TRAUMA, RETRIEVAL & EMST- B (59)

Question 1

CLINICAL DIFFERENTIATION OF PNEUMO AND HAEMO THORAX

Answer 1

• Both cause resp distress and decr BS, but PT percusses resonant, and haemothorax dull

Question 2

THE FIRST RIB YOU CAN FEEL BELOW THE CLAVICLE IS…..

Answer 2

The First Rib

Question 3

PHYSIOLOGICAL IMPACT OF SIMPLE vs TENSION PT

Answer 3

• the main effect of a SIMPLE PT is hypoxia due to lung collapse and SHUNTING
• TENSION PT adds haemodynamic compromise as well, by raising ITP, which impairs venous return

Question 4

TREATMENT OF SIMPLE, TENSION AND OPEN PT

Answer 4

• SIMPLE PT = 4*ICSMAL tube
• TENSION PT = 2ICS needle then 4ICSMAL tube (or finger alone if IPPV)
• OPEN PT = seal, then 4ICSMAL tube

* EMST states 4th or 5th, going higher reduces risk of being below diaphragm. The 4th interspace is about the nipple level in males, go higher if anything.

Question 5

WHAT IS RE-EXPANSION PULMONARY OEDEMA?

Answer 5

• = sudden onset of Ipsilateral, bilateral or even contralateral PULMONARY OEDEMA after drainage of a large PNEUMOTHORAX or EFFUSION
• it is a rare (1%) but life threatening (20%) complication, the risk of which can be reduced by
  
  • limiting initial effusion drainage to 1500mls, and
  • not using suction to re-expand PT

Question 6

TREATMENT OF PULMONARY CONTUSION

Answer 6

Supportive, with:

• Oxygen
• Analgesia
• Judicious IVT
• Ventilatory support as needed

Question 7

MANAGEMENT OF HAEMOTHORAX

Answer 7

• bleeding in haemothorax is usually self limiting and manageable with a 4ICSMAL tube
• surgery only if:
  
  • large initial drainage (>1500ml*) or
  • ongoing loss requiring transfusion

* note: both needles AND CHEST TUBES block easily with clot, so neither reliably estimate loss

Question 8

MEDSTAR EMERGENCY CLAMSHELL THORACOTOMY: INTENT AND METHOD

Answer 8

INTENT:

• To find and fix a Tamponade in a penetrating chest trauma pt who has been down <10m

METHOD

1. do bilateral 4ICSM*AL f_in_ger thoracostomies first (excludes PT)
2. join up across the midline with knife & trauma shears in the ICS & GIGLI saw for the sternum**
3. spread and look for (dark) blood of tamponade, and if found:

• slit pericardium widely
• plug hole with finger then foley (small holes tend to self seal)
• refill circn
• restart (flick with a finger/ext defib if VF)
• perform 2 handed ICM if indicated
• consider aortic compression above or below the diaphragm
• * go well posterior to maximise chest exposure*
• ** keep the hands well spread so the saw is not describing an acute loop around the bone: this causes jamming*

Question 9

WHAT IS A RESUSCITATIVE THORACOTOMY

Answer 9

• this is a L anterior thoracotomy performed as part of a trauma resus
• it has modest success (~10%) if performed within 10m of loss of vitals in patients with penetrating chest injury*, esp tamponade from cardiac stab wounds, but is usually futile in blunt trauma
• it has 6 potential benefits:

1. find and fix a cardiac tamponade
2. control exanguinating upper limb junctional bleeding
3. control lung bleeding, eg by hilar twist/clamp
4. perform ICM, which is much more effective than ECM
5. gain IV access directly into the RA
6. Aortic cross clamp to control any bleeding below

* or for exanguinating subdiaphragmatic bleeding from blast/gsw

Question 10

PERICARDIOCENTESIS LANDMARKS

Answer 10

• insert the needle in subxiphoid space and advance toward tip of L scapula
• NOTE: the myocardium has a tendency to self seal and blood often wont reaccumulate after initial evacuation

Question 11

EFFICIENCY OF ICM vs ECM

Answer 11

• Internal Cardiac Massage is much more effective, producing outputs of up to 66% of normal, vs 25% for ECM

Question 12

ICM SHOULD BE DONE HOW?…….

