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You are in Home >> Exams >> Mitchell Anaesthetic Notes

Trauma

Created: 31/10/2006
Updated: 8/1/2007

 

Initial assessment and management


Preparation

  • Pre-hospital
    • Minimize scene time
    • Priorities
      • Airway maintenance
      • Control external bleeding and shock
      • Immobilization
      • Immediate transport to the closest appropriate facility
      • Obtain information for handover
    • Criteria for transfer to trauma centre
      • GCS <14, RR <10 or >29, systolic <90 mmHg, RTS <11, PTS <9
      • Flail chest, >2 proximal long bone fractures, amputation proximal to wrist or ankle, penetrating trauma proximal to elbow or knee, limb paralysis, pelvic fracture, trauma with burns
    • Consider trauma centre for
      • Ejection from car, death in same compartment, pedestrian thrown or run over, high speed crash, extrication time >20 min, fall >6 m, roll over, pedestrian struck at >8 km/h, motorcycle crash at >32 km/h or with separation of bike and rider
      • Age <5 or >55, pregnancy, immunosuppression, cardiac or respiratory disease, diabetes, cirrhosis, morbid obesity, coagulopathy
  • In hospital
    • Resuscitation area
      • Airway equipment, warm IV solutions, monitoring
      • Means to summon medical help, means to summon diagnostic services
      • Transfer agreement with trauma centre
      • Universal precautions to be observed

Triage


Revised Trauma Score

Respiratory rate
>29 4
10-29 3
6-9 2
1-5 1
0 0
Systolic BP
>89 4
76-89 3
50-75 2
1-49 1
0 0
GCS
13-15 4
9-12 3
6-8 2
4-5 1
<4 0


 

Paediatric Trauma Score

Weight
<20 kg 2
10-20 kg 1
<10 kg -1
Airway
Normal 2
O2 1
Intubated -1
Systolic BP
>90 2
50-90 1
<50 -1
Consciousness
Awake 2
Any LOC 1
Coma -1
Fracture
None 2
Single closed 1
More / open -1
Skin
Intact 2
Lac. <7 cm 1
More -1
Score >8 should have zero mortality

  • Priorities
    • Multiple casualties are treated in order of severity.
    • Mass casualties (exceeding capacity of available facilities) are treated in order of probability of survival with least expenditure of resources.

Primary survey

  • Examination and management take place simultaneously
  • Airway maintenance with cervical spine protection
    • Assess patency of the airway: fractures, foreign bodies
    • Establish a patent airway
    • Definitive airway is usually required if GCS ≤8
    • Cervical spine must be immobilized in any multi-system trauma
    • Deterioration of conscious state may demand reassessment of airway
  • Breathing and ventilation
    • Requires function of lungs, chest wall and diaphragm
    • Examine the chest for acute causes of impaired ventilation
      • Tension pneumothorax, open pneumothorax, flail chest with pulmonary contusion, massive haemothorax
    • Intubation may worsen pneumothorax
    • Chest X-ray is required as soon after intubation as practical
  • Circulation and haemorrhage control
    • Haemorrhage is the commonest cause of post-injury death treatable in hospital
    • Volume status is assessed by conscious state, skin colour and pulse rate and strength
    • Hypotension is caused by hypovolaemia until proved otherwise
    • Bleeding is controlled by local pressure
    • Occult haemorrhage occurs into the chest or abdomen, retroperitoneum following pelvic fracture or soft tissues following long bone fracture
    • Blood pressure is not a good indicator of volume status
  • Disability (neurological evaluation)
    • Rapid assessment of GCS or AVPU status
    • Impaired consciousness after correction of hypoxia and hypovolaemia is usually due to CNS trauma
    • Drugs may confuse examination findings
    • Frequent reassessment is required
  • Exposure and environmental control
    • Complete exposure is required for examination
    • Prevention of hypothermia is required, using warming blankets, warmed
    • IV fluids and early control of haemorrhage

Resuscitation

  • Airway
    • Definitive airway if there is doubt about the patient’s ability to maintain an airway
    • Application of a hard collar for cervical spine immobilization
  • Breathing and ventilation
    • All patients should receive supplemental oxygen
  • Circulation
    • Two large IVs should be inserted
    • Blood taken for crossmatch, baseline bloods and pregnancy test
    • IV fluid administration, initially warmed Hartmann’s 2-3 L
    • Hypovolaemic shock is treated with operative intervention to stop bleeding and continued fluid resuscitation, not pressors, steroids or bicarbonate

Adjuncts to primary survey and resuscitation

  • ECG monitoring
    • Signs of cardiac injury, pulseless electrical activity, hypoxia or hypoperfusion
  • Urinary and gastric catheters
    • Urine output provides an indication of volume status
    • Catheter should not be inserted if the urethra might be injured
      • Blood at meatus, perineal ecchymoses, blood in scrotum, high riding prostate, pelvic fracture
    • Gastric catheter reduces the risk of regurgitation and aspiration, but does not eliminate it
    • Nasogastric insertion is contraindicated if the cribriform plate might be disrupted
  • Other monitoring
    • Ventilatory rate and ABGs
    • CO2 confirmation of ETT placement
    • Pulse oximetry
    • Blood pressure
  • Diagnostic studies
    • CXR and pelvis X-ray can guide resuscitation but must not cause delay
    • Lateral cervical spine X-ray is useful if it shows an injury
    • Further tests during secondary survey

