Trauma Flashcards
TBI
Commonest cause of M&M in major trauma
Prehospital care can improve outcomes by reducing 2 brain injury (hypoxia, hypotension etc) and delivering to neurosurgical centre (Poon paper) and Chestnut paper.
SOP deals with
Patient assessment
TBI management
-Airway/PHEA
-Ventilation
-hypotension
-raised ICP
Triage and packaging
1) key points of assessment
2)Indications for PHEA
3)What targeted Max do we aim for?how do we ventilate
3) HTS indication and dose
4) where does CN3 exit
5) triage?
1) Low GCS <8
Inability to protect airway
Dysfunctional ventilation
Cerebral agitation/seizures
2) SpO2 > 94%
ETCO2 4-4.5kpa PEEP 5
SBP > 120 (or 90-100 in polytrauma)
Loose ties, head up 20-30 degrees,
normothermia, normoglycaemia
TXA within 3h if GCS <13
3) 2.7% NaCl 3ml/kg up to max 250
Indicated if signs of Inc ICP resistant to measures above eg unilateral or both pupils fixed and dilated +- Cushing response
4) CN 3 occulomotor exits via SOF - compression can cause sphincter pupillae motor block = fixed dilated pupil
Bilateral pupil dilation = coning
Abnormal flexion/decorticate = tonsilar brain hernition and damage to cerebral hemisphere and internal capsule
5) GCS 13 or less and HI = moderate HI so MTC
Suspected basal skull # or depressed/open # = MTC
Prehospital amputation - rare. Top cover call needed.
Indications (4)
1)Life in danger and unable to move as trapped
2) Deteriorating and unable to treat as trapped - likely to die
3) Formalising tissue cut in non salvageable limb
4)Dead but body trapped and stopping rescuers getting to live patients
New thoracotomy SOP
Indications
Procedure
Post-procedure mx
1)
A) TAMPONADE
Penetrating trauma in chest/epigastric/supraclavicular region and possible Tamponade potential
Or probable Tamponade in blunt trauma
Or TCA with loss of output/signs of life within 15 mins and suspected tamponade
B) non-compressible haemorrhage subdiaphragmatic or thoracic exsanguination and either
PEA Arrest with confirmed mechanical cardiac activity (digital palpation or US)
or loss of output/signs of life within 10 mins
Procedure - time critical. No delay. Poor outcome of prolonged down time or asystole.
Top cover call if time/concerns
Doctor procedure/para sharps/kit dump/blood/packaging/transport etc
Scoop, 360 access, arms out, chlorhex and gloves/eye wear
4th ICS thoracostomies and pause
RT
Arterial line indications
1)
2)
1) should be considered prior to rsi in TBI or medical neurological emergencies or in any patient who has undergone PHEA
2) may be considered in those, in cardiac arrest (left radial) or if haemodynamic instability IABPM would improve care of
Lateral canthotomy
1) Indication
2) what is an RAPD
3) Time to release?
1) clinical suspicion of orbital compartment syndrome with defect in vision or abnormal pupillary response (RAPD etc)
2) light in good eye both constrict then swing to bad and and shine in and both pupils dilate
3) 2 hours
Penetrating trauma SOP
Key points
Scene
Scene safety paramount
Police / HART
Dynamic risk assessment
PPE Inc body armour
Clinical
These patients have risk of rapid catastrophic deterioration - short scene time with rapid/thoro assessment (see Bicknell paper)
IV access etc en route
Don’t forget stab check
Leave penetrating weapons in situ of required
Permissive hypotension where applicable but give blood if req
Triage to MTC if central
GMC report stab/shootings and safeguarding
TCA SOP
General principles
Rapidly identify and treat reversible pathologies in TCA
Remember might be medical
HOTT
Hypovolaemia - stop bleeding first (TQ, packing, aortic compression) replace volume second, large bore access, blood, TXA, calcium.
Oxygenation - oxygen and airway asap
Tension - decompress as able, if rosc and SV then thoracostomy will need chest seal or drain or PHEA
Tamponade - US - thoracotomy
Triage MTC unless v unstable
TBI/hanging/drowning/electrocution manage per ALS
Burns SOP
Talks about
Scene safety - risk of injury etc
Assessment TBSA etc
Management
First aid
Airway management
Ventilation and escharotomy
Fluid
Electrical/chemical
Triage
- draw the fluid regime box
- What 3 things optimise outcomes
- Burn grading - why important?
