trunk trauma Flashcards
(80 cards)
1
Q
3 Mechanisms of chest injury
A
blunt, crush, penetrating
2
Q
Blunt happens when? (acceleration/deceleration)
A
Commonly result from fall from height, or RTA at speed
3
Q
Blunt consequences?
A
Sudden deceleration leads to intrathoracic organs taking on large apparent weights
Causes destruction of attached vasculature
4
Q
crush happens when
A
elastic limits of the chest and its contents have been exceeded
5
Q
crush presentation
A
flail chest with multiple rib fractures, pneumothorax or haemothorax,
pulmonary contusion
6
Q
Penetrating happens when
A
Stabbing, shrapnel, missile or bullet
7
Q
other mechanism of injury
A
blast, inhalation burns, foreign body aspiration
8
Q
ATMIST: paramedic handover to trauma team stands for
A
Age time of injury mechanism of injury injuries identified symptoms and signs treatment given
9
Q
what is major trauma
A
Major injury affecting more than one body system
Injury severity score >15
10
Q
what is “golden hour”
A
- urgency of care required by major trauma patients to prevent ‘early deaths’
- Some patients have overwhelming injuries and will die immediately, others have injuries that are
salvageable if addressed in time, if this window is missed then they will die
11
Q
what is seatbelt sign
A
Contusions and abrasions on abdomen of a restrained occupant in an MVA
12
Q
what will seatbelt sign mandates?
A
Mandates close observation of abdominal CT
13
Q
seatbelt syndrome?
A
small bowel, stomach and colon and vertebral injury
Chance fracture
14
Q
primary survey airway includes?
A
- maintenance with cervical spine protection(Jaw thrust/chin lift, suction)
- Two aspects to a good airway :patent and protected
- Endotracheal intubation with decreased LOC
15
Q
Breathing includes?
A
- Inspect thorax and neck for deviated trachea, open wounds, abnormal chest movement,
crepitus-
Auscultate for breath sounds
16
Q
consequence of rib fracture?
A
Isolated = CXR to exclude associated injury
Multiple = beware pneumothorax
Flail segment = beware pneumothorax
17
Q
Circulation and haemorrhage control
A
Assess blood volume–skin colour, cap refill, radial/femoral/carotid pulse,BP
18
Q
Signs of haemorrhagic shock:
A
- Tachycardia > reduced pulse pressure > hypotension > reduced perfusion to peripheries and brain
19
Q
haemorrhage control includes?
A
- Place 2 large bore peripheral IV catheter
- Rapid infusion of warm crystalloid solution if needed
- Direct pressure to sites of external bleeding
- Consider central venous access if peripheral sites are unavailable
- Consider pericardiocentesis for suspected pericardial tamponade Left lateral decubitus position for third trimester pregnancy
20
Q
Disability includes assessment of?
A
Neurologic screening, MSE Pupil size and reactivity -Limb length and movement ,grip strength - Orientation,GCS - Measure glucose
21
Q
exposure means?
A
Expose the patient–inspect for burns, toxic exposure
- Log roll maintaining neck stabilisation – inspect and palpate thoracic spine, flank, back and buttocks
22
Q
what is DCR
A
Damage control resuscitation
- Approach to trauma combining ABC rather than just ABC o Catastrophic bleeding > airway > breathing > circulation
- Requires early recognition and pre-emptive management
23
Q
6 killing conditions in primary survey: ATOM-FC
A
Airway obstruction or disruption Tension pneumothorax Open pneumothorax Massive haemothorax Flail chest Cardiac tamponade
24
Q
The bloody viscous cycle
A
Bleeding > acidosis > hypothermia > coagulopathy
25
What is secondary survey?
Top to toe examination for additional injuries or findings
26
what does secondary survey include?
```
Scalp wound bleeding – direct pressure, sutures o Facial instability, potential for airway instability
Identify haematotympanum
Identify epistaxis
Identify avulsed teeth, jaw instability
Abdominal distention and tenderness
Penetrating injuries
Pelvic stability
Inspect urethral meatus for blood
Peripheral pulses for vascular compromise
```
27
what is stress responses?
