Trauma Flashcards
1
Q
We are the liver and spleen so susceptible to injury via blunt forces? (3)
A
- Heavy and relatively free to move which leads to tearing
- Soft so when starts bleeding it is propagated
- Very vascular
2
Q
How much of traumatic pelvic bleeding is venous?
A
Around 80%
3
Q
What is the mortality of an open pelvic fracture?
A
50%
4
Q
Which patients does the FPHC consensus statement suggest may not need a binder? (5)
A
- Mechanism not suggestive of pelvic injury and
- Haemodynamically stable (HR<100, SBP >90)
- GCS >13
- no distracting injury
- no pain in pelvis
5
Q
What does FPHC consensus statement say about type of pelvic binder used? (2)
A
- No good evidence for one device over another
- Best evidence currently is for SAM Splint or T-POD device
6
Q
What is the FPHC consensus statement with regards to femoral fractures and suspected unstable pelvic fractures and haemodynamically unstable patients?
A
- if traction of legs will delay transfer +/- worsen instability of patient (via pelvic disruption), they should be pulled to length and then tied together at knees and a figure of 8 around ankle
7
Q
What does JRCALC recommend with regards to transporting the distal part of of an amputation? (4)
A
- Remove any gross contamination
- Cover the part with a moist dressing
- Secure in plastic bag
- place bag in a container with ice
8
Q
What are the protective layers of the skull from outer layer inwards
A
- Skull
- Dura mater
- Arachnoid mater
- Pia mater
9
Q
What is the Monro-Kellie Doctrine?
A
The sum of the volumes of brain/CSF/blood is constant. A rise in 1 will therefore precipitate a drop in 1 or both of the others.
10
Q
What 2 syndromes are associated with hyperacute head injury?
A
- Neuroventilatory syndrome
- Neuro-cardiac syndrome
11
Q
What is neuroventilatory syndrome?
A
Impact brain apnoea
Concussive force to Pre-Botzinger complex of medulla oblongata
12
Q
What is neurocardiac syndrome?
A
- Cardiogenic failure secondary to locally released noradrenaline from myocardial sympathetic nerve terminals leading to neurogenic stunned myocardium.
- creates reverse-Takusubo picture (intact apical contraction/ impaired heart base contracticility)
- pump failure may decrease further secondary to systemic cathecolamine induced afterload +/- impact brain apnoea
13
Q
How is cerebral perfusion pressure calculated?
A
CPP = MAP - ICP
assume ICP >20cmH20 so aim MAP >80 mmHg
14
Q
How much % decrease in effect does each 20mins delay in TXA cause?
A
10%
15
Q
At what GCS does nice recommend giving TXA?
A
12 or less
16
Q
What does JRCALC states about anti-platelet tx nd HI?
A
Should be conveyed unless aspirin monotherapy
17
Q
What does JRCALC recommend for agitated head injuries?
A
Cautious use of midazolam
18
Q
A
19
Q
What are the indications for immediate CTH in children? (8)
A
- GCS <14 at presentation
- GCS <15 at 2 hour
- Seizure
- Focal neurological deficit
- ? skull # / tense fontanelle
- Basal skull # signs
- Bruising/swelling >5cm in <1years
- ?NAI
20
Q
What are the risk factors that may require observation in paeds head injurys? (5)
A
- LOC >5mins
- Amnesia > 5 mins
- Abnormal drowsiness
- 3 or more vomits
- Dangerous MOI
21
Q
If a child has one risk factor following head injury what should be their management?
A
4 hours observation
22
Q
If a child has more than one risk factor following head injury what should be done?
A
CTH < 1hour
23
Q
What are the increased risk factors needing imagine in the Canadian c-spine rules? (3)
A
- Over 65years
- Dangerous MOI
- Parasthesia in the extremities
24
Q
What constitutes a dangerous MOI in the Canadian C-spine rules? (5)
A
- Fall over 3 foot or 5 stairs
- Axial load to head
- High speed MVC (>100kmph)/rollover/ejection
- Motorised recreational vehicles
- Bicycle collision
25
What are the low risk factors in the Canadian C-Spine rules? (5)
1. Simple rear end shunt
2. Walking at any point
3. Delayed onset neck pain
4. Sitting position in ED
5. Absence of midline tenderness
26
How many low risk factors do you need to avoid imaging in the Canadian C-spine rules?
1
27
What is the final step in the Canadian C-Spine rules?
Can they rotate their neck 45 degrees left to right
28
What are the indications for immediate CTH in adults? (7)
1. GCS <13
2. GCS <15 after 2 hours
3. Open/suspected skull #
4. Signs basal skill #
5. Seizure
6. Focal neurology
7. More than 1 vomit
29
Within what period should patients on anticoagulation have a CTH according to NICE?
8 hours
30
If an adult patient has no indication for CTH immediately and is not on anticoagulation, what is the next question to be asked?
Any LOC or amnesia - if no then no imaging
If yes move onto risk factors
31
What are the risk factors used to determine whether an adult patient needs a CTH within 8 hours who have had a LOC or amnesia? (4)
1. Over 65years
2. Hx bleeding/clotting disorder
3. Dangerous MOI
4. > 30mins retrograde amnesia (events before injury)
32
Describes the myotomes in the upper limb (6)
C5 - deltoid
C5/6 - biceps jerk
C6 - wrist extensors
C7 - elbow extensor/triceps jerk
C8 - finger flexors
T1 - little finger abductors
33
Describe the lower limb myotomes (5)
L2 - hip flexors
L4 - knee extensors
L5 - ankle dorseflexors
S1 - ankle plantar flexors
S5 - anal reflex
34
What dermatome is the thumb?
C6
35
Where is the dermatone C7?
Middle finger
36
What dermatone is the little finger?
C8
37
What dermatone is the:
1. nipple
2. xyphoid process
3. Umbilicus
1. T4
2. T6
3. T10
38
Describe the dermatomes of the lower limbs (4)
1. L3 = medial knee
2. L4 = lateral knee
3. L5 = dorsum foot + 1st-3rd toes
4. S1 = lateral malleolus
39
What spinal levels to the sympathetic fibres extend from?
T1 - L3
40
What spinal levels do the parasympathetic fibres extend from?
S2-4
41
At what spinal level can a SCI lead to neurogenic shock?
T6 or above
42
What causes neurogenic shock?
Loss of sympathetic autonomic outflow
43
What neurology is associated with central cord syndrome?
