Major Trauma

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Major Trauma
Question 1 of 28 1 Unanswered
A 63 year old man is brought to ED by ambulance after being involved in a minor rear-end 2 Unanswered
motor vehicle collision. You are assessing his cervical spine.
3 Unanswered
a. Give two features that would suggest the patient is at high risk of cervical spine injury as
4 Unanswered
per the Canadian C-spine rules. (1 mark)
b. You determine the patient has no high risk features. How would you next assess the 5 Unanswered
patient’s need for imaging? (1 mark)
6 Unanswered
c. The patient is unable to perform the above satisfactorily. What imaging should be
requested for this patient as per NICE guidelines? (1 mark) 7 Unanswered
8 Unanswered
You did not answer this question 9 Unanswered
10 Unanswered
11 Unanswered
Answer
12 Unanswered
a. Any two of:
age 65 years or older
dangerous mechanism of injury (fall from a height of greater than 1 metre or 5 steps, axial load to the
head – for example diving, high-speed motor vehicle collision, rollover motor accident, ejection from a
http://intermediate.frcemsuccess.com/rev/majortrauma/ 1/5
motor vehicle, accident involving motorised recreational vehicles, bicycle collision, horse riding
accidents)
paraesthesia in the upper or lower limbs
b. Ask the patient to actively rotate their neck 45 degrees to the left and right and assess for pain
c. CT cervical spine
Notes
Assessment for cervical spine injury
Assess whether the person is at high, low or no risk for cervical spine injury using the as follows:
the person is at high risk if they have at least one of the following high-risk factors:
dangerous mechanism of injury (fall from a height of greater than 1 metre or 5 steps, axial load to the
head – for example diving, high-speed motor vehicle collision, rollover motor accident, ejection from a
motor vehicle, accident involving motorised recreational vehicles, bicycle collision, horse riding
accidents)
paraesthesia in the upper or lower limbs
the person is at low risk if they have at least one of the following low-risk factors:
involved in a minor rear-end motor vehicle collision
comfortable in a sitting position
ambulatory at any time since the injury
no midline cervical spine tenderness
delayed onset of neck pain
the person remains at low risk if they are:
unable to actively rotate their neck 45 degrees to the left and right (the range of the neck can only be
assessed safely if the person is at low risk and there are no high-risk factors).
the person has no risk if they:
have one of the above low-risk factors and
are able to actively rotate their neck 45 degrees to the left and right.
Assessment for thoracic or lumbosacral spine injury
Assess the person with suspected thoracic or lumbosacral spine injury using these factors:
age 65 years or older and reported pain in the thoracic or lumbosacral spine
dangerous mechanism of injury (fall from a height of greater than 3 metres, axial load to the head or base of
the spine – for example falls landing on feet or buttocks, high-speed motor vehicle collision, rollover motor
accident, lap belt restraint only, ejection from a motor vehicle, accident involving motorised recreational
vehicles, bicycle collision, horse riding accidents)
pre-existing spinal pathology, or known or at risk of osteoporosis – for example steroid use
suspected spinal fracture in another region of the spine
abnormal neurological symptoms (paraesthesia or weakness or numbness)
on examination
abnormal neurological signs (motor or sensory de cit)
new deformity or bony midline tenderness (on palpation)
bony midline tenderness (on percussion)
midline or spinal pain (on coughing)
on mobilisation (sit, stand, step, assess walking): pain or abnormal neurological symptoms (stop if this
occurs).
Spinal immobilisation
During initial assessment, protect the person’s cervical spine with manual in-line spinal immobilisation, particularly
during any airway intervention and avoid moving the remainder of the spine.
Carry out full in-spine spinal immobilisation if spinal assessment cannot be done or if the person:
has any signi cant distracting injuries

is under the in uence of drugs or alcohol
is confused or uncooperative
has a reduced level of consciousness
has any spinal pain
has any hand or foot weakness (motor assessment)
has altered or absent sensation in the hands or feet (sensory assessment)
has priapism (unconscious or exposed male)
has a history of past spinal problems, including previous spinal surgery or conditions that predispose to
instability of the spine.
After spinal assessment, carry out or maintain full in-line spinal immobilisation if:
After spinal assessment, carry out or maintain full in-line spinal immobilisation if:
a high-risk factor for cervical spine injury is identi ed and indicated by the Canadian
C-spine rule
a low-risk factor for cervical spine injury is identi ed and indicated by the Canadian
C-spine rule and the person is unable to actively rotate their neck 45 degrees left and
right
indicated by one or more of the factors suggesting thoracic or lumbosacral spine injury
After spinal assessment, do not carry out or maintain full in-line spinal immobilisation in people if:
they have low-risk factors for cervical spine injury as identi ed and indicated by the Canadian C-spine rule,
are pain free and are able to actively rotate their neck 45 degrees left and right
they do not have any of the factors suggesting thoracic or lumbosacral spine injury
Pain management
For people with spinal injury use intravenous morphine as the rst-line analgesic and adjust the dose as
needed to achieve adequate pain relief.
If intravenous access has not been established, consider the intranasal route for atomised delivery of
diamorphine or ketamine.
Consider ketamine in analgesic doses as a second-line agent.
Imaging
Perform CT in adults (16 or over) if:
imaging for cervical spine injury is indicated by the Canadian C-spine rule
there is a strong suspicion of thoracic or lumbosacral spine injury associated with abnormal neurological
signs or symptoms.
If, after CT, there is a neurological abnormality which could be attributable to spinal cord injury, perform MRI.
Perform an X-ray as the rst-line investigation for people with suspected spinal column injury without abnormal
neurological signs or symptoms in the thoracic or lumbosacral regions (T1–L3). Perform CT if the X-ray is abnormal
or there are clinical signs or symptoms of a spinal column injury. If a new spinal column fracture is con rmed, image
the rest of the spinal column.
the rest of the spinal column.
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Major Trauma
A 56 year old farrier is brought into the Emergency Department after being kicked in the 2 Current Question
abdomen by a horse. He is alert, maintaining his own airway and has no signs of chest injury. On
3 Unanswered
examination you note a large bruise to the anterior abdomen.
4 Unanswered
a. Give the three organs most commonly injured in blunt trauma. (1 mark)
b. What is the investigation of choice in the assessment of an unstable patient with blunt 5 Unanswered
trauma? (1 mark)
6 Unanswered
c. Give two indications for laparotomy in patients with blunt trauma. (1 mark)
7 Unanswered
8 Unanswered
You did not answer this question
9 Unanswered
10 Unanswered
Answer 11 Unanswered
a. Spleen, liver and small bowel
12 Unanswered
b. Focussed Assessment Sonography in Trauma (FAST)
c. Any two of:
Blunt abdominal trauma with hypotension with a positive FAST or clinical evidence of intraperitoneal
bleeding
Blunt abdominal trauma with a positive DPL

