Trauma Flashcards
1
Q
Principles/Components of damage control
A
- Restoring physiology before anatomy to avoid the lethal triad of coagulopathy, hypothermia and acidosis
- C ABC simultaneous assessment & management as per EMST principles
- Damage control resuscitation
— permissive hypotension
— avoid crytalloid
— early and balanced blood transfusion
— keep warm
— TXA and targeted reversal of coagulopathy - Damage control surgery
— stage 1: patient selection
— stage 2: operative haemostasis and contamination control
— stage 3: ICU physiological resuscitation
— stage 4: definitive surgery
— stage 5: abdominal wall closure
2
Q
Stage 1: Patient selection (DCS)
A
Patient/Disease/Resource/Reassess
Patient factors
- lethal triad (hypothermia, coagulopathy and acidosis)
- hypothermia <35C
- coagulopathy (aptt 60 seconds, PT 16, deranged TEG)
- acidosis (pH<7.2, BE >-4, lac 5)
- haemodynamic instability SBP<90 or MTP
- poor premorbid state
Disease/anatomical factors
- complex injuries (serious organ or multiple organ injury i.e. major liver/vascular injury or any vascular plus hollow viscus injury)
- time consuming repair >60 minutes
- inability to close the abdomen
Resource factors
- relatively austere environment
- disease exceeds technical abilities available
- mass casualty incident
Reassess & reconsider
3
Q
Stage 2: Haemostasis and contamination control
A
Haemorrhage control
- ligate
- shunt (50% diameter, 3-4cm in each end)
- resect
- pack
- REBOA
- embolize
Contamination control
- staple off bowel
- divert and drain complex injuries
- avoid stomas, restorative procedures or creating feeding routes
- leave drains
Temporary abdominal closure
- prevent visceral adherence to the abdominal wall
- allow drainage of the oedema
- some tension between the skin and fascial edges to prevent retraction (to allow secondary closure at a later
- prevent infection and abdominal hypertension
4
Q
Stage 3: ICU physiological resuscitation
A
- Aim to restore normal physiology; temperature, organ perfusion, coagulation, glucose, oxygen
– endpoints
Lactate clearance (<2.5) and pH
Reversal of coagulopathy
Urine output
Decreasing inotrope requirement - Prevention of complications; abdominal compartment syndrome, stress ulcer prophylaxis, VTE prophylaxis
- House keeping
ABCDEFG, FASTHUGS
• Feeding
• Analgesia
• Sedation
• Thromboprophylaxis
• Head up 30 degree
• Ulcer prophylaxis
• Glucose control
5
Q
Stage 4: Definitive surgery
A
Return to theatre 24-36 hours or sooner if needed
- Remove and document packs
- Reassess for missed injuries
- Resection or reconstruction as needed
6
Q
Stage 5: abdominal wall closure
A
Consider placing stomas outside the rectus muscle to allow for future hernia repair
7
Q
Damage Control Orthopaedics
A
External fixation
Fasciotomies
8
Q
Le Forte fractures
A
- Must have pterygoid fracture to be a le fort fracture
- 3 is floating midface
Types
• 1:
o Separation of alveolar process from body of maxilla
o Fracture extends to anterolateral margin of nasal fossa
• 2:
o Pyramid shape, teeth being the base and nasofrontal suture the apex
o Cross inferior orbital rim, orbital floor and medial orbital wall
o Anterior and lateral walls of the maxillary sinuses fractures
• 3:
o Separation of the bones of the face from the skull
o Upper posterior maxillary sinuses are fractured along with zygomatic arch, lateral orbital wall and lateral orbital rim
o Fracture at junction of frontal bone and greater wing of the sphenoid, and across the nasofronatal suture
9
Q
Neck zones
A
10
Q
Signs of neck injury
A
11
Q
No zones approach
A
12
Q
Blunt neck injury (cerebrovascular)
A
-
Definition:
- Non penetrating injury to the carotid or vertebral arteries
-
Incidence/epidemiology:
- 1-2% of all blunt traumatic injuries
-
Aetiology & risk factors:
- Anything above the clavicles or high energy blunt mechanism
- High speed MVA (account for 50%)
- Chiropractor
- Head or C spine injury
- Mandible and facial bone fracture
- Connective tissue disorders (marfans, elhers)
-
Pathophysiology:
- Stretching or impingement of the vessel wall as the head and neck are forcibly moved by flexion and extension or rotation
- Intimal tears and exposure of the subintimal layers to blood flow thrombus formation
- Partial or complete occlusion
- Dissection
- Pseudoaneurysm
- Transection of the vessel
- Complications
- Stroke due to occlusion or embolism
-
Clinical manifestations:
- Neurological deficits, ½ present with symptoms +12 hours after the injury
-
Macroscopic features:
- Denver grading classification (1-5)
- Grade 1
- Intimal irregularity or dissection, <25% lumen narrowed
- Grade 2
- Intramural haematoma or dissection, +25% lumen narrow
- Intraluminal clot
- Intraluminal flap
- Grade 3
- Pseudoaneuryms
- Haemodynamically insignificant AV fistula
- Grade 4
- Complete vessel occlusion
- Grade 5
- Transection
- Haemodynamically significant AV fistula
- Grade 1
- Denver grading classification (1-5)
-
Investigations:
- Screening guidelines
- Denver screening criteria
- Screening guidelines
- Radiological
- CT (at the time, a week and at 3 months)
- Angiogram of the neck
- If injury or symptomatic CTb with perfusion protocol
- MRA good for assessing vertebral artery for injury
- T1 fat saturated sequence
- CT (at the time, a week and at 3 months)
-
Treatment:
- Non operative
- Antithrombotic for 3 months
- Aspirin (grade 1, 2, 4– not 3&5)
- Heparin
- Neurology or vascular advice?