Consider need for transfer

  • However life saving interventions should start at the time the problem is identified

Secondary survey

  • Begins when resuscitation is underway and vital signs are normalizing
  • History
    • Allergies, medications, past illnesses or pregnancy, last meal, events related to the injury (mnemonic: AMPLE)
  • Physical examination
    • Head
      • Complete examination for soft tissue or bony injury
      • Eye examination for acuity, pupils, hyphaema, penetrating injury, contact lenses, lens dislocation, muscle entrapment
      • Facial bones for fractures
    • Cervical spine and neck
      • Head or face injury implies cervical spine injury until it is excluded
      • Penetrating injuries should be explored in theatre
      • Cervical spine injury should be excluded as soon as convenient and hard collar removed
    • Chest
      • Inspection and palpation of the entire thorax
      • Auscultation for heart sounds and breath sounds
      • Bony or soft tissue injury makes visceral injury likely
      • Children have a more compliant chest wall, which may hide deeper injuries
    • Abdomen
      • Specific diagnosis is not as important as recognizing that an injury exists
      • Repeat examination for changing signs may be necessary
      • If injury is suspected
        • Ultrasound or lavage
        • CT if stable
    • Perineum
      • Inspection, PR, PV, urinary catheter
    • Musculoskeletal
      • Limbs must be inspected and palpated
      • Pelvis integrity should be assessed
      • The back must be examined
      • Soft tissue injury may be difficult to detect in an unconscious patient
    • Neurological
      • Assess conscious state (and reassess)
      • Examine for peripheral signs of nerve or cord injury
      • Prevent abrupt rises in ICP in head-injured patients

Specialized diagnostic tests (as indicated)

  • X-rays
    • CXR, pelvis, cervical spine, thoracolumbar spine, sites of injury
  • CT
    • Head (±MRI), chest, abdomen, spine
  • Contrast studies
    • Urography, angiography
  • Ultrasound
    • Abdomen, gynaecological, transoesophageal
  • Endoscopy
    • Bronchoscopy, gastroscopy
  • Tests requiring transport demand a stable patient

Reevaluation

  • Continuous monitoring of vital signs
    • ECG, BP, SpO2, conscious state, urinary output, ABG, ETCO2
  • Analgesia

Definitive care

  • Surgical intervention
  • Transfer to an appropriate facility

Documentation

  • Essential for continuity of medical care and evidence in case of medicolegal problems
  • A dedicated record-taker is needed in the resuscitation setting
  • Consent should be obtained before procedures if possible
  • If criminal involvement is likely, evidence must be preserved

Airway and ventilatory management


Airway

  • Problems
    • Maxillofacial trauma, neck trauma, laryngeal trauma
  • Signs
    • Talking patient: airway is patent and not compromised
    • Agitation, obtundation, cyanosis, rib retraction, accessory muscle use
    • Noisy breathing, stridor, hoarseness, confusion (hypoxia)
    • Palpable larynx and trachea

Ventilation

  • Problems
    • Airway patency, chest and lung integrity, innervation, CNS function
  • Signs
    • Chest movement
    • Breath sounds
    • Oximetry

Management

  • All require protection of cervical spine if injury is suspected
  • Airway maintenance
    • Chin lift, jaw thrust, Guedel airway, nasopharyngeal airway
  • Definitive airway
    • “A tube present in the trachea with the cuff inflated, the tube connected to some form of oxygen-enriched assisted ventilation, and the airway secured in place with tape.”
    • Orotracheal, nasotracheal, surgical options
    • Indications
      • Apnoea, inability to maintain a patent airway, protection from aspiration, impending or potential airway compromise, closed head injury (GCS ≤8), inadequate oxygenation with face mask ventilation
  • Intubation
    • Method depends on practitioner’s experience, usually orotracheal
    • Cervical immobilization, preoxygenation, cricoid pressure, drugs (if required), laryngoscopy, ETT placement, auscultation, CO2 analysis, CXR
    • Nasotracheal intubation is only used in spontaneously breathing patients
    • Induction agents typically suxamethonium and benzo.
  • Surgical airway
    • Needle cricothyroidotomy
      • 12g or 14g cannula inserted through cricothyroid membrane
      • Intermittent jet O2 insufflation (1 s on 4 s off)
      • Contraindicated in glottic obstruction (--> barotrauma)
      • Provides 30-45 minutes oxygenation (limited by PCO2)
    • Surgical cricothyroidotomy
      • Palpate thyroid notch and sternal notch, find cricothyroid
      • Local anaesthetic if required, prepare skin
      • Stabilize trachea with one hand, transverse incision through skin and cricothyroid membrane
      • Insert scalpel handle or artery and dilate opening
      • Insert cuffed tube (5-6 mm), inflate cuff and check ventilation
      • Secure tube
  • Oxygenation
    • All patients require supplemental oxygen
    • Oximetry should be used where available
      • Unreliable with poor peripheral perfusion, anaemia, abnormal Hb
  • Ventilation
    • Bag-valve-mask is best performed with two operators
    • Ventilation is required during prolonged attempts at intubation
    • Pressure-limited ventilation is required post-intubation