Arms weaker than legs
44
What neurology is associated with anterior cord syndrome? (4)
1. Complete motor loss below lesion
2. Loss of pain/temp below lession
3. Preserved light touch/vibration
4. Autonomic dysfunction
45
What neurology is associated with Brown-Sequard syndrome?
1. Weakness/paralysis on 1 side
2. Loss on sensation on the other
46
What is the mechanism for acid burns?
Coagulative necrosis
47
What is the mechanism for alkali burns?
Liquefactive necrosis
48
What are alkali burns worse than acid?
Acid burns form a barrier which prevents deep penetration into the skin, alkalis cause liquefactive necrosis which means it can penetrate deeper into the skin
49
What is are the voltage cut off of:
- low voltage
- high voltage
1. <1000V
2. >1000V
50
What type of current is normal low voltage and can it lead to?
1. AC domestic current
2. Arrhythmia
51
What does high voltage electricity normally cause? (3)
1. Full thickness burns at both entry and exit sites (internal damage can be far worse than appears externally)
- Tissue damage secondary to heat generated by resistance of tissues
2. Muscle spasms/secondary trauma from being thrown causing bony/SCI
3. Arrhythmia particularly if chest involved
52
What type of tissue leads to the most damage when conducting high voltage electricity and why?
Bone because it has the highest resistance, it is the resistance that causes heat and bone can therefore become very hot and lead to further damage once the current has stopped.
53
What surgical interventions might be require of high voltage burns?
- may need aggressive surgical intervention inc. fasciotomy and amputation
54
What can muscle damage related to high voltage burns lead to?
Myonecrosis, compartment syndrome and rhabdo with renal failure
55
What does a lightening strike lead to and what might be a protective factor?
Death unless it has already passed throught another object
56
Describe the palm method of assessing burns size and in what are the weakness of using it
1. Palm INC. adducted fingers = around 1% TBSA (patients hand, not clinicians)
2. Some debate as to the accuracy, particularly in small kids and obese patients
57
What burns assessment does the FPHC consensus statement recommend? (2)
1. Lund and Browder chart
2. Mersey burns app (or similar)
58
Describe superfical burns?
Erythema only,not included in burns calculation
59
What differentiates superficial burns from superficial dermal/superficial partial?
Blisters - fluid lifts dead epidermis off dermis
60
What is the difference between deep dermal/ partial and superficial dermal/partial? (3)
Extends into dermis
1. Decreased sensation secondary to damage to nerve endings
2. Hallmaark = increase CRT due to damage of dermal vascular plexus
3. Can be 'blotchy' pink/red colour secondary to extravasation of the Hb from damaged vessels
61
Describe full thickness burns
Can include fat/fascia/muscle/bone
- 'charred' or 'leathery'
- 'woody' feel
- insensitive (but surrounding non full thickness burns with be painful)
- non blanching
62
What questions should be asked to any burns patient? (4)
1. Were they trapped and if so for how long?
2. Did clothes catch fire?
3. Any cooling?
4. Any explosion/ were they thrown?
63
What level of CO is classed as severe?
>30%
64
Why does CO lead to hypoxia?
CO x 240 more affinitity to Hb than oxygen which shifts 02 dissociation curve to the left
65
What will pulse oximetry be like with CO poisoning and why?
Normal as unable to differentiate between carboxyhaemoglobin and haemoglobin
66
What is a normal value of COHB in:
1. non-smokers
2. smokers
3. heavy smokers
1. < 3%
2. <5%
3. <9%
67
What is the treatment (initially) for CO poisoning and why does it help?
High flow oxygen because it reduces the half life of COHb from 320mins to 80mins
68
What is the mechanism of cyanide poisoning?
Usually from burning plastic
Poisons mitochondria and prevents further cellular oyxgen use leading to anaerobic metabolism
69
What are 2 treatments available for cyanide poisoning?
1. Hydroxycobalamin (Cyanokit)
2. Dicobalt edetate (Kelocyanor)
70
To what depth should an escharotomy incision be?
Down to fat (not muscle)
71
What 3 lines should be made in a breast plate escharotomy?
1. Mid clavicular to ant axillary line to costal margin bilaterally
2. Transverse subcostal
3. Transverse infraclavicular
72
What are the % burn NICE in hospital thresholds for:
1. Adults
2. Kids
3. < 18months old
1. 15%
2. 10%
3. 8 %
73
What is the Parkland formula?
4 x wt (kg) x TBSA
3 x wt (kg) x TBSA (kids)
First half in initial 8 hours
Second half in following 16 hours
74
What does JRCALC recommend for burns fluid resusitation?
1L warmed fluids / hr (adult)
10ml/kg/hr paeds
75
What should the first steps be in with chemical burns?
Remove agent, removed contaminated clothes and if liquid, irrigate well
76
What is the recommended to use in decontaminating both acids and alkalis?
Diphoterine (normalises PH more quickly)
77
If Diphoterine is not available, what fluids should be use to decontaminate acids/alkalis?
Isotonic or hypertonic fluid because water can propagate chemical deeper into the skin
78
How long should chemical burns be irrigated for?
- until pain improved which is a useful crude sign that PH has improved
79
How does hydrofluric acid lead to burns?
- H+ ions dissociate on contact with skin and lead to liquefactive necrosis allowing acid to penetrate deeply
- Free flouride ions bind to calcium and magnesium ions leading to systemic hypomagnesia and hypocalcaemia
80
How should hydrofluric acid be treated? (4)
1. Irrigate
2. Calcium gluconate gel
3. IV/intra-arterial calcium if extreme
4. Specific agent = hexaflourine
81
What is the specific agent for hydrofluric acid tx?
Hexaflourine
82
How should tar/bitumen burns be treated?
- they are heated to around 150 degrees and cause full thickness burns
- cool with water to solidify and then remove with toluene or peanut/paraffin oil
83
How does the FPHC consensus statement divide airways burns? (2)
1. Supraglottic (nose/oropharynx and larynx) - most common
2. Infraglottic
84
How can infraglottic burns be caused? (5)
Steam inhalation
Aspiration of scalding liquid
Blast injury
Flammable gas under pressure
Aerosolised chemicals
85
What are the features of infraglottic burns? (5)
1. Impaired ciliary activity
2. Hypersecretion
3. Oedema
4. Mucosal ulceration
5. Bronchial spasm
86
What 3 considerations should be made with intubation in patients with airway burns?