Answer 12

• 2 handed
• gently
• with the flats of the fingers, not the tips: they can perforate the myocardium

Question 13

BLOOD VOLUMES, ADULT V CHILD

Answer 13

• Adult = 70ml/kg
• Child = 80-90 ml/kg

Question 14

SHOCK =

Answer 14

• Any condition characterized by inadequate tissue perfusion

Question 15

TYPES OF SHOCK IN TRAUMA

Answer 15

• is usually HYPOVOLAEMIC, with clear sympathetic responses: pallor and tachycardia

but may also be:

• CARDIOGENIC (includes Contusion, Rupture, Tamponade or Tension)
• NEUROGENIC (warm, slow hypotension)
• SEPTIC (late)

Question 16

NEUROGENIC v SPINAL SHOCK

Answer 16

• NEUROGENIC SHOCK = warm slow hypotension due to loss of SNS tone after cord injury
• SPINAL SHOCK = widespread flaccid skeletal muscle paralysis seen immediately after cord injury

Question 17

CARDIAC OUTPUT FORMULA ?

Answer 17

CO = HR X SV where SV is determined by:

• PRELOAD (which is a volume)
• CONTRACTILITY (which is a %)
• AFTERLOAD (which is a resistance)

Question 18

SIGNIFICANCE OF A NARROW PULSE PRESSURE in TRAUMA?

Answer 18

• = raised diastolic pressure compared to systolic
• in trauma, it indicates significant SNS compensation for Hypovolaemia

Question 19

DIAGNOSIS OF OESOPHAGEAL RUPTURE?

Answer 19

• Epigastric trauma
• Severe abdominal pain
• Shock
• widened or pneumo-mediastinum
• Left pleural effusion/food in chest drain

Question 20

5 CAUSES OF RETRO-PERITONEAL HAEMATOMA

Answer 20

BLEEDING FROM:

1. Duodenum or pancreas
2. Aorta or IVC
3. Kidney
4. Ascending or Descending Colon
5. tracking up from the pelvis

Question 21

5 MAJOR SITES OF OCCULT BLOOD LOSS IN TRAUMA

Answer 21

1. chest
2. abdomen
3. pelvis
4. long bones
5. retro-peritoneum

(and, in children, from the scalp)

Question 22

XRAY SIGNS OF AORTIC INJURY ?

Answer 22

• wide mediastinum
• L pleural effusion/cap
• NGT or trachea displaced to the R

Question 23

HOW/WHEN TO ASSESS PELVIC STABILITY IN TRAUMA

Answer 23

It should be done:

• once only
• by the most experienced clinician
• by stressing the iliac crests in then out
• and avoided entirely where pelvic injury is obvious (to avoid disrupting the clot)

Question 24

BLOOD AT THE (MALE) URETHRAL MEATUS IS…..

Answer 24

• An ABSOLUTE C/I to IDC (as likely urethral injury)

Question 25

WHICH PELVIC FRACTURES BLEED MORE?

Answer 25

Fractures which 'open' the pelvic ring, like _AP COMPRESSION_ or _VERTICAL SHEAR_ fractures bleed more then those which close it, eg _LATERAL COMPRESSION_ fractures.

Question 26

FIRST AID FOR PELVIC FRACTURES

Answer 26

CLOSE the pelvic ring with * Pelvic binder (or sheet) * Internal rotation of the legs + knee and ankle bandages

Question 27

CAN THE PELVIC BINDER BE USED CO-INCIDENT WITH A FEMORAL SPLINT?

Answer 27

* Yes it can

Question 28

A BETTER TERM THAN 'HAEMODYNAMICALLY STABLE' is....

Answer 28

* 'CURRENT haemodynamics are NORMAL'

Question 29

WHEN TO DO THE LOG ROLL IN EMST?

Answer 29

* as _early as possible_ in SHARP trauma (its part of C & B in C-ABCDE), _preferrably at initial transfer onto the resus gurney_, and certainly before D * at leisure in blunt trauma, usually as part of the secondary survey

Question 30

ROLE OF FAST IN EMST?

Answer 30

* FAST is now part of the _primary survey_ to look for pneumothorax or bleeding into the abdomen or chest

Question 31

REMOVAL OF CLOTHES IN EMST?

Answer 31

all clothes should be cut off _as soon as possible_ in: * _all_ penetrating trauma * any _SERIOUS_ blunt trauma, preferably in parallel with the ABCs

Question 32

HOW NEGATIVE IS INTRATHORACIC PRESSURE IN RESPIRATION?

Answer 32

* approx -5cm H2O in normal respiration * up to -30cm H2O at a maximum

Question 33

WHAT ARE THE 6 PARTS OF A '6 PACK' CT

Answer 33

The '6 pack' is an _initial trauma pan-scan_ which images: 1. Head with contrast 2. Head without contrast 3. Entire spine 4. Chest 5. Abdomen 6. Pelvis to mid femur

Question 34

10% OF PATIENTS WITH A C-SPINE FRACTURE......

