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1
Q

Outline the trimodal death distribution after trauma?

A

Highest chance of death…

• immediately following the injury as a result of brain or high spinal injuries, cardiac or great vessel damage
• Early hours following injury due to splenic rupture, subdural haematomas and haemopneumothoraces
• Days following - sepsis or multi organ failure

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2
Q

Which simple airway manoeuvre should you not do on trauma patients and why?

A

Dont do head tilt due to high risk of c-spine injury

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3
Q

What do we use to assess the risk of a c-spine injury following trauma?

A

The Canadian C-spine rules

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4
Q

What are the Canadian C-spine rules?

A

Pt is considered high risk if they meet 1 or more of the following criteria…
• ages 65 or older
• Dangerous mechanism of injury
• Paraesthesia in any limbs

Pt is low risk if they meet none of the high risk criteria and 1 or more of the following:
• involved in a minor rear-end motor vehicle collision
• Comfortable sitting
• Ambulatory since the injury
• No midline cervical spine tenderness
• Delayed onset of neck pain

Pt is at no risk if no high risk factors, 1 or more low-risk factors and can rotate their head 45 degrees actively to the L and R

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5
Q

Investigation for c-spine injury?

A

CT

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6
Q

Interventions for C-spine injury?

A

Hard board and collar with head blocks

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7
Q

What are the 6 widely recognised life-threatening chest injuries following trauma?

A

TOM CAT

Tension pneumothorax
Open pneumothorax
Massive Haemothorax
Cardiac tamponade
Airway injury
Tracheobronchial injury

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8
Q

What does “on the floor, and four more” refer to?

A

Locating a haemorrhage - on the floor refers to the visible blood loss from an external wound and four more refers to 4 potential spaces inside the body where a large volume of blood may be lost: chest, abdomen, pelvis and long bones

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9
Q

Which groups of patients should you be cautious about relying on their observations in trauma?

A

Young people and athletes can compensate very well
Elderly dont compensate well at all

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10
Q

Imagine in trauma?

A

Whole body CT scan
FAST US can be done if CT not available or pt not stable enough

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11
Q

What is done in a secondary survey?

A

Once pt is haemodynamically stable:
AMPLE history
Head, maxillofacial, neck, abdomen, pelvis, perineum, genital, rectum neurological, spine, MSK exam

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12
Q

Pathophysiology of tension pneumothorax?

A

air enters the pleural space and is unable to escape, creating a one-way valve effect e.g. due to a flap of tissue. The continous accumulation of air leads to increased intrapleural pressure which exceeds atmospheric pressure throughout the resp cycle.
This compresses the affected lung leading to a decrease in functional residual capacity and impaired gas exchange, medistanial shift which can compress the opposing lung and compress the great veins reducing venous return to the heart and the direct pressure on the heart impairs cardiac filling which leads to a lower CO and systemic BP.

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13
Q

Causes of a tension pneumothorax?

A

Penetrating or blunt chest trauma
Iatrogenic - thoracdentesis, central venous catheter etc
Spontaneous - may have underlying lung disease or lung blebs

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14
Q

Clinical features of tension pneumothorax?

A

Acute onset dyspnoea
Pleuritic chest pain
Tachypnoea
Hyperresonance on percussion
Diminished breath sounds on affected side
Tracheal deviation away from affected side
Signs of shock

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15
Q

How is tension pneumothorax diagnosed?

A

Clinically - treatment should not await confirmation on imaging
Portable CXR is recommended if easily available??

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16
Q

Management of a tension pneumothorax?

A

Finger or needle thoracostomy initially
Placement of a chest drain in the safe triangle of the chest

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17
Q

What are the borders of the triangle of safety

A

Lateral border of pectoralis major anterior, mid-axillary line posterior, level of nipple inferior

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18
Q

What is a simple pneumothoraces?

A

The accumulation of air in the pleural space resulting in the partial or complete collapse of the affected lung

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19
Q

What are the types of simple pneurmothoaces?

A

Spontaneous - primary or secondary to underlying lung disease
Traumatic
Iatrogenic

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20
Q

What is a catamenial pneumothorax?

A

recurrent spontaneous pneumothorax occurring within 72 hours before or after onset of menstruation
Thought to be caused by endometriosis within the thorax

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21
Q

Features of simple pnuemothoraces?

