Trauma

Initial survey (the ABCs), shock in the nontrauma setting, a review from head to toe, burns, bites and stings.

If the patient is unconscious or their voice is not normal…

they need an airway.

If the patient is conscious and their voice is normal but they have an expanding hematoma in the neck or subcutaneous emphysema in the neck or the upper chest…

they need an airway.

Expanding hematoma in the neck

Rapid aenesthetic induction with pulse oximetry and oro-/naso- tracheal intubation.

Subcutaneous emphysema in the neck or the upper chest

Fibreoptic intubation due to possible bronchial tree injury.

Intubation of an unconscious patient with a suspected spinal cord injury

Fibreoptic naso-/oro- tracheal intubation without moving the neck.

Intubation when the naso/oro pharynx is inaccessible, etc. major facial trauma, anaphylactic shock

Cricothyroidotomy (not tracheostomy, done to a patient who already has an airway).

Also percutaneous catheter into the trachea with high-frequency ventilation (contraindicated with head injury).

Indications for assisted breathing

If a patient is not breathing spontaneously, doesn’t have bilateral breath sounds or his pulse oximetry is abnormal.

Immediate shock parameters in a trauma patient

ABP < 90 mm Hg and poor quality, fast pulse.

Diaphoretic, cold, shivering, anxious.

Common types of shock in the trauma setting

1. hypovolemic hemorrhagic

2. pericardial tamponade

3. tension pneumothorax.

For the latter two, the chest has to be included in the trauma. May not be obvious with blunt trauma.

Signs of pericardial tamponade or tension pneumothorax

Trauma to the chest, signs of shock, and distended neck and facial veins (CVP > 20-25 mm Hg).

Signs of hypovolemic hemorrhagic shock

Trauma, signs of shock and empty neck and facial veins (CVP < 2 mm Hg).

Difference between pericardial tamponade and tension penumothorax

Tension pneumothorax causes dyspnea, unilateral breath sounds, hyperressonance on percussion and mediastinal shift.

Management of hemorrhagic shock

1. If at all possible stopping the source of bleeding*

2. filling the vascular tree.

*Patient has to be close to a trauma center, the source of bleeding must be located.

Control of bleeding from an extremity

Direct pressure.

Route of access for filling the vascular tree

• 16 gauge catheters in each of the arms or

• saphenous veins in the ankles or

• direct puncture of the femoral vein.

Crystalloids for hemorrhagic shock

1-2 L in 20-30 min of balanced electrolyte solution - no sugars for urinary output evaluation followed by blood as soon as it becomes available.

Acetate is preferred with liver failure or head trauma.

Most important parameters for crystalloid infusion in a trauma patient

Hour urinary output and CVP.

Management of pericardial tamponade

1. (Blood transfusion)

2. decompression of the pericardial sack: pericardial window, pericardiocentesis, pericardial tube, median sternotomy.

Management of tension pneumothorax

Decompression of the pleural space: big bore needle/catheter into the II intercostal space, followed by a chest tube under suction and a water seal.

Can a trauma patient develop haemorrhagic shock from intracranial beelding?

No, requires 1.5 L of blood lost which the cranial cavity cannot accommodate.

Shock in the non-trauma setting

1. Spontaneous bleeding, eg. ruptured aneurysm, peptic ulcer etc.

2. cardiogenic shock

3. vasomotor shock

Signs of cardiogenic shock in the non-trauma setting

Distended neck and face veins, increased CVP.

Differentiation between vasomotor and other types of shock

A patient is warm and flush. Restore intravascular volume.

Management of a patient with foreign penetrating head trauma

Removal of the object in the operating room.

Management of linear skull fracture with laceration of the scalp

Sewing up the laceration, conservative management of the linear fracture.

Management of comminuted depressed skull fracture

Surgery to restore the cranial wall.

Every patient who has loss consciousness secondary to head trauma gets a <…>.

Every patient who has loss consciousness secondary to head trauma gets a CT scan.

Ecchymosis under both eyes (racoon eyes), rhinorrhea, otorrhea or echimosis behind the ears.

Skull base fracture.

Management of skull base fracture

CT scan of the head and neck, if no other symptoms are present, conservative management.

Presentation of acute epidural haematoma

Head trauma

Loss of consciousness

Gain of consciousness

Loss of consciousness again

Unilateral mydriasis (haematoma localised on the side of the blown pupil) of and contralateral hemiparesis in relation to the blown pupil.

Differentiation between acute epidural vs subdural haematoma

Epidural haematoma present with trivial trauma, there is regain of consciousness, lens-shape, biconvex haematoma, and better prognosis.

Management of epidural haemtoma

Craniotomy and evacuation of the cranial cavity.

Damage to the brain during head trauma

1. Trauma itself

2. haematomas with midline shift

3. cerebral oedema and increased ICP.

Presentation of subdural haematoma

Biconcave, semilunar, crescent-shaped haematoma, midline shift in the CT scan.

Lateralizing signs

Unilateral mydriasis, contralateral hemiparesis etc. midline shift.

Management of acute subdural haemtoma with no lateralizing signs

Control and monitoring of ICP, hyperventilation, mannitol, maintenance of brain perfusion.

Trauma, bilateral, fixed pupils, diffuse blurring of white-grey matter interface, and multiple, small-point haemorrhages

Diffuse axonal injury. Management consists of control and monitoring of ICP.

Acute dementia (3-4 weeks) preceding a head trauma.

Chronic subdural haematoma. Seen in senile and alcoholic patients. Managed with intracranial decompression.

Brain shrinkage with rupture of a dural venous sinus.

Absolute indications of surgery for neck trauma

1. Any penetrating injury to the neck with patients is rapidly deteriorating

2. all gunshot wounds to the middle part of the neck

3. penetrating injury to the neck with suspected injury to a major organs (expanding haematoma, hemoptysis).

Management of upper neck injury

Emergency angiogram and embolization.

Management of lower neck injury

Arteriogram, oesophagrom, oeshophagocopy, bronchoscopy. Median sternotomy, neck dissection.

Management of bony injury to the cervical spine

Neck/head roentgenography or CT scan.