- Antithrombotic for 3 months
- Interventional
- Grade 3 – stenting
- No evidence for prophylactic stenting
- Operative
- Grade 3 & 5
- Non operative
-
Prognosis:
- Untreated blunt carotid artery injuries
- Morbidity rate of 32%–67%
- Mortality rate of 17%–38%
- Untreated blunt vertebral artery injuries
- Morbidity rate of 14%–24%
- Mortality rate of 8%–18%
- Injury evolution is largely dependent on the initial injury grade. As a general rule, low-grade injuries (grade I or II) are more likely to heal or improve than high-grade injuries (grade III, IV, or V)
- Up to 75% of grade I injuries will heal over the course of weeks to months,
- While 8% of grade II injuries will completely resolve and 30% will improve to grade I in the same time frame. Injury progression is highly unlikely for grade I injuries, with only 8% of these lesions increasing in severity at follow-up imaging
- Untreated blunt carotid artery injuries
13
Q
Head injury CT
A
Canadian CT head rule
14
Q
How to interpret CT brain
A
3 steps (location, density, mass effect)
- Density
- Hypodense and hyperdensity is abnormal
- Blood
- Acute – high <3days
- Subacute – less dense
- Chronic - >14 days, CSF density
- Location
- Mass effect (5 spaces)
- Sulcus space
- Ventricle
- Midline shift
- Subfalcine
- Uncal
- Tonsillar
15
Q
Raised ICP/TBI
A
- ICP
- 0-15mmHg adult
- Munro Kelly doctrine brain/blood/csf
- Epidemiology
- 30% of traumatic deaths
- Leading cause of death of people <40 years
- MVA and falls majority cause
- Pathophysiology
- Primary neurological injury
- Immediate
- Indirect
- Direct
- Tissue deformation from compression, sheering
- Secondary injury
- Hours to days
- Major determinate of outcome
- Cellular damage from neurochemical mediators
- Primary neurological injury
- Classification
- Mild 13-15
- Moderate 9-12
- Severe <8
- Investigations
- Indications for CT
- Focal neurological
- Seizure
- Low GCS
- Intoxication
- Penetrating skull injury
- BOS fractures
- Canadian CT head rule
- Consider neck vasculature imaging for dissection and pseudoaneurysm
- MRI
- Logistically challenging, better for white matter changes
- ICP monitoring
- Indication for monitor
- Abnormal CT scan and GCS 3-8
- Normal GCS, 2+ features (40+, motor posturing, BP <90)
- 3 devices
- EVD
- Most accurate
- Placed into a ventricle
- Position
- Frontal using Kochers point
- ICP monitor (coddmans)
- Inaccurate
- Subdural/extradural catheters
- EVD
- Shape of the ICP pressure wave form indicates the brain tissue compliance
- 3 waves
- Indication for monitor
- Indications for CT
- Treatment
- Brain Trauma Foundation Guidelines
- CPP of 60-70 (MAP – ICP)
- Supportive
- Maintain normal physiological limits
- Seizures
- Vasospasm
- Infection
- Rebleeds
- Management
- Conservative
- Head up 30 degree
- Remove ties and tape
- Remove collar
- Analgesia
- Sedation
- CSF removal
- ~20ml/hr with EVD
- Hyperosmolar therapy
- Salty; hypertonic saline
- Na153 target
- 1mmol/kg
- Sweet; mannitol
- Look old for dehydration
- 0.25-1g per kg
- Not in SBP<90
- Reduce blood viscosity
- Salty; hypertonic saline
- 35-40 CO2
- Antiseizure prophylaxis
- Risk factors
- GCS 10
- Serizure on injury
- Amnesia >30 minutes
- Skull fracture
- Blood
- Contusions
- Alcohol
- Age <65
- Drugs
- Phenytonin or Keppra for 7 days
- Risk factors
- Temperature
- Eurotherm 32-35 worsened clinical outcome with bad mortality
- End line
- Medical barbiturates
- Thiopentone
- Surgical
- Decompressive craniectomy
- DECRA
- Worsened outcomes
- RESCUE ICP
- Increased survival but
- Worsened outcomes long term
- DECRA
- Decompressive craniectomy
- Medical barbiturates
- Summary
- 3 tiered therapy
- Stage 1 – good ICU house keeping
- Stage 2 – Mannitol or hypertonic
- Stage 3 – end of line stuff
- Conservative
- Brain Trauma Foundation Guidelines
-
Prognosis
- Clinical
- Poor risk factors
- Prolonged hypotension
- Elderly
- Poor risk factors
- Radiological
- Poor risk factors
- 3rd ventricle, midline shift, SAH or petechial
- Rotterdamn Severity Score
- Poor risk factors
- Clinical
- Biomarkers
- Experimental
- GCS + presenting complaint into CRASH or IMPACT
- 3 phases
- Survival
- Recovery
- Rehabilitation
- Most improvements by 6 months, done by 2 years
17
Q
EVD landmarks
A
The key landmarks for this procedure are the midline, nasion, ipsilateral tragus, ipsilateral pupil, and medial canthus
Should pop through by 7-7.5cm, if not then consider abandoning
18
Q
Blunt C spine injury
A
- CT 98.5% sensitive
- Early surgical decompression of complete spinal cord injury important <24hrs
- Timing of decompression less important in complete spinal cord injury?
