Trauma Flashcards
1
Q
blunt force trauma
most obvious findings
A
haemoperitoneum
liver laceration
active haemorrhage
2
Q
blunt force trauma with active intra abdominal bleed
A
3
Q
blunt force trauma with intra abdominal bleed
A
4
Q
A
5
Q
what are the contraindications for FAST scan in trauma?
A
- presence of more critical problem eg airway obstruction
- clear indication for emergency laparotomy eg penetrating trauma with shocked patient
6
Q
What are the classical CT findings with a seatbelt sign?
A
perforation with leakage of contrast
mural haematoma/thickening
abdo bowel wall enhancement (ischaemia)
fat stranding
7
Q
blunt force injury
what are the major findings?
A
- renal parynchymal laceration
- devascularisation of part of kidney (hypodense)
- large perinephric haematoma
8
Q
what are the complications of a traumatic renal injury
A
hypertension
haemorrhagic shock
death
abscess
delayed bleeding
9
Q
abnormalities
A
- teeth malocclusion
- fracture body of manible
10
Q
what needs to be documented with a mandible fracture
A
- degree of mouth opening
- missing/occlusion of teeth
- ?open fracture to mouth
- ?haematoma to floor of mouth
- brusing/bleeding
- other injuries
- ?inferior alveolar nerve parasthesia
11
Q
how do you manage mandible fracture in ED?
A
- ADT
- abx eg cefzolin 2g IV OD
- analgesia - be specific
- NBM and iv fluids
- mouth washes - QID hydrogen peroxide
12
Q
?facial burn
what clinical signs must you look for?
A
- facial or oral burns
- singed nasal hair
- swollen lips
- singed eyebrows or lashes
- oedema - facia;
- tachypnoea
- wheeze
- stridor
13
Q
?facial burn
Investigations?
A
- carboxyhaemoglobin level
- CK
- ABG
- glucose
- U+E
- ECG
- CXR
14
Q
whar are the criteria for transferring to specialist burns unit?
A
- mid to deep dermal burns over 10% TBSA
- Full thickness over 5% TBSA
- burns to face/feet/hands/genitalia or major joints
- chemical burns
- electrical burns eg lightning
- burns with associated inhalation
- burns with significant other trauma
- pregnancy with cutaneous burns
- any mid - deep over 5% in kids
- burns at extremes of age
- NAI
- significant co-morbidities eg diabetes
15
Q
when methods are used for calculating burns
A
rule of 9s
ludlow and browder chart
16
Q
what are the five different depths of burns?
A
- Epidermal
- Superficial dermal
- Mid dermal
- Deep dermal
- Full thickness
17
Q
when do patients with burns need fluids?
A
- electrical burns
- delayed presentation
- inhalation injury
- over 10% tbsa for adults
- coexistant traumatic injuries
18
Q
what are the most common findings with central cord syndrome (central cervical cord syndrome) ?
A
- Incomplete paralysis (upper over lower)
- Incomplete sensory loss (upper over lower)
- Urinary retention
19
Q
what is the immediate plan for central cord syndrome
A
- apply C-spine precautions
- transfer to centre with MRI if MRI not available
- refer to neurosurgery
20
Q
what is the prognosis for central cord syndrome?
A
Good
most people will ambulate and have return of hand movement
21
Q
what are the common causes of central cord syndrome?
A
- Trauma
- tumour
- cervical spondylosis
22
Q
what life threatening injuries are associated with a chest stabbing?
A
- cardiac - tampanade, STEMI, rupture, contusion
- Lung - haemothorax, pneumothorax, hilum injury
- vessels - aorta, SVC, pulmonary artery or vein damage
- organs - diaphragm, spleen, liver
- nerve - phrenic nerve
23
Q
how would you prepare the ED with a chest stabbing pre alert
A
- team - allocate roles, ask skill set, alert specialty teams (anaesthetics/gen surg/radiology) - trauma call
- equipment - intubation, thoracotomy. IV access, USS
- blood products, rapid infuser, warmer
24
Q
what are the indications for thoracotomy in ED?
Thoracostomy
A
Thorocotomy
- penetrating chest trauma and witnessed arrest
- severe shoick with signs of tamponade
- blunt thoracic trauma with rapid exanguanation or persistant hypotension
Thorocostomy
Widely accepted
o Penetrating chest injury with cardiac arrest/ peri-arrest non-responsive to resus
measures and signs of life within previous 10 minutes
Controversial:
penetrating non thoracic trauma with cardiac arrest
25
26
MVA, tubed, hypotensive
findings?
