILD
- Adult = 70ml/kg
- Child = 80-90 ml/kg
SHOCK =
- Any condition characterized by inadequate tissue perfusion
TYPES OF SHOCK IN TRAUMA
- 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)
NEUROGENIC v SPINAL SHOCK
- 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
CARDIAC OUTPUT FORMULA ?
CO = HR X SV where SV is determined by:
- PRELOAD (which is a volume)
- CONTRACTILITY (which is a %)
- AFTERLOAD (which is a resistance)
SIGNIFICANCE OF A NARROW PULSE PRESSURE in TRAUMA?
- = raised diastolic pressure compared to systolic
- in trauma, it indicates significant SNS compensation for Hypovolaemia
DIAGNOSIS OF OESOPHAGEAL RUPTURE?
- Epigastric trauma
- Severe abdominal pain
- Shock
- widened or pneumo-mediastinum
- Left pleural effusion/food in chest drain
5 CAUSES OF RETRO-PERITONEAL HAEMATOMA
BLEEDING FROM:
- Duodenum or pancreas
- Aorta or IVC
- Kidney
- Ascending or Descending Colon
- tracking up from the pelvis
5 MAJOR SITES OF OCCULT BLOOD LOSS IN TRAUMA
- chest
- abdomen
- pelvis
- long bones
- retro-peritoneum
(and, in children, from the scalp)
XRAY SIGNS OF AORTIC INJURY ?
- wide mediastinum
- L pleural effusion/cap
- NGT or trachea displaced to the R
HOW/WHEN TO ASSESS PELVIC STABILITY IN TRAUMA
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)
BLOOD AT THE (MALE) URETHRAL MEATUS IS…..
- An ABSOLUTE C/I to IDC (as likely urethral injury)
WHICH PELVIC FRACTURES BLEED MORE?
Fractures which ‘open’ the pelvic ring, like AP COMPRESSION or VERTICAL SHEAR fractures bleed more then those which close it, eg LATERAL COMPRESSION fractures.
FIRST AID FOR PELVIC FRACTURES
CLOSE the pelvic ring with
- Pelvic binder (or sheet)
- Internal rotation of the legs + knee and ankle bandages
CAN THE PELVIC BINDER BE USED CO-INCIDENT WITH A FEMORAL SPLINT?
- Yes it can
A BETTER TERM THAN ‘HAEMODYNAMICALLY STABLE’ is….
- ‘CURRENT haemodynamics are NORMAL’
WHEN TO DO THE LOG ROLL IN EMST?
- 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
ROLE OF FAST IN EMST?
- FAST is now part of the primary survey to look for pneumothorax or bleeding into the abdomen or chest
REMOVAL OF CLOTHES IN EMST?
all clothes should be cut off as soon as possible in:
- all penetrating trauma
- any SERIOUS blunt trauma, preferably in parallel with the ABCs
HOW NEGATIVE IS INTRATHORACIC PRESSURE IN RESPIRATION?
- approx -5cm H2O in normal respiration
- up to -30cm H2O at a maximum
WHAT ARE THE 6 PARTS OF A ‘6 PACK’ CT
The ‘6 pack’ is an initial trauma pan-scan which images:
- Head with contrast
- Head without contrast
- Entire spine
- Chest
- Abdomen
- Pelvis to mid femur
10% OF PATIENTS WITH A C-SPINE FRACTURE……
- will have a second, non contiguous vertebral #
HOW DO FEMORAL TRACTION SPLINTS REDUCE BLEEDING?
- by reducing movement (which disrupts clot) at the site
- by converting the thigh space from a sphere to a cylinder, reducing its volume
OPEN FRACTURES AND COMPARTMENT SYNDROME
- A fracture being open does not prevent compartment syndrome
HOW TO SECURE A CHEST TUBE
- close the skin incision each side of the tube with interupteds
- use a large suture through the skin adjacent to secure the tube itself
- no purse strings: seal with an occlusive dressing on removal
NASAL FENTANYL DOSE & TECHNIQUE
- 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
GENERIC FEATURES OF POISONING AND OD, AND INITIAL Rx
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
TREATMENT OF PARACETAMOL OD
- 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
SPECIFIC TREATMENT OF METHANOL POISONING
- 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%
PARAQUAT POISONING
- 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
GIVING INOTROPES VIA PERIPHERAL IVT
- 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
NGT AFTER TRAUMA RSI IN CHILDREN
- 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)
HOW TO DO A SUPRAPUBIC CATHETER
- 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
HOW TO RELOCATE THE RECALCITRANT OPEN ANKLE #
- _Bend i_t: flex the knee: dont pull on a straight leg
- Over bend it: exaggerate the deformity to hook the bone ends together
INTRA ARTICULAR BLOCK FOR DISLOCATED SHOULDER
- 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*
STIMSONS (HANGING) METHOD FOR SHOULDER REDUCTION
- 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
ETOMIDATE FOR RSI (US)
- 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
WHAT ARE THE THREE “10mm” COMPARTMENT PRESSURES?
Normal pressures inside the:
- head
- abdomen and
- muscle compartments
do not exceed 10mmHg
10 CAUSES OF ACUTE SOB IN MEDICAL PATIENTS
- bronchospasm
- PT
- PE
- effusion
- ischaemia
- arryhthmia
- failure
- anaemia
- infection
- exacc COAD
HOW TO DO EXTERNAL PACING
- 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
HOW TO DO A CARDIOVERSION
- 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)
CARDIOVERSION AND DEFIBRILLATION DOSES?
-
CARDIOVERSION (AF/SVT/VT)
- = (sync) 100 then 150J (kids 1 then 2 J/kg)
-
DEFIBRILLATION (V__F)
- = 200J (kids 4J/kg)
MANAGING SEVERE MAXILLOFACIAL BLEEDING
- Secure airway with ETT
- Insert DENTAL PROPS bilaterally
- Ensure C-Collar on to support jaw
- 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
PUPILLARY HIPPUS
- = 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
FIXED DILATED PUPILS IN STATUS EPILEPTICUS
- are NOT indicative of cerebral herniation unless otherwise suspected
WHAT ARE ‘DIAGNOSTIC’ ECG CHANGES IN MI?
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
TREATMENT OF ALKALINE BURNS TO THE EYE
- = 8 hours continuous irrigatin with water, eg with a small cannula affixed to the eyebrow