1. Largest size tube that will be placed (bronchoscopy on ITU)
2. Uncut (airway will swell)
3. Careful with tube tie
87
What features have been shown to correlate with need for RSI (FPHC)? (6)
1. Full thickness facial burns
2. Stridor
3. Resp distress
4. Swelling on larygnoscopy
5. Smoke inhalation
6. Singed nasal hairs
88
When does FPHC recommend using cyanide antidote?
Suspected smoke inhalation AND:
- altered mental status
- CV instability
89
What 3 categories of burns severity does FPHC recommend using pre-hospital?
< 20%
20-50%
> 50 %
90
What does FPHC say about water cooling of thermal burns? (3)
1. Water < 20 degrees (12 ideal)
2. 20 mins
3. Not ice water secondary to risk of tissue necrosis
91
What does FPHC recommend with regards to first aid for chemical burns? (3)
1.Treat any chemical burn ASAP regardless of delay to presentation
2. Use amphoteric solution as first line
3. Irrigate for as long as possible
92
When does FPHC state fluid resus should be commenced pre-hospital in:-
- adults
- paeds
> 20%
93
Describe the FPHC 'threshold' method for estimating pre-hospital fluid resusitation?
94
What analgesia should be avoided in burns?
NSAIDs if requiring fluid resus
95
When does FPHC recommend chest escharatotomy?
Circumferential or near circumferential eschar with imprending or established respiratory compromise to to thoraco-abdominal burns
96
What is the definition of crush injury?
Direct injury to a body part which has undergone a prolonged static compressive force sufficient to interfere with normal tissue metabolic function
97
What is the definition of crush syndrome?
Systemic consequences of muscle + soft tissue trauma
98
What 3 factors make crush syndrome more likely?
1. Increased compressive force
2. Increased muscle bulk
3. Increased time
99
Describe rescue cardioplegia
Occurs on release of compressing force
- cold 'toxic' blood released back into systemic circulation leading to a sudden and transient increased preload. Causes atrial stretch which can lead to asystole of AF
- Simultaneous rapid drop in afterload + SVR as blood moves back into affected limb
- both lead to acute hypotension when limb released
100
What can make the affects of rescue cardioplegia worse?
- blood released 'ideal cardioplegic solution' leading to arrhythmia
- cold/hyptertonic/acidotic/ raised k+/ca2+/Mg2+/P04D
101
Describe the pathophysiology of crush syndrome
- Constant external mechanical force prevents cell wall integrity by forcing extracellular cations + fluid against normal electrochemical + osmotic gradient into cells
- cell wall extrusion pumps become overhwhelmed allowing water with dissociated Na+/Cl-/Ca2+ into cell
- ultimately leads to death
102
When is irreversible cell death caused by crush syndrome?
<1 hour but no universally accepted 'safe time'
103
What is compartment syndrome?
Intramuscular compartment forces act continualy above DBP leading to comrpession and death of nerves/blood vessels/muscle
104
Describe the pathophysiology of compartment syndrome
Integrity of muscle cell wall breached and intracellular components move extracellular and into damaged tissue
Cell content forced into vascular compartment lead to systemic affects
105
How are kidneys damaged in compartment syndrome? (2)
1. Direct damage of intracellular substances (proteases/purines)
2. Indirect - attempt to filter acidotic plasma + myoglobin damage
106
How does myoglobin damage kidney?
- Myoglobin itself not nephrotoxic but when systemic acidosis lead to pH urine< 5.6 myoglobin converted to larger protein Ferrihaemate.
- This is directly nephrotoxic and causes mechanical obstruction of nephron lumen
- hypovolaemia and third space shift makes this worse
107
What is the protein that myoglobin becomes when urine PH < 5.6
Ferrihaemate
108
How should suspended patients be rescued?
ASAP and placed horizontally
109
What has been shown to improved outcomes in trapped earthquake patients?
Systemic resus with sodium and potassium containing fluids (20ml/kg - 10ml/kg elderly)
110
Describe the pain response in crush injury
Initially reduced due to endorphins and pressure neuropraxia but this will increase as limbs swell and endorphins wear off
111
When should alkaline diuresis be considered in crush injury?
If evacuation time >4 hours
112
How is alkaline diuresis performed?
1. 50ml 8.4% soidum bicarbonate to each alternate 1L fluid
2. If prolonged transfer alternate 5% dex to prevent sodium overload
3. Aim urine PH >6.5
Really should be done in hospital
113
Describe the pathology of tissue damage caused by projectiles?
- Shockwave drives tissue radially leading to a temporary cavity
- Contamination drawn into this cavity, which collapse once the projectile has passed leaving a permanent cavity (smaller) and traps contamination in wound.
114
Why are solid organs more effected than muscle/lungs etc in terms of projectile injury?
Not very elastic, unable to stretch, therefore tolerate cavitation poorly and causes more damage
115
Describe the physics of a blast
- Rapid chemical transformation of solid/liquid into a gas.
- Under increased pressure this gas expands rapidly outward as a wave of pressure
116
What is a blast wave?
Air at leading edge of explosion is highly compressed
117
What is a primary blast injury?
-Only occur in high pressure explosions
- Blast wave interacts with body tissues leading to stress/shear
118
What areas/organs normal affected by primary blast injury? (3)
1. Tympanic membrane
2. Lungs
3. Bowel
119
What can severe primary blasts causes?
Vagally mediated bradycardia/hypotension and apnoea
120
What is a secondary blast injury?
Fragments from device or other materials energised by the blast
121
With regards to secondary blast injuries what are:
1. Primary fragments
2. Secondary fragments
1. From device
2. From other materials energised by the blast
122
If fragments from other victims lead to secondary blast injuries what should be advised?
PEP
123
What is a tertiary blast injury?
Blast wave displaces objects in its path (blast wind) e.g. bodies thrown agains solid objects or structural collapse
124
What is a quaternary blast injury?
Any other explosion related injury e.g. burn, psychological trauma
125
What are the 6 types of lung injury caused by blast lung?
1. Interstitial haematoma/oedema
2. Intra-alveolar injury
3. Pulmonary oedema (can be delayed)
4. PTX
5. Alveolar-venous fistula
6. Air embolism
126
What are the 3 types if injury to bowel caused by blast bowel?
1. Contusion
2. Perforation
3. Intra-luminal bleeding
127
Which type of bowel is most affected by 'blast bowel'?
Large bowel
128
'Blast ear' can cause which 3 injuries?