Shock


Assessment

  • Signs
    • Peripheral vasoconstriction, tachycardia, narrowed pulse pressure
    • Hypotension is a late sign (>30% volume loss)
    • Haemoglobin is not a measure of volume status
  • Causes
    • Haemorrhagic
      • Present in most patients with multiple injuries, responds to filling
    • Non-haemorrhagic
      • Cardiogenic, tension pneumothorax, neurogenic, septic

Haemorrhagic shock

  • Haemorrhage is the acute loss of circulating blood volume
  • Normal blood volume is 70 ml/kg in adults (80-90 ml/kg in children)
  • Classification
    • Class I
      • Loss up to 15% of blood volume
      • Usually fully compensated
      • Recovers by transcapillary refill within 24 hours
    • Class II
      • 15%-30% blood volume lost
      • Tachycardia, tachypnoea, reduced pulse pressure, anxiety
      • Urine output 20-30 ml/h
      • Responsive to crystalloid filling
    • Class III
      • 30-40% blood volume lost
      • Marked tachycardia, tachypnoea, hypotension, mental changes
      • Urine output low 5-15 ml/h
      • Will require transfusion
    • Class IV
      • More than 40% blood volume lost
      • Immediately life-threatening
      • Minimal urine output
      • Requires immediate transfusion and usually surgery
  • Soft-tissue haematoma may consume litres of blood.

Management

  • Examination
    • ABCDE
    • Gastric decompression
    • Urinary catheter insertion
  • Vascular access
    • Large peripheral IVs initially (16g or 14g short)
    • Cut-down if required depending on level of experience
    • Intraosseous infusion if under 6 years and no other access
    • CVC insertion is not the best choice for rapid infusion
    • Blood taken for crossmatch, investigations including βhCG, ABG
  • Initial fluid therapy
    • 20 ml/kg Hartmann’s as a bolus
    • Further therapy guided by response to initial bolus and on-going losses
    • Response
      • Urine output, conscious state, peripheral perfusion, CVP

Evaluation of resuscitation

  • Normalization or improvement of HR, BP and pulse pressure
  • Urine output >0.5 ml/kg/h (1 ml/kg/h in children, 2 ml/kg/h in infants)
  • CVP or PAOP or CO (if PA catheter inserted)
  • ABG
    • Initial respiratory alkalosis followed by metabolic acidosis
    • Persistent metabolic acidosis if peripheral perfusion is inadequate

Response to initial therapy

  • Rapid response
    • Haemodynamic normalization with bolus fluid
  • Transient response
    • Deterioration following initial response to bolus fluid indicates inadequate resuscitation or ongoing losses
    • Likely requirement for transfusion and surgery
  • Minimal or no response
    • Likely exsanguinating haemorrhage requiring surgery, or
    • Non-haemorrhagic cause for shock
    • Differentiate using CVP or echocardiography

Choice of fluid

  • Blood
    • Usually packed cells
    • Used to replace oxygen carrying capacity
    • Not the first choice for volume replacement
    • Type-specific or O negative can be used in extreme urgency
    • Component therapy for coagulopathy as indicated by pathology tests
  • Crystalloids
    • Hartmann’s or normal saline
    • Heated to 39°C

Special considerations

  • Use of vasopressors is contraindicated in haemorrhagic shock
    • Increased SVR, decreased CO --> “death spiral”
  • Elderly have reduced physiological reserve
  • Tachycardia may be a poor sign if on β-blockers or pacemaker or in athletes
  • Hypothermia may prevent a response to fluid
  • Always suspect ongoing haemorrhage if response is poor
  • Under-resuscitation is far more common than fluid overload
  • CVP can guide fluid therapy

Thoracic trauma

Primary survey

  • Airway
    • Assess air movement at nose and mouth, inspect oropharynx, observe for intercostal retraction
    • Laryngeal injury or posterior dislocation of sternoclavicular joint can obstruct the airway
  • Breathing
    • Expose chest, observe, palpate and auscultate
    • Tension pneumothorax
      • Decompress with large Jelco in second intercostal space in midclavicular line followed by chest tube in the fifth intercostal space between the midaxillary and anterior axillary lines
    • Open pneumothorax
      • Flap-valve dressing, surgical closure and chest tube
    • Flail chest
      • Underlying pulmonary contusion is usually the major concern
      • Administer oxygen, limit IV fluids unless shock is present, analgesia
      • May require intubation and ventilation
  • Circulation
    • Assess pulse, blood pressure, JVP
    • Monitor ECG and SpO2
    • Massive haemothorax
      • Rapid accumulation of more than 1500 ml in the chest cavity, usually manifest as shock with absent breath sounds and dullness on one side of the chest
      • Rapid IV fluid administration, decompression with a chest tube, thoracotomy likely if >1500 ml or >200 ml/h evacuated or persistent transfusion requirement or penetrating injury medial to nipple or scapula
    • Cardiac tamponade
      • 15-20 ml in pericardial space is enough to cause haemodynamic compromise
      • Difficult to diagnose acutely, echocardiography may help
      • IV fluid may produce transient improvement
      • Pericardiocentesis may be performed without definitive diagnosis
      • Open pericardiotomy may be required to evacuate clot and inspect the heart