* ETT just above the level of his clavicles
* NG tube in situ that migrates below the level of the right hemidiaphragm and curls
around to the left above the level of the right hemidiaphragm
* Deviation of the NG tube to the right
* Elevation of the left hemidiaphragm
* Fracture left scapula(subtle)
* Left lung basal collapse/consolidation
* Left apical capping
* Widened mediastinum
27
MVA, tubed, hypotensive
Differentials in order of severity
1. aortic dissection
1. diaphragm rupture
1. blunt cardiac injury
1. lung contuison
1. splenic injury
1. bony injuries
28
high speen MVA
injuries present on x ray and radiograpghic evidence
Multiple displaced Rib Fractures – displaced rib fractures seen posteriorly
Rt TENSION Pneumothorax – expansion Rt hemithorax, deviation NGT to left, visible lung edge,subcut emphysema
Rt Pulmonary Contusion – Increased opacification throughout Rt lung field
Lt Pneumothorax – subcutaneous emphysema
Left Clavicle fracture – comminution of mid-clavicle
29
how do you improve oxygenation in trauma and bilateral significant pneumothoraces?
bilateral thoracotomy
increase fio2
increase peep
30
barcode sign
pneumothorax
31
management prioritoes
32
33
34
what is a paeds CT head calculator?
PECARN
CATCH
35
What does PECARN say the indications for ct head in kids is?
36
how do you safely prepare child for CT head in trauma
1. consent
2. access and sedation - 0.5-1mg/kg ketamine
3. anti emetic eg 0.15mg/kg ondansetron
4. monitoring - sats/BP/HR
37
how could you anaethetise these teeth?
* infra orbital nerve block - 2ml lidnocaine below infra orbtial notch
* local infiltration - supraperiostial infiltration with 2ml lidocaine into deepest part of sulcus formed by trauma
38
delay to dentist - describe ED management
Ideally need OPG to assess fracture of alveolar bone
* Local anaesthetic analgesia
* Reinsert tooth into normal position (mould alveolar bone if needed, check occlusion)
* Splint to adjacent teeth with Glass Ionomer Cement (GIC). If no GIC available need
alternate splint – e.g. “blue tac” and a mouth guard
* Cover exposed fracture surface (dentine) with GIC
* If no GIC available needs relatively urgent (< 24h) f/u with dentist
* Will need splinting for 2-4 weeks
* adt
* abx
39
what are the adverts events associated with severe dental injury
* dental abscess
* pulp necrosis
* root resorption
* need for root canal
* tooth colour change
40
describe injury
x Subluxed 1:1 (R upper 1st incisor)
x Extruded or Lateral luxation 2:1 (Lt upper 1st incisor)
x Lip contusion
x Alveolar Fracture
41
goals of treatment for this injury
* stablise to prevent aspiration
* approximate anatomical position to aid healing
* see dentist for definitive management**
* analgesia
* exclude other injuries
*
42
advers effects of ketamine for sedation
* Laryngospasm
* x Emergence reactions
* x Transient Apnea
* x Emesis
* x Allergy
43
abnormalities
* right maxillary intrusion and luxation
* left maxillary horizontal fracture involving pulp
44
dental trauma terminology
45
46
47
collapse onto heater and facial burn (severe)
what issues need to be considered
cardiac monitoring for cause of syncope
airway assessment
signs of head trauma
ADT status
48
how would you describe this burn?
Burn involves approx. 2% TBSA
* Central area of full thickness burn (approx. 1% TBSA) with white/leathery appearance of
skin and no capillary refill
* Surrounded by partial thickness burn with evidence of deroofed blisters
* Area extends from the patients left ear (involving the inferior 2 thirds of their helix,
antihelix and the tragus), the majority of the patients left maxillary, mandibular and
zygomatic areas, to the patient’s chin.
* Left eye, lips and airway appear to be spared
49
fall with trauma and bleeding with hypotension.
