Trauma

Question 1

Trimodal distribution of death

Answer 1

Three major times death occurs after an accident/trauma
Instant - 1hr –> laceration or trauma to the brain/brainstem, aorta, spinal cord, heart
3 - 5hrs –> Epidural, subdural, haemopneumothorax, open-book pelvic #, long bone #, abdominal trauma, blood loss and shock
2 - 4wks –> Sepsis or MOF

Question 2

Golden Hour

Answer 2

The first hour following a trauma - need to recognise threats to life and treat them - massive influence on later mortality and morbidity

Question 3

Principles of early trauma care

Answer 3

Do no harm - Cervical spine control
Adequate oxygen delivery to organs - Patent airway
- Functioning lung
- Additional high flow oxygen
- Organ perfusion - preserve and replace blood volume

Question 4

Primary Survey

Answer 4

A - Airway + C spine control
B - Breathing & ventilation + oxygen
C - Circulation + Haemorrhage control (consider analgesia)
D - Disability + CNS
E - Exposure + Environment

Question 5

Timeline of trauma care

Answer 5

Primary survey –> Resuscitation (re-evaluate) –> secondary survey (Re-evaluate primary survey) –> Definitive Care

Question 6

Principles of Pre-hospital care

Answer 6

Safety first –> yourself, others and patient
Make the best use of the ‘Golden Hour’
Swoop and scoop Vs Stay and play
Treat immediate threats to life and transport to nearest appropriate facility

Question 7

Way to protect the patient during transport

Answer 7

Spinal board
Cervical collar/blocks and straps
Limb splints and pelvic binder
Pressure on external haemorrhages

Question 8

Preparations while awaiting the patient

Answer 8

Anticipate injuries and assemble team members
Define the roles and prepare the kit
Universal safety precautions

Question 9

Roles of the trauma team

Answer 9

Simultaneous ABCDE management
Rapid critical and definitive interventions
Rapid test results allow for directed management
Senior multidisciplinary input immediately avaliable

Question 10

C-spine control

Answer 10

Collar and blocks & straps for in-line immobilisation
Can be done manually
Use Jaw thrust to open the airway but not head tilt

Question 11

Airway protection

Answer 11

Clear airway with suction (vomit, teeth, blood, FB etc)
Airway adjunct - Nasopharyngeal / Oropharyngeal airway
Definitive airways - an endotracheal tube - required if GCS is below 8

Question 12

Guedel

Answer 12

An Oropharyngeal airway adjunct - not a definitive airway
Measure by incisors to the angle of the jaw
Insert upside down and once in the mouth rotate and fully insert - use a tongue depressor and no turn with children

Question 13

Definitive airway

Answer 13

Cuffed Oro-endotracheal tube (COETT) - Oro/nasal tracheal airways or combitube
Surgical airways - Cricothyroidotomy & Tracheostomy
Others - LMA or jet insufflation (Not definitive)

Question 14

Emergency respiratory assessment

Answer 14

Rapid exam - RR & inspect, palpate, percuss, auscultate
Investigate with X-ray if concern of trauma
Pulse oximetry, ABG

Question 15

Thoracic Trauma

Answer 15

Major cause of mortality
Blunt: less than 10% require operation
Penetrating: 15-30% require surgical treatment
Can be life threatening and should be identified in primary survey – most require only simple procedures

Question 16

Traumatic injuries which may impair breathing

Answer 16

Airway obstruction or Tracheobronchial tree injury
Tension, open or haem- pneumothorax
Flail chest

Question 17

Laryngeal injuries causing airway obstruction

Answer 17

Rare but serious and will cause hoarseness
May be signs of subcutaneous emphysema
Treat with cautious intubation and possible tracheostomy

Question 18

Tension pneumothorax

Answer 18

Respiratory distress with distended neck veins and unilaterally absent breath sounds –> BP drops. Tracheal deviation is a later sign
Needle aspiration through the 2nd intercostal space, mid-clavicular line

Question 19

Flail chest

Answer 19

Where multiple rib fractures have produced a flail segment which will move paradoxically with breathing
Tx - re-expand lung and give oxygen. cautious use of intubation, analgesia and fluids

Question 20

Cardiac Tamponade

Answer 20

Often found after penetrating chest injury - Drop in arterial pressure, distended neck veins and muffled heart sounds - May develop PEA

Question 21

Potentially lethal cardiac injuries

Answer 21

Cardiac tamponade
Blunt cardiac injury
Traumatic aortic disruption
Mediastinal traversing wound

Question 22

Circulation and haemorrhagic control

Answer 22

Identify site of bleeding - open wounds or internal (thorax, abdomen, pelvis, retroperitoneal, long bones)
Control haemorrhage –> Direct pressure, splint/realign long bones, emergency surgery, reduce pelvic/3rd space volume
Replace volume and RBCs (warmed crystalloid or blood)