Peritonitis
Free air, retroperitoneal air or rupture of the hemidiaphragm
Contrast-enhanced CT that demonstrates ruptured GI tract, intraperitoneal bladder injury, renal
pedicle injury or severe visceral parenchymal injury after blunt or peritoneal trauma
Notes
Anatomy of abdomen
Anterior abdomen
Area between the costal margins superiorly, the inguinal ligament and pubic symphysis inferiorly and
the anterior axillary lines laterally
Contains majority of hollow viscera
Thoraco-abdomen
Area inferior to the trans-nipple line anteriorly and the infra-scapular line posteriorly and superior to
the costal margins
Contains the diaphragm, liver, spleen and stomach
Flank
Area between the anterior and posterior axillary lines from the sixth intercostal space to the iliac crest
Together with back contains the abdominal aorta, inferior vena cava, most of the duodenum, pancreas,
kidneys and ureters, the posterior aspect of the ascending and descending colons, and the
retroperitoneal components of the pelvic cavity
Back
Area located posterior to the posterior axillary lines from the tip of the scapulae to the iliac crest
Together with ank contains the abdominal aorta, inferior vena cava, most of the duodenum, pancreas,
Pelvic cavity
The lower part of the retroperitoneal and intraperitoneal spaces
Contains the rectum, bladder, iliac vessels and, in females, the internal reproductive organs
Mechanism of injury
Most commonly injured in blunt trauma:
Spleen (40 – 55%)

Liver (35 – 45%)
Small bowel (5 – 10%)
Retroperitoneal haemorrhage (15%)
Most commonly injured in stab wounds:
Liver (40%)
Small bowel (30%)
Diaphragm (20%)
Colon (15%)
Most commonly injured in gunshot wounds:
Small bowel (50%)

Colon (40%)
Liver (30%)
Abdominal vascular structures (25%)
Investigations
In patients with haemodynamic abnormalities, rapid evaluation is necessary with either of:
Focussed Assessment Sonography in Trauma (FAST)

Diagnostic Peritoneal Lavage (DPL)
CT imaging
CT is a diagnostic procedure that requires transport of the patient to the scanner, administration of contrast and
scanning of the upper and lower abdomen, as well as the lower chest and pelvis. It is a time-consuming procedure
that should be used only in haemodynamically normal patients in whom there is no apparent indication for
immediate laparotomy.
CT provides information relative to speci c organ injury and its extent, and can diagnose retroperitoneal and pelvic
organ injuries that are dif cult to assess with physical examination, FAST and DPL. It is non-invasive and the most
speci c investigation for injury.
CT can miss some intestinal, diaphragmatic and pancreatic injuries. In the absence of hepatic or splenic injuries, the
presence of free uid in the abdominal cavity suggests an injury to the gastrointestinal tract and/or its mesentery
and some trauma surgeons nd this to be an indication for emergency laparotomy
Relative contraindications to the use of CT include haemodynamically unstable patients, delay until scanner is
available, an uncooperative patient who cannot be sedated and allergy to contrast agent where nonionic contrast is
not available.
Procedure FAST DPL CT
Indications Unstable blunt Unstable blunt Stable blunt trauma

trauma trauma Stable penetrating
Stable penetrating back/ ank trauma
trauma
Contraindications An existing An existing Hemodynamically

indication for indication for unstable patient
laparotomy laparotomy (absolute)
(absolute) (absolute) Delay until scanner
Previous available
abdominal surgery Uncooperative
Morbid obesity patient who cannot
Advanced be sedated
cirrhosis Allergy to contrast
Pre-existing agent
coagulopathy
Time 2 – 4 mins 10 – 15 mins Variable
Sensitivity Medium High High

