Trauma Slides Flashcards
What are the 5 stages of a motor vehicle collision?
- Deceleration of vehicle
- Deceleration of occupants
- Deceleration of organs
- Secondary Collisions (other objects in vehicle)
- Additional Impacts (car involved in subsequent impacts)
Which contributes more to kinetic energy, mass or velocity?
velocity!
KE = M/2V2
Give examples of anatomical restraints and mobile organs which may be involved in deceleration injuries
Anatomical Restraints
- Skull
- Sternum
- Ribcage
- Spine
- Pelvis
Mobile Organs
- Brain
- Heart
- Liver
- Spleen
- Kidneys
- Intestines
Where are spinal injuries due to shear forces likely to arise in deceleration trauma
At junctions between mobile and non-mobile areras
ex: C7/T1 or T12/L1
List three ways in which aortic rupture occurs in deceleration trauma
- Shear forces
- Hydrostatic Forces (water hammer effect)
- Bony compression
What is a bucket handle injury of the intestine
Free floating section of bowel, severed from mesentery due to deceleration trauma
How does brain tissue respond to compressive forces?
It doesn’t! Brain tissue does not compress, but it does swell afterwards
What are the two common injury patterns to front seat occupants in MVI? What injuries are commonly seen?
Down and under
- Slide under dash
- Transfer of energy through femurs to pelvis
- Impact chest on steering column
- Rotation of torso
Up and over
- Go over dash
- Head impacts windshield
- Steering wheel impacts chest, abdomen, and pelvis
- Risk of ejection
- Anterior neck impacts steering wheel
List three findings on examination of the front compartment of a vehicle which may give clues to potential injury patterns
- Deformed windscreen/front of vehicle
- Deformed dashboard
- Deformed steering column
List possible injuries associated with a deformed front of vehicle or windshield
- Traumatic brain injury
- Cervical spinal injury
- Injury to trachea/larynx/pharynx/ hyoid
- Soft tissue and bony injury to face
List possible injuries associated with a deformed steering wheel/column
- Injury to trachea/larynx/pharynx/ hyoid
- Fractures- Ribs, sternum, clavicle
- Flail chest
- Myocardial/pulmonary contusion
- Cardiac tamponade
- Pneumothorax/hemothorax
- Aortic tear/rupture
List possible injuries associated with a deformed dashboard
- Rupture of abdominal organs
- Fracture or dislocation of patella
- Femur fracture
- Pelvis fracture
- Hip dislocation
- Tib/fib fracture
- Spinal fracture due to hyperflexion
Lateral impacts to vehicles are associated with ________ (more/less) serious injuries to occupants. Why?
MORE!
Fewer safety features = faster acceleration/deceleration
Describe the pattern of injury when an adult pedestrian is struck by a vehicle of normal size.
- Vehicle’s bumper impacts lower limbs
- Pedestrian strikes vehicle’s bonnet
- Pedestrian thrown from bonnet to ground
Describe the pattern of injury when an pediatric pedestrian is struck by a vehicle of normal size.
- Vehicles bumper impacts pelvis/femur
- Chest/abdo hit grill or low on bonnet
- Head strikes bonnet then ground
What is Waddell’s triad?
The triad of injury patterns seen in pediatric ped struck situations
- Vehicles bumper impacts pelvis/femur
- Fractured femoral shaft
- Chest/abdo hit grill or low on bonnet
- Intrathoracic/abdominal injuries
- Head strikes bonnet then ground
- Contralateral head injury
What five factors should be considered when assessing a fall from height?
- Height of fall
- Orientation on landing
- Area of impact
- Surface of impact
- Physical condition of the patient (pre-existing)
Children tend to fall _________ (head/feet) first while adults fall ________first
Children = head first
Adults = feet first
What are four physical factors of a patient which may exacerbate injuries from a fall from height?
- Osteoporosis
- Conditions resulting in enlarged organs
- Coagulopathy
- Young children
What are the four main injury mechanisms in blasts?
- Primary injury
- Caused by pressure shockwave
- Secondary injury
- Struck by flying debris
- Tertiary injury
- Being thrown into other objects
- Other injuries
- random other things associated with blasts
What are the meningeal layers and regions where intracranial bleeding can occur?