Question 23

Assessing Disability in the primary survey

Answer 23

Checking CNS function (5 P’s) - monitor for deterioration
Pernicketiness - GCS
Pupils - responsive? size and papilloedema
Planatars - normal reflexes
Power - Any focal weakness
Protruded tongue

Question 24

Preventing secondary Brain injury

Answer 24

ABC is most important because it keeps blood going to the brain - MABP should be >60mmHg to maintain CPP
If a concern about ICP raise head 30 degrees - if there is a bleed refer for surgery if cerebral oedema - head up, diuretics, ventilate

Question 25

Exposure and environment

Answer 25

Expose for primary and secondary survey but keep warm (warmed environment, fluids, blankets etc) May be hypothermic on arrival and so will need warming

Question 26

Additional monitoring after primary survey

Answer 26

Obs - RR, Stats, BP, ECG ABG + bloods Catheters and NG tube Imaging - CT, CXR, Pelvic X-ray, C-spine X-ray, abdo USS

Question 27

Secondary Survey

Answer 27

AMPLE history Check for injuries - head to toe body check Systems reveiw - neurological, musculoskeletal

Question 28

AMPPLEE history

Answer 28

``` Allergies Medications Past medical History and Pregnancy Last Meal Events leading up and including the injury ```

Question 29

Use of emergency C-spine X rays

Answer 29

An X-ray will not totally exclude a C-spine injury so it is not considered useful to have early in management - thus it is not an emergency measure

Question 30

Easy and quick first assessment?

Answer 30

Ask the patient their name/get them to talk to you Indicates they have a patent airway, enough air to speak and enough cerebral perfusion to think and enough senses to hear

Question 31

Dangers when securing the airway

Answer 31

Occult airway injury Progressive loss of airway patency - keep re-evaluating Equipment failure Inability to intubate

Question 32

Dangers when securing breathing

Answer 32

Lower airway problems verses ventilation problems Risks of iatrogenic pneumothorax Ventilation/perfusion mismatching

Question 33

Dangers when securing the circulation

Answer 33

Assess organ perfusion - level of consciousness - skin colour and temp and pulse rate and character Beware of children, the elderly and athletes as they have weird CV systems anyway

Question 34

When performing a secondary survey on the head

Answer 34

External exam - scalp palpation for skull fractures or lacerations - Check eyes and ears Red Flags - continued unconsciousness, periorbital oedema (panda eyes) and occluded auditory canal

Question 35

When performing a secondary survey on the face

Answer 35

Feel for bony crepitus, deformity or malocclusion (fucked up teeth) Red Flags -- Potential airway obstruction, Cribiform plate fractures, skull base fractures

Question 36

When performing a secondary survey on the neck

Answer 36

Consider was the injury blunt or penetrating Check for hoarseness or airway obstruction Signs - crepitus, haematoma, stidor, Red Flags --> delayed onset symptoms, occult injuries, airway obstructions

Question 37

When performing a secondary survey on the pelvis

Answer 37

Possible injury if there is: pain on palpation, leg length inequalities, bony instability, leg/foot rotation -- x-ray if needed Be cautious about excessive pelvic manipulation or underestimating pelvic blood loss (its alot)

Question 38

When performing a secondary survey on the limbs

Answer 38

Check for contusions and deformity - always check peripheral perfusion and neurological status Red flags -- missed fractures, ligamentous injury, compartment syndrome

Question 39

When performing a secondary survey on the spine

Answer 39

Check the whole spine for tenderness and swelling Complete motor and sensory exams with reflexes Consider imaging if there is altered sensorium or inability to perform exam properly - refer or perform further investigations

Question 40

Accidents in children

Answer 40

15-20% of children attending AnE are due to accidents. cause 1/3 of all childhood deaths and are the single commonest cause of death in children 1-15yrs old. Boys and lower social class children are at a higher risk and RTAs are the most common cause of fatal accidents

Question 41

Primary Prevention

Answer 41

Preventing an accident from happening - stair guards, speed limits, teaching road safety, window safety catches

Question 42

Secondary Prevention

Answer 42

Preventing or reducing injury from the accident - wearing seat belts, cycling helmets, smoke alarms, laminated safety glass

Question 43

Tertiary Prevention

Answer 43

Limiting the impact of the injury - eg teaching parents first aid.

Question 44

Disaster Triage

Answer 44

Can they walk? - if yes priority 3 Are they breathing? - if no dead Is there RR abnormal or cap refill prolonged - yes priority 1 - if not priority 2

Question 45

Process of Decontamination

Answer 45

Remove clothes - rinse - wash - rinse - dry.