Speci city High Low High
Advantages Early diagnosis Early diagnosis Most speci c

Noninvasive Rapid High sensitivity
Rapid and mobile High sensitivity Noninvasive
Repeatable Detects bowel
injury
Disadvantages Operator- Invasive Cost and time

dependent Low speci city Misses diaphragm,
Bowel gas and Misses injuries to bowel and some
subcutaneous air diaphragm and pancreatic injuries
distortion retroperitoneum Radiation
Misses
diaphragm, bowel
and pancreatic
injuries
Indications for laparotomy in patients with trauma
bleeding
Blunt or penetrating abdominal trauma with a positive DPL
Hypotension with a penetrating abdominal wound
Gunshot wound with a transperitoneal trajectory
Evisceration
Bleeding from the stomach, rectum or genitourinary tract from penetrating trauma
Peritonitis
Contrast-enhanced CT that demonstrates ruptured GI tract, intraperitoneal bladder injury, renal pedicle
injury or severe visceral parenchymal injury after blunt or penetrating trauma
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Major Trauma
A 34 year old man is brought into the Emergency Department after falling down a full ight 2 Unanswered
of stairs whilst intoxicated. He has a large haematoma and scalp laceration to the right parietal
3 Current Question
region. The paramedics tell you he was initially GCS 15. He was immobilised at the scene.
4 Unanswered
a. Give three clinical features that would warrant a CT head being performed within 1 hour
of the risk factor being identi ed. (1 mark) 5 Unanswered
b. The patient is now only opening his eyes to voice. He is talking but appears confused. He
6 Unanswered
is obeying all motor commands. What is his GCS? (1 mark)
c. Give two indications for immediate intubation and ventilation in a patient with head 7 Unanswered
injury. (1 mark)
8 Unanswered
9 Unanswered
10 Unanswered
11 Unanswered
a. Any three of:

GCS less than 13 on initial assessment in the emergency department
GCS less than 15 at 2 hours after the injury on assessment in the emergency department
Suspected open or depressed skull fracture

Any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, cerebrospinal uid leakage from the ear
or nose, Battle’s sign)
Post-traumatic seizure
Focal neurological de cit
More than 1 episode of vomiting
b. E3, V4, M6 = 13
c. Any two of:
Coma – not obeying commands, not speaking, not eye opening (that is, GCS 8 or less).
Loss of protective laryngeal re exes.
Ventilatory insuf ciency as judged by blood gases: hypoxaemia (PaO2 < 13 kPa on oxygen) or
hypercarbia (PaCO2 > 6 kPa).
Spontaneous hyperventilation causing PaCO2 < 4 kPa.
Irregular respirations.
Notes
Glasgow Coma Scale
The Glasgow Coma Scale provides a practical method for assessment of impairment of conscious level in response
to de ned stimuli. It is based on three responses; eye opening, verbal response and best motor response. The
maximum score for GCS is 15 and the minimum score is 3.
The eye opening response (scored out of 4)

Eyes opening spontaneously (4)
Eyes opening in response to voice (3)
Eyes opening in response to pain (2)
Eyes not opening (1)
The verbal response (scored out of 5)
Orientated (5)
Confused (4)
Inappropriate words (3)
Incomprehensible sounds (2)
No verbal response (1).
Best motor response (scored out of 6)
Obeys commands (6)

Localises to pain (5)
Withdrawal to pain (4)
Abnormal exion to pain (3)
Abnormal extension to pain (2)
No motor response (1)
Criteria for performing a CT head scan
For adults who have sustained a head injury and have any of the following risk factors, a CT head scan should be
performed within 1 hour of the risk factor being identi ed:

Any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, cerebrospinal uid leakage from the ear or
nose, Battle’s sign)
More than 1 episode of vomiting.
For adults with any of the following risk factors and who have experienced some loss of consciousness or amnesia
since the injury, a CT head scan should be performed within 8 hours of the head injury:
Age 65 years or older

Any history of bleeding or clotting disorders
Dangerous mechanism of injury (a pedestrian or cyclist struck by a motor vehicle, an occupant ejected from
a motor vehicle or a fall from a height of greater than 1 metre or 5 stairs)
More than 30 minutes’ retrograde amnesia of events immediately before the head injury.
For patients who have sustained a head injury with no other indications for a CT head scan and who are having
warfarin treatment, a CT head scan should be performed within 8 hours of the injury.
Criteria for performing a CT cervical spine in patients with head injury
For adults who have sustained a head injury and have any of the following risk factors, perform a CT cervical spine
scan within 1 hour of the risk factor being identi ed:
GCS less than 13 on initial assessment.

The patient has been intubated.
Plain X-rays are technically inadequate (for example, the desired view is unavailable).
Plain X-rays are suspicious or de nitely abnormal.
A de nitive diagnosis of cervical spine injury is needed urgently (for example, before surgery).
The patient is having other body areas scanned for head injury or multi-region trauma.
The patient is alert and stable, there is clinical suspicion of cervical spine injury and any of the following
apply:
dangerous mechanism of injury (fall from a height of greater than 1 metre or 5 stairs; axial load to the
head, for example, diving; high-speed motor vehicle collision; rollover motor accident; ejection from a
motor vehicle; accident involving motorised recreational vehicles; bicycle collision)
focal peripheral neurological de cit
paraesthesia in the upper or lower limbs.
For adults who have sustained a head injury and have neck pain or tenderness but no indications for a CT cervical
spine scan, perform 3-view cervical spine X-rays within 1 hour if either of these risk factors are identi ed:
It is not considered safe to assess the range of movement in the neck.

Safe assessment of range of neck movement shows that the patient cannot actively rotate their neck to 45
degrees to the left and right.
Be aware that in adults and children who have sustained a head injury and in whom there is clinical suspicion of
cervical spine injury, range of movement in the neck can be assessed safely before imaging only if no high-risk
factors and at least 1 of the following low-risk features apply. The patient:
was involved in a simple rear-end motor vehicle collision.

is comfortable in a sitting position in the emergency department.
has been ambulatory at any time since injury.
has no midline cervical spine tenderness.
presents with delayed onset of neck pain.
Involving the neurosurgical department

Discuss with a neurosurgeon the care of all patients with new, surgically signi cant abnormalities on imaging.
Regardless of imaging, other reasons for discussing a patient’s care plan with a neurosurgeon include:
Persisting coma (GCS 8 or less) after initial resuscitation.

