CLS106 Foundation of Trauma Practice

Define trauma
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What is the purpose of a secondary trauma survey?More comprehensive exam designed to identify injuries that may have been missed.What is methoxyflurane?emergency analgesic inhaler,What is an indication of methoxyflurane?painWhat are contraindications of methoxyflurane?Malignant hypothermic, uraemia, behaviourally disturbance, concurrent tetracycline use, age >1, altered LOC, pre-eclampsia or eclampsia.What is blunt force trauma?An injury causes by a rapid forward deceleration or rapid vertical deceleration. Energy exchange between the object and body without intrusion of object through the skin eg. MVAWhat is penetrating force trauma?Projectiles, knives, falls leading to impalement. Physical principles govern the energy exchange (low velocity & high velocity. Type of weapon involved can impact the severity of the injury.What is an MVA?motor vehicle accidentWhat are the 3 collisions of an MVA?1. Machine collision (car to car) 2. Body collision (body to car) 3. Organ collision (crush organs)What is a shear injury?Opposing forces tear tissue similarly to blades of scissors, with tissues sliding in opposite directions alone parallel plane.What is a compression injury?One tissue or organ is pushed into another, compressing and damaging small blood vessels, connective tissues, and all structures within.What is a stretch injury?One part of the body pulled away from another.What are some clues to injury?velocity, environment, deformity of vehicle, deformity of interior structureWhat are common types of impacts for MVAs?frontal, lateral, rear, rollover, rotationalDescribe a frontal impact and potential injuries occurred.Head on collision with another vehicle. Patient is retrained via seatbelt and airbag. Injuries could include those related to patient going up and over steering wheel: head, chest, spinal, abdominal - or down and under steering wheel: legs, abdominal. Patient can be ejected.Describe a lateral impact and potential injuries occurred.Collision with another car from the side of the vehicle (doors). Difficult to predict injuries as it depends on the specific impact, severe injuries can occur as there are minimal safety measures in place compared to frontal.Describe a rear impact and potential injuries occurred.Collision from behind resulting in rapid acceleration and deceleration. May involve multiple impacts if other cars involved. Risk for neck injury increased.Describe a rollover impact and potential injuries occurred.Vehicle rolls over after collision. Multiple impacts from multiple directions + increased risk of ejection. High risk of multiple injuries due to vehicle being impacted on areas not built to sustain impact.Describe a rotational impact and potential injuries occurred.Combination of body lateral and frontal impacts.What are the increased risks associated with motorcycle collisions?lack of safety measures increases the likelihood of serious injury and ejectionWhat are some additional impacts of collisions associated with motorcycle collisions?sliding, angularExplain the significance of a paediatric pedestrian collision.Children turn away from an oncoming vehicle. Their smaller anatomy increases the body surface area impacted and therefore the injuries they develop.What are some MOI considerations when attending a callout to a fall.fall height, anatomical point of impact, nature of impact surface, force of impact, transmission pathway of forces along skeletonOutline some spinal injuries.hyperextension, hyperflexion, compression, rotation, lateral stress, distractionWhat is a hyperextension spinal injury?Excessive posterior movement of head or neck. eg. head into windshield, elderly fallWhat is a hyperflexion spinal injury?Excessive anterior movement of head onto chest eg. dive into shallow waterWhat is a compression spinal injury?Weight of the head or pelvis driven into stationary neck or torso. (Compression/ crushing of the vertebrae)What is a rotation spinal injury?Excessive rotation of the torso or neck, moving one side of the spinal column against the other. eg. rollover MVAWhat is a lateral stress spinal injury?Direct lateral force on the spinal column, typically shearing one level of cord from the other. (Excessive sideways movement). eg T-bone MVAWhat is a distraction spinal injury?Excessive stretching of column and cord. (Pulling the spinal cord apart)What are some signs of a spinal injury?pain, parasthesia (pins and needles), paralysis, weakness, obvious deformity or woundsWhat is neutral alignment?Manually holding the head and neck to prevent further injury to the c-spine.Provide examples of SMR.collar, neutral alignment, log roll, spinal board, spinal scoopWhat are some complications of SMR?airway compromise due to collar, head and lower back pain due to being on hard backboard, life-threatening hypoxia from obesity, pressure sores from uneven skin pressure, delayed scene time, injury of rescuer due to weight of patient.What is the ASNSW protocol for SMR?Suspicious MOI Pain or