Resuscitative thoracotomy

  • May be helpful in penetrating chest injury with pulseless electrical activity
  • Only performed by an appropriate surgeon

Secondary survey

  • Further examination
    • Upright CXR, ABG, SpO2, ECG
  • Simple pneumothorax
    • Decreased breath sounds, resonant percussion
    • Chest tube inserted in fifth intercostal space, underwater seal drain, CXR to confirm lung re-expansion all required before IPPV or air transport
  • Haemothorax
    • Usually due to laceration of intercostal or internal thoracic arteries, bleeding is usually self-limiting
    • Chest tube allows drainage of blood and monitoring ongoing loss
    • Thoracotomy for severe bleeding
  • Pulmonary contusion
    • Most common potentially lethal chest injury, gradual respiratory failure
    • PaO2 >65 mmHg or SpO2 <90% demands intubation and ventilation
    • Repeated assessment of ABG, ECG and SpO2
  • Tracheobroncheal tree injuries
    • Most injuries are within 2.5 cm of the carina and cause death at the scene
    • Haemoptysis, subcutaneous emphysema or tension pneumothorax
    • Large air leak after chest tube insertion, two chest tubes may be required
    • Diagnosis confirmed at bronchoscopy, may require double lumen tube, may require urgent surgical repair
  • Blunt cardiac injury
    • Pain, hypotension with increased CVP, wall motion abnormality, conduction abnormalities (PVCs, ST, AF, RBBB, STΔ)
    • Treatment of arrhythmia as indicated, ECG monitoring
  • Traumatic aortic disruption
    • Common cause of death after severe deceleration injury
    • Survivors to hospital have contained haematoma
    • Signs on CXR: widened mediastinum, obliterated aortic knob, tracheal deviation to right, no space between aorta and PA, depressed left main bronchus, deviation of oesophagus to right, widened paratracheal stripe, widened paraspinal interfaces, apical cap, left haemothorax, fractures of first or second rib or scapula
    • Diagnosed at angiography or TOE
  • Traumatic diaphragmatic injury
    • Commonly missed, may be diagnosed on CXR with NGT or contrast, or by drainage from chest tube of DPL fluid, or at thoracoscopy or laparotomy
    • Treated by direct repair
  • Mediastinal traversing wounds
    • Penetrating injury crossing from one hemithorax to the other or with metallic fragment lodged in the mediastinum
    • 50% unstable, 20% mortality
    • Early surgical consultation
    • Injury to great vessels, tracheobronchial tree, oesophagus, heart, spinal cord and lung must be considered
    • Chest tubes may be required bilaterally, early operation if unstable
    • Stable patients require angiography, contrast swallow, gastroscopy, bronchoscopy, CT or echocardiography
  • Associated problems
    • Subcutaneous emphysema
    • Crush injury
    • Rib, sternum and scapula fractures
      • Ribs 1-3 protected by upper limb; fracture suggests great vessel injury
      • Ribs 4-9 most commonly injured, require greater force in the young
      • Ribs 10-12 fracture suggest hepatic or splenic injury
      • Analgesia is required for good ventilation
    • Blunt oesophageal rupture
    • Due to forced expulsion of gastric contents with oesophageal tearing or instrumentation
    • May present as left pneumothorax without rib fracture, particulate matter in chest tube
    • Required operative repair to prevent mediastinitis and sepsis
  • CXR examination
    • Confirm ID of film
    • Trachea and bronchi
      • Interstitial or pleural air, pneumomediastinum, pneumothorax, subcutaneous or interstitial emphysema, pneumoperitoneum
    • Pleural space and lung parenchyma
      • Lung infiltrate, consolidation or haemothorax
    • Mediastinum
      • Altered cardiac silhouette, signs of aortic rupture (above)
    • Diaphragm
      • Elevation, disruption, obscured, mass above or air below
    • Bony thorax
      • Clavicle, scapula, ribs, sternum fractures or dislocation
    • Soft tissues
    • Tubes and lines

