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Year 3 Surgery > 8 - Major Trauma > Flashcards

8 - Major Trauma Flashcards

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1
Q

What is ROCSM?

A

Restriction of Cervical Spine Motion

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2
Q

At what GCS score are patients unable to maintain their airway?

A

8 or below

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3
Q

What is important about a fracture to the first rib?

A

Requires such significant energy that it is v likely there are other injuries

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4
Q

What is shock?

A

Failure of the circulation to provide adequate perfusion to the tissues

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5
Q

What are the classes of shock?

A

Class I - <15% blood loss - normal vitals
Class II - 15-30% blood loss - tachycardia + narrowing of pulse pressure
Class III - 30-40% blood loss - low BP, reduced urine output, anxiety/mild confusion, tachypnoea
Class IV - >40% blood loss - reduced consciousness

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6
Q

What are the 5 places that blood can be sequestered in the body during major trauma? (On the floor and four more…)

A

External bleeding
Abdominal bleeding
Chest bleeding
Long bone bleeding (especially femoral)
Retroperitoneal bleeding

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7
Q

What is Poiseuille’s law

A

That flow through a tube is proportional to the radius to the power 4 and inversely proportional to the length (i.e. short and fat tubes better than long thin ones for resus)

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8
Q

What is the definition of a major transfusion?

A

Replacement of total blood volume in 24 hours (i.e. > 10 units of blood)

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9
Q

What are the common complications of major transfusion?

A

Metabolic alkalosis
Hypocalcaemia
Hypothermia
Hyperkalaemia

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10
Q

Why does major transfusion cause hypocalcemia?

A

There is addition of sodium citrate to blood products - the citrate binds to calcium in the patient and inactivates it.

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11
Q

Why does major transfusion cause metabolic alkalosis?

A

Citric acid and lactate from the stored blood are converted to bicarbonate in the liver.

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12
Q

Why does major transfusion cause hyperkalaemia?

A

Cell lysis in the stored blood = release of K+
Also K+ / H+ pump stops working as well - allows K+ to leak out of the cells.

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13
Q

What is the function of tranexamic acid? How does it do this?

A

It stops clots breaking down
It binds (reversibly) to plasminogen - reduces the conversion of plasminogen to plasmin (plasmin is used to break down fibrin in clots)

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14
Q

What is the window for tranexamic acid to be given as treatment to significant reduce death?

A

Within 3 hours

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15
Q

Deceleration injuries can do what to the aorta?

A

Cause a tear at the ligamentum arteriosum - is unsurvivable.

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16
Q

In deceleration injuries - at which point does the aorta tear?

A

At the ligamentum arteriosum (between aortic arch and pulmonary trunk).

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17
Q

What is Beck’s triad

A

Signs of cardiac tamponade
- Muffled heart sounds
- Low BP
- Distended neck veins

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18
Q

What is the most common cause of cardiac tamponade?

A

Blunt chest injury from hitting a steering wheel

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19
Q

What is the immediate management of a long bone fracture?

A

Splinting - can tamponade bleeding and reduce pressure on nerves or TVs

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20
Q

How much blood can be lost with a femoral fracture?

A

1-2L

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21
Q

Which three things are scored for GCS?

A

Eye Response
Speech Response
Motor Response

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22
Q

How is the eye scored on GCS?

A

4 - Spontaneous movement
3 - To Speech
2 - To Pain
1 - No response

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23
Q

How is speech scored on GCS?

A

5 - Orientated to time and place
4 - Confused
3 - Inappropriate words
2 - Incomprehensible sounds
1 - No response

(Orientated, confused, words, sounds, unresponsive)

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24
Q

How is motor control scored on GCS?

A

6 - Obeys command
5 - Moves to localised pain
4 - Flex to withdraw from pain
3 - Abnormal flexion
2 - Abnormal extension
1 - No response