Unexplained confusion which persists for more than 4 hours.
Deterioration in GCS score after admission (greater attention should be paid to motor response
deterioration).
Progressive focal neurological signs.
A seizure without full recovery.
De nite or suspected penetrating injury.
A cerebrospinal uid leak.
Indications for intubation and ventilation
Intubate and ventilate the patient immediately in the following circumstances:
Ventilatory insuf ciency as judged by blood gases: hypoxaemia (PaO2 < 13 kPa on oxygen) or hypercarbia
(PaCO2 > 6 kPa).
Use intubation and ventilation before transfer in the following circumstances:
Signi cantly deteriorating conscious level (1 or more points on the motor score), even if not coma.
Unstable fractures of the facial skeleton.
Copious bleeding into mouth (for example, from skull base fracture).
Seizures.
Ventilate an intubated patient with muscle relaxation and appropriate short-acting sedation and analgesia. Aim for a
PaO2 greater than 13 kPa, PaCO2 4.5 to 5.0 kPa unless there is clinical or radiological evidence of raised intracranial
pressure, in which case more aggressive hyperventilation is justi ed. If hyperventilation is used, increase the
inspired oxygen concentration. Maintain the mean arterial pressure at 80 mm Hg or more by infusion of uid and
vasopressors as indicated.
Admission
Use the criteria below for admitting patients to hospital following a head injury:
Patients with new, clinically signi cant abnormalities on imaging.

Patients whose GCS has not returned to 15 after imaging, regardless of the imaging results.
When a patient has indications for CT scanning but this cannot be done within the appropriate period,
either because CT is not available or because the patient is not suf ciently cooperative to allow scanning.
Continuing worrying signs (for example, persistent vomiting, severe headaches) of concern to the clinician.
Other sources of concern to the clinician (for example, drug or alcohol intoxication, other injuries, shock,
suspected non-accidental injury, meningism, cerebrospinal uid leak).
Observation
Perform and record observations on a half-hourly basis until GCS equal to 15 has been achieved. The minimum
frequency of observations for patients with GCS equal to 15 should be as follows, starting after the initial
assessment in the emergency department half-hourly for 2 hours, 1-hourly for 4 hours, and 2-hourly thereafter.
Should the patient with GCS equal to 15 deteriorate at any time after the initial 2-hour period, observations should
revert to half-hourly and follow the original frequency schedule.
Any of the following examples of neurological deterioration should prompt urgent reappraisal by the supervising
doctor.
Development of agitation or abnormal behaviour.

A sustained (that is, for at least 30 minutes) drop of 1 point in GCS score (greater weight should be given to a
drop of 1 point in the motor response score of the GCS).
Any drop of 3 or more points in the eye-opening or verbal response scores of the GCS, or 2 or more points in
the motor response score.
Development of severe or increasing headache or persistent vomiting.
New or evolving neurological symptoms or signs such as pupil inequality or asymmetry of limb or facial
movement.
Discharge
If CT is not indicated on the basis of history and examination the clinician may conclude that the risk of clinically
important brain injury to the patient is low enough to warrant transfer to the community, as long as no other factors
that would warrant a hospital admission are present (for example, drug or alcohol intoxication, other injuries, shock,
suspected non-accidental injury, meningism, cerebrospinal uid leak) and there are appropriate support structures
for safe transfer to the community and for subsequent care (for example, competent supervision at home).
After normal imaging of the head or cervical spine, the clinician may conclude that the risk of clinically important
brain injury requiring hospital care is low enough to warrant transfer to the community, as long as the patient has
returned to GCS equal to 15, and no other factors that would warrant a hospital admission are present.
Discharge advice:
Give verbal and printed discharge advice to patients with any degree of head injury who are discharged from an
emergency department or observation ward, and their families and carers. Advice should include:
Details of the nature and severity of the injury.

Risk factors that mean patients need to return to the emergency department.
A speci cation that a responsible adult should stay with the patient for the rst 24 hours after their injury.
Details about the recovery process, including the fact that some patients may appear to make a quick
recovery but later experience dif culties or complications.
Contact details of community and hospital services in case of delayed complications.
Information about return to everyday activities, including school, work, sports and driving.

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Major Trauma
An elderly patient, taking aspirin for vascular disease, is brought to ED with decreased 2 Unanswered
consciousness after falling at home. He opens his eyes when you ask, localises to pain and is using
3 Unanswered
inappropriate words. His daughter accompanies him and tells you that he has fallen over a few
times recently but is refusing more help or support at home. A CT head is performed and shown 4 Current Question
below:
5 Unanswered
6 Unanswered
7 Unanswered
8 Unanswered
9 Unanswered
10 Unanswered
11 Unanswered
12 Unanswered
Courtesy of 2007-06-24 17:16 Glitzy queen00 (Wikipedia Commons