Abdominal trauma


Assessment

  • History
    • Mechanism of injury: e.g. vehicle crash, speed, direction, position in car etc. or weapon and range in penetrating trauma
    • Location of pain and referral of pain
  • Examination
    • Inspection
      • Including posterior abdomen and chest and perineum
    • Auscultation, percussion
    • Palpation
      • Guarding, pregnancy
    • Evaluation and local exploration of penetrating wounds
      • Dependent on surgical experience
      • 25-33% of anterior stab wounds do not penetrate peritoneum
    • Assess pelvic stability
    • Perineal, penile/vaginal and rectal examination
      • Signs of pelvic fracture or urethral injury
    • Gluteal examination
  • Intubation
    • Insertion of NGT, urethral catheter (if no indication of injury)
  • Blood and urine sampling
  • Imaging
    • Screening X-rays: cervical spine, CXR, pelvis
    • Supine and erect AXR (lateral decubitus if can’t be sat up)
    • Contrast studies
      • Urethrography, cystography if injury suspected
      • IVP only if contrast CT unavailable
      • GI contrast studies if injury suspected and patient stable
  • Special investigation
    • Diagnostic peritoneal lavage
      • 98% sensitive for intraperitoneal bleeding
      • Indications
        • Haemodynamically abnormal, multiple blunt injuries
        • Altered conscious state
        • Spinal cord injury
        • Equivocal abdominal examination
        • Prolonged “loss of contact” with abdomen expected (e.g. CT)
        • CT or US not available
      • Relative contraindications
        • Previous surgery, morbid obesity, cirrhosis, coagulopathy
      • Lavage catheter inserted and aspirated
      • If no aspirate, 1000 ml Hartmann’s used for lavage
      • Positive if ≥100,000 RBC/mm3, ≥500 WBC/mm3 or gram stain +ve
    • Ultrasound
      • As good as DPL or CT in experienced hands
      • Gives views of pericardium, hepatorenal fossa, splenorenal fossa, pelvis
      • Repeat scan at 30 minutes to detect slow bleeding
    • Computed tomography
      • Time-consuming, only for stable patients
      • Most specific test for injury
      • Will miss some diaphragmatic, bowel and pancreas injuries
  • Special investigation in penetrating trauma
    • Lower chest wounds
      • Serial examination and imaging, laparoscopy, thoracoscopy
    • Anterior abdominal stab wounds
      • Serial examination or DPL help to detect asymptomatic penetration of peritoneum
    • Back or flank stab wounds
      • Serial examination or contrast CT or DPL plus follow up beyond 24 hours if asymptomatic

Indications for laparotomy

  • Blunt trauma with
    • Positive DPL or ultrasound
    • Hypotension despite resuscitation
  • Peritonitis
  • Penetrating trauma with
    • Hypotension
    • Bleeding from GI or urogenital tract
    • Gunshot wounds
  • Evisceration
  • AXR with free air, diaphragmatic defect or retroperitoneal air
  • CT with ruptured viscus, injury to bladder, renal pedicle or other viscus

Pelvic fractures

  • Classification
    • Anteroposterior compression injury
      • Commonly sacral fracture or dislocation
      • Haemorrhage from posterior venous or internal iliac vessels
    • Lateral compression injury
      • Pubis commonly injures bladder or urethra
      • Haemorrhage less common
    • High energy shear force injury
      • Disrupts sacrospinous and sacrotuberous ligaments
      • Major instability
  • Assessment
    • Inspection for bruising, lacerations, urethral injury, PR
    • Manual test of mechanical stability
    • X-ray
  • Management
    • Exsanguination
      • ABCDE, PASG, operate if open or DPL positive, post-op fixation
      • Angiography if unstable and DPL negative
    • Stable following resuscitation and unstable fracture
      • ABCDE, PASG, operate if DPL positive, post-op fixation, angiography if still unstable
    • Normal BP
      • ABCDE, PASG if hypotension develops, treat other injuries, fix

DPL technique

  • Urinary catheter, NGT
  • Prep, local below umbilicus
  • Vertical incision to fascia, peritoneal incision (alternatively Seldinger tech.)
  • Insert catheter, advance into pelvis
  • Aspirate, irrigate, agitate, drain after 5-10 min
  • Send sample for RBC, WBC counts and gram stain

Head trauma

  • Classification
    • Mechanism: blunt or penetrating (dura)
    • Severity: by GCS: severe 3-8, moderate 9-13, mild 14-15
    • Morphology
      • Usually determined at CT scan
      • Skull fractures
        • Vault: linear or stellate, open or closed, depressed or not
        • Basilar: with or without CSF leak, VII nerve palsy
      • Intracranial lesions
        • Focal
          • Extradural haematoma
            • 9% of comatose head injuries
            • Lenticular lesion, usually arterial
          • Subdural haematoma
            • 30% of severe head injuries
            • Cover entire hemisphere, usually venous
          • Intracerebral haematoma or contusions
            • Usually frontal and temporal and associated with subdural
        • Diffuse “concussion”
          • Mild, classical and diffuse axonal injury
  • Management
    • Mild
    • 80% of head-injury presentations
    • All require CT scan if any LOC, amnesia or headache
    • Skull X-rays only for penetrating injury
    • Usual cervical spine X-rays, blood tests etc.
    • Avoid narcotics
    • 12 hours of observation (can be at home) even if normal CT
    • Discharged only if asymptomatic, uninjured, living nearby and in the company of a responsible adult
  • Moderate
    • 10% of head-injury presentations
      • 10-20% will deteriorate
    • History
    • Examination
    • Investigations
      • CT head (40% abnormal), baseline bloods
    • Surgery if indicated (8% on CT scan)
    • Admission for observation
      • Repeated examination and CT if any deterioration
  • Severe
    • 10% of head-injury presentations
    • ABCDE
      • Hypotension and hypoxia are associated with 75% mortality
      • Require rapid resuscitation
        • Early intubation, moderate hyperventilation (PCO2 25-35 mmHg)
        • Maintenance of cerebral perfusion pressure
        • Management of other injuries as indicated
        • Priority of CT versus DPL/US depends on response to fluid resuscitation: poor response --> DPL/US first
      • High incidence of other injuries
        • Long bone or pelvic fracture 32%
        • Mandible or maxillary fracture 22%
        • Major chest injury 23%
        • Thus detailed secondary survey
      • Neurological examination
        • GCS and pupils at least prior to relaxation
        • Serial examinations over time, recording best responses on each side
      • Diagnostic procedures
        • Emergency CT scan unless precluded by instability
        • Looking for lesions and midline shift