Answer 34

* will have a second, non contiguous vertebral #

Question 35

HOW DO FEMORAL TRACTION SPLINTS REDUCE BLEEDING?

Answer 35

1. by reducing _movement_ (which disrupts clot) at the site 2. by converting the _thigh space_ from a sphere to a cylinder, _reducing its volume_

Question 36

OPEN FRACTURES AND COMPARTMENT SYNDROME

Answer 36

* A fracture being open _does not prevent_ compartment syndrome

Question 37

HOW TO SECURE A CHEST TUBE

Answer 37

1. close the skin incision each side of the tube with _interupteds_ 2. use a large suture through the skin adjacent to secure the tube itself 3. _no purse strings_: seal with an occlusive dressing on removal

Question 38

NASAL FENTANYL DOSE & TECHNIQUE

Answer 38

* 1.5 mcg/kg, atomised only via a MAD, 27g needle does not work * NOTE * _prime_ MAD prior * use neat with 1ml _LUER LOCK_ syringe (or blows off) * administer as fast as possible to get best _atomisation_

Question 39

GENERIC FEATURES OF POISONING AND OD, AND INITIAL Rx

Answer 39

_Generic features_ of poisonings and ODs include: * LOC * Seizures * Airway/Respiratory depression * Arrhythmias and hypotension * Nausea/vomiting _General Treatment Plan_: * Assess/secure airway and ventilation * For ingestions, consider warm water lavage (only if within 1h), and Activated Charcoal 50g O/NGT * Give IV fluids and vasoconstrictors for Hypotension, not adrenergics lest prolonged QT * Consider pacing for bradycardia * Specific antidotes if available, eg ACETYL CYSTEINE for Paracetamol or ETHANOL for Methanol

Question 40

TREATMENT OF PARACETAMOL OD

Answer 40

* PARACETAMOL is mostly metabolised harmlessly in the liver, but a secondary pathway exists with hepatotoxic metabolites. * These are normally mopped up by Hepatic _GLUTATHIONE_, but this depletes in OD (\>10g/20 tabs). * ACETYL-CYSTEINE (PARVOLEX) can be hepatoprotective in OD by regenerating GLUTATHIONE _Management of OD_ * general measures, plus: * check Paracetamol levels _after 4h_ and consult risk nomogram: if at risk, or unknown, and _within 12h_, give ACETYL CYSTEINE per the protocol

Question 41

SPECIFIC TREATMENT OF METHANOL POISONING

Answer 41

* METHANOL is not toxic per se, but is metabolised to _FORMALDEHYDE_ which is, producing a severe METABOLIC ACIDOSIS, and neuro toxicity after 12-18h. * _ETHANOL_ may be used as a _competetitive substrate_ to block the metabolism of Methanol * _DOSE_: give _50g of Ethanol_ as either * _ORAL/NGT_ : give _5 std drinks_, diluted to 1000mls with water * _IV_ : give _50 mls of 100% Ethanol_ slowly via CVC, or diluted to 1000mls with NS and given peripherally * repeat 4/24 for several days, titrated to a BAC of 0.10-0.15%

Question 42

PARAQUAT POISONING

Answer 42

* _PARAQUAT_ is a common herbicide, and occasional suicide agent * Ingestion of as little as _a mouthful can kill_, even if immediately spat out, and despite patients initially appearing quite well: they subsequently develop lethal ARDS. * _Treatment_ is supportive, there is no specific antidote, although _FULLERS EARTH_ absorbs it

Question 43

GIVING INOTROPES VIA PERIPHERAL IVT

Answer 43

* ADREN up to ~10mcg/min into a large free flowing vein is OK but NORAD less so: it causes severe vasospasm * IO may be a better option

Question 44

NGT AFTER TRAUMA RSI IN CHILDREN

Answer 44

* children are very prone to _acute gastric dilatation_ in trauma, so should always have a stomach tube passed after trauma RSI (as should adults really)

Question 45

HOW TO DO A SUPRAPUBIC CATHETER

Answer 45

* confirm bladder is full clinically or by U/S * go in vertically, just above symphysis with large IV cannula or proprietary kit * aspirate as you go to confirm placement