File:Trauma subdural.jpg) [Public domain], via Wikimedia Commons
a. What is the diagnosis? (1 mark)

b. What is his GCS? (1 mark)
c. What anatomical structure is likely to have been damaged to cause this diagnosis? (1
mark)
Answer
a. Acute subdural haematoma with midline shift
b. Eyes 3/4, Speech 3/5, Motor 5/6 = 11
c. Tearing of weak cortical bridging veins
Notes
A subdural haematoma is a collection of blood that forms in the subdural space (between the dura mater and the
arachnoid mater). Brain damage underlying an acute subdural haematoma is typically much more severe than that
associated with epidural haematomas due to the presence of concomitant parenchymal injury.
Subdural haematoma may be acute, subacute (3 – 7 days after initial injury) or chronic (2 – 3 weeks after initial
injury).
injury).
Mechanism of injury
An acute SDH is usually caused by tearing of cortical bridging veins from the cortex to one of the draining venous
sinuses.
Blunt head trauma e.g. during a fall or RTC is the usual mechanism of injury but spontaneous SDH can occur
as a consequence of clotting disorder or arteriovenous malformations for example.
Cerebral atrophy occurs in people over 60 years, causing tension on the veins which are consequently more
susceptible to injury.
Alcohol misuse leads to a risk of cerebral atrophy, thrombocytopenia, prolonged bleeding times and blunt
head trauma and hence is a signi cant risk factor for SDH.
Anticoagulation treatment (including with aspirin or warfarin) is another risk factor.
Clinical features
Acute SDH usually presents shortly after a moderate-to-severe head injury. Loss of consciousness may occur but
not always.
Chronic SDH usually presents after 2 – 3 weeks after the injury, which may well have been relatively trivial,
particularly in the context of the elderly patient on anticoagulants or alcohol misuse. There may be a gradually
evolving neurological de cit and progressive headache.
Imaging
A CT scan demonstrates a hyperdense crescentic shaped lesion which conforms to the shape of the brain. In the
subacute phase the collection of clotted blood lique es. In the chronic phase it becomes a collection of serous uid
in the subdural space. With increasing chronicity, the lesion becomes isodense and then hypodense.
Management
The patient should be referred urgently to neurosurgery.
Management includes:
Correcting coagulopathy
Managing raised ICP
Preventing or managing seizures
Conservative management for small asymptomatic acute SDH (observation, serial examinations and serial
CT imaging)
Surgical management for acute SDH (if focal neurological signs, deterioration, large haematoma, raised ICP
or midline shift) with craniotomy and clot evacuation
Burr hole drainage for chronic SDH
Complications
Complications include:
Death due to cerebellar herniation

Raised ICP
Cerebral oedema
Recurrent haematoma
Seizures
Wound infection
Intracranial infection
Permanent neurological or cognitive defect due to pressure effects.

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Major Trauma
A 42 year old woman has been found after being assaulted in town. Witnesses report 2 Unanswered
seeing her being attacked by a group of women who kicked and stamped on her chest and
3 Unanswered
abdomen multiple times. She is tachycardic and hypotensive. One of your colleagues has recently
spent some time working in America and praises the bene ts of diagnostic peritoneal lavage 4 Unanswered
(DPL).
5 Current Question
a. What is an absolute contraindication for this procedure? (1 mark)
6 Unanswered
b. Give two possible complications of this procedure. (1 mark)
c. Give one advantage and one disadvantage of this procedure as compared to other 7 Unanswered
methods of evaluating abdominal trauma. (1 mark)
8 Unanswered
9 Unanswered
10 Unanswered
11 Unanswered
a. An existing indication for laparotomy

b. Any two of:
Haemorrhage, secondary to injection of local anesthetic or incision of the skin or subcutaneous tissues,
which produces false positive results

Peritonitis secondary to intestinal perforation from the catheter
Laceration of the urinary bladder (if bladder not evacuated prior to procedure)
Injury to other abdominal and retroperitoneal structures
Wound infection at the lavage site
c. Any two of:
Advantages
Early diagnosis
Rapid
High sensitivity
Detects bowel injury
Disadvantages
Invasive
Low speci city
Misses injuries to diaphragm and retroperitoneum
Notes
Diagnostic Peritoneal Lavage (DPL) is another rapid study to identify haemorrhage. Although invasive, it also allows
investigation of possible hollow viscus injury. DPL can signi cantly alter subsequent examination of the patient and
is considered 98% sensitive for intraperitoneal bleeding.
Indications
Haemodynamically unstable patient with blunt trauma

Haemodynamically stable patient with penetrating trauma
Haemodynamically stable patient with blunt trauma where ultrasound or CT is not available
In settings where either or both of these modalities is available, DPL is rarely used as it is invasive and
requires some surgical expertise
Contraindications
Absolute contraindication to DPL:

An existing indication for laparotomy
Relative contraindications to DPL include:
Previous abdominal surgery

Morbid obesity
Advanced cirrhosis
Pre-existing coagulopathy
Procedure
Either an open or closed (seldinger) infraumbilical technique is acceptable for trained clinicians.
Free aspiration of blood, gastrointestinal contents, vegetable bres, or bile through the lavage catheter in
patients with haemodynamic abnormalities mandates laparotomy.
If gross blood (> 10 mL) or gastrointestinal contents are not aspirated, lavage is performed with 1 L of
warmed isotonic crystalloid solution (10 mL/kg in a child).
After ensuring adequate mixing of peritoneal contents with the lavage uid by compressing the abdomen
and moving the patient around by logrolling or tilting them into head-down and head-up positions, the
ef uent is drained from the abdomen and sent to the laboratory for quantitative analysis (adequate uid
return is >20% of the infused volume).
A positive test is indicated by > 100,000 RBC/mm³, 500 WCC/mm³ or Gram stain with bacteria present.
A negative test does not exclude retroperitoneal injuries, such as pancreatic and duodenal injuries.
Complications
DPL is a relatively safe procedure but being invasive it is not without its complications including:
Haemorrhage, secondary to injection of local anesthetic or incision of the skin or subcutaneous tissues,
which produces false positive results
Peritonitis secondary to intestinal perforation from the catheter
Laceration of the urinary bladder (if bladder not evacuated prior to procedure)
Injury to other abdominal and retroperitoneal structures
Wound infection at the lavage site
Evaluation in trauma