1. TM rupture
2. Ossicle dislocation
3. Inner ear damage
129
What are the 4 C's in terms of an explosion?
Police use for their initial approach
Confirm threat
Clear people away
Cordon
Control - create Incident Control Point (ICP)
130
In terms of forensics post an explosion, what should we remember to do to preserve evidence? (4)
1. Only touch objects to tx patients
2. Only move bodies to tx patients
3. When cutting off clothes try to avoid cutting through points of penetration
4. Take limbs with patients even if unsalvageable
131
In terms of triaging post explosion, what can be a useful marker of injury and why?
TM rupture because blast injuries can deteriorate later
132
What denotes a high mortality in a patient injured during an explosion?
1. Blast lung + amputation
133
Following a traumatic amputation secondary to an explosion when should we use a tourniquet?
Always - can no bleed initially due to vasospasm/cauterisation but will start to
134
In proximal amputations following an explosion, what other injury is likely?
Pelvic fractures - place binder emperically
135
What is the mortality in penetrating head if the patient is?
Alert
Voice
Pain
Unresponsive
A = 11.5%
V = 33.3%
P = 7%
U = 100%
136
Describe the zones of the neck?
1. Clavicle to cricoid
2. Cricoid to angle of mandible
3. Angle of mandible to bottom of ear
137
Why were the neck zones divided as they are?
Zone 2 more easily explored surgical, whereas 1 and 2 more likely to need CT angiography
138
What does JRCALC state about giving IV fluids in paeds burns:
1. >20%
2. 10-20%
3. <10%
1. Give 10ml/kg normal saline over 1 hour
2. If journey time >30 mins given 10ml/kg over 1 hour
3. No fluids
139
What is classed as a dangerous MOI in the NICE head injury guidelines (6)?
1.A fall from a height of more than 1 meter or 5 stairs
2. A high-speed RTC (pedestrian, cyclist, or vehicle occupant)
3. Roll over RTC/ ejection
4. An accident involving motorized recreational vehicles
5.Bicycle collision
6. Diving accident
140
What are the borders of the 'safety triange' for chest drains?
1. Lateral border pec major
2. Nipple line
3. Anterior border of latissimus dorsi
141
What is the causes of life threatening chest trauma in order of how frequently they occur in TARN?
Flail chest ( 1 in 50 )
Tension PTX (1 in 250)
Massive HTX (1 in 1000)
Cardiac tamponade (1 in 1250)
Open PTX (1 in 10,000)
142
What mechanism is most commonly associated with posterior hip dislocation?
Unrestrained passengers with frontal impact
143
What is the effect of an:
1. engine
2. tow bar
on injuries
1. Protective against frontal collisions
2. Transmits energy directly to passenger cabin and bypasses crumped zonesW
144
What is Waddells triad?
Injury in children hit by car whilst walking:
- contralteral head injury
- intrathoracic or intrabdominal injury
- fractured femur
145
In a self ventilating patient with suspected PTX/tension PTX what does FPHC recommend as:
1. First line
2. Second line
3. Third line
1. Needle decompressoin 2nd IC space mid clavicular
2. 5th IC space mid-axillary line
3. Thoracostomy followed up by CD if level 6 practitioner
146
What does the FPHC say about chest drains pre-hospital in their consensus statement
- Should be avoided where possible due to:
- prolongation of on-scene time
- risks of kinking
- blocking or falling out during transfers
- long-term infection risks with non-sterile insertion techniques.
It is accepted that chest
drain insertion will be necessary in some circumstances eg high-altitude aero-medical retrieval.
147
What is the complication rate of pre-hospital thorocostomy?
10-15%
148
What does FPHC recommend with respects to abx and thoracostomy?
Should be considered for pre-hospital thoracostomy, especially in cases of penetrating chest trauma, or with transport times >3 hours
149
What does FPHC recommend for treatment open PTX? (2)
1. Commercial chest seal, vented preferably (3 sided dressing no longer recommended)
2. IV abx prophx
150
What is the FPHC consensus statement on massive HTX? (3)
1. If no respiratory compromise then drainage should be delayed until ED
2. Where thoracostomy has shown significant haemorrage then a chest drain maybe beneficial to monitor blood loss, however should not significantly impact of scene time.
3. Clamping chest drain for exsanguinating chest trauma, however caution needed as high chance of co-existing PTX which could tension with PPV etc.
151
What is the FPHC consensus statement recommendations on flail chest?
1. Where possible, sit uo
2. Patient may find holding their ribs helps with pain
3. Pain score and suitable analgesia
4. No entonox a 1/3 patients with >3 rib #s have PTX as well
152
What factors associated with ribs #s have been shown to lead to worse outcomes and trigger clinicians to convey to centre with CTS? (8)
1. age 65 years or more
2. Chronic lung disease
3. BM >25
4. Anticoagulant use
5. three or more rib
fractures
6. bilateral flail chest
7. co-existent underlying lung injury
8. oxygen saturation <90% in the Emergency Department.
153
What does FPHC consensus statement say about pre-hospital pericardiocentesis?
1. No evidence for its use
2. Can cause damage
3. Unlikely to be able to aspirate clotted blood from needle
154
What are the 4 things needed for to indicate pre-hospital thoracotomy according to FPHC?
1. Stab wounds to the chest or upper abdomen
2. Cardiac arrest with loss of vital signs ≤ 15 minutes
3. The suspected injury is suitable for temporary repair and control
4. A chain of survival exists for definitive management following Resuscitative Thoracotomy
155
How quickly does NICE suggest and RSI should be performed if needed?
Within 45 mins of the 999 call
156
What is the time limit that NICE recommend for diverting to a TU for a trauma patient requiring an RSI as opposed to continuing onto a MTC?
If 60 mins or less continue to MTC, if above this divert to TU
157
What does NICE state about tension PTX? (3)
1. Clinical diagnosis but can used eFAST to augment this
2. Only decompress if severe ventilatory failure of haemodynamic compromise
3. Use thoracostomy instead of needle if expertise available
158
How does NICE recommend managing open PTX?
Simple occlusive dressing
159
When does NICE recommend decompressing a tension PTX in hospital before CXR?
Severe ventilatory failure of haemodynamic compromise?
160
When does NICE recommend using TXA in major trauma?
Active or suspected bleeding ASAP but no >3 hours
161
What agent does NICE recommend using in major haemorrhage in patients taking vit K antagonists?
PCC
162
What target does NICE recommend for volume resusitation in major trauma patients without head injury?