- Epidural Space (between Dura and skull)
- Dura Mater
- Subdural Space (between Dura and arachnoid)
- Arachnoid Mater
- Subarachnoid Space (between Arachnoid and Pia)
- Pia Mater
- Intracerebral/intraparenchymal/vestibular (within brain matter or ventricles)
What is the Monro-Kellie doctrine?
- Cranium is a fixed-volume container of:
- brain
- blood
- csf
- Increasing pressure forces one (or more) of the three out
- usually starts with CSF, then blood, then brain.
- Hydrocephalus removes this compensatory mechanism
What form of bleeding (arterial or venous) is associated with each kind of intracranial bleeding following trauma?
- Epidural = Arterial
- Subdural = Venous
- Subarachnoid = Usually venous in trauma, arterial if spontaneous
- Intracerebral = either or both
Which form of ICH is most salvageable if caught on time and managed appropriately?
epidural hemorrhage
On the other hand, cataastrophic if not caught/managed early. Brain death within 1-2h if left untreated
Which form of ICH is associated with blow to the temporal region with immediate LOC, followed by a lucid period?
Epidural hematoma/hemorrhage
Indicates rupture of middle meningeal artery. Prompt identification is absolutely essential or brain death occurs within 1-2h
Cerebral contusion bost commonly occurs in which lobe?
Frontal
The Babinski reflex ____ (is/is not) a reliable indicator of injury in the field
is not!
Which of the GCS categories (E,V, or M) is highest yield in assessing TBI?
Motor
What are SBP and MAP targets for TBI management?
SBP > 110mm Hg, MAP >80mm Hg
Slides state SBP>90 mm Hg, Figures above from CPGs
Describe best practice principles for TBI management
- Anticipate airway deterioration
- Anticipate for seizures
- Avoid hypotension (SBP >110, MAP >80)
- Keep normothermic
- High flow oxygen SpO2 >94%
- Maintain EtCO2 30-35 mmHg, do not hyperventilate
- Head of bed at 30 degrees!!
- Loose neck ties!!
What is Cushing’s triad?
- Dysregulation of the sympathetic and parasympathetic impulses in severe brain injury (hypoxia, increased ICP)
- Characterized by: Hypertension, Bradycardia and apnea (some literature states irregular breathing)
What are the classes of lefort fractures?
- I: “floating palate” speak no evil
- involvement of the lateral bony margin of the nasal opening
- II: “Pyramidal” see no evil
- involvement of inferior orbital rim
- III: “Craniofacial dissociation” hear no evil
- invariably involve the zygomatic arch, or cheek bone
What are the 3 neck zones in penetrating neck trauma?
- Zone 3: above the angle of the mandible
- Zone 2: cricoid cartilage up to angle of mandible
- Zone 1: below the cricoid cartilage
Which neck zone houses the laryngeal structures?
Zone 2
Which neck zone contains the trachea, lung apices, and common carotid artery?
Zone 1
What is a fundamental difference between the C1/C2 junction and other vertebral joints?
there is no intervertebral disc at C1/C2 (atlanto-axial junction)
What is the transverse ligament of the spine, and what is the significance of injuries to it?
joins C1 to C2
Transverse ligament injury leads to highly unstable antlanto-axial junction. SCI is likely
Is anterior cord syndrome or posterior cord syndrome more common?
anterior cord injury
the posterior cord is well protected
What is the most common form of incomplete spinal cord injury syndrome (anterior, posterior, central, brown-sequard)
Central!
Where are the primary ascending and descending white matter tracts located in the spinal cord?
All white matter tracts are superficial, while grey matter is deep
- Ascending (sensory) tracts are dorsal, lateral, AND ventral
- Descending (motor) tracts are primarily ventral and lateral
easiest to remember the only exception: there are no descending/motor tracts in the posterior/dorsal spinal cord. They are all ventral or lateral
Briefly describe anterior cord syndrome:
incomplete SCI
- Vibration and proprioception are preserved at all levels
- Ipsilateral motor impairment below injury
- Ciontralateral pain/temperature sensation loss below injury
Briefly describe central cord syndrome:
Most common incomplete SCI
- mostly affects motor skills below injury, sensation is spared
- weakness is more pronounced in upper limbs
- Loss of bladder function leads to urine retention!