trauma

Previous available
Advanced be sedated
Pre-existing agent
coagulopathy

injury

Misses
diaphragm, bowel
and pancreatic
injuries

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Major Trauma
You are asked to perform an open thoracostomy and chest drain insertion on a trauma 2 Unanswered
patient with a large pneumothorax.
3 Unanswered
a. Which muscles form the anterior and posterior axillary folds? (1 mark)
4 Unanswered
b. How will you minimise damage to intercostal vessels during this procedure? (1 mark)
c. Give two possible complications of this procedure. (1 mark) 5 Unanswered
6 Current Question
8 Unanswered
9 Unanswered
Answer
10 Unanswered
a. Both of:
Anterior axillary fold = pectoralis major 11 Unanswered
Posterior axillary fold = latissimus dorsi 12 Unanswered
b. Going over the top of the rib avoids injuring the neurovascular bundle that is present underneath the inner
inferior aspect of the rib.
c. Any two of:
Laceration or puncture of intrathoracic and/or abdominal organs
Injury to diaphragm
Introduction of pleural infection
Damage to the intercostal nerve, artery or vein
Converting a pneumothorax to a haemothorax
Resulting in intercostal neuritis/neuralgia
Incorrect tube position, extrathoracic or intrathoracic
Chest tube kinking, clogging or dislodging from chest wall, or disconnection from underwater-seal
apparatus
Persistent pneumothorax
Large primary leak
Leak at skin around chest tube (sucking on tube too strong)
Leaky underwater-seal apparatus
Subcutaneous emphysema
Recurrence of pneumothorax on removal of chest tube (seal of wound not immediate)
Lung fails to expand due to plugged bronchus (bronchoscopy required)
Anaphylactic or allergic reaction to surgical preparation or anesthesia
Notes
By Brantigan, Otto C. [Public domain], via Wikimedia Commons
Open thoracostomy and chest drain insertion
Indications
Chylothorax
Empyema
Haemopneumothorax
Haemothorax
Pleural effusion with symptoms and signs of instability
Pneumothorax
Severe surgical emphysema constricting respiration following crush injury
Procedure
Position the patient, ideally sitting in the supine position (although may not be possible if patient is
haemodynamically unstable)
Abduct patient’s arm and ex the elbow with hand up above the head to expose the area of insertion
Identify the fth intercostal space just anterior to the midaxillary line
Con rm that de ned site is well within ‘safe triangle’ (bordered by anterior border of latissimus dorsi,
lateral border of pectoralis major muscle, and a line superior to the horizontal level of the nipple)
Avoid placement directly over an area of infected soft tissue e.g. cellulitis, skin abscess
Consider 4th ICS in patients who are pregnant, have massive ascites or large haemoperitoneum where
the increase intra-abdominal contents can ellevate the diaphragm
Surgically prepare and drape chest
Locally anaesthetise the skin and rib periosteum
Make a 2 – 3 cm incision at the predetermined site and bluntly dissect through subcutaneous tissues just
superior to the lower rib (to protect neurovascular bundle)
Puncture the parietal pleura and put a gloved nger into the incision to avoid injury to other organs and to
clear any adhesions, clots etc.
Clamp the proximal end of the thoracostomy tube and advance it into the pleural space to the desired
length, directing it posteriorly along the inside of the chest wall
Look for misting of the chest tube with expiration and listen for air movement
Release the clamp and connect the end of the thoracostomy tube to an underwater-seal apparatus
Suture tube in place
Apply an occlusive dressing and tape the tube to the chest
Obtain a chest x-ray to verify lung reexpansion and placement of the chest tube
Monitor pulse oximetry/arterial blood gas
Complications

Injury to diaphragm
apparatus
Large primary leak

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Major Trauma
A 54 year old man is brought into the Emergency Department by ambulance. He fell from a 2 Unanswered
ladder whilst decorating. He tells you he hit his head on the wall as he fell and his wife reported a
3 Unanswered
2 minute loss of consciousness at the scene. He is currently GCS 15 with a normal neurological
examination. 4 Unanswered
a. Give two clinical features that would warrant a CT head performed within 8 hours of this 5 Unanswered
head injury. (1 mark)
6 Unanswered
b. Give three indications for admission in a patient presenting with head injury. (1 mark)
c. You decide the patient is low risk and can be discharged. What advice should be given to 7 Current Question
the patient on discharge? (1 mark)
8 Unanswered
9 Unanswered
10 Unanswered
11 Unanswered
a. Any two of:

Dangerous mechanism of injury (a pedestrian or cyclist struck by a motor vehicle, an occupant ejected
from a motor vehicle or a fall from a height of greater than 1 metre or 5 stairs)
Warfarin therapy
b. Any three of:
either because CT is not available or because the patient is not suf ciently cooperative to allow
scanning.
Continuing worrying signs (for example, persistent vomiting, severe headaches) of concern to the
clinician.
Other sources of concern to the clinician (for example, drug or alcohol intoxication, other injuries,
shock, suspected non-accidental injury, meningism, cerebrospinal uid leak).
c. Advice should include:
A speci cation that a responsible adult should stay with the patient for the rst 24 hours after their
injury.
Notes
Glasgow Coma Scale

Orientated (5)
Confused (4)
Obeys commands (6)



apply:



deterioration).
(PaCO2 > 6 kPa).
Seizures.
Admission

Observation
doctor.

movement.
Discharge
Discharge advice:

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Major Trauma
An 18 year old man is brought to the Emergency Department following a ght in a nearby 2 Unanswered
pub. He has suffered a single stab wound to the abdomen.
3 Unanswered
a. Give the three organs most commonly injured in stab wounds to the abdomen. (1 mark)
4 Unanswered
b. Give two indications for laparotomy in patients with penetrating abdominal trauma. (1
mark) 5 Unanswered
c. The patient has none of the indications above and is haemodynamically stable. What is
6 Unanswered
the investigation of choice to determine the extent of his injuries, and give one
advantage and one disadvantage of this investigation. (1 mark) 7 Unanswered
8 Current Question
10 Unanswered
11 Unanswered
Answer
12 Unanswered
a. Any three of:
Liver
Small bowel
Diaphragm
Colon
b. Any two of:
Penetrating abdominal trauma with a positive DPL
Evisceration
Peritonitis
Contrast-enhanced CT that demonstrates ruptured GI tract, intraperitoneal bladder injury, renal
pedicle injury or severe visceral parenchymal injury after penetrating trauma
c. CT scan – any two of:
Advantages
High sensitivity
High speci city
Non-invasive
Repeatable
Disadvantages
Unsuitable for haemodynamically unstable patient
Cost and time
May miss diaphragm, bowel and some pancreatic injuries
Radiation
Notes
Anatomy of abdomen
Anterior abdomen
Area between the costal margins superiorly, the inguinal ligament and pubic symphysis inferiorly and
the anterior axillary lines laterally
Contains majority of hollow viscera
Thoraco-abdomen
Area inferior to the trans-nipple line anteriorly and the infra-scapular line posteriorly and superior to
the costal margins
Flank
Area between the anterior and posterior axillary lines from the sixth intercostal space to the iliac crest
Together with back contains the abdominal aorta, inferior vena cava, most of the duodenum, pancreas,
Back
Area located posterior to the posterior axillary lines from the tip of the scapulae to the iliac crest
Together with ank contains the abdominal aorta, inferior vena cava, most of the duodenum, pancreas,
Pelvic cavity
The lower part of the retroperitoneal and intraperitoneal spaces
Contains the rectum, bladder, iliac vessels and, in females, the internal reproductive organs
Mechanism of injury
Most commonly injured in blunt trauma:
Spleen (40 – 55%)

Liver (35 – 45%)
Small bowel (5 – 10%)
Retroperitoneal haemorrhage (15%)
Most commonly injured in stab wounds:
Liver (40%)
Small bowel (30%)
Diaphragm (20%)
Colon (15%)
Most commonly injured in gunshot wounds:
Small bowel (50%)

Colon (40%)
Liver (30%)
Abdominal vascular structures (25%)
Investigations
In patients with haemodynamic abnormalities, rapid evaluation is necessary with either of:

CT imaging
CT is a diagnostic procedure that requires transport of the patient to the scanner, administration of contrast and
scanning of the upper and lower abdomen, as well as the lower chest and pelvis. It is a time-consuming procedure
that should be used only in haemodynamically normal patients in whom there is no apparent indication for
immediate laparotomy.
CT provides information relative to speci c organ injury and its extent, and can diagnose retroperitoneal and pelvic
organ injuries that are dif cult to assess with physical examination, FAST and DPL. It is non-invasive and the most
speci c investigation for injury.
CT can miss some intestinal, diaphragmatic and pancreatic injuries. In the absence of hepatic or splenic injuries, the
presence of free uid in the abdominal cavity suggests an injury to the gastrointestinal tract and/or its mesentery
and some trauma surgeons nd this to be an indication for emergency laparotomy
Relative contraindications to the use of CT include haemodynamically unstable patients, delay until scanner is
available, an uncooperative patient who cannot be sedated and allergy to contrast agent where nonionic contrast is
not available.

trauma

Previous available
Advanced be sedated
Pre-existing agent
coagulopathy

injury

Misses
Misses
diaphragm, bowel
and pancreatic
injuries
Indications for laparotomy in patients with trauma
bleeding
Blunt or penetrating abdominal trauma with a positive DPL
Evisceration
Peritonitis
Contrast-enhanced CT that demonstrates ruptured GI tract, intraperitoneal bladder injury, renal pedicle

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Major Trauma
An 80 year old man is brought to ED having fallen down a full ight of stairs. A tension 2 Unanswered
pneumothorax has been identi ed during the primary survey, and needle thoracocentesis
3 Unanswered
performed. Your consultant now observes you placing an intercostal drain.
4 Unanswered
a. At what site should this procedure be performed? (1 mark)
b. Give two checks that should be made post-procedure. (1 mark) 5 Unanswered
c. Give three possible complications of this procedure. (1 mark)
6 Unanswered
7 Unanswered
8 Unanswered
9 Current Question
a. Fifth intercostal space just anterior to the midaxillary line 11 Unanswered

b. Look for misting of the chest tube with expiration and listen for air movement AND obtain chest x-ray to
12 Unanswered
check position of chest drain
c. Any three of:
Injury to diaphragm