tenderness in spinal region intoxication with medication, alcohol or illicit substances numbness, tingling or either sensory or motor loss any distracting painful injury ALOCWhat is a low velocity penetrating injury?knife or blade stabbing, injury limited to tissue contact by object.What is a high velocity penetrating injury?rifles, guns, involve dramatic energy exchanges and extensive injury pathways.What are Langer's lines?orientation of contusion in skin revealed in characteristic patterns. Effects tension on skin evident when skin transected. Can be static or dynamic.What are the 7 categories of wounds?contusions, abrasions, lacerations, incisions, punctures, burns, gunshot.Explain the 3 types of haemorrhages.Capillary: slow, even flow. Bright red blood Venous:, steady, slow flow. Dark red colour (low pressure) Arterial: spurting blood, pulsating flow, bright red colour (high pressure)What is haemostasis?Physiological response to bleeding. Local vasoconstriction, formation of platelet plug, coagulation, if haemorrhage is sever enough, mechanisms may fail resulting in shockWhat are the 4 stages of wound healing?haemostasis, inflammatory, proliferative, remodellingWhat are closed wounds?contusions and haematomasDescribe a contusion.bruising from closed bleeding into soft tissue. Blunt, non-penetrating forced trauma that crush/damage small blood vessels.Describe a haematoma.Larger bleeding in deeper tissue. Trapped pool of blood (appears as lump. eg egg on head). Visible in head trauma, less pronounced in other body areas.What are open wounds?lacerations, incisions, punctures, impaled objects, abrasions, avulsions, avulsion-degloving, amputationDescribe a laceration.tear or splitting of skin - separated without tissue loss. Pathway for infectionDescribe an incision.Clean wound margins caused by sharp instrument. Tends to bleed freely.Describe a puncture.Small entrance wound, damage extends into body interior. Increased danger of infection.Describe an impaled object.Object inside body with complications of puncture or laceration. Object may be irregular shaped. May be entangled in structures such as arteries, nerves or tendons. Removal can result in further damage or uncontrollable bleeding.Describe an abrasion.Scraping or abrasive action, removing layers of epidermis and dermis. Bleeding can be persistant, large area of epidermis = risk of serious infection and pain.Describe an avulsion.Tearing away of skin, either partially or completely. Seriousness depends on area involved, any impairment to circulation, degree of contamination. Minor form would be a skin tear (common in elderly)Describe an avulsion-deglovingSkin completely torn away off hand or limb. Carries poor prognosis for limb.Describe an amputation.Partial or complete severance of digit or limb. Often results in complete loss of limb at site of severance. Surgeon may attempt to reattach or use for grafting.What is a crush injury?Body part compressed, sustaining deep injury to muscles, blood vessels, bones, internal structures. Damage can be massive, despite minimal signs of damage to skin.What is crush syndrome?The systemic effects of a crush injury - potentially life-threatening. Accumulation of myoglobin, potassium, lactic acid and uric acid. Toxic products enter bloodstream when pressure released causing severe metabolic acidosis, hyperkalaemia and kidney failure.What is compartment syndrome?Increased pressure in a muscle compartment due to swelling and/or bleeding which leads to compromised perfusion to tissues.What is an injection injury?Bursting high pressure line (hydraulic) may inject fluid through patient's skin and into subcutaneous tissue. Chemically damages surrounding tissue causing severe damage. Local and systemic toxicity can be substantial.Outline the assessment of a wound.- clean and irrigate to allow closer inspection - consider MOI + potential for complications - fractures: feel, look, move - foreign bodies: irrigate/stabilise - infection: clean and dress - consider damage to underlying structuresHow can you estimate blood loss?looking at saturation of gauze, utilising vitals such as BP and HR and cap refillWhat are some complications of wound healing?impaired hemostasis, rebleeding, pressure injuries, delayed healing, compartment syndrome, abnormal scar formation, crush syndrome, infection, gangrene, tetanusHow do you manage minor wounds?use wet gauze to clean, wiping away from wound to avoid contamination. Irrigate wounds with saline to avoid rubbing/scrubbing. Once cleaning is complete, cover with a sterile non-adhesive dressing and secure.With what and how would you manage a catastrophic haemorrhage?Using a tourniquet, apply to the lowest part of the limb as possible. Place, twist, lock and record time. Use a second tourniquet if bleeding doesn't stop.What are some haemostatic agents?olaes/israeli dressing, celox, quikclot, XSTATWhat is involved in musculoskeletal trauma?bones, joints, ligaments, tendonsWhat are bony injuries?Simple or complicated fractures, traumatic amputations.What are soft tissue injuries?Sprains, strains