A

Dyspnoea
Pleuritic chest pain
Hyperresonant lung percussion
Reduced breath sounds
Reduced lung expansion
Tachypnoea
Tachycardia

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22
Q

Management of a simple pneumothoraces if no significant symptoms or physiological compromise?

A

Conseervative care regardless of size
If primary it must be reviewed every 2-4 days as an outpatient
If secondary they must be monitored as an inpatient

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23
Q

What are the high risk characteristics of simple pnuemothroaces?

A

Haemodynamic compromise
Significant hypoxia
Bilateral
Underlying lung disease
>=50
Significant smoking history
Haemotgorax

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24
Q

Management of a traumatic simple pneumothoraces with high-risk characteristics?

A

Chest drain with inpatient family review

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25
Management of a traumatic simple pneumothoraces but without any high-risk characteristics?
Conservative management or ambulatory or needle aspiration
26
When must all pmeumothoraces be followed up?
Must have FU 2-4 weeks after as an outpatient
27
How are recurrent pneumothoraces managed?
Video-assisted thoracoscopic surgery should be considered to allow for pleurodesis and a bullectomy
28
Discharge advice after a pneumothorax?
• avoid smoking • Generally you can fly 2 weeks after resolution but normally recommended to =wait for a CXR confirming resolution • Scuba diving should be permenantly avoided unless pt has undergone bilateral surgical pleurectomy and has normal lung function and chest CT post op
29
How can you tell a chest drain is lying within the chest cavity?
Look for fogging of the tube and swinging of the chest drain with respiration
30
What is an open pneumothorax and what usually causes it?
This is a hole on the chest that competes with the normal airway for delivery of air Very rare and most commonly caused by a shot gun injury
31
Management of an open pneumothorax?
Cover wound and tape only 3 sides to allow for a 1 way valve where air can escape Definitive diagnosis is surgical
32
What is a massive haemothorax?
A haemothorax with >1500ml or >1/3rd of the pt’s blood volume
33
Management of a massive haemothroax?
Patients should all have a wide bore 36F chest drain. May require blood Indications for thoracotomy include loss of more than 1.5L blood initially or ongoing losses of >200ml per hour for >2 hours.
34
What usually cause a massive haemothroax?
laceration of lung vessel or internal mammary artery by rib fracture.
35
What is becks triad?
The 3 signs of cardiac tamponade: hypotension, raised JVP, muffled heart sounds
36
How do we diagnose a cardiac tamponade?
eFAST (Extended Focused Assessment using Sonography in Trauma)
37
Tx of cardiac tamponade?
Fluid resuscitation Pericardiocentesis Some say thoracotomy is indicated
38
What is flail chest>?
When 2 or more rib fractures along 3 or more consecutive ribs occur and this makes the flail segment move paradoxically during respiration, impairing ventilation of the lung on the side of injury Can cause serious contusional injury to the underlying lung if not treated
39
How is flail chest diagnosed?
CXR
40
Management of flail chest?
intubation and ventilation IPPV, address pain, fluid resuscitation and definitive surgery to prevent complications
41
Important investigations for pulmonary contusions?q
ABG Pulse oximetry CXR - look for associated rib fracture and haemo/pneumothorax
42
Management of pulmonary contusions?
Intubation and ventilation within 1 hour if significant hypoxia
43
Whats the risk of pulmonary contusion?
can cause parts of the lung to consolidate, alveoli to collapse, and atelectasis to occur Can cause significant hypoxia
44
Why are myocardial contusions so dangerous?
They often cause unexplained tachycardia and arrhythmias
45
Management of myocardial contusions
Resuscitation Cardiac monitoring Manage any arrhythmias expectantly - risk of arrhythmias fall aftr 24 hours
46
What traumas tend to cause aortic injuries?
Rapid deceleration injuries e.g. RTAs
47
Presentation of aortic injury?
Hypertension Weak femoral pulses Harsh systolic murmur
48
Management of aortic injur?
Sugrical repair or endovascular stenting Labetalol to control acute hypertension
49
Where does diaphragmatic injury most commonly occur and why?
Left posterolaterally - weakest point and not protected by the liver
50
Management of diaphragmatic injury?
NGT to drain stomach Chest drain Direct surgical repair
51
What causes tracheobronchial injury?
Very rare Caused by significant deceleration injuries Most die at the scene of the accident
52
Features of tracheobronchial injury?