Medical management of head injury

  • 36% mortality for severe head injury
  • IV fluids: maintain euvolaemia with saline or Hartmann’s (not glucose)
  • Maintain perfusion pressure ≥70 mmHg
  • Moderate hyperventilation: PCO2 25-35 mmHg
  • Mannitol for oedema if normotensive
  • Frusemide and anticonvulsants with surgical consultation
  • Steroids and barbiturates probably not beneficial

Surgical management

  • Scalp laceration without underlying fracture
    • Closed after shaving and irrigation
  • Depressed fracture
    • Elevated surgically if depressed more than the skull thickness
  • Mass lesions
    • Transfer to neurosurgical unit
    • Emergency burr holes by a non-specialist are rarely justified

Spine and spinal cord trauma

  • Epidemiology
    • 450 spinal injuries per year in Australia, 2% mortality
    • Level of injury
      • C4-7 --> 48%
      • T3-6 -->  13%
      • T10 --> 12 18%
      • Other --> 21%
  • Classification of injury
    • Level
      • The most caudal segment with normal sensory and motor function
      • Dermatomes
      • Myotomes

 C5  Deltoid
 C6  Wrist extension
 C7  Elbow extension
 C8  Middle finger flexion
 T1  Finger abduction
 L2  Hip flexion
 L3  Knee extension
 L4  Ankle dorsiflexion
 L5  Toe extension
 S1  Ankle plantar flexion



      • Differs from bony level of injury
    • Severity
      • Complete, incomplete
    • Cord syndromes
      • Central cord
        • Anterior spinal artery compromise
        • Usually cervical extension injury
        • Upper limb weakness > lower limb
      • Anterior cord
        • Anterior spinal artery infarction
        • Pain and temperature sensation loss, paraplegia
        • Intact vibration, proprioception
      • Brown-Sequard
        • Cord hemisection
        • Ipsilateral motor and vibration/proprioception loss
        • Contralateral pain and temperature loss two segments lower
    • Morphology
      • Fracture, fracture dislocation, SCIWORA, penetrating injury
      • Stable or unstable (all assumed to be unstable)
  • X-ray evaluation
    • Cervical spine
      • Must see BOS to T1
      • May require lateral and swimmer’s views: 85% sensitivity for fractures
      • Addition of AP and open-mouth views: 92% sensitivity
      • Addition of oblique views: slight increase in sensitivity
      • CT scan if unable to see low vertebrae or injury suspected
      • 10% of cervical spine fractures have a second vertebral fracture
      • To detect spinal cord compression: MRI or CT myelography
    • Thoracic and lumbar spine
      • AP views routine
      • Lateral or CT if injury suspected
  • Management
    • Rules for cervical spine
      • Paraplegia or quadriplegia suggests cervical instability
      • Alert, normal and pain-free patients can be cleared if full-range voluntary movement is pain-free
      • Alert, normal patients in pain need lateral, AP and open-mouth films. If a flexion lateral film is also of good quality and clear there is no need for CT
      • Unconscious or confused or uncommunicative patients require AP, lateral and, if possible, open-mouth films before assessment by a surgeon before being cleare
      • If there is doubt, the collar should be left on
      • Neurosurgical or orthopaedic referral is required for all suspected injuries
      • Paralyzed patients should be removed from a backboard as soon as practicable
      • Never force the neck
      • If operation is required prior to clearing the neck, the collar should be left on
      • Assess the cervical spine X-rays for
        • Bony deformity
        • Fracture of the vertebral body or processes
        • Loss of alignment
        • Increased distance between spinous processes
        • Narrowing of the canal
        • Increased prevertebral soft-tissue shadow
    • Immobilization
      • A semirigid collar does not ensure immobilization.
      • A collar, backboard, tape and straps should be applied before definitive transfer
      • Sedation, paralysis and intubation may be required to maintain immobilization
      • Two-handed technique for cricoid may reduce cervical spine movement
    • Steroids
      • Not used in Australia for spinal cord injury