and muscular damage. Joint injury, dislocation and subluxationWhat is a strain?Damage to muscle or tendons by over stressing beyond functional capacity. Can be due to an acute injury or repetitive strain. Mild: minimal loss to function. Moderate: partial muscle tear and some function loss. Severe: complete tearWhat is a sprain?Ligamental injuries that involve partial or complete tear of the ligament. Mild: stretching of ligaments. Moderate: partial tearing, some loss of function and swelling. Severe: complete tear. Unstable joint, may also associate fracture.What is a dislocation?Head of one bone remains out of alignment from joint after force.What is a subluxation?partial misalignment of jointWhat is a fracture?break or breaks in continuity of bone.What is a compound fracture?bone through skin (increased risk of infection)What is a simple fracture?Inside skin (increased risk of internal blood loss)What is an oblique fracture?Diagonal to shaftWhat is a comminuted fracture?shattered boneWhat is a spiral fracture?Twisting of boneWhat is a greenstick fracture?incomplete fracture (paediatric)What is a transverse fracture?Perpendicular to shaftWhat is the goal of splinting?To immobilise the injured body part.How would you splint if there was neurovascular compromise.apply gentle traction in effort to straighten, pad and splint in most comfortable position, rapid safe transport.Describe a mid-femur fracture.may be open wound, large muscle mass which could cause spasm, increased bleeding due to large blood vessels surrounding the bleedingDescribe a pelvic fracture.identified by MOI and RTS, risk of serious haemorrhage, requires rapid transportDescribe a hip fracture.common in elderly, affected leg will almost always be shortened and rotated, frequently ignored, can allow weight bearing, nerve damage increased.What are the deadly dozen?1. airway obstruction 2. flail chest 3. open pneuomothorax 4. massive haemothorax 5. tension pneuomothorax 6. cardiac tamponade 7. myocardial infarction 8. traumatic aortic rupture 9. tracheal or bronchial tree injury 10. diaphragmatic tears 11. pulmonary contusion 12. blast injuriesDescribe an airway obstruction.common cause of preventable death, leads to hypoxia, airway is obstructed by foreign body, tongue, vomit or blood.Describe a flail chest.respiratory distress, possible subcutaneous emphysema, may have external contusions or abrasions, chest moves abnormallyDescribe a tension pneumothorax.Air entering the pleural space causing respiratory distress. Can be heard by percussing for hyper-resonance. Can appear to have tracheal deviation or JVD. Caused by air entering pleural space when breathing and doesn't evacuate.Describe an open pneumothorax.Air enters pleural space as a result of an open chest wound. Signs and symptoms appear similar to tension pneumothorax.Describe a massive haemothorax.Accumulation of blood in the pleural space causing difficulty in breathing. Breath sounds are reduced, neck veins may be flat due to hypovolaemia. Hypo-resonance heard if percussed.Describe a cardiac tamponade.Becks triad: hypotension, distended neck veins, muffled heart sounds. Occurs when fluid accumulated in the sac around your heart, causing increased pressure therefore making it hard for the heart to keep beating. Can develop into a haemothorax or pneuomothorax.Describe a myocardial contusion.Most common cardiac injury caused by a blunt anterior chest injury. Bruising of the heart muscle. Appears the same as myocardial infarction.Describe a traumatic aortic rupture.most common cause of immediate death. No obvious sign of chest trauma. Hypertension in upper extremities and hypotension in lower extremities. Complete tear of the structures within the aorta of the heart.Describe a bronchial or tracheal tree injury.Subcutaneous emphysema present - chest, neck, face. Caused by trauma to the chest, inhalation of smoke, or aspiration of liquid or objects. Monitor for haemothorax and pneumothorax.Describe a diaphragmatic tear.Severe blow to the abdomen. Herniation of abdominal organs. Breath sounds are diminished and bowel sounds can be heard when auscultating the chest.Describe a pulmonary contusion.common chest injury. Can take hours to develop. Caused by rapid deceleration after a force to the chest.Describe a blast injury.Mix of blunt and penetrating injuries. Difficult to assess in the field. Primary to quinary factors leading to injury.Provide examples of blunt abdominal trauma.Direct compression of the abdomen, deceleration forces, fracture of solid organs, fracture of hollow organsProvide examples of penetrating abdominal trauma.Direct trauma to organ or vasculature (projectile or fragments)Define shock.A clinical state in which the delivery of oxygenated blood and other nutrients to the body's tissues is not adequate enough to meet metabolic demands.What are the 4 types of shock?Hypovolemic, Cardiogenic, Distributive, ObstructiveWhat causes hypovolaemic shock and how might the patient present?blood or fluid loss: tachycardic, tachypnoea, hypotension, pale, clammy,How might you