Hormonal and metabolic changes following trauma/surgery
28
endocrine changes in stress response?
Increased secretion of pituitary hormones > increase in catabolism of food substrates (carb, protein, fat)
Increased activation of SNS
Insulin resistance in perioperative period
29
Sympathoadrenal changes in stress response?
Hypothalamic activation of ANS > increased secretion of catecholamines from adrenal medulla + release of NE from presynaptic nerve terminals = tachycardia, hypertension
30
what is local inflammatory response in stress response?
o Cytokines released – IL-1, TNF-a
o IL-6 (acute phase response): Production of acute phase proteins in the liver
- Increased CRP, fibrinogen, alpha 2 macroglobulin, copper
- Decrease in transferrin, albumin, zinc and iron
- Act as inflammatory mediators
31
what is type1 resp failure?
Hypoxemic - most common form
o Occurs because of damage to lung tissues, preventing oxygenation of blood (V/Q mismatch and
shunting, leading to widening of alveolar-arterial PaO2 gradient)
o Low arterial PaO2 + low/normal arterial PaCO2
o Almost all diseases of lung involving fluid filling or collapse of alveoli – cardiogenic and non-cardiogenic
pulmonary oedema, pneumonia, pulmonary haemorrhage
32
what is type 2 resp failure
Hypercapnic
o ‘Ventilatory failure’ – alveolar ventilation is insufficient to excrete CO2 produced o Low arterial PaO2 + high arterial PaCO2
o Drug overdose, neuromuscular disease, chest wall abnormalities and COPD
33
pattern of death in major traumas?
1. immediate death(s-min)
- unpreventable
- high spinal or brain injury (apnoea)
- great vessel disruption ( catastrophic haemorrhage)
2. early death(min-hr)
- haemorrhage related
3. late deaths(hr-wk)
- multiorgan failure or sepsis
34
clinical presentation of airway obstruction?
```
o External neck deformity or haematoma
o Crepitus from laryngeal fracture
o Hoarse voice or gurgling
o Signs of complete airway obstruction – silent chest, paradoxical chest movements o Signs of partial airway obstruction – stridor, respiratory distress
o Cyanosis
```
35
Rx of airway obstruction?
o High flow O2 via non-rebreather mask
| o Achieve airway patency via airway maneuver or surgical airway
36
what happens in tension pneumothorax
lung defect acts as a one-way valve, allowing ongoing air leaks into the pleural space without letting it leak back out
37
how fatal is tension pneumothorax?
Can be rapidly fatal as intra-thoracic pressure rises causes decreased venous return and kinking of the great
vessels – obstructive shock
38
presentation of tension pneumothorax?
o Tracheal deviation to the contralateral side
o Ipsilateral hyper expansion and decreased chest movement
o Ipsilateral hyper-resonance
o Anxiety and agitation
o Respiratory distress
o Tachycardia and hypotension
o Neck vein distention
39
how to treat tension pneumothorax?
o High flow O2 to maintain saturation targets
o Immediate needle thoracocentesis – 14 gauge
o Intercostal catheter insertion after needle decompression
40
what happens in open pneumothorax?
“Sucking” chest wound – communication between pleural space and surrounding atmospheric pressure
41
presentation of open pneumothorax?
```
o trachea in the midline
o Open wound on chest wall
o Anxiety and agitation
o Respiratory distress – due to lung collapse o Tachycardia
o Decreased chest movement ipsilaterally
o Hyper-resonance ipsilaterally
o Decreased breath sounds ipsilaterally
```
42
how to treat open pneumothorax?
o three sided dressing
o High flow O2 to maintain saturation targets o Cover with ‘flutter valve’
o Catheter in separate intercostal space
o Formal exploration prior to closing
43
when does Massive haemothorax happens?
blunt or penetrating trauma to the thoracic organs; massive haemothorax defined by volume on thoracotomy
44
classification of massive harm-thorax?
o Blood loss >1500ml or 1/3 blood volume
| o Blood loss >200ml/hr for 2-4 hours
45
aetiology of Massive haemothorax?