Haemoptyasis Surgical emphysema Tension pneumothorax Vigorously bubbling chest drain that fails to alleviate respiratory compromise
53
Whats the most commonly injured organ in abdominal trauma?
The spleen
54
What causes bladder injuries?
Mostly blunt trauma with 85% associated with pelvis fractures
55
Presentation of bladder injury?
Haematuria Suprapubic pain Inability to void
56
Investigating bladder injuries?
IV urography or cystogram
57
Who do urethral injuries typically occur in and how do they present?
In males Blood at the meatus in 50% of cases. Urinary retention, perineal oedema/haemotoma. Displaced prostate on PR
58
How are urethral injuries managed?
With surgically placed suprapubic catheters
59
What is the deadly dozen?
The lethal six = immediate, life-threatening injuries that require evaluation and treatment during the primary survey. It includes airway obstruction, tension pneumothorax, cardiac tamponade, open pneumothorax, massive haemothorax and flail chest. The hidden six = potentially life-threatening injuries that should be detected during the secondary survey. It includes thoracic aortic disruption, tracheobronchial disruption, myocardial contusion, traumatic diaphragmatic tear, oesophageal disruption and pulmonary contusion.
60
What are examples of systemic complications of poly trauma?
Coagulation disorders Fat embolisms Crush syndrome PE ARDS
61
Outline how poly trauma can cause coagulation disorders?
In the early hours, hypocoagulability is typically present, resulting in bleeding, whereas later there is a hypercoagulable state associated with venous thromboembolism and multiple organ failure. Remmeber the lethal triad of coagulopathy, hypothermia and acidosis!
62
What is the pathophysiology behind fat embolisms?
2 theories: fatty tissue is directly released into the vascular circulation as a result or trauma or the inflammatory response to the trauma causes release of free fatty acids into the venous system from the bone marrow. The fatty emboli cause a severe inflamamtory response in the local tissue which increases vessel permeability and can lead to cerebral oedema and ARDS.
63
What causes fatty emboli?
Normally associated with long bone fractures
64
Presentation of fat emboli?
24-72 hours after trauma with worsening SOB. May also be confusion, drowsiness, and an impalpable petechial rash. To will be tachypnoeic, tachycardia, hypoxic, may have neurological signs and low grade fever.
65
What diagnostic tool can be used to diagnose fat embolism syndrome?
Gurd and williams criteira
66
Outline gurd and williams criteria for fat emboli?
The presence of 2 Major or 1 Major + 4 Minor criteria is deemed diagnostic Major criteria = Petechial Rash, Respiratory Insufficiency, Cerebral Involvement Minor criteria = Tachycardia, Pyrexial, Retinal Changes, Jaundice Thrombocytopaenia, Anaemia, Raised ESR, Fat macroglobulinaemia
67
What will lung CT show in fat embolism?
May show a ground glass appearance at the peripheries of the lung
68
Management of fat emboli?
Fix fractures ASAP DVT prophylaxis Supportive care
69
Mortality rates in fat emboli?
5-15%
70
What is crush syndrome?
Systemic manifestations resulting from a crush injury which can result in organ dysfunction or death
71
What is crush syndrome characterised by?
Hypovolaemic shock Hyperkalaemia Metabolic acidosis AKI DIC
72
Why is crush syndrome known as “smiling death”?
the victim smiling after being released from the crush injury cause suddenly arrests from V fib due to efflux of K+, phosphate and myoglobin from the areas of injury.
73
What is silver trauma?
major trauma in a patient ≥ 65 years old. Different patterns of injury e.g. falling from own height can be major trauma These pt likely to have underlyign hypertension and on HR controlling meds so increased potential for devastating haemorrhage and they have a reduced physiological reserve
74
What is the leading cause of death in people under 45?
Major trauma
75
Outline the configuration of trauma services in England?
Major trauma care is delivered through an inclusive trauma network delivery model. This includes all providers of trauma care e.g. pre-hospital services, trauma units and rehabilitation centres. Major trauma centres are the centres of excellence providing multi-speciality hospital care to seriously injured patients; they are the focus of the trauma network and provide consultant-level care and access to tertiary and specialised level services. Trauma networks compromise 1 or more major trauma centres and a number of trauma units. Some patients will need training in trauma units before being transferred to a major trauma centre.

ACUTE (18 decks)

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