Titrate to carotid/femoral pulse
163
What does NICE recommend as first line analgesia in major trauma with:
1. IV access
2. No IVA
1. Morphine
2. IN diamorphine or ketamine
164
How is CPP calculated?
MAP-ICP
165
In terms of GCS, what defines
1. Mild HI
2. Moderate HI
3. Severe HI
1. 13-15
2. 9-12
3. 8 or less
166
In pre-verbal children, in terms of GCS, what score can be used instead of the verbal score
Grimace score
167
Describe the components of an adult GCS?
Eye response (E)
1 -No eye opening
2- Eye opening in response to pain stimulus (a peripheral pain stimulus, such as squeezing the lunula area of the patient’s fingernail is more effective than a central stimulus such as a trapezius squeeze, due to a grimacing effect)
3- Eye opening to speech (not to be confused with the awakening of a sleeping person; such patients receive a score of 4, not 3)
4- Eyes opening spontaneously
Verbal response (V)
1 -No verbal response
2- Incomprehensible sounds (moaning but no words)
3- Inappropriate words (random or exclamatory articulated speech, but no conversational exchange)
4- Confused (the patient responds to questions coherently but there is some disorientation and confusion)
5- Oriented (patient responds coherently and appropriately to questions such as the patient’s name and age, where they are and why, the year, month)
Motor response (M)
1- No motor response
2- Extension to pain (extensor posturing: abduction of arm, external rotation of shoulder, supination of forearm, extension of wrist, decerebrate response)
3- Abnormal flexion to pain (flexor posturing: adduction of arm, internal rotation of shoulder, pronation of forearm, flexion of wrist, decorticate response)
4- Flexion/Withdrawal to pain (flexion of elbow, supination of forearm, flexion of wrist when supra-orbital pressure applied ; pulls part of body away when nailbed pinched)
5- Localizes to pain (Purposeful movements towards painful stimuli; e.g., hand crosses mid-line and gets above clavicle when supra-orbital pressure applied)
6- Obeys commands (the patient does simple things as asked, e.g. stick out tongue or move toes)
168
Describe the paediatric GCS
169
Describe the grimace score?
170
What does the AAGBI guidelines for transfer in HI/CVA recommend as triggers for intubation? (2)
1.Glasgow Coma Scale (GCS) ≤ 8
2. significantly deteriorating conscious level (GCS fall in 2 or more or motor score of 1 or more)
171
What does the AAGBI guidelines for transfer in HI/CVA suggest about patients accepted for thrombectomy with regards to intubation? (2)
Should be transferred without delay, anterior circulation CVA rarely needs i+v
172
What is the conventionally understood time target for neurosurgery with expanding heamatoma?
< 4 hours from injury
173
What is the current indication for
1. Thrombolysis
2. Thrombolysis and thrombectomy
3. Thrombectomy only
1. Acute ischaemic
stroke with symptoms up to 4.5 h after onset
2. Demonstrable proximal artery occlusions in the anterior circulation who can be treated within 24 h of
symptom onset
3. If i.v. thrombolysis is contraindicated (e.g. in a warfarin-treated patient with
therapeutic anticoagulation) mechanical thrombectomy is
recommended as the first line of treatment
174
What does the AAGBI guidelines for transfer in HI/CVA recommend as essential equipment? (6)
1. Portable ventilator with airway pressure/ MV and disconnect alarm
2. Oxygen - minimum reserve of 1 hour or twice the journey times, whichever is longer
3. Portable, battery powered monitor
4. Adequate drugs
5. Communication equipment
6. Other equipment; glucometer (if receiving insulin),
battery-powered syringe pumps, battery-powered i.v.
volumetric pumps, appropriate intubation equipment,
self-inflating bag, valve and mask, venous access
equipment, chest drain or equipment for finger
thoracostomy (if major trauma), DC defibrillator,
insulating blanket, torch (to assess pupils), a means to
record physiological variables and the administration of
drugs/fluids during the transfer
175
What does the AAGBI guidelines for transfer in HI/CVA recommend as essential drugs? (9)
1. Hypnotics e.g propofol
2. Paralytic
3. Opioid analgesics,
4. Anticonvulsants
5. Mannitol 20% or hypertonic saline
6. Vaso-active drugs
7. Resuscitation drugs (as in hospital resuscitation boxes)
8. Intravenous fluids
9. Cross-matched blood (e.g. in trauma patients)
176
What does the AAGBI guidelines for transfer in HI/CVA recommend as essential monitoring? (6)
1. GCS
2. Pupils
3. Pulse oximetry
4. IBP (but don't delay time critical tranfer if NIBP ok)
5. Capnopgraphy
6. UO (catheter)
177
What does the AAGBI guidelines for transfer in HI/CVA recommend for RSI induction agent in traumatic HI?
Ketamine + fentany
178
What cardiovascular physiological parameters does the AAGBI guidelines for HI/CVA suggest for
1. TBI
2. Haemorrhagic stroke/ IC bleed
3. Acute ischaemic CVA
4. Spontaneous SAH
1. SBP >110 and < 150, MAP >90
2. SBP <150 if within 6h symptoms and immediate surgery not planned
3. SBP >140 and < 185 (if had thrombolysis/is candidate) or <220 (if not for thrombolysis)
4. SBP >110 and <160
179
What does the AAGBI guidelines for HI/CVA suggest for:
1. PaC02
2. Oyxgenation
1. 4.5-5.0 (if uncal herniation imminent brief period of 4 - 4.5 can be used)
2. 13 or above / SATS 95% or above
180
What does AAGBI recommend should be checked before transfer of HI/CVA patient in terms of venitlation?
ABG
181
During transfer for HI/CVA patients what does AAGBI recommend in terms of:
1. Head position
2. PEEP
3. Fluid
4. Sedation
1. 20-30 degrees head up
2. Mimimum of 5 to prevent atelectasis, up to 10 not shown to raise ICP
3. Normal saline (isotonic)
4. If RSI not used propofol be careful with infusion/BP
182
What specific indications does the AAGBI mention are appropriate for emergency transfer by the local team? (6)
1. Extradural haematoma;
2. Acute subdural haematoma with mass effect;
3. Obstructive hydrocephalus
4. Acute ischaemic stroke requiring urgent thrombolysis
5. Subarachnoid haemorrhage;
6. Malignant middle cerebral artery infarction
183
What MAP does AAGBI recommend in TBI/CVA in paeds?