What patient meds may be important in this situation?
anticoagulants
anti platelets
anti hypetensives
diabetic meds
opioids
sedatives
50
fall with trauma and bleeding with hypotension.
four causes and ways to confirm the hypotension in resus room
1. haemothorax - CXR
2. tension pneumothorax - clinical exam
3. tamponade - efast
4. intraperitoneal haemorrhage - efast
5. long bone fracture - x ray
6. pelvic fracture. x ray
51
what are the common components of a massive haemorrhage pack
* PRBC
* FFP
* Platelets
* cryoprecipitate
* TXA
* calcium gluconate
52
other than normal INR what are the anticoag targets in massive haemorrhage
53
fall from roof
main pathology
mediastinal haematoma - likely large vessel injury
Why:
widened mediastinum
loss of aortic knob
depressed left main bronchus
left apical pleural cap
54
trauma with hypotension but normal scans. what is the other cause?
neurogenic shock
55
what are the early complications of head injury and their signs
56
what are the high risk features on canadian head CT tool
- GCS <15 at 2h after injury
- suspected open or depressed skull #
- any sign of basal skull #: haemotympanum, 'racoon' eyes, CSF otorrohoea/rhinorrhoea, Battle's sign
- vomiting > or +2 episodes
- age >65yo
57
what are the medium risk features on canadian head CT tool
* amnesia before impact >30min
- dangerous mechanism (pedestrian v. MVA, ejection from vehicle, fall from height >3ft or 5
stairs)
58
what are the neuroprotective measures for head injury
* **Normoxia**: keep the PaO2 above 60 mmHg
*
* **low normocapnia**: keep the PaCO2 between 35-40 mmHg
* **Normotension:** measure the MAP, and keep the systolic above 90mmHg
*** Intracranial Pressure monitoring: **keep it under 20mmHg
* **Cerebral perfusion pressure:** keep it 50-70mmHg
*** Cerebral oxygenation monitoring:**keep the SjO2 >50%, and PbrO2 >55mmHg
**Manage ICP**
59
how do you manage ICP in head injury
o Draining the EVD ( about 20ml/hr, max)
o Head up 30 degrees
o Positioning the head straight
o Removing the C-spine collar
o Sedation :
▪ Propofol sedation to decrease distress and thus decrease ICP
▪ Barbiturate coma if other methods of lowering ICP have failed
▪ Analgesia to prevent increased ICP in response to suctioning and routine care
o Paralysis
60
what are the indications for CT head in child with trauma
Pecarn criteria
61
positive findings
1. left frontal extradural haematoma
2. left frontal lobe compressed
3. fluid in left frontal sinus
4. external soft tissue swelling
62
child deteriorates
what are the priorities?
* Resuscitate: Move to RR/Team Leader. Delegate Roles. Resus Equipment/Monitoring
* RSI/Ventilation. Maintain BP/avoid Hypotension and hypoxia. Appropriate drugsketamine. Ongoing sedation and paralysis.
* CPP: Avoid Hypotension/hypoxia. Aim PaO2 100mmHg or more, low normal CO2. Headup. Avoid tight tapes. Mannitol/Hypertonic saline
* Mobilise Surgeon (Burr holes/EVACUATION)/Retrieval team. Tertiary referral centre andNeurosurgery.
* Inform parents/NOK/SW
63
abnormalities
* Large extradural haematoma – high density bi convex lesion left temporal region
* Hyperacute extradural with “swirl sign” mixed density
* Large scalp haematoma left temporal region
* Parietal cerebral contusion left
* Significant midline shift to right
* Loss of sulci and gyri consistent with raised intracranial pressure
64
treatment priorties of ICH in in ED
Immediate neurosurgical referral for surgical drainage of haematoma
Intubation for airway control and management of CO2
Maintain MAP >80 (accept approx.) mmHg with IV N/S +/- noradrenaline infusion
Maintain oxygenation sats >95%
Ventilate for low normal CO2 (35 – 40)
Other neuroprotective measures (max 4 marks)
Well sedated, paralysed
Slightly head-up position
Loosen ties / restriction to venous return
Na high normal range
Normothermia
normoglycaemia
65
findings
* Acute on subacute subdural haematoma / haemorrhage
* High attenuation anterior – acute blood
* Iso-attenuation – subacute blood
* Loss of sulci left hemisphere – raised ICP
66
MVA, intubated
list the findings and radiological evidence
67
what does this show?