Question 46

HOW TO RELOCATE THE RECALCITRANT OPEN ANKLE #

Answer 46

1. _Bend i_t: flex the knee: dont pull on a straight leg 2. _Over bend it_: exaggerate the deformity to hook the bone ends together

Question 47

INTRA ARTICULAR BLOCK FOR DISLOCATED SHOULDER

Answer 47

* this can be a useful technique when anaesthesia/sedn is not desired * puncture the skin 2cm inf to the acromion directly lateral with a long needle (eg spinal)\* * advance 45 degrees down _until blood aspirated_\*\* * inject _20mls 1% lignocaine_ * works in 5-10m ## Footnote * \* its deeper than you think* * \*\* if you dont get blood, you are not in*

Question 48

STIMSONS (HANGING) METHOD FOR SHOULDER REDUCTION

Answer 48

* this is an old technique suitable for simple analgesia or intra-artic block * pt lies _prone on a table_ with the arm hanging down with a _5-10kg wt_ on the wrist * may take 10-15m

Question 49

ETOMIDATE FOR RSI (US)

Answer 49

* Until recently, _ETOMIDATE_ was a popular IV Induction agent for _trauma RSI_ in US circles for its ability to support the circulation, without raising ICP * Its now falling from favour, particularly for compromised ICU patients, due to recognition that even a single dose can cause long term _Adrenocortical Suppression_ * _DOSE_ : * 0.3 mg/kg

Question 50

WHAT ARE THE THREE "10mm" COMPARTMENT PRESSURES?

Answer 50

Normal pressures inside the: 1. head 2. abdomen and 3. muscle compartments do not exceed 10mmHg

Question 51

10 CAUSES OF ACUTE SOB IN MEDICAL PATIENTS

Answer 51

1. bronchospasm 2. PT 3. PE 4. effusion 5. ischaemia 6. arryhthmia 7. failure 8. anaemia 9. infection 10. exacc COAD

Question 52

HOW TO DO EXTERNAL PACING

Answer 52

* Consider _pharmacological pacing_ * Consider _sedation_ * _Apply dots_ (reqd as well as pads) * Apply PADS (_AP over L central chest_) * Select _Pace mode_ on DEFIB * Commence pacing at 20mA and 100 BPM * increase until capture, typically ~_50mA_ * Confirm _palpable pulse_ accompanies electrical capture * If _hiccups_ occur, move pads cranially, away from diaphragm

Question 53

HOW TO DO A CARDIOVERSION

Answer 53

* check anticoagulation/TOE * Apply PADS _AP over L central chest_ * consider sedation * CHARGE to 100 then 150J (1 then 2 J/kg) * _SYNC_ on ***ALWAYS*** (on R wave) * Press and HOLD the SHOCK button (there may be a short delay for sync)

Question 54

CARDIOVERSION AND DEFIBRILLATION DOSES?

Answer 54

* _CARDIOVERSION (AF/SVT/VT)_ * = (**_sync_**) 100 then 150J (kids 1 then 2 J/kg) * _DEFIBRILLATION (V__F)_ * = 200J (kids 4J/kg)

Question 55

MANAGING SEVERE MAXILLOFACIAL BLEEDING

Answer 55

1. Secure airway with ETT 2. Insert _DENTAL PROPS_ bilaterally 3. Ensure C-Collar on to support jaw 4. insert _EPISTATS_ bilaterally * Inflate each _posterior balloon_ with _10mls_ NS & pull forwards * SEQUENTIALLY\* inflate each _anterior balloon_ with _20-30mls_ NS, a few mls at a time ## Footnote *\* to avoid # displacement*

Question 56

PUPILLARY HIPPUS

Answer 56

* = rhythmically oscillating\* pupillary size sometimes seen in fitting patients. This may be the only sign that a paralysed, anaesthetised patient is still seizing ## Footnote *\* as on the back of a galloping horse*

Question 57

FIXED DILATED PUPILS IN STATUS EPILEPTICUS

Answer 57

* are NOT indicative of cerebral herniation unless otherwise suspected

Question 58

WHAT ARE 'DIAGNOSTIC' ECG CHANGES IN MI?

Answer 58

STEMI consists of: * \>1mm elevation in _2 contiguous limb leads_ or * \>2mm elevation in _2 anterior chest leads_\* *\* T Inversion does not count, nor does ST Depression, unless in the anterior chest leads, when it can represent the reciprocal changes of Posterior MI*

Question 59

TREATMENT OF ALKALINE BURNS TO THE EYE

Answer 59

* = _8 hours_ continuous irrigatin with water, eg with a small cannula affixed to the eyebrow