< 3 months = 40–60
3 month-1 year = 45–75
1–5 years = 50–90
6–11 years = 60–90
12–14 years = 65–95
184
What does AAGBI recommend considering in intubation children with TBI?
Bolus of hypertonic saline to avoid an associated rise in ICP during predictable PCO2 rise while performing laryngoscopy (i.e. apnoea), and to prevent the potential associated fall in BP
185
What does AAGBI mention as specifc considerations with respects to paeds transfer with brain injury?
1. More prone to hypoglycaemia
2. Accel/decel will have more affect - discuss with crew before leaving
3. Less space around brain so small amounts of increased ICP will have big affect
4. Do not tape eyes shut to allow frequent pupil check but care re: eye hydration
5. If possible bring parents to allow consent at other end
186
What does AAGBI suggest for audit parameters in terms of HI/CVA transfer? (10)
1. Clinician accompanying patient is suitably trained in
transfers
2. Patient’s trachea intubated if GCS ≤ 8 before departure
3. If intubated, capnography used during the transfer and
all values 4–5 kPa
4. Arterial blood gas measurement performed before
departure
5. Blood sugar 6–10 mmol.l1
6. MAP ≥ 90 mmHg at all times in patients with isolated TBI
7. Sedation, if used, administered by continuous i.v.infusion
8. Pupillary size and reaction during transfer recorded
9. Written record of vital sign observations
10. Time from acceptance by receiving unit to departure
from sending unit
187
What are the BP targets to secondary transfer set by NICE in TBI
MAP >80
188
What does JRCALC recommend in terms of BP targets in TBI? (3)
1. MAP >90
2. SBP >120
3. Fluids if absent carotid pulse
189
What does NICE reccomend in TBI for:
1. TXA (paeds and adults)
2. Hypertonic
3. When to give a pre-alert
1. 2 g adult/ 30mg/kg paeds IV for moderate/severe TBI (GCS 12 or less) within 2 hours of injury
2. 3ml/kg 5% saline
3. GCS 8 or less
190
What are the recommend doses of mannitol and hypertonic and which one has the strongest evidence?
3ml/kg hypertonic
0.5-1g/kg mannitol
No evidence for one over the other
191
What is the quickest/most efficent way to measure burns and recommended by FPHC?
Threshold method
192
What lung protection measures should be used in traumatic lung injury? (3)
1. TV 4-6ml/kg
2. Plateau pressure of <30cmH20
3. Use of PEEP to increase FRC
193
What landmarks demarcate zone 1 neck and what structures are there? (8)
Clavicles/sternum to cricoid
1. Proximal common carotid artery
2. Subclavian arterties
3. Vertebral arterties
4. Lung apices
5. Trachea
6. *Thyroid*
7. Oesophagus
8. Spinal cord
194
What landmarks demarcate zone 2 neck and what structures are there? (6)
Cricoid to angle of mandible
1. Carotid and vertebral arteries
2. Jugular veins
3. Pharynx and larynx
4. Trachea
5. Oesophagus
6. *Vagus and recurrent laryngeal nerves*
195
What landmarks demarcate zone 3 neck and what structures are there? (6)
Angle of mandible to base of skull
1. Distal carotid arteries
2. Jugular veins
3. Vertberal arteries
4. Spinal cord
5. *Salivary and parotid glands*
6. *CN IX-XII*
196
In what type of injury and patient demographic is fat embolism more common?
Pelvic or long bone fractures
Young men
197
When does Fat Embolism Syndrome (FES) normally present?
24-72 hours post injury
(acute normally leads to cardiac arrest)
198
What is the triad of symptoms for Fat Embolism Syndrome (FES)
1. Respiratory distress
2. Neurological dysfunction
3. Petechial rash
199
What artery normally causes massive maxfax bleeding?
Ethmoidal artery which is a branch of the internal carotid artery
200
Describe max fax packaging in terms of which part splints what anatomy
1. Maxilla - Epistat
2. Hard palate - bite blocks
3. Mandible - cervical collar
201
What is the most common cardiac injury caused by blunt trauma?
Cardiac contusion
202
How is shock index calculated?
HR / SBP
203
What value of shock index (SI) is predictive of high morbidity and need for MHP?
> 0.9
204
What nerves are likely to be damaged in a posterior hip dislocation and what neurology will it lead to?
Sciatic most likely, then common peroneal (once sciatic nerve branches into tibial + common peroneal at popiteal fossa)
Sciatic nerve - knee flexion/hip adduction and movement ankle/foot
Common peroneal - weakness dorsiflexion, great toe extension
205
What is the definition of traumatic asphyxia?
Mechanical hypoxia caused by blunt compression of chest, in conjunction with inspiration against a closed glottis (Valsalva)
206
How does traumatic asphyxia lead to rupture of venules in face/conjunctiva?
Changes in pressure in thoracic cavity cause compression of right atrium
207
Why should metaraminol not be used in neurogenic shock and what can be used instead?
Can cause reflex bradycardia
Use ephidrine or adrenaline as both are alpha and beta agonists
208
209
What are the indications for pre-hospital amputation (4) and what is strongly advised beforehand?