Musculoskeletal trauma

  • Primary survey
    • Occur in 85% of trauma patients
    • Major importance in primary survey is haemorrhage
      • Control with local pressure
    • Fracture immobilization
      • Aim to reduce fracture, minimize pain and bleeding
      • Not more important than ABCDE
    • X-rays
      • Obtained when convenient
      • AP pelvis is indicated early in multi-trauma
  • Secondary survey
    • History
      • Detail of mechanism of injury: time, force…
      • Environment: temperature, poison, fragments, contamination
      • Preinjury status: AMPLE…
      • Prehospital observations
    • Physical examination
      • Complete exposure
      • Detection of life-threatening, limb-threatening and other injuries
      • Systematic examination: skin, neuromuscular, circulation, skeletal and ligamentous
        • Look, feel, pulses/circulation, X-ray
  • Potentially life-threatening extremity injuries
    • Major pelvic disruption with haemorrhage
      • Falls, motorcycle or pedestrian accidents are associated with ringopening injuries: sacroiliac disruption and major haemorrhage
      • Motorcar accidents are associated with lateral force injuries with genitourinary injury and less incidence of haemorrhage
      • Signs
        • Progressive swelling or bruising
        • Failure to respond to fluid resuscitation
        • Signs of urethral injury
        • Mechanical instability
        • X-ray findings
      • Management
        • Haemorrhage control with immobilization ± PASG
        • Rapid fluid resuscitation
        • Early surgical consultation
    • Major arterial haemorrhage
      • Penetrating or blunt injury with fracture or dislocation
      • Signs of ischaemia or haematoma
      • Management
        • Direct pressure
        • Fluid resuscitation
        • Surgical consultation
    • Crush syndrome
      • Prolonged crush injury to muscle causes rhabdomyolysis
      • Signs: dark urine, hypovolaemia, acidosis, hyperkalaemia, hypocalcaemia, DIC
      • Management fluid loading, osmotic diuresis, urinary alkalinization
  • Limb-threatening injuries
    • Open fractures and joint injuries
      • Communication between external environment and bone
      • Management sterile dressing, examination of soft-tissue, circulatory and neurological involvement, surgical consultation
      • Tetanus prophylaxis
    • Vascular injuries, traumatic amputation
      • Suggested by circulatory insufficiency associated with limb trauma
      • May result from circumferential dressings or casts
      • Urgent surgical revascularization
      • Replantation is indicated only in isolated limb injuries, not in patients requiring intensive resuscitation
        • Amputated part is washed in Hartmann’s, wrapped in penicillin-soaked gauze and transported on crushed ice
    • Compartment syndrome
      • Caused by injury within a closed fascial space or external compression
      • Compartment pressure exceeds perfusion pressure
      • High risk: tibial and forearm fractures, tight dressings or casts, severe crush injuries, interstitial oedema due to reperfusion, increased capillary permeability or exercise
      • Signs
        • Unexpectedly severe pain, worse with stretching
        • Dysfunction of nerves in the compartment
        • Tense swelling
        • Weakness and loss of pulses are late signs
        • Compartment pressure >35-45 mmHg
      • Management
        • Removal of dressings or casts
        • Fasciotomy if no improvement over 30-60 min
    • Neurological injury secondary to fracture dislocation
      • Assessment of nerve function requires a cooperative patient
      • Documentation of progression of disability and repeat examination is important, especially after reduction manoeuvres (table below)
  • Other extremity injuries
    • Contusions and lacerations
      • Examine for associated injury
      • Superficial injury from crushing or degloving may be minor
      • Tetanus risk increased: >6 h old, abraded, >1 cm deep, due to burn, cold or missile, contaminated
    • Joint injuries
      • May not be associated with fractures
      • Hyperextension or hyperflexion soft tissue injury
      • Examine for associated nerve or vessel damage
      • Immobilize
    • Fractures
      • Usually associated with soft tissue injury
      • Clinical examination to make diagnosis, accompanied by X-rays in two planes
      • Joint above the injury must also be X-rayed
      • Examine for associated nerve or vessel injury
      • Immobilize

 Nerve  Motor  Sensation  Injury
 Ulnar  Index finger abduction  Little finger  Elbow injury
 Median (distal)  Thenar opposition  Index finger  Wrist dislocation
 Median (anterior interosseous)  Index tip flexion    Supracondylar fracture of humerus
 Musculocutaneous  Elbow flexion  Lateral forearm  Anterior shoulder dislocation
 Radial  Thumb, finger MCP extension  1st dorsal web space  Distal humeral shaft, anterior shoulder dislocation
 Axillary  Deltoid  Lateral shoulder  Anterior shoulder dislocation, proximal humerus fracture
 Femoral  Knee extension  Anterior knee  Pubic rami fractures
 Obturator  Hip adduction  Medial thigh  Obturator ring fractures
 Posterior tibial  Toe flexion  Sole of foot  Knee dislocation
 Superficial peroneal  Ankle eversion  Lateral dorsum of foot  Fibular neck fracture, knee dislocation
 Deep peroneal  Ankle/toe dorsiflexion  Dorsal 1st to 2nd web space  Fibular neck fracture, compartment syndrome
 Sciatic  Plantar flexion  Foot  Posterior hip dislocation
 Superior gluteal  Hip adduction    Acetabular fracture
 Inferior gluteal  Gluteus maximus hip extension    Acetabular fracture

  • Physical examination
    • Look
      • Age, sex
      • Wounds, deformity, position
      • Colour of extremities
      • Spontaneous activity: evidence of pain or paraplegia
      • Urine colour
    • Feel
      • Palpate pelvis for instability
      • Peripheral pulses and capillary refill
      • Muscle compartment palpation
      • Joint stability
      • Neurological examination: sensory and motor

