Trauma

Question 1

What are the percentages for different mechanisms of injury?

Answer 1

• Fall < 2m = 59%
• Falls > = 11%
• RTA = 15%
• Assault = 5%
• Other = 10%

Question 2

Describe what is trauma

Answer 2

-Any external force applied to the body which results in injury
-High amount of morbidity in working age and the elderly
=Loss of income, pain, prolonged bed rest etc.
-Leading cause of death and disability in first 4 decades of life
-50% of Orthopaedics is dealing with consequences of trauma

Question 3

What is a fracture?

Answer 3

A disruption in bone continuity

Question 4

What is a dislocation?

Answer 4

Complete loss of continuity of 2 bones forming a joint

Question 5

What is subluxation?

Answer 5

Partial loss of continuity of 2 bones forming a joint

Question 6

What is comminution?

Answer 6

Multiple fragments

Question 7

What does antra-articular mean?

Answer 7

Fracture extends into a joint

Question 8

What is a fracture dislocation?

Answer 8

A dislocated joint with associated fracture

Question 9

What causes a fracture?

Answer 9

1. Injury mechanism that exceeds maximum force the bone can withstand leading to a fracture (normal bone, abnormal force)
2. Comorbidity that increase risk of fracture after injury
3. Comorbidity that increases risk of injury

Question 10

Describe comorbidity that increases risk of fracture after injury

Answer 10

-Congenital
=Osteogenesis imperfecta (brittle bones)
-Acquired
=Metabolic (Rickets/osteomalacia)
=Degenerative (Osteoporosis)
=Tumour
Abnormal bone, normal force

Question 11

Describe comorbidity that increases risk of injury

Answer 11

-Visual impairment
-Alcohol/drug use
-Neuropathy
-Balance disorder
-Epilepsy
Normal bone, abnormal force, increased risk of trauma

Question 12

Which fractures need fixed?

Answer 12

-Only the minority
=Anything which would cause suffering and prolonged bed rest e.g. hip fracture, femur, tibia
=To prevent long term complications or loss of function e.g. malunion or nonunion
-Major trauma patients with open fractures or long bone injuries need early intervention

Question 13

What is the assessment map?

Answer 13

A Airway (+ C-spin control)
B Breathing
C Circulation
D Disability
E Exposure

Question 14

What do we look for in Airways?

Answer 14

-Talking?
-Noises
=Snoring
=Stridor
=No noise…
-Physical blockage
=Food, blood, vomit, tongue= at risk
-Evidence of injury
=Face, oropharynx, neck

Question 15

How do we treat airway obstruction?

Answer 15

-Suction
-Remove foreign body
-High flow O2
-Basic manoeuvres
+ C-spine control
-Airway adjuncts
-Definitive airway
– don’t forget the neck
ATLS teaches the ‘live long and prosper sign’ either side of the patient’s ears

Question 16

What do we look for in Breathing?

Answer 16

• Colour of patient – pink, blue…
• Work of breathing – hard, shallow
• Evidence of injury – bruising, wound
• Observations – SpO2, RR, pulse, BP
• Chest symmetry
• Air entry
• Percussion note

Question 17

How is thoracic cavity different in trauma from health?

Answer 17

• In health – thoracic cavity full of lung
• In trauma – thoracic cavity full of something else
• OR a disrupted ‘shell’/ rib cage

Question 18

What is Tension Pneumothorax?

Answer 18

• Internal ‘one-way valve’

- Pressure on mediastinum= decreased venous return to the heart= cardiac arrest

Question 19

Describe the presentation of a tension pneumothorax

Answer 19

• Decreased breath sounds on affected side
• Increased percussion note (hyper-resonant)
• Engorged neck veins
• Reduced lung expansion
• Deviation of trachea to opposite side

Question 20

How do we treat tension pneumothorax?

Answer 20

• High flow oxygen, needle decompression in 2nd intercoastal space
• Definitive chest drain
• Sternal angle, 2nd intercostal space

Question 21

Describe an open pneumothorax

Answer 21

• ‘sucking chest wound’
• External ‘one-way valve’
• Air passes into the cavity through path of least resistance
• Treat with oxygen and three-sided dressing
• Definitive chest drain – 4th or 5th intercostal space, mid-clavicular line

Question 22

What is Flail Chest?

Answer 22

• 2 or more ribs fractured in 2 or more places
• Separation of a segment of the thoracic cage that is then unable to contribute to lung expansion
• Paradoxical movement of a segment of the chest wall
• Indrawing on inspiration
• Moving outwards on expiration

Question 23

What do we look for in Circulation?

Answer 23

• Colour of patient – pink, blue…
• Work of breathing – hard, shallow
• Evidence of injury – wound, blood loss
• Observations – SpO2, RR, pulse, BP
• Heart sounds
• Pulses
• Peripheral circulation - CRT
• Mental state – cerebral perfusion?

Question 24

What is Cardiac tamponade?

Answer 24

• Pericardium is a ‘fixed’ sac (like the skull)
• Small pressure increase (from blood) has big effect
• Pericardiocentesis
• Under ultrasound guidance

Question 25

What is Beck's Triad?

Answer 25

- Hypotension: decreased stroke volume - Jugular venous distension: impaired venous return to the heart - Muffled heart sounds: fluid inside the pericardium

Question 26

What is a massive haemothorax?