Injury to lung parenchyma, intercostal artery or internal mammillary branch
46
why Massive haemothorax is life threatening?
1. Acute hypovolemia doesn’t allow sufficient preload to sustain left ventricular function and CO
2. Collapsed lung promotes hypoxia by creating alveolar hypoventilation, V/Q mismatch and anatomic shunting
3. Hydrostatic pressure of haemothorax compresses vena cava and pulmonary parenchyma,
further impairing preload
47
presentation of massive hemothorax?
o Haemorrhagic shock – pallor, tachycardia, hypotension, cool peripheries
o Ipsilateral dullness
o Anxiety and agitation
o Evidence of external thoracic injury
o Decreased breath sounds ipsilaterally
o Persistent blood loss following intercostal catheter insertion
48
how to treat massive hemothorax?
o High flow O2 to maintain saturation targets
o Treat with rapid restoration of blood volume
o Concurrent drainage of thorax
o Immediate intercostal catheter insertion
o Haemostatic resuscitation - transfusion
49
what is flail chest?
Defined as fractures of 2 or more contiguous ribs in 2 or more locations; results in segment of the chest wall no longer being in continuity with the rest of the thoracic cage
50
what will flail chest result in?
o Paradoxical movement results
- Segment moves inwards on inspiration (when the rest of the chest expands)
- Segment moves outwards on expiration( when the rest of the chest deflates)
51
presentation of flail chest?
o Paradoxical chest wall movements of the affected segment
o Chest pain
o Respiratory distress
o Boney crepitus
52
treatment for flail chest?
o High flow O2
o Analgesia
- Paracetamol, titrated opiates, ketamine infusion
- Consider adjunctive medications–pregabalin
- Early use of regional anaesthesia–intercostal nerve blocks, epidural anaesthesia
o Respiratory monitoring o Surgical intervention
53
when will cardiac tamponade happen?
Accumulation of pericardial fluid under pressure
• As little as 75ml of blood accumulating in the pericardial space can impair cardiac filling, resulting in tamponade and obstructive shock
• Up to 80% of myocardial stab wounds may develop cardiac tamponade
54
why cardiac tamponade result in death?
o Intrapericardial blood accumulation
o Elevated intrapericardial pressure
o Decreased right and left ventricular filling
o Myocardium shifts towards the left side, further reducing left ventricular function o Hypovolemic shock results in other organs from low CO and low venous return
55
clinical presentation of cardiac tamponade?
o Obstructive shock – tachycardia, narrow pulse pressure, hypotension, cool peripheries
o Becks triad – muffled heart sounds, hypotension and distended neck veins
o Pulsus paradoxus
o Anxiety and agitation
56
how to treat cardiac tamponade
o High flow O2
| o Needle pericardiocentesis
57
mechanism of blunt cardiac injury?
o Direct precordial impact
o Crush injury from compression between sternum and spine o Deceleration or torsion causing tear in heart
o Blast injury
58
pathophysiology of blunt cardiac injury?
o Often right heart due to its anterior location
o Subendocardial haemorrhage > focal oedema > interstitial haemorrhage > myocytolysis with infiltration
of PMNs
o Lead to death from arrhythmias, cardiac free wall rupture or coronary artery laceration
59
Commotio Cordis means?
“Disturbance of the heart” – sudden death because of blunt trauma to the chest wall; usually affecting young athletes with hypertrophic obstructive cardiomyopathy (HOCM), who are struck in the chest by hard projectiles
60
pathogenesis of Commotio Cordis?
o Low velocity impacts with seemly innocent looking chest trauma
o However, in some people, especially young athletes with HOCM, this causes a primary electrical event
presentation
inducing V fib
61
what causes pericardial inflammation syndrome?
delayed hypersensitivity reaction to presence of damaged myocardium
62
presentation of pericardial inflammation syndrome?