fluid in hepatorenal angle
68
what is the blood ratio given in trauma
1:1:1
PRBC:platelets:FFP
69
MVA
findinds and radiological evidence
**Left haemothorax **– veiled hemithorax, pleural cap
**Mediastinal haematoma **– wide mediastinum, rightward displacement NGT, paratracheal stripe,depressed left main bronchus
**Right pulmonary contusion **– right midzone opacities/consolidation
**Right PTX –** lucent right hemithorax, subcut emphysema
70
MVA
main abnormalities and why
**Respiratory acidosis** – underventilation, need to increase MV
**HAGMA** – mainly lactate due to tissue hypoperfusion
**Hyperkalaemia** – when corrected for acidosis is approx. 3.6
**Hypoxia **– due to lung pathologies V/Q mismatch – haemothorax, contusions, PTX
71
how do you minimise chance of coagulopathy post trauma
1. normothermia
2. correct any acidosis
3. 1:1:1 blood resus
4. Rotem to target
5. calcium
72
trauma
pertinent findings
Displaced Chance type fracture of T12 vertebra
- Ventral displacement of distal vertebral column
- 3 column fracture (ie unstable)
- Likely retropulsion into spinal canal
- S3 fracture
73
what are the clinical features of neurogenic shock
1. warm peripheries
2. normotensive
3. bradycardia
4. poikilothermia
74
what are the management priorties for neurogenic shock
75
76
describe injury
Penetrating injury with ?knitting needle to right lower anterior chest (?9th-11th
interspace), line of nipple – knitting needle in situ, appears to be at right angle to
chest wall, with foreign material at entry point
Unable to assess depth
Child appears comfortable, not distressed, co-operative and well perfused
Chest appears equally expanded right vs left
(IV access in right cubital fossa)
77
complications of this injury
pneumothorax
tension pneumothorax
haemothorax
hepatic injury
vascular injury
bowel injury
infection
78
how do you conduct wound irrigation
* local with lidocaine
* wash with normal saline with pressure
* 100-300ml
79
what wounds are candidates for delayed primary closure?
How do you do delayed primary closure
bite wounds
heavily contaminated
late presentation
Process:
irrigated and debrided
packed with saline gauze and dressed
return in 4/5 days and close if not infected
80
when do you give abx prophylaxis in wounds?
bites
heavily containated
seawater
deeper structures
delated presentation
penetrating wounds
81
post head injury the pupils are differnte sizes
what would you do?
500ml IV hypertonic saline to lower ICP
plus usual neuroprotective
82
1.describe injury
2.What are the next steps in assessing patient
3. management priorities
* open fracture/dislocation left ankle with profound angulation
* large wound
* minimal active bleeding
* calf flap
**Next steps**
* Primary survey to address life threatening injuries
* neurovascular status of limp
* AMPLE (allergies, medications, past history, last ate, event)
**Management priorities**
* analgesia
* abx
* gross decontamination
* reduction under sedation
* admit to orth/vasc
83
Detail the main differences between research evidence behind the PECARN, CHALICE and CATCH clinical decision rules.
* C and C are rule in, pecarn rule out
* Pecarn has highest sensitivity and prospectively validated
84
key things to explain in parent demanding CT head
* Not required as per best evidence
* CTB performed to diagnose injury that requires neurosurgical intervention
* Concussion managed conservatively
* Risk of radiation: lifetime cancer mortality risk from a single head CT is about
* 1 in 1,500 in a 1 year old; 1 in 10,000 in a 10 year old
* Risk related to sedation if required
85
what are the contraindications to thoracotomy
unwitnessed cardiac arrest
severe head injury
penetrating abdo injury
no cardithoracics available
86
what measures can be performed post thoractomy
* cardiac massage
* clamp aorta
* ventricular repair
87
steps in thorocostomy
88
what is this
pericardial effusion
89
steps in thorocotomy
90
91
what clinical features suggest critical vascular injury
* pulsatile
* rapidly expanding haematoma
* thrill
* bruit
92
what are the four acute cord syndromes
93
trauma
calcium chloride 10mls 10% IV
94
BP target in ICH and why?