Briefly describe Brown-Sequard syndrome
Fully lateralized incomplete SCI (i.e. injury to one side of the spinal cord)
- Contra-lateral loss of pain and temperature
- Ipsilateral motor, proprioception and vibration loss
- All below the injury
What level of injury is typically associated with autonomic dysreflexia?
cervical or high thoracic (down to T6)
How much blood can fill each of the following compartments before a significant tamponade (enough to halt bleeding) occurs?
- pleural cavities
- abdominal cavity
- pelvic cavity
- pleural cavities
- 1.5L each
- abdominal cavity
- 5L
- pelvic cavity
- 6L
What are the three components of the trauma triad of death?
- Hypothermia
- Coagulopathy
- Acidosis
What is the 90,90,9 rule of TBI?
For each of the following, mortality doubles:
- Hypotension <90mmHg
- Hypoxemia <90% SpO2
- DLOC
What are considered low voltage vs. high votlage electrical injuries?
- Low: <500V
- High: >500V
Describe the rule of 9s for estimating BSA in adult burns
- Head = 9%
- Anterior torso = 18%
- Anterior Thorax = 9%
- Anterior abdomen = 9%
- Posterior torso = 18%
- Posterior thorax = 9%
- Posterior abdomen = 9%
- Each leg = 18%
- Anterior/posterior = 9% each
- Each arm = 9%
- Genitals = 1%
The leading preventable cause of death in trauma is:
hemorrhage/bleeding
What are the four types of shock most commonly seen in trauma?
- Hypovolemic/hemorrhagic
- Bleeding
- Obstructive
- Pneumo/hemothorax
- Tamponade
- Distributive
- Neurogenic/spinal
- Cardiogenic
- Arrhythmia
- Direct myocardial injury
How is spinal shock different from neurogenic shock?
Spinal shock is NOT SHOCK! It is loss of function below the level of injury in acute SCI
Neurogenic shock is a distributive shock state caused by loss of sympathetic innervation and may be a result of spinal shock
What are classic signs of neurogenic shock?
- Bradycardia
- Hypotension
- Warm, flushed, well-perfused skin
- Hx suggestive of SCI
Are vital signs changes in severe hemorrhage reliable indicators of shock progression?
NO!
It’s not just kids that compensate well! Treating to vital signs targets only leads to under-resuscitation in 50% of patients.
What are reasonable SBP and MAP targets in trauma (not including suspected TBI)
SBP 80-90mmHg, MAP >65
What two processes contribute to traumatic coagulopathy?
- acute coagulopathy of trauma (TC)
- Loss of blood, platelets, clotting factors
- Metabolic derangement
- resuscitation-induced coagulopathy (IC)
- Injudicious fluid admin
- Iatrogenic hypothermia
What is ACoTS?
Acute Coagulopathy of Trauma-Shock
Early coagulopathy following trauma, seems to have a lot to do with early hyper-fibrinolysis and factor consumption
What are the pillars of reducing ACoTS in trauma patients?
- Permissive hypotension / judicious fluid resuscitation
- Prevention of hypothermia
- Administration of TXA EARLY!
Is Fentanyl administration in trauma associated with hypotension?
NO!!!!!!!!!
NO!!!!!!!!!!!!!!
NO! NO! NO!
Kill this myth. Fentanyl is not morphine. No evidence of significant iatrogenic harm from fentanyl admin in trauma. Don’t force your patients to suffer!
Why is ketamine dosing reduced in patients with a shock index >1?
Because Ketamine is more likely to cause hypotension in these patients
- Ketamine is only hemodynamically stable because it stimulates endogenous catecholamine release*
- Patients with shock index >1 are already releasing all the catecholamines that they can. Ketamine can not stimulate more release. The result is hypotension caused by the CNS-depressant effects of ketamine*
What is an NCTH?
Non-compressible traumatic hemorrhage
e.g. junctional, abdominal, thoracic bleeding
What is the best fluid for resuscitation of trauma patients?
Blood!
Get thee to a hospital, or call for a friendly blood delivery