1. Immediate risk to patients life due to scene safety
2. Patient deteriorating and physically trapped by their limb and most likely will die during the time it takes to extricate
3. Mutilated non-survivable limb with minimal soft tissue attachment causing a delay to extrication that is not life threatening
4. A patient is dead but heir entrapment is blocking access to potentially live casualties
Call with senior clinician on call (or another consultant)
210
What are the recommended antibiotics for animal/human bites according to the NICE guidelines:
1. first line
2. Pencillin alllergy oral
3. Penicillin allergy IV
1. Co-amoxiclav
2. Doxy and metronidazole
3. Cefuroxime and metronidazole
211
What do the NICE guidelines recommend in terms of abx for human bites that:
- haven't broken skin
- have broken skin but not bleeding
- broken skin and bleeding
1. No abx
2. Conisder abx if high risk patient or area*
3. Give abx
* High-risk areas include the hands, feet, face, genitals, skin overlying cartilaginous structures or an area of poor circulation
People at high risk include co-morbidity (such as diabetes, immunosuppression, asplenia or decompensated liver disease)
212
What do the NICE guidelines recommend in terms of abx for dog bites that:
- haven't broken skin
- have broken skin but not bleeding
- broken skin and bleeding
1. No abx
2. No abx
3. Offer antibiotics if it has
caused considerable, deep
tissue damage or is visibly
contaminated (for example,
with dirt or a tooth)
Consider antibiotics if it is in
a high-risk area or person at
high risk
* High-risk areas include the hands, feet, face, genitals, skin overlying cartilaginous structures or an area of poor circulation
People at high risk include co-morbidity (such as diabetes, immunosuppression, asplenia or decompensated liver disease)
213
What do the NICE guidelines recommend in terms of abx for cat bites that:
- haven't broken skin
- have broken skin but not bleeding
- broken skin and bleeding
1. No abx
2. Consider if could be deep
3. Offer abx
214
What are the key BOAST guidelines for pelvic injuries? (5)
1. Pelvic injuries with CV instability should have a binder applied, go to an MTC and have TXA ASAP or within 1 hour
2. Active bleeding pelvic injuries not responding to resusitation should undergo surgical packing (with binder in situ during surgery) or embolisation
3. Patients undergoing damage control laparotomy from blunt injuries should have pelvic imaging (XR or CT) before theatre
4. Pelvic binder should be removed within 24 hours of injury
5. Reconstruction of pelvic ring should occur within 72 hours of injury
215
What are the key recommendations from BOA with regards to open fractures? (5)
1. IV abx with 1 hour
2. Only remove gross contaminant
3. Highly contaminated wound will need immediate surgical intervention
4. High energy open fractures should have surgery within 12 hours of injury
5. Low energy open fractures should have surgery within 24 hours of injury
216
What abx should be given for open fractures and how quickly according to BOA in:
- first line
- penicillin allergy
- anaphx to penicillin
1. Co-amox
2. Cephalosporin
3. Gentamicin
All within 1 hour of injury
217
What 3 bit of kit are needed to perform FONA?
1. Size 10 scalpel
2. Bougie
3. 6mm cuffed ETT
218
What are the 4'Es mentioned in the ERC guidance about thoractomy?
1. Elapsed time <10 mins?
2. Expertise present?
3. Equipment available?
4. Enviroment optimised?
219
At what voltage should internal defib pads be used in VF post thoracotomy?
10J increased to 20J if needed
220
How can primary blast waves lead to vagal mediated shock?
Waves trigger C-fibre pulmonary baroreceptors leading to vagal stimulation
221
What is the 'critical phase of impact brain apnoea?
First 10 mins:
2 phases - apnoea and catacholamine surge
222
What can the catecholamine surge lead to systemically? (6)
1. Hyperglycaemia
2. HTN
3. Raised ICP due to vasoconstriction which worsens the cerebral vasoconstriction already caused by hypercapnia
4. Vasoconstriction in other vascular beds leading to ischaemic gastric mucosal ulceration +
5. Neurogenic pulmonary oedema
6. Myocardial necrosis
223
What is traumatic mydriasis, what are the signs, and how is it caused?
Pupillary dilatation following blunt eye trauma due to injury of the iris sphincter muscles. It will be poorly reactive to both direct and consensual light reflex
224
What should be ensured following an explosion if someone if pregnant and why? (2)
1. anti-D immunoglobulin if Rhesus negative within 27 hours as blast waves cause microscopic damage and cellular interface leading to foetal cells entering maternal bloodstream
2. US to rule out uterine rupture/placental abruption
225
Re TXA + TBI what are the recommendations from:
1. CRASH-2
2. CRASH-3
3. NICE
1. Give < 3 hours and not after (evidence of increased mortality >8 hours)
2. Reduced mortalitiy in mild/mod isolated head injuries < 3hours. Earlier better. No improvement in severe HI. Adults only
3. 2g IV or 30mg/kg paeds in HI with GCS 12 or less if within 2 hours injury.
226
How quickly following injury can crush syndrome develop?
1 hour
227
What does the FPHC receommend for the fluid management of crush injuries?
2L warmed crystalloid (not Hartmanns) prior to extrication if possible followed by 1.5L/hr following this
228
What is the FPHC definition of
1. Crush injury
2. Crush syndrome
A crush injury is a direct injury resulting from crush.
Crush syndrome is the systemic manifestation of
muscle cell damage resulting from pressure or crushing
229
Shock in crush is multifactoral, what are 3 contributing factors?
1. Blood loss from injuries
2. Shift of fluid out of IV compartment
3. Acidosis/low Ca2+/high K+ lead to negative ionotropy
230
Aside from hyperkalaemia, what is the other common electrolyte imbalance in crush syndrome?
Hypocalcaemia
231
What role does the FPHC suggest using mannitol for in crush injury?
Diuresis - more in the hospital phase to augment alkaline diuresis
Some evidence it may help avoid fasciotomy in compartment syndrome
232
Following a blast injury with open wounds and suspected human contamination what vaccinations should patients have? (2)
1. Accelerated Hep B
2. Tetanus
233
What is:
1. Simple impalement
2. Complex impalement
1. Impaled by simple object e.g knife and does not interfere with managemend
2. Patient trapped by impaling object
234
What is the Mangled Extremity Severity Score (MESS)
Scoring system to predict whether limb likely to be salvageable:
Uses:
1. Type of injury (4)
2. Degree of shock (3)
3. Level of ischaemia (4)
4. Age (2)
7 or more likely to need amputation
235
What are the pros/cons for the following amputation devices?
1. Homatro device ('jaws of life')
2. Reciprocating saw
1. Pros: Can be used underwater
Cons: only can be used by FRS (but medical team likely to need to cut down to soft tissue), causes most tissue damage
2. Pro: quickest, can be direct to skin
Cons: Risk to rescuer, blood spatter, aerolisation of tissue, potential battery failure and cutting through surface under the limb
Cons:
236
What is suspension syndrome and what is current understanding of its mechanism?
Multifactoral circulatory collapse during passive hanging on a rope or in a vertical harness.
Thought to be due neurocardiogenic mechanism.
237
What is the end result of suspension syndrome and give 4 reversible causes?
Cardiac arrest:
1. Hyperkalaemia
2. Hypoxia
3. Hypothermia
4. PE
238
What are the features of acute suspension syndrome? (4)
1. Near suspension syncope
(dizziness/confusion/nausea/blurred vision/bradycardia)
2. Suspension syncope
3. Suspension cardiac arrest
4. Post suspension cardiac arrest within 60mins of rescue
239
What are the features of subacute suspesion syndrome? (3)
1. Sensory or motor deficit in lower limbs persisting > 24 hours of rescue
2. End organ dysfunction, particularly rhabo and AKI
3. Delayed cardiac arrest > 60mins from rescue
240
Following inhalational burns injury what lung protective ventilatory measures may be needed?