prevent hypovolaemic shock?control of catastrophic haemorrhage, fluid replacement, medication, rapid transport to trauma centre, definitive surgery.What are the 3 types of distributive shock?anaphylaxis, sepsis, neurogenicHow will a patient in neurogenic shock present and how might you treat them?bradycardic, systolic lower than diastolic, flushed, prioprism, indication of spinal injury. May need fluid therapy, medication, careful handling so as not to exacerbate injury.What is obstructive shock and how would you treat it?Obstructive shock is DIB and tachypnoea usually due to tension pneumothorax. Treat with o2, fluid therapy, rapid tx, decompression.What is cardiogenic shock and how would you treat it?Chest pain, DIB, tachycardia/bradycardia, hypotensive, dysrhythmias. Mostly caused by a severe heart attack. Manage with o2, analgesia, reperfusion therapy, rapid tx.How does management of a traumatic cardiac arrest differ from a medical cardiac arreststronger focus on reversible causes, more likely to present outside of a shockable rhythm and so stronger focus of ventilation over defibrillation and compressions, survivability of patient decreases.What is the structure used for traumatic cardiac arrest.Massive (external) haemorrhage control - apply tourniquet, haemostatic agents Airway - open immediately, cleared, advanced airway Respiration - bilateral decompression (ICP) Circulation - pelvic binder, IV/IO access, restoration of circulating volume, chest compressions Head injury/hypothermia Everything else - ie burns managementWhat are some reasons to withhold in a traumatic cardiac arrest and why?isolated head injury: low chance of survival w/o neurological deficits electrocution: defibrillation priority children: not appropriate to withhold, immediate tx pregnant: treatment mostly the same, early pre-alert in case of emergency c-section commotiocordis: direct force onto chest, defib prioritised crush syndrome: hypokalaemia likely, early txWhen do you withhold resuscitation?If there is no pulse, breathing and heart rate is in asystole, injuries are incompatible with life (decapitation), evidence of significant time without pulseWhen do you cease resuscitation?no breathing, pulse and asystole, no response after 20mins of resus once all potential causes have been identified and treated.What is a mass casualty incident?When the number of casualties and/or severity of the injuries exceed the capacity of the initial crew or crews, preventing effective management and transport.What is command + control and outline their responsibilities.Incident commander: first crew on scene. Responsible for initial scene assessment, METHANE, plan of action, risk assessments, communication between services, allocation of roles on scene, liase with control, brief and debrief, record actions.What is the role of the primary triage officer?responsible for coordinating triageWhat is the role of the casualty clearing officer?responsible for management of casualty clearing station and maintain effective communication to ensure appropriate triage, treatment and transport.What are the two types of triage and how are they performed?triage sieve: SMART tags triage sort: triage revised trauma scoreWhat is the aim of triage?To do the greatest good for the greatest amount of patients.What are the 4 triage priority colours and definitions?P1: red, life threatening injuries - immediate tx P2: yellow, non-life threatening injuries - delayed tx P3: green, minor injuries - hold and treat P4: black, deceased - not transportedWhen can a priority 4 be declared?After opening patients airway, if they are still not breathing P4 is declared.What is the easiest approach to the triage sieve?Assess mobility: all walking are P3 Assess Airway: open = P1, closed = P4 Assess Breathing: resp.rate <9 or >30 = P1 Assess Circulation: PR >120 = P1 Cap > 2 sec = P1 PR <119 = P2 Cap <2 sec = P2How is a patient triaged in the triage sort?resp.rate: 10-29 = 4 > 29 = 3 6-9 = 2 1-5 = 1 0 = 0 systolic BP: >90 = 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 0 = 0 Trauma Score: 1-10 = P1 11 = P2 12 = P3 0 = P4What makes up the intercranial volume?brain, CSF, blood vessel volumeWhat is a primary brain injury?immediate damage to brain tissue from a direct force. Little can be done after the injury occurs.What is a secondary brain injury?Result from hypoxia or decreased perfusion. Prehospital care can help prevent.What is intercranial pressure?Pressure of brain and contents in the skull.What is cerebral perfusion pressure?Pressure required to perfuse brain. Remain above 60mmHgWhat is mean arterial pressure?Pressure maintained in vascular system. MAP = Diastolic BP + 1/3(systolic BP - diastolic BP)What is the cushing reflex?As ICP increases, systolic BP increase and pulse rate increases.What is cushing's triad?Increased BP, bradycardia, irregular respirationsDescribe facial injuries and their management.Injuries to face, highly vascular and bleed briskly, possible airway compromise, aspiration, possible shock, nasal fractures common. Manage with direct pressure and airway