Trauma

Question 1

Death from injury occurs in 1 or 3 time periods

Answer 1

• First peak - witihin seconds to minutes
• second peak - within minutes to several hours
• third peak - after several hours to weeks, sepsis and mutli organ failure

Question 2

Golden hour

Answer 2

refers to the period when medical care can make the maximum input on death and disability. It implies the urgency and not a fixed time period of 60 min

Question 3

Airways

Answer 3

• Protect spinal cord with immobilisation devices
• Access airway for patency (if patient can speak airway is not compromised)
• Consider foreign body and facial, mandibular, r tracheal fractures if unconscious.
• Perform chin lift/jaw thrust.
• Consider nasopharyngeal/oropharyngeal airway
• If unable to maintain airway, secure a definitive airway (orotracheal, nasotracheal, cricothyroidotomy

Question 4

Breathing

Answer 4

• Administer high flow O2 using a non-rebreather mask
• Inspect for chest wall expansion, symmetry, respiratory rate, and wounds
• Percuss and auscultate the chest
• Look for tracheal deviation and surgical emphysema
• Identify and treat life threatening conditions: tension pneumothorax, open pneumothorax, flail chest with pulmonary contusion, massive haemothorax

Question 5

Circulation

Answer 5

• Look for shock
• Hypotension usually due to blood loss. Think: chest, abdomen, retroperitoneal (blood on the floor and four more)
• Control external bleeding with pressure
• Obtain IV access with two 12G cannulae, send blood for cross match
• Commence bolus of warmed ringers lactate: unmattec, type-specic blood only for immediate life threatening blood loss

Question 6

Disability

Answer 6

• Perform rapid neurological examination
• AVPU method:
  
  • Alert
  • Responds to Vocal stimuli
  • Painful stimuli
  • Unresponsive to all stimuli
• Glasgow coma scale
• Glucose

Question 7

Exposure

Answer 7

• Expsoure
  
  • Undress patient for further examination
  • Prevent hypothermia by covering with warm blankets

Question 8

Secondary survey

Answer 8

• Constant reassessment of all vital signs
• Take history – AMPLE
  
  • Allergy
  • Medication
  • Past medical history
  • Last meal
  • Events of the incident
• Head to toe physical examination

Question 9

Pneumothorax

Answer 9

• Depends on size and severity
• In context of trauma, always managed by chest drain
• Inserted into triangle of safety on affected side (ie 5^th intercostal in midaxillary line)

Question 10

Intra-abdominal trauma Causes

Answer 10

Blunt trauma most frequently are spleen (45%), liver (40%) and retroperitonal haematoma (15%)

Penetrating trauma

• Stab wounds and low veolicty gun shot wounds
• Cause damage by laceration or cutting; stab wounds commonly involve the liver (40%), small bowel (30%) diaphragm (20%)

Question 11

History and physical exam of intra-abdominal trauma

Answer 11

• History
  
  • Patient, other passengers, observersm police and emergency personnel
  • Mechanism of injury- seat belt usage, steering wheel deformitis, speed
  • Pre-hospital condition
• Physical exam
  
  • Inspect anterior abdomen, perineum, and log roll to inspect posterior abdomen
  • Palpate abdomen for tenderness, involuntary muscle guarding, rebound tenderness
  • Asculate for bowel sounds

Question 12

Investigations of intra-abdominal trauma

Answer 12

• Blood and urine sample – raised serum amylase
• Radiogrpah- free air
• FAST (focused abdominal sonography for trauma)
  
  • Imaging of four Ps (Pouch of Morrison, pouch of douglas, perisplenic and pericardium)
• CT
  
  • Investigation of choice haemodynamically stable patients where there is not apparent indication for laparotomy

Question 13

Intra-abdominal trauma management

Answer 13

Postive FAST - laparascopy or laparotomy follows CT

Question 14

Glasgow coma scale

Answer 14

EYES (4 letters)

• nil
• in response to pain
• in response to speech
• spontaneous

MOTOR (5 letters)

• nil
• extension
• abnormal flexion
• flexion away from pain
• localises pain
• obeys commands

VERBAL (6 letters)

• nil
• sounds
• inapproriate words
• confused sentences
• orientated fully -

Question 15

How to use glasgow coma scale

Answer 15

• Minor head injury 13-15 - monitor, if supervised and GCS 15 then discharge, may need CT if remains 14 or lower at 1hr after admission
• moderate head injury -9-130 CT head, intervene as necessary
• severe head injury (GCs8 r less) - intubate, ct, neurosurfical intervention

Question 16

Types of head injury

Answer 16

• Scalp lacerations – Close laceration
• Skull fractures – CT, Observe, may need surgery
• Epidural haematoma – Neurosurgeons
• Subdural haematoma – Neurosurgeons
• Contusion – Observation/Neurosurgeons
• Intracerebral Haemorrhage – Usually observe +/- neurosurgeons
• Diffuse Brain Injury

Question 17

Primary surgery of vascular trauma

Answer 17

• Apply direct pressure to open haemorrhaging wound
• Carry out aggressive fluid resuscitation
• A rapidly expanding haematoma suggest significant injury
• Realign and splint any associated fracture
• Immobilise dislocated joint

Question 18

Secondary survey of vascular trauma

Answer 18

• Identify life threatening limb
• Look for hard or soft signs of vascular injury
  
  • Hard signs- massive external blood loss, expanding or pulsatile haematomaa, absent or diminished distal pulses, and a thrill or audible continuous murmur
  • Soft sings- History if active bleeding at the accident scene, proximity of penetrating or blunt trauma to a major artery, small non pulsatile haemoatoma
• Immediate operative intervention for hard signs