Trauma

Question 1

Traumatic Brain Injury (TBI) classification

Answer 1

TBI an be classified by both severity and cause

Severity

• Mild
  
  • GCS 13-15
  • Also:
    
    • LOC <30mins
    • PTA <1 day
• Moderate
  
  • GCS 9-12
  • Also:
    
    • PTA 1-7 days
    • LOC 0.5-24 hours
• Severe
  
  • GCS 3-8
  • Also:
    
    • PTA >7 days
    • LOC >24 hours

Cause

• Primary
  
  • fracture
  • haemorrhage
  • DAI
• Secondary
  
  • hypoperfusion and hypoxia

Question 2

Management of ICP

Answer 2

Needs to be below 20mmHg

nursing at 30 degrees

check collar (or remove)

EVD

Mannitol

Hyperventillation to PaCO2 of 30-35mmHg

Decompressive craniectomy

Question 3

Anatomy of an underwater sealed drain

Answer 3

Question 4

Considerations of extent of trauma in animal bites

Answer 4

May represent blunt and penetrating trauma

• Blunt
  
  • Animals limbs
  • Crushing with jaws
  • Body weight
  • Rotational distortion injuries
• Penetrating
  
  • Amputation
  • Penetration of body cavities
• Transmisable disease
  
  • Bacterial
  • Rabies (Rhabdovirus)
  • Viral

Question 5

Dog bite management

Answer 5

TRAUMA and EMST management, ABCDE approach

Tetanus

Antibiotics with Augmentin

• or cefoxitin
• consider pip-taz in severe infection

Wound care- the most important intervention for both bacterial and zoonotic infections e.g rabies

• clean
• debride
• healing by primary, delayed primary or secondary intention depending on wound and site

Question 6

Fight bite

Answer 6

Human bite injury to the extensor surface of the metacarpophalangeal joint.

• due to striking closed fist against teeth
• high risk injuries
  
  • NB: often appear minor
• tendon and joint are often involved
• secondary infection can be devastating to hand function.

Question 7

Mammalian bite bacteriology

Answer 7

Pasteurella (most common esp canine and feline)

Staph species

Strep species

Humans: Eikenella corrodens

Question 8

Name the key organism in human bite infections

Answer 8

Eikenella corrodens

Question 9

Neck trauma zones

Answer 9

Question 10

AAST liver injury grading:

Grade I

Answer 10

• Haematoma: subcapsular, <10% surface area
• Laceration: capsular tear, <1 cm parenchymal depth

Question 11

AAST renal injury grading

Grade I

Answer 11

grade I

• subcapsular hematoma or contusion, without laceration

Question 12

AAST renal injury grading

Grade II

Answer 12

grade II

• superficial laceration ≤1 cm depth not involving the collecting system (no evidence of urine extravasation)
• perirenal hematoma confined within the perirenal fascia

Question 13

AAST renal injury grading

Grade III

Answer 13

grade III

• laceration >1 cm not involving the collecting system (no evidence of urine extravasation)
• vascular injury or active bleeding confined within the perirenal fascia

Question 14

AAST renal injury grading

IV

Answer 14

grade IV

• laceration involving the collecting system with urinary extravasation
• laceration of the renal pelvis and/or complete ureteropelvic disruption
• vascular injury to segmental renal artery or vein
• segmental infarctions without associated active bleeding (i.e. due to vessel thrombosis)
• active bleeding extending beyond the perirenal fascia (i.e. into the retroperitoneum or peritoneum)

Question 15

AAST renal injury grading

Grade V

Answer 15

grade V

• shattered kidney
• avulsion of renal hilum or laceration of the main renal artery or vein: devascularisation of a kidney due to hilar injury
• devascularised kidney with active bleeding

Question 16

AAST splenic injury grading

All grades

Answer 16

grade I

• subcapsular hematoma <10% of surface area
• parenchymal laceration <1 cm depth
• capsular tear

grade II

• subcapsular hematoma 10-50% of surface area
• intraparenchymal hematoma <5 cm
• parenchymal laceration 1-3 cm in depth

grade III

• subcapsular hematoma >50% of surface area
• ruptured subcapsular or intraparenchymal hematoma ≥5 cm
• parenchymal laceration >3 cm in depth

grade IV

• any injury in the presence of a splenic vascular injury* or active bleeding confined within splenic capsule
• parenchymal laceration involving segmental or hilar vessels producing >25% devascularisation

grade V

• shattered spleen
• any injury in the presence of splenic vascular injury* with active bleeding extending beyond the spleen into the peritoneum

Question 17

AAST splenic injury grading

Grade I

Answer 17

grade I

• subcapsular haematoma <10% of surface area
• parenchymal laceration <1 cm depth
• capsular tear

Question 18

AAST splenic injury grading

Grade II

Answer 18

Grade II

• subcapsular haematoma 10-50% of surface area
• intraparenchymal haematoma <5 cm
• parenchymal laceration 1-3 cm in depth

Question 19

AAST splenic injury grading

Grade III

Answer 19

Grade III

• subcapsular haematoma >50% of surface area
• ruptured subcapsular or intraparenchymal haematoma ≥5 cm
• parenchymal laceration >3 cm in depth

Question 20

AAST splenic injury grading

Grade IV

Answer 20

Grade IV

• any injury in the presence of a splenic vascular injury or active bleeding confined within splenic capsule
• parenchymal laceration involving segmental or hilar vessels producing >25% devascularisation