```
o Fever
o Chest pain
o Pleural and pericardial effusions o Friction rub
o Arthralgia
o Pulmonary infiltrates
```
63
presentation of cardiac rupture?
```
More common in thin walled atria
o Splashing mill wheel murmur (rare)
o ECG may show conduction defects
o Axis deviation – if herniation through pericardium has occurred o Cardiac thrill
o Hypotension
```
64
aortic injury happens when?
Proximal ascending is most commonly injured in blunt trauma because of the fixation of vessels between left subclavian artery and ligamentum arteriosum
• Deceleration produces shearing forces that tear the aorta
• Diagnosis is rarely made because very few people survive it
o 15% of fatal MVC victims have aortic rupture (85% of which die instantly and 15% survive to hospital)
65
oesophageal perforation présentation
```
o Chest/epigastric pain
o Dysphagia
o Hematemesis
o Neck or chest wound
o Pleural effusion
o Drainage of GI contents from an intercostal catheter o Shock
```
66
how to treat oesophageal perforation?
o High flow O2
o Fluid resuscitation
o Nasogastric tube
o Broad spectrum antibiotics o Surgical repair
67
when does tracheobronchial injury occur?
Usually occurs close to the carina, associated with severe blunt trauma
68
presentation of tracheobronchial injury?
o Haemoptysis, cough and respiratory distress
| o Subcutaneous emphysema
69
how to treat tracheobronchial injury?
o High flow O2
| o Multiple intercostal catheter o Urgent bronchoscopy
70
when will blunt abdominal trauma happen?
Often insidious onset – can remain symptomatic with 50% volume loss
71
3 mechanisms of blunt abdominal trauma?
1. decelerations
- Shearing forces causes organs to tear–distal aorta ,hepatic tear along ligamentum teres
2. crushing
- Abdominal contents crushed between anterior abdominal wall and posterior vertebral column
- Kidneys and spleen especially vulnerable
3. external decompression
- Increases intra-abdominal pressure>rupture organ(usually liver and spleen)
72
presentation of blunt abdominal injury?
o Lap belt marks – small intestine rupture
o Steering wheel contusions
o Ecchymosis indicating retroperitoneal haemorrhage – flanks (Grey-Turner sign), umbilicus (Cullen sign) o Abdominal distention
o Auscultation of bowel sounds in thorax – herniation through diaphragm injury
o Abdominal bruit – traumatic AV fistula
o Tenderness, guarding, rigidity, rebound tenderness – peritoneal injury
o Fullness on palpation – intra-abdominal haemorrhage
o Crepitus – instability of lower thoracic cage
o Look out for hip fractures (especially in elderly)
73
how to dx blunt abdominal injury?
FAST scan
| CT
74
how common you will see chest trauma in paediatrics?
Children’s chest walls are quite compliant and may not show external signs of intrathoracic injury
75
what is common mechanism of injure that cause chest trauma in paediatrics?
Blunt trauma is more common
76
presentation of chest trauma in paediatrics?
§ Bony defects
§ Crepitus
§ Paradoxical chest movement
§ Unequal breath sounds
77
presentation in paediatric abdominal trauma?
```
§ Abdominal tenderness ,distention, bruising
§ Haematuria
§ Vomiting
§ Neurologicobtundation
§ Fallingorlowhaematocrit
§ Absent bowel sounds
```
78
How common is paediatric splenic trauma?
Most commonly injured abdominal organ in children
79
what is difference in paediatric in terms of splenic trauma?
Children with splenic injuries are more likely to be haemodynamically unstable than adults, but are more
likely to be managed non-operatively
- Thicker splenic capsule
- Larger amounts of elastin and smooth muscle § Lower velocity injuries
80
how to treat paediatric splenic trauma?
Splenectomy required
| - Pneumococcal vaccine required to prevent post-splenectomy sepsis