- Mx
5.
1)
2) what 3 things; right Hospital for ongoing mx, reducing systemic inflammatory response, maintaining tissue perfusion
3) erythema (not in tbsa)
Superficial partial thickness (wet, blistered red)
Deep partial thickness (cherry red, painful non blanching)
Full thickness - dark white leathery insensate
- Remove jewellery/clothing as able
Cool burn (tap water 20 mins up to 3h post)
Pain relief
Cover cling film laid across
Warm patient
Chest trauma
Underlying principles
General management
Needle decompression
Indications
Ads/Disadvs
Finger thoracostomy
Indication
Ads/disads
ICD
Indication
Ads/disads
General principles
All procedures done in sterile environment
Formal assessment and land marking for all procedures
Priority is to maximise o2 delivery asap
Polytrauma patients should have any obstructive element dealt with ASAP and no patient should arrive to hospital with reversible lung pathology causing oxygen debt
General management
Oxygen - apply as per BTS guidelines
Position - upright if possible/able
Analgesia - key, hard and early
Penetrating objects - leave in situ if able
Open pneumo - chest seal and ICD
Massive haemo - rx as pneumo and quantify blood loss of able
Needle decompression
Indicated if trapped and unable to perform formal thoracostomy
PeriArrest to buy time to formal thoracostomy
Ads - delegate, quick, easy
Disads - lung expansion poor, fail, block, kink, fall out, damage
Finger thoracostomy
Indication - Suspected pneumothorax causing clinical compromise after PPV
Actual or peri-TCA
Unexplained hypotension in polytrauma
Ads - diagnostic and therapeutic, quick, refinger
Disads - can block and retension
ICD
Indication - Suspected unilateral pneumothorax in SV patient causing significant respiratory distress
Ads - allows complete re-expansion of lung
Disads - can kink or get blocked, invasive procedure (risk empyema)
Max fax
Approach/assessment
Management (airway -> haemorrhage control)
Key points in assessment
Key points in Max airway and haem control
Assessment
Often obvious. Can bleed +++ don’t be distracted and do full primary survey.
Le fort 1 - hard palate off maxilla
Le fort 2 - nasal bones and orbital floor
Le fort 3 - craniofacial distuption through orbit
Assess pupils, eye movement and other cranial nerves if able
Inspect teeth
TBI sop
Management
Airway - blood +++ external carotid artery
Pre-oxygenate sat up
Double suction and suction catheters for ET suction ready
Haemorrhage splinting
ABCDE
Open fracture SOP
Assessment
Management
Assessment - NV status forces and mechanism
Wound photo
Only gross decontamination
Management
Sedate
Reduce (anatomical position and NV status)
Immobilise
Abx within 1h injury BOAST
Triage (orthoplastic QMC, Derby and Leisceseter)
Spinal injuries sop
General assessment
Management
-immobilisation methods
-paediatric
-general max
Dermatomes and myotomea
General assessment
Document GCS, limb movement and spinal immobilisation employed
Consider in any incident with potential for spinal injury
Document motor and sensory level
Priapism
Haemodynamic status
Resp/vent status
Spinal pain/deformity
Immobilisation
MILS
Scoop and straps
Board - Extrication only
Collar and blocks and tape
Controlled roll 10drgrees
Paeds - tricky. Pragmatic. No collars
General mx
Self extricate if able
Clearing c spine risky prehospital
Monitor for deterioration
Stop secondary injury from hypoxia/hypotension
PHEA if needed
Beware bleeding
Myotomes
C4 shrug
C5 elbow flexion
C6 wrist extension
C7 elbow extension
C8 finger flexion (middle)
T1 finger abduction (little)
L2 hip flexion
L3 knee extension
L4 ankle do rsi flexion
L5 big toe extension
S1 plantar flexion
Dermatomes
C4 clavicles
C5 deltoid
C6 thumb
C7 middle finger
C8 little finger
T1 inside arm
T4 nipples
T10 belly button
L1 hip
L3 knee