Question 21

AAST splenic injury grading

Grade V

Answer 21

Grade V

• shattered spleen
• any injury in the presence of splenic vascular injury with active bleeding extending beyond the spleen into the peritoneum

Question 22

AAST pancreatic injury grading

Answer 22

grade 1:

• haematoma with minor contusion/laceration but without duct injury

grade 2:

• major contusion/laceration but without duct injury

grade 3:

• distal laceration or parenchymal injury with duct injury

grade 4:

• proximal (i.e. to the right of the superior mesenteric vein) laceration or parenchymal injury with an injury to bile duct/ampulla

grade 5:

• massive disruption of the pancreatic head

Question 23

Injury Severity Score (ISS) score

Answer 23

Score is intended primarily for research but does correlate with LOS, ICU days so may have wider uses esp in ICU for prognostication

Score 0-75 points

Calculated mathematically from simple parameters

• 6 body regions
  
  • Head and Neck
  • Facial
  • Chest
  • Abdomen
  • Extremity
  • External
• Graded:
  
  • No injury
  • Minor
  • Moderate
  • Serious
  • Severe
  • Critical
  • Unsurvivable

Question 24

How can blast injuries be classified?

Answer 24

Primary

• Wounding of air filled viscera as a result of blast wave

Secondary

• Penetrating trauma from bomb fragments and other projectiles

Tertiary

• Casualties propelled by blast- usual blunt injury mechanisms

Quaternary

• Crush from structural collapse
• Burns
• Other mechanisms not classed as primary, secondary, tertiary

Question 25

What is the most common injury in underwater blast injuries

Answer 25

Bowel perforation * often delayed presentation with developing peritonitis 24-48 hours later

Question 26

Techniques used to control bleeding in liver trauma

Answer 26

Pack, Pringle, Angio Juxtahepatic caval injuries- sternotomy Balloon tamponade of missile tracts Haemostatic agents

Question 27

In trauma the pancreas is like a lobster

Answer 27

Bite the Tail Suck the Head Top knife includes the distal pancreas in "the take-outables"

Question 28

What is the lethal triad

Answer 28

The triad is: * Acidosis * Coagulopathy * Hypothermia This triad is a late sign of severe trauma which, if develops, almost certainly heralds death * avoid it developing, get out fast where possible.

Question 29

What are the options for major traumatic vascular injury

Answer 29

Temporary * Pressure * Finger * Packing * Clamping * Balloon occulsion * REBOA * Shunt Definitive * Ligation * Almost anything can be ligated * Even the portal vein if necessary * Repair * Interposition * Primary

Question 30

The Mattox maneouvre

Answer 30

Left sided medial visceral rotation * Useful for access to the midline supramesocolic retroperitoneus * Especially great vessels * An expanding haematoma will often do most of the dissection for you * Mobilise left colon * Incise the white line of Toldt, * continue it posteriorly around the kidney if you want to access the aorta well or * Infront of the kidney if you want to access the kidney to remove it * and superiorly around the spleen * Roll the viscera to the midline * Provides access to the non paired visceral aortic branches * Division of the left crus superiorly can facilitate aortic access as high as T6 for clamping

Question 31

AAST liver injury grading: Grade II

Answer 31

Haematoma: subcapsular, 10-50% surface area Haematoma: intraparenchymal \<10 cm diameter Laceration: capsular tear 1-3 cm parenchymal depth, \<10 cm length

Question 32

AAST liver injury grading: Grade III

Answer 32

Haematoma: subcapsular, \>50% surface area or ruptured subcapsular or parenchymal hematoma Haematoma: intraparenchymal \>10 cm Laceration: capsular tear \>3 cm parenchymal depth Vascular injury with active bleeding contained within liver parenchyma

Question 33

AAST liver injury grading: Grade IV

Answer 33

Laceration: parenchymal disruption involving 25-75% hepatic lobe or involves 1-3 Couinaud segments Vascular injury with active bleeding breaching the liver parenchyma into the peritoneum

Question 34

AAST liver injury grading: Grade V

Answer 34

Laceration: parenchymal disruption involving \>75% of hepatic lobe Vascular: juxtahepatic venous injuries (retrohepatic vena cava / central major hepatic veins)

Question 35

What is the AAST liver trauma grading system What are the elements What is the range of grades given

Answer 35

A standardised radiological grading system for severity of liver injury Elements include * Haematoma * Capsular * Parenchymal * Laceration * Vascular * Arterial and minor venous * Juxtahepatic great veins Graded in severity from grade I to grade V

Question 36

In median sternotomy for access to the great vessels, which 2 structures will usually need to be divided

Answer 36

The remnant thymus The left innominate vein

Question 37

Landmarks for an anterolateral thoracotomy

Answer 37

4th or 5th intercostal space In women use the inframammary fold In men go below pec major ideally as it simplifies the entry

Question 38

Explain the concept of damage control in trauma

Question 39

What are the key principles of damage control resuscitation

Answer 39

1. Permissive hypotension * the aim is to achieve end organ perfusion while minimising blood loss * systolic of 80mmHg * MAP of 80mmHg in severe head injury 2. Minimise the use of crystalloid in early trauma * switch to the use of blood products early 3. Use an MTP with balanced RBC, platelets and FFP 4. Targeting coagulopathy with use of TEG/RoTEM 5. Restore normothermia