- Imaging
- Canadian c spine rule
- NEXUS
19
Q
Reviewing CT C spine
A
ABCS
Adequacy and allignment
- C7 included
- Anterior vertebral bodyline
- Posterior vertebral bodyline
- Spinolaminar line
- Spinous process line
Bones
Connective tissue and cartilage
- Pre dental height
- Disc height
- Facet joint interval
- Interspinous interval
Soft tissues
- Prevertebral space
(5mm at C3) and (20mm at C7)
Stability
21
Q
Rapid sequence intubation
A
- Indication
- Difference between patent airway, protecting the airway (treatment vs prophylaxis)
- A – protection and patency
- B – respiratory failure (hypercapnic or hypoxic), increase FRC, decrease WOB, secretion management/ pulmonary toilet, to facilitate bronchoscopy
- C – minimise oxygen consumption and optimize oxygen delivery (e.g. sepsis)
- D – unresponsive to pain, terminate seizure, prevent secondary brain injury
- E — temperature control (e.g. serotonin syndrome)
- Other — safety for transport (e.g. psychosis), humanitarian reasons
- Phase 1
-
Prepare
- Drugs (ideal body weight):
- Fentanyl (3 mcg/kg)* not sure about this in shock – maybe 1mcg/kg
- Ketamine (2 mg/kg) onset: 60 seconds
- Rocuronium (1 mg/kg) onset: 60 seconds
- This was known as the 3:2:1 regimen. Drugs were all given in rapid succession in the order fentanyl-ketamine-rocuronium. If haemodynamic compromise 1:1:1, although if arrested then only rocuronium given.
- Drugs (ideal body weight):
-
Position
- Horizontal line between earlobe and sternal notch
- Displace uterus in pregnancy
- Preoxygenation
- Plan
- Optimise (resuscitate before you intubate)
-
Prepare
- Phase 2
- Intubation
- A: Direct
- BMV
- B: Video laryngoscopy
- BMV
- C: LMA
- BMV
- D: Scalpel-finger-bougie
- Vortex approach, Elaine Bromley
- Key things to remember
- Beware tunnel vision
- Get into the green zone or move on! (Bag valve mask)
- Surgical airway
- Key things to remember
- A: Direct
- Intubation
If you can wake the patient up then do it! For fuck sake.
- Phase 3
- Post intubation
- A; confirm ETT position
- B; lung protection and chest decompression if needed
- C; Resuscitation
- D; Analgesia>sedation, neuroprotective
- Post intubation
- Ventilator settings
- Tidal volume 8ml/kg
- RR 8/min
- PEEP 5cmH20
- Peak pressure <30cmH20
24
Q
Subclavian artery
A
- Right: innominate artery arises from the aorta, gives rise to the RCA and R subclavian
- Left: subclavian arises directly off the aorta after the LCA
- The subclavian vessels lie deep to the clavicle (thus the name), the vein is anterior and inferior to the artery (like the axilla), they are separated by the anterior scalenes muscle which inserts into the 1st rib (vein, anterior scalenes, artery, middle scalenes)
- (Like the axillary artery) The subclavian artery is divided into thirds by a muscle (anterior scalenes)
- Mneumonic VIT C D
- 1st part medial to the muscle
- Vertebral artery
- Internal thoracic artery
- Thyrocervical trunk
- 2nd part posterior to the muscle
- Costocervical trunk
- 3rd part lateral to the muscle to the lateral edge of the 1st rib
- Dorsal scapular artery: courses posteriorly (less commonly, it branches from the second part); some authors describe this branch as arising from the thyrocervical trunk
- The phrenic nerve runs on the anterior surface of the anterior scalenes muscle running from lateral to medial as it descends, thoracic duct anterior and medial to this
26
Q
Rules of 9s
A
30
Q
Renal trauma grading
A
32
Q
Splenic injury AAST grading
A
33
Q
Grades of haemorrhagic shock
A
- Approximate blood loss = tennis scores
- In grade 1, only the BE will be effected
- In grade 2, HR and Pulse pressure (2 things) will be start going off
- In grade 3, everything is going off
- In grade 4, you are dying
34
Q
Aortic injury AAST grading
A
1; intimal tear
2; contained mural haematoma
3; pseudoaneurysm
4; rupture