95
pregnancy and MVA
what ar the pregancy specific trauma conditions you want to excluce
1. fetal distress
2. placental abruption
3. amniotic fluid embolism
4. uterine rupture
5. laceration of placenta
6. premature labour
7. premature rupture of membranes
8. fetomaternal haemorrhage
9. direct fetal injury
96
pregnancy, MVA, heavy bleed
what are the initial steps
1. resusciate mother MAP over 60
2. check fetal heartrate with CTG/US
3. notify OG
4. large cannula
5. URgent US
6. +/- steroids for fetal lung maturation
97
punch to face
abnormalities
what are the important components of exam and what pathology are you looking for
* Inferiorly displaced left orbital floor fracture
* Fluid (blood) in left maxillary sinus
* Inferior rectus is displaced in to fracture segment –
98
what x ray featurs suggest inferior orbital wall fracture
fluid in maxillary sinus
orbital emohysema
teardrop sign - herniation of fat inferiorly
99
with trauma, what are the causes of optin neuropathy
1. compressive optic neuropathy eg haemorrhage, foreign body
2. optic nerve sheath haematoma
3. optic nerve head avulsion
4. optic nerve laceration
100
what are the indications for intercostal cathether post rib fractures
1. hypoxia
2. ventilatiry failure needed positive pressure
3. need for operative intervention
4. progressive pneunothorax or presence of haemothorax
101
patient is GCS 15 wth no motor function below C5. wht are the managmenet priorities
Manage ventilatory failure -
(Control of airway with intubation using MILS as ventilatory failure likely given
phrenic nerve involvement at this spinal level)
BP management - high risk of hypotension from neurogenic shock
- initially iv fluids +/- pressors
- consider concurrent hypovolaemia from bleeding and Ix as required
Maintain spinal immobilisation
Assess and manage concurrent injuries (eg chest, abdo, pelvis, limb fractures)
Temperature control
Methylprednisolone controversial- discuss with local spinal team
Refer to spinal team for definitive management once other injuries excluded
102
103
what US features suggest cardiac tamponade
* pericardial effusion
* right sided collapse in diastole
104
what are the potential complications of resuscitave thoracotomy
* Coronary artery injury/ligation
* Phrenic Nerve laceration
* Diaphragmatic injury
* Chest wall vascular injury (intercostals, internal mammary)
* Infection
* Health care worker body fluid exposure
105
trauma and rapid deterioration
106
what are the three goals of resus in trauma
1. maintain perfusion to organs eg MAP over 65 and BP over 100 depending on head injury
2. correct or prevent coagulopaty - 1:1:1 and rotem based tx
3. avoid hypothermia and acidosis
107
what is the triad of death in trauma
coagulopathy
hypothermia
acidosis
108
109
acute complications of head injuries
* raised ICP
* impact apnoea
* ICH
* CSF leaf
* diffuse axonal injury
* C spine injury
* cranial nerve injury
* seizures
* haemorrhagic shock
* aspiraiton pneumonia
110
MVA
initial priorities
primary and seconday survery
analgesia
pressure dressing to miminise haeatoma
imaging for bony and vascular injury
111
what are the potential consequences of rapid release of prolonged crush injury?
How could you mitigate this
1. washout of 'bad blood' - cold, acidotic and K ridden
2. arrhythmias
Mitigate:
IV access and saline pre load
IV bicarb
IV calcium
112
how do you measure compatment pressures?
What figure suggests CS?
* Stryker needle and insert into muscle of concern post prepping skin
* Clinical suspicion trumps measurement
Over 35mmHg
113
with a high CK and trauma, what are the risks of starting mannitol for renal protection?
* lack of evidence it is more effective than NaCl
* fluid shifts causing hypotension and hypovolaemia
* increased blood viscosity
* allergy
114
interpretation and why
normal swischuk line
115
what is the Nexus criteria to clinically rule out c spine fracgure
* No midline tenderness
* No neurological abnormalities
* No distracting injury
* Not intoxicated
* No altered consciousness
116
abnormalities
* Soft tissue swelling in front of C6/7
* Antero-superior corner fracture C7
* Disruption of posterior spinal line
* Widening between spinous processes C6 – C7
117
what are the C-spine lines
118
119
120
investigations and why post C spine injury
121
classify pelvic injury
what is the classification system
antero posterior
classification system
Young-Burgess
122
list complications, assessment findings and management of associared pelvic fractures
123
classify injury and why
**vertical shear:**
* Superior and inferior pubi rami fracture
* fracture left iliac wing
124
abnormalities
Pubic diastasis
Widened R Sacro-Iliac Joint
Widened L Sacro-Iliac Joint
125
what is the treament for open book pelvic fracture
pelvic binder to close pelvic diastasis
+/- IR for vascular injury