Injuries due to burns and cold

  • Immediate management
    • ABCDE
    • Airway
      • Immediate intubation if inhalational injury likely
      • Facial burns, eyebrows or nasal hair singed, acute inflammation or carbon deposits in mouth, carbonaceous sputum, history of confinement in burning environment, explosion with burns to head or torso, COHb >10%
    • Stop the burning process
      • Remove all clothing, chemical residue
      • Rinse with water
    • Intravenous access
      • Required if burns >20% of BSA
      • Large bore, upper limb preferable, unburned area preferable
  • Assessment
    • History
      • AMPLE history, tetanus status
    • Examination
      • Area burned
        • “Rule of nines” for adults, modified for children
          • Adult: head, arm, half of leg, quarter of torso = 9%
          • Infant: head = 18%, half of leg = 7%
          • Palm excluding fingers = 1%
      • Depth of burn
        • First degree
          • Erythema, pain, no blisters - e.g. sunburn
        • Second degree, partial thickness
          • Red or mottled, blisters, weeping, hypersensitive
        • Third degree, full thickness
          • Dark and leathery, painless, dry
      • “Major” burns
        • >10% full thickness or >25% partial or inhalational injury
  • Stabilization
    • Airway
      • Early intubation if any suggestion of inhalational injury
    • Breathing
      • Injury mechanisms
        • Thermal injury
          • Upper airway oedema, obstruction
        • Inhalation of smoke and toxins
          • Tracheobronchitis, oedema, pneumonia
        • CO poisoning
          • <20% COHb asymptomatic
          • 20-30% headache and nausea
          • 30-40% confusion
          • 40-60% coma
          • >60% death
          • Treat with high FiO2 (hyperbaric if pregnant)
    • Circulation
      • IV access and IDC required for management
      • Aim for urine output 1 ml/kg/h in children, 30-50 ml/h in adults
      • Initial fluids
        • Hartmann’s 2-4 ml/kg/%burn over 24 h
          • Half given in 8 hours, half in next 16
        • Plus acute losses and fasting requirements
        • Adjust according to urine output, vital signs
    • Examination
      • Document extent and depth of burns
      • Assess for associated injuries
      • Weigh patient
    • Investigations
      • FBE, XM, ABG (COHb), glucose, U&E, βhCG if indicated
    • Adjuncts to initial management
      • Assessment of limbs with circumferential injury for circulatory compromise, escharotomy if necessary
      • NGT insertion for gastric stasis and nausea initially
        • Later may be required for hyperalimentation
      • Analgesia with IV narcotic or ketamine
        • Small graduated doses, as circulation is centralized in shock
        • May worsen hypotension, hypoxia if not adequately resuscitated
      • Dress burns with clean linen
      • Prevent hypothermia
  • Special burns
    • Chemical injury
      • Alkali, acid or petrochemical burns
      • Alkali burns are generally the most serious
      • Remove all traces of chemical and irrigate
      • Burns to the eye may require continuous irrigation
    • Electrical burns
      • Frequently small entry and exit burns with extensive deep tissue injury underlying
      • Rhabdomyolysis common
      • Manage the same except
        • High index of suspicion of rhabdomyolysis, cardiac injury
          • ECG monitor, urine colour observation
          • Osmotic diuresis ± alkalinization of urine

Trauma in women
 

  • Alterations in pregnancy
    • Uterus
      • Intrapelvic until week 12, thick-walled, embryo well cushioned
      • At umbilicus by week 20
      • At costal margin at week 34-36, thin-walled, vulnerable to injury
      • Protects bowel from blunt trauma
      • High risk of placental abruption with trauma
    • CVS
      • Increased blood volume, decreased Hb, increased WCC (15-25,000/mm3), deceased albumin (22-28 g/L)
      • Increased CO (by 1-1.5 L/min), increased HR (10-15/min), decreased BP (5-15 mmHg), ECG LAD
    • Resp
      • Increased MV, decreased PCO2, decreased RV, FRC
    • Other
      • Increased gastric emptying time
      • Increased RBF, GFR, uterine compression of ureters
      • Inctreased pituitary size
      • Ligamentous laxity
  • Assessment and management
    • Primary survey and resuscitation
      • Mother
        • Usual ABCDE
        • Except left lateral tilt with uterine displacement unless spinal injury suspected
        • Vigorous fluid resuscitation to prevent uterine vasoconstriction and fetal hypoxia
        • Indicated X-rays must be performed, risk to fetus is low
      • Fetus
        • Good maternal resuscitation is good fetal management
        • Assessment by abdominal examination
          • Signs of uterine rupture
          • Signs of abruption
        • Fetal heart sounds, ultrasound, CTG
    • Secondary survey
      • Usual, including DPL or ultrasound
      • Except DPL must be above the umbilicus
      • Additional attention to uterine contraction, obstetric pelvic examination
      • Admission and fetal monitoring is required for even minor injuries
    • Specific conditions
      • Uterine rupture
        • Massive haemorrhage and shock if severe
        • Abnormal fetal position, extended limbs, free intraperitoneal air
        • Laparotomy required if rupture suspected
      • Abruption
        • Leading cause of fetal death after trauma
        • Vaginal bleeding, pain, uterine rigidity, shock
        • 30% show no external bleeding
      • Amniotic fluid embolism
        • Hypotension, hypoxia, DIC
      • Fetomaternal haemorrhage
        • Fetal anaemia and death
        • Maternal isoimmunisation (use anti-D even if Kleihauer negative)
      • Perimortem Caesarean section
        • Indicated after 4-5 minutes of failed acute resuscitation

Kindly provided by Dr James Mitchell from his pharmacodynamics series


ArticleDate:20061031
SiteSection: Article
 
   
    
                                            
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