Major trauma

Question 1

Define thoracotomy

Answer 1

Thoracotomy is a surgical incision into the chest wall (thorax) to access the lungs, heart, esophagus, mediastinum, and great vessels for diagnostic or therapeutic purposes

Question 2

Indications for thoracotomy

Answer 2

• Massive haemothorax
• Cardiac tamponade
• Resuscitative thoracotomy

Question 3

Massive haemothorax criteria

Answer 3

1. > 1.5L of blood loss OR
2. > 200ml/hr for >2hr OR
3. 1/3 blood vol.

Question 4

Define Laparotomy

Answer 4

Laparotomy is a surgical incision through the abdominal wall to access the abdominal cavity for diagnostic or therapeutic purposes.

Question 5

Indications for Laparotomy

Answer 5

1. Trauma + emergencies
   Penetrating abdo trauma with peritoneal breach
   Blunt trauma with +ve FAST scan
2. Acute abdo / Peritonitis
   Bowel perforation
   Acute appendicitis w/ peritonitis
   Diverticulitis w/ perforation or abscess
3. GI bleed

Damage control laparotomy

Question 6

ATOM FC

Chest Trauma mnemonic

Answer 6

1. Airway obstruction: Intubation Endotracheal tube (ETT)
2. Tension pneumothorax: 1-way valve, increase intra-pleural Pa, compress against the SVC, leading to a obstructive shock
3. Open penumothorax: Chest wall defect 2/3 the size of the trachea Air sucking in through chest instead of the normal airway
4. Massive haemothorax
5. Flail chest: 2 or more fracture contigiously –> paradoxical movement of the chest wall
6. Cardiac tamponade: Percardium fluid compressed on to the heart, reduce heart filling during diastole, reduce CO –> obstructive shock

Question 7

Tension pneumothorax initial Mx

Answer 7

Needle decompression: Large bore cannula 14-16G 2nd ICS, MCL

Question 8

Tension pneumothorax definitive Mx

Answer 8

Thorocostomy: Chest drain insertion, 5th ICS, MAL

Question 9

what is in-situ within the chest drain to avoid backflow of air

Answer 9

water seal

Question 10

what sign is indicative of a working chest drain

Answer 10

‘Swinging’ of the drain - changes in the intra-pleural pressure

Question 11

what sign is indicative of a blocked chest drain

Answer 11

Chest drain not ‘swinging’

Question 12

Open pneumothorax inital Mx

Answer 12

Occlusive dressing (3-sided)

Question 13

Open pnuemothorax definitive Mx

Answer 13

Chest drain + wound closure

Question 14

Haemothorax CXR finding

Answer 14

white-out

Question 15

what emergency condition should be consider in a penetrated neck injury

Answer 15

Pneumothorax

Question 16

Damage Control Resuscitation steps

Answer 16

1. Permissive hypotension: SPB 90mmHg

Question 17

Purpose of permissive hypotension

Answer 17

• To avoid exacerbation of bleeding - can dislodge clots –> further blood loss
• To avoid Dilutional coagulopathy - Rapid fluid infusion can dilute clotting factors, impairing the body’s ability to form clots
• Hypothermia - Large volumes of cold fluids can lead to hypothermia, which can further impair coagulation

Question 18

FAST scan 4 regions

Answer 18

1. RUQ - Morrison’s pouch Liver/R kidney injury - most common location for free fluid collection
2. LUQ - Spleen / L kidney injury
3. Suprapubic - bladder injury
4. Pericardial - Pericardial fluid –> cardiac tamponade

Question 19

Catastrophic haemorrhage Mx

Answer 19

• tourniquet on amputated limps
• direct pressure on wound
• Tranexamini acid

Question 20

‘on the floor and four more’

Answer 20

Floor: Visible blood loss from an external inj;ury
Four more
1. Chest - Haemothorax
2. Bleeding into the Abdomen (e.g. secondary to splenic laceration)
3. Bleeding into the Pelvis
4. Bleeding from a long bone fracture (femur)