Answer 26

``` >1500 mls of blood in pleural cavity -decreased breath sounds, respiratory compromise (=‘B’) -large volume loss (= ‘C’) -needs a chest drain (B) AND fluid resuscitation due to SHOCK (C) ```

Question 27

What is Shock?

Answer 27

-End-organ dysfunction =due to inadequate oxygen availability for tissues (perfusion) =cardiac, GI, neurology, renal… -Demand for O2 increased as delivery decreases

Question 28

What are the types of shock?

Answer 28

- Anaphylactic - Cardiogenic - Haemorrhagic - Neurogenic - Septic

Question 29

Which types of shock affect supply and demand of oxygen?

Answer 29

Decrease delivery: anaphylactic, cardiogenic, haemorrhagic, neurogenic Increase demand: septic

Question 30

Describe haemorrhagic shock

Answer 30

- Most common in trauma - Body’s balance between blood loss and compensation - Four classes based on blood volume (70kg person has circulating volume of 5L= 70ml/kg)

Question 31

Describe the 4 classes of haemorrhagic shock

Answer 31

1. <15% blood loss (<750ml), pulse <100, normal BP, >30 ml/hr urine output 2. 15-30% (750-1500), 100-120, normal BP, 20-30 ml/hr 3. 30-40% (1500-2000), 120-140, decreased BP, 5-15 ml/hr 4. >40% (>2000), >140, decreased BP, neg

Question 32

What trends develop in haemorrhagic shock?

Answer 32

-Through classes 1 to 3, the body compensates, but trends develop: RESPIRATORY RATE – increases as lactic acid rises PULSE – tachycardia; heart rate increases to compensate for falling stroke volume BLOOD PRESSURE – remains fairly constant URINE OUTPUT – falls with renal vasoconstriction PERIPHERIES – cool with vasoconstriction MENTAL STATE – increasing confusion / agitation with reduced cerebral perfusion

Question 33

What happens to compensation in class 4?

Answer 33

By class 4, compensation reaches ‘overload’ RESPIRATORY RATE – falls with fatigue PULSE – tachycardia reaches maximum, chest pain due to myocardial ischaemia BLOOD PRESSURE – drops dramatically URINE OUTPUT –negligible PERIPHERIES – cold, mottled MENTAL STATE – confused, comatose

Question 34

Describe fluid resuscitation

Answer 34

``` STOP THE BLEEDING =haemostasis is the most effective resuscitation -Initial fluid bolus (10-20ml / kg) -Low thresh-hold for blood products= RBC, platelets, FFP -Tranexamic acid promotes clotting -Assess the response -Permissive hypotension =low BP is better in trauma =just enough to keep cerebral perfusion =not enough to start bleeding again =roughly 80mmHg systolic ```

Question 35

What do we look for in Disability?

Answer 35

``` -GCS =best response in eye opening, verbal responses and motor, total out of 15 -AVPU scale =alert, verbal, pain or unresponsive -Temperature -Blood Glucose ```

Question 36

What do we look for in Exposure?

Answer 36

-Full examination of the patient -While keeping them warm =clotting is temperature dependent -Common sites to miss injuries: =Back of head =Back =Buttocks =Perineum =Axillae =Skin folds

Question 37

What are the life threatening conditions in trauma?

Answer 37

``` Airway Obstruction Tension Pneumothorax Open Pneumothorax Massive Haemothorax Flail Chest Cardiac Tamponade ```

Question 38

What occurs during secondary survey?

Answer 38

-Patient ABC stabilized - any change = review -Systematic ‘top to toe’ examination with log roll =Head, face, eyes, ears, nose and throat =Neck =Chest =Abdomen =Pelvis =Back =Extremities =All wounds

Question 39

What occurs during tertiary survey?

Answer 39

- Repetition of the secondary survey - Over several days - Broken pinky may be missed initially but still important!

Question 40

What questions are to be considered when examining peripheral injuries?

Answer 40

- Where is it? - What side? - Which bone? - Open or closed? - Blood supply to leg? - Nerve supply? - What was the environment?

Question 41

Describe open fractures

Answer 41

``` -Bone penetrates skin =Bone can go back in! -Skin penetrated from outside -Prompt management is imperative -Increased risk of infection ```

Question 42

How do you treat any fracture?

Answer 42

``` -4 ‘R’s of fracture management =Resuscitate =Reduce =Restrict =Rehabilitate ```

Question 43

Describe A and E management

Answer 43

``` -IV antibiotics =Early as possible =Cefuroxime 1.5g TDS =Clindamycin (pen allergy) =Gentamicin if heavy contamination -Anti Tetanus =No tetanus within 5yrs- give booster -Splint or Cast =Correct length and alignment =Get the bone back in =Tamponade bleeding vessels -Sterile saline soaked dressing ```

Question 44

Describe surgical management

Answer 44

``` Within 24 hours or sooner… -Primary =Wound debridement (Dead tissue = culture for bacteria) =Skeletal stabilisation (IM nailing) (External fixation) - +/- Secondary =Tissue inspection and further debridement =Wound closure ```

Question 45

Overview of open fracture assessment and treatment

Answer 45

- Fracture with break of dermis in same area - Carefully examine the wound - Sterile saline dressing - Realign and splint wound - IV abx and Tetanus - Surgical referral