1. TV 6ml/kg
2. PEEP + plateau pressure <30cmh20
3. Prolonged I:E ratio and low RR if risk of air trapping
4. Nebulised heparin and NAC have been shown to be beneficial
241
What is the predominant and most likely fatal aspect of primary blast injury?
Primary blast lung injury
242
What is the definition of primary blast lung injury?
Radiological and clinical evidence of acute lung injury
occurring within 12 hours of exposure and not due to
secondary or tertiary injury
243
What 2 factors dictate the severity of primary blast lung injury?
Proximity to blast
Wether or not in enclosed space - far worse if you are
244
In primary blast lung injury what factor makes it unlikely patient will need I+V
Delayed to symptoms >2 hours
> 6 hours likely to lead to clinically important disease
245
In penetrating blast injuries what abx prophx should be used for:
1. Penetrating CNS
2. Penetrating eye
3. All others
1. Cef + met
2. Ciprofloxacin
3. Co-amox (If GI add fluconazole if perforation)
246
Following bomb blast and suspected contantimation of human remains what is the PHE advice for BBV PEP?
1. Take and store blood and check for seroconversion at 3 + 6 months
2. Hep B - accelerated vaccine schedule to start < 72 hours
2. Hep C and HIV PEP not routine recommended (HIV partly due to s/e of PEP and low risk)
247
What is the single biggest determining factor of injury with respects to gunshot injuries?
Velocity of weapon
248
What is the definition of:
1. High explosive
2. Low explosive
1. Detonation caused by supersonic shockwave that spreads through the explosive material
2. Deflagration, not detonation, e.g gunpowder. Combustion and subsonic speeds
249
What has the strongest evidence for preventing secondary TBI?
1. Avoiding hypotension
Hypoxia second, both together = worst
250
Followowing vomiting and open chest wound, what should be done if concerns re: tension/increased pressure?
Remove occlusive dressing and then replace on expiration ('burping')
251
What is the difference in presentation of dislocation:
1. anterior hip
2. posterior hip
1. Anterior Dislocation (rare): leg ABDucted and EXTernally rotated.
2. Posterior Dislocation: leg is ADDucted and INTernally rotated with the hip in a flexed position.
252
What are the Ottawa ankle rules?
1. Unable to WB immediately after and now
2. Tenderness of posterior medial or lateral malleolus
253
Describe the Weber ankle classification
A - below syndesmosis and stable
B - at the level, can be either
C - above the level of syndesmosis and unstable
254
What are the indications for CT neck over XR neck in kids? (7)
1. GCS <15
2. I+V
3. Needs rapid definitive diagnosis i.e. theatre
4. Polytrauma requiring other body parts CT
5. Peripheral neuro signs
6. Parasthesia upper/lower limbs
7. XR normal but ongoing concerns
255
What is the primary modality for chest imaging in paediatric trauma?
XR
256
What 2 circumstances require CT chest in paeds trauma?
1. Penetrating trauma
2. Severe blunt trauma
257
What is the imaging recommended for high suspicion of spinal injury in children?
XR and MRI
(CT if unable to perform MRI)
258
What are 6 risk factors for needing CT abdomen in paeds trauma?
1. Abdominal wall bruising
2. Lap belt injury
3. Abdominal tenderness
4. Abdominal distension
5. Persistent hypovolaemia
6. PR or NG blood
259
What is the imaging of choice for paeds pelvic injuries?
CT
Pelvic XR as primary survey not recommended
260
In which group is SCIWORA more common?
Children (around 30%)
261
Describe the 3 columns in the 3 column spinal theory
Anterior column - anterior longitudinal ligmaent, anterior 1/2 of vertebral body
Middle column - posterior ligament, posterior half of vertebral body
Posterior column - everything posterior to vertebral ligament - neural arch, facet joints etc.
262
Which column is the most important for the spines stability?
Middle
Posterior also unstable
263
What are the 3 mechanisms leading to smoke inhalation injury?
1. Heat (infra-glottic burns)
2. Particulate matter deposition and respiratory irritants
3. Asphyxiation and systemic toxicity
264
What makes smoke inhalation much more likely?
Trapped in enclosed spaces
265
What are the particulate matter deposits involved in inhalational lung injury, and how do they cause injury?
- Mainly carbonaceous particles containing toxic chemicals (soot).
- The particles cause mechanical obstruction, increasing airway resistance and reducing compliance, thus increasing the work of breathing.
- chemical irritants on the soot (depending on what has been burning) can also lead to inflammatory response
266
What causes the systemic toxicity in inhalation lung injury?
Products of incomplete combustion -mainly
1. CO (80%)
2. Hydrogen cyanide
267
What are the landmarks for a radial nerve block?
Palpate radial styloid and radial artery (to avoid hitting).
Inject proximal to radal styloid process and lateral to artery.
Then inject medially to midpoint of wrist to avoid missing superficial branches.
268
What are the landmarks for an ulnar nerve block?
Medial border for flexor carpi ulnaris, 2cm proximal to palmar crease
Insert needle 0.5-1cm and inject 2-4ml LA
269
What are the landmarks for a median nerve block?
1cm between tend of palmaris longus and flexor carpi radials 4cm from palmar crease and inject 5ml LA
270
What are the landmarks for the following ankle blocks?
1. Ring block technique
2. Posterior tibial nerve block
3. Deep peroneal nerve block
1. Includes saphenous/sural and superficial peroneal nerve. Ring of LA (15-20ml) subcutaneously at level of malleolus, anterior to Achilles tendon
2. Palpate PT artery and insert just posterior to this to bone. Withdraw 1-3mm and inject 5ml LA
3. Immediately lateral to extensor hallucis, 3cm distal to the intermalleolar line and medial to DP artery
271
What are the landmarks for FIB?
ASIS and pubic tubercle - junction between lateral and middle third of this line. Move 1cm caudal to this
Will feel 2 pops - first through fascia lata and second through fascia iliaca
272
What are the indications for pre-hospital amputation (4) and what is strongly advised beforehand?
1. Immediate risk to patients life due to scene safety
2. Patient deteriorating and physically trapped by their limb and most likely will die during the time it takes to extricate
3. Mutilated non-survivable limb with minimal soft tissue attachment causing a delay to extrication that is not life threatening
4. A patient is dead but heir entrapment is blocking access to potentially live casualties
Call with senior clinician on call (or another consultant)