support.Describe scalp injuries and their management.Highly vascular and bleed briskly, shock more common in children, if adult has shock look for another cause. Manage with direct pressure and dressings if no fracture, and with just dressing if there is a fracture.Describe skull fractures and their management.linear non-displaced: straight line, minimal neurological deficit depressed: affects brain, risk of primary brain injury open: risk of contamination base of skull: may see signs of battle signs, periorbital echimosis, CSF drainage. Manage symptoms, avoid direct pressure on obvious depressions, secure any penetrating objects,What is a cerebral contusion?Bruising of the brain tissue. Movement of the brain within the skull such as as a coup and contra-coup injuries. ALOC, nausea, vomiting, visual disturbances, weakness, speech difficultyWhat are the intercranial haemorrhages?Epidural: between skull and durra Subdural: between durra and arachnoid traumatic subarachnoid: between arachnoid and pia mater intercerebral: directly into brain tissueWhat is an acute epidural haematoma?Arterial bleed: temporal fracture common, onset of minutes or hours. Initial LOC then lucid interval followsWhat is an acute subdural haematoma?Venous blood: onset of hours or days. fluctuations of LOC, headache. Patients at high risk are alcoholics, elderly, those taking anticoagulants.What is a sub arachnoid haemorrhage?Intravascular fluid leaks into brain. Fluid leak causes more oedema. Severe headache, vomiting, coma, cerebral herniation syndrome possible.What is an intracerebral haemorrhage?Arterial or venous: surgery often not helpful. ALOC common, symptoms vary, pattern similar to stroke, headache and vomiting.What is a concussion?No structural injury to brain. LOC varied with period of unconsciousness/confusion. Retrograde short-term amnesia. May have dizziness, headache, nausea, ringing in earsWhat is a diffuse axonal injury?Blunt force trauma resulting in disruption of neuronal structures. Generalised oedema. May experience LOC, can recover if mild or moderateWhat is an axonic brain injury?Small cerebral artery spasms due to anoxia (complete loss of o2). Cannot restore perfusion of cortex after 4-6 mins of anoxia. Hypothermia seems protective.What are the functions of the skin?protective barrier, mechanical barrier, sensory organ, temperature regulation.What are the sources of burn trauma?thermal, chemical, electrical, radiation.How can burns be classified?Superficial (1st degree), partial-thickness (2nd degree), full-thickness (3rd degree).What is a superficial burn?Minor tissue damage to outer epidermal layer. Intense and painful inflammatory response. Manage symptoms.What is a partial-thickness burn?Entire epidermis into variable depth of dermis. Superficial dermal - pink, fine blisters, very painful. Mid dermal - dark red, large blisters, delayed CRT, maybe painful Deep dermal - blotchy red, may blister, no CRT and no sensation. Manage by cooling and covering with clean, dry dressing.What is a full-thickness burn?extends through epidermis and dermis. White, waxxy, or charred, no blisters, CRT or sensation. Leather-like eschar. Manage at burn centre.Explain a progressing burn.The inflammatory response extends damage and depth (1-2 days), severe fluid loss (hours), sepsis (days). Reduced circulation extends depth. Manage by limiting progression of depth and extent.Describe thermal burns.Burn after contact to extreme heat. Site of injury leads to cell death. Can be progressive if not cooled. Can be superficial, partial-thickness or full-thickness. Increased risk of burn due to inhalation if there is smoke present.What could indicate a burn associated with smoke inhalation?wheezing, coughing, increased WOB, increased secretionsWhat is carbon monoxide poisoning and why is it crucial to understand it's properties.Inhalation of carbon monoxide causes the molecule to bind with haemoglobin because it has more affinity than o2. Gas is colourless, odourless and tasteless and spo2 monitor can confuse the gas with oxygen.Describe chemical burns.Burn injury from exposure to caustic or toxic chemicals. Tissue damage is affected by concentration of chemical, amount, manner, duration of contact, mechanism of chemical agent. If absorbed into body it can cause organ failure. Manage with PPE, irrigation, removal of clothing, brush from skin if dryDescribe electrical burns.Burn from any source of current: AC, DC or voltage. Monitor for dysrhythmias, entrance and exit wounds, flame burns, fractures, internal injuries.Describe radiation burns.Appear same as thermal but have an onset of several days. Danger of fluid shift, need specialised resources to treat. Treated as thermal burn.What is parklands formula for fluid therapy with burn victims?Fluid for first 24hrs(ml) = weight(kg) x 4 x %TBSA - first half delivered in first 8 hrs - second half delivered in the remaining 16 hrsWhat is the Phifteen-B formula for fluid therapy for burns victims?15 x TBSA% (nearest 10%) - hourly fluid rate - if patient over 100kg to administer an extra 200ml/h