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25
What are the GCS thresholds for brain injury?
13-14 = mild brain injury 9-12 = moderate brain injury 8 or below = severe brain injury
26
Why is the airway at risk with a GCS less than 8
Risk of occlusion of the airway from the tongue
27
What is the difference between primary and secondary brain injury?
Primary = result of direct injury to the brain tissue Secondary = failure to maintain adequate oxygenation and perfusion the brain tissue during assessment
28
What is the Monro-Kellie doctrine?
It says that the brain is in a fixed chamber - and that venous volume and CSF will be moved out first in the case of raised ICP (75ml of each)
29
What is the point of decompensation with raised ICP?
Is the point where the brain starts to herniate out of the foramen magnum.
30
What clinical sign can indicate the point of decompensation? What CN is effected to result in this?
Blown / dilated pupil CN III which travels around the border of the foramen magnum
31
10% of Ps with a cervical spine fracture will have?
A second non-continuous vertebral column fracture elsewhere
32
What do you need to worry about if a patient has been lying on a hard board for > 2 hours?
Pressure ulcers
33
Why can trauma patients be at risk of hypothermia?
Pre-hospital exposure Iatrogenic - removal of clothing, rapid infusion of cool fluids
34
How high does the diaphragm go in expiration? What does this mean for trauma?
5th intercostal space That Lowe chest injuries can affect th abdomen
35
What do you need to be cautious of with pelvic injuries?
Pelvic injuries require massive force - therefore need to be concerned about soft tissue in the area - can have significant bleeding in this area.
36
Which is the most commonly injured abdominal organ?
The liver
37
Which imaging is good to detect liver trauma?
CT with contrast
38
How is liver injury managed?
Often conservatively If severe - may need surgery for packing or resection (v rare). Can do endovascular tx if available.
39
How is the spleen most commonly injured?
Blunt trauma
40
How is splenic injury treated?
If unstable with significant injury = splenectomy Lesser injury & stable = splenic artery embolisation Minor injury = conservative manage & close monitoring
41
What can result from splenic injury?
Catastrophic haemorrhage
42
How is the kidney most commonly injured?
Blunt trauma
43
If the kidney is injured from trauma - what should you also check for?
Other injuries - in up to 95% of cases there is another injury. Kidney is seldom an isolated injury
44
What is the most common clinical sign that the kidney is injured? How do you diagnose kidney injury?
Haematuria (visible or microscopic) Diagnosed with CT
45
How are renal injuries often managed?
95% can be managed conservatively Surgery or endovascular intervention if unstable
46
How does the pelvis commonly break?
In more than one place - like a polo mint
47
What is the commonest cause of pelvic injury?
High energy blunt injury
48
What is important to consider when dealing with a pelvic injury?
That blood loss can be significant in this area - the pelvis can hold the entire blood volume. Is lots of pelvic vasculature that can bleed. Damage can occur to abdomen or pelvic viscera
49
What is the cause of an unstable "open book" pelvic fracture?
Anterior-posterior compression
50
What are the signs of an unstable pelvic fracture?
Externally rotated legs Bleeding / bruising (perineum, PR, PV)
51
How do we initially treat an unstable pelvic fracture? Why?
Pelvic binder - reduces the volume and therefore the potential blood loss.
52
What is the management of a pelvic fracture?
Diagnosis - CT, MRI, Retrograde urethrogram, angiography (+/- embolisation) Control bleeding - pelvic binder (temporary), surgery (less common), radiological intervention (v common) Fix bones - externally or internally
53
Which burns should be discussed with a specialist burns unit?
ALL facial, extensive or specialised area burns (i.e. hands, genitals)
54
What are the following all warning signs of? What should you do? Soot in mouth/nose Facial burns Singed facial hair Stridor / noisy breathing Swelling of lips or tongue
Signs of possible impending airway obstruction Secure an early definitive airway
55
If chest burns are substantial, what intervention can help with the patient's breathing? Why?
Escharotomy Burned skin = inelastic = restricts chest wall movement
56
Why do burns patients needs fluids?
To replace losses from capillary leaks due to inflammation (not bleeding)
57
What do we do for chemical burns?
Flush with large amounts of warm water for 20-30 minutes
58
Which chemical burn is worse - acid or alkali?
Alkali - penetrates more deeply and causes widespread tissue necrosis
59
What is the consequence of electrical burns that we need to be worried about?
Muscle breakdown --> rhabdomyolysis --> renal failure
60
Why can muscle breakdown cause kidney failure?
Breakdown release creatine kinase, lactic acid, myoglobin and potassium - some of these block the renal tubules --> tubular necrosis --> renal failure
61
What is a secondary survey of a patient in the trauma setting?
Top to toe exam of the P after completion of immediate treatment to ensure that nothing has been missed.
62
63
What airway can you give a P if they cannot use the oral airway?
Cricothyroidotomy
64
What does presence of bowel sounds in the chest suggest?
Diaphragmatic rupture
65
66
How can you detect a pneumothorax clinically?
Get tracheal deviation to the opposite side Hyper-resonance Absence of breath sounds on one side
67
Why is tension pneumothorax an emergency?
Get severe respiratory distress Reduces venous return / preload due to inc intrathroacic pressure -> Shock (Can see distended neck veins due to sluggish venous return) Need to decompress and drain
68
What is a flail segment defined as?
Frax of 2 or more adjacent ribs in more than one place -> paradoxical breathing + impaired ventilation
69
What do muffled heart sounds suggest?
Cardiac tamponade
70
Why do we catheterise sick Ps?
Is a sensitive measure of end organ perfusion
71
What scan can be done in traumatic injuries?
FAST Scan - Focussed Assessment Sonography in Trauma - USS done at bedside that looks at the abdomen, pericardial space and chest for fluid
72
What is associated with intracellular ice crystal formation, microvascular occlusion and tissue hypoxia?
Frostbite
73
What is it termed when you have severe soft tissue injuries?
Degloving
74
What can crush injuries result in?
Traumatic rhabdomyolysis -> releases CK, lactic acid, myoglobin and K+ => renal tubular necrosis and renal failure
75
How are crush injuries managed?
IV fluids Fasciotomies Amputation Bicarb therapy
76
What is the purpose of bicarbonate therapy?
Alkalises the urine - therefore decreases precipitation of myoglobin in the renal tubules in rhabdo.
77
What are common mechanisms of degloving injuries?

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