apparatus
Large primary leak
Notes
By Brantigan, Otto C. [Public domain], via Wikimedia Commons
Open thoracostomy and chest drain insertion
Indications
Chylothorax
Empyema
Haemopneumothorax
Haemothorax
Pleural effusion with symptoms and signs of instability
Pneumothorax
Severe surgical emphysema constricting respiration following crush injury
Procedure
Position the patient, ideally sitting in the supine position (although may not be possible if patient is
haemodynamically unstable)
Abduct patient’s arm and ex the elbow with hand up above the head to expose the area of insertion
Identify the fth intercostal space just anterior to the midaxillary line
Con rm that de ned site is well within ‘safe triangle’ (bordered by anterior border of latissimus dorsi,
Consider 4th ICS in patients who are pregnant, have massive ascites or large haemoperitoneum where
the increase intra-abdominal contents can ellevate the diaphragm
Surgically prepare and drape chest
Locally anaesthetise the skin and rib periosteum
Make a 2 – 3 cm incision at the predetermined site and bluntly dissect through subcutaneous tissues just
superior to the lower rib (to protect neurovascular bundle)
Puncture the parietal pleura and put a gloved nger into the incision to avoid injury to other organs and to
clear any adhesions, clots etc.
Clamp the proximal end of the thoracostomy tube and advance it into the pleural space to the desired
length, directing it posteriorly along the inside of the chest wall
Look for misting of the chest tube with expiration and listen for air movement
Release the clamp and connect the end of the thoracostomy tube to an underwater-seal apparatus
Suture tube in place
Apply an occlusive dressing and tape the tube to the chest
Obtain a chest x-ray to verify lung reexpansion and placement of the chest tube
Monitor pulse oximetry/arterial blood gas
Complications

Injury to diaphragm
apparatus
Large primary leak

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Major Trauma
A 19 year old male is brought into hospital following a road traf c collision (RTC). During 2 Unanswered
the primary survey you note paradoxical chest wall movements on the right side, with the chest
3 Unanswered
wall moving inwards on inspiration.
4 Unanswered
a. What is the most likely diagnosis?
b. What might you expect to see on x-ray in this patient? (1 mark) 5 Unanswered
c. What intervention could be used to manage this patient’s pain? (1 mark)
6 Unanswered
7 Unanswered
8 Unanswered
9 Unanswered
Answer 10 Current Question
a. Flail chest 11 Unanswered

b. Multiple rib fractures (two of more rib fractures in two or more places), +/- subcutaneous emphysema +/-
12 Unanswered
pulmonary contusion
c. Intercostal nerve blocks
Notes
A ail chest occurs when a segment of the chest wall does not have bony continuity with the rest of the thoracic
cage. This condition usually results from trauma associated with multiple rib fractures (two or more ribs fractured in
two or more places).
The presence of a ail chest segment results in disruption of normal chest wall movement, with paradoxical inward
movement of the ail segment on inspiration and outward movement on expiration. However, this defect alone does
not cause hypoxia; the major dif culty in ail chest stems from the injury to the underlying lung (pulmonary
contusion).
Clinical features
In ail chest, the movement of the thorax will be asymmetrical and uncoordinated. Palpation of of abnormal
respiratory motion and crepitation of rib or cartilage fractures can aid the diagnosis. A chest x-ray may show
multiple rib fractures (but may not show costochondral separation).
Management
Initial treatment includes adequate ventilation (with positive pressure ventilation if necessary), administration of
humidi ed oxygen, and uid resuscitation.
The de nitive treatment is to ensure adequate oxygenation, administer uid judiciously and provide analgesia to
improve ventilation. Analgesia may be provided with intravenous opioids or local anesthetics (e.g. intermittent
intercostal nerve blocks).

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Major Trauma
You are part of a trauma team caring for a 21 year old man who was involved in a 2 Unanswered
motorcycle accident. A chest x-ray has been rapidly obtained and is shown below:
3 Unanswered
4 Unanswered
5 Unanswered
6 Unanswered
7 Unanswered
8 Unanswered
9 Unanswered
10 Unanswered
11 Current Question
12 Unanswered
By James Heilman, MD (Own work) [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via

Wikimedia Commons
a. Describe four ndings seen on the chest x-ray. (2 marks)

b. What immediate action should be performed? (1 mark)
Answer
a. Any four of:
Left sided tension pneumothorax
Tracheal deviation to the right
Pneumomediastinum
Multiple left sided rib fractures
b. Needle thoracocentesis – 2nd intercostal space midaxillary line
Notes
A tension pneumothorax develops when a one-way valve air leak occurs from the lung or through the chest wall. Air
is forced into the pleural space without any means of escape and eventually results in collapse of the affected lung.
The mediastinum is displaced to the opposite side, compressing the opposite lung and decreasing venous return
resulting in a reduction in cardiac output and thus obstructive shock.
Causes
Mechanical ventilation with positive-pressure ventilation in patients with visceral pleural injury
Complication of simple pneumothorax following penetrating or blunt chest trauma in which a parenchymal
lung injury fails to seal
Complication of subclavian/internal jugular venous catheter insertion
Complication of a traumatic defect in the chest wall which is covered incorrectly with occlusive dressings or
if the defect itself constitutes a ap-valve mechanism
Rarely from markedly displaced thoracic spinal fractures
Clinical features
Symptoms
Chest pain
Dyspnoea
Signs
Respiratory distress
Tachycardia
Tachypnoea
Hypotension
Tracheal deviation away from side of injury
Neck vein distension
Unilateral reduced/absent breath sounds
Unilateral reduced chest expansion
Unilateral hyperresonant percussion note
Management
Tension pneumothorax is a clinical diagnosis requiring immediate decompression

Rapid insertion of large calibre needle into the second intercostal space in the midclavicular line of the
affected hemithorax
De nitive treatment requires the insertion of a chest tube into the fth intercostal space just anterior to the
midaxillary line
Question Navigator
Major Trauma
Multiple casualties have been brought to your ED following a high speed multi-vehicle 2 Unanswered
collision on a nearby motorway. You are caring for a patient with evidence of signi cant blunt
3 Unanswered
force to the chest. The patient has distended neck veins and muf ed heart sounds. A FAST scan
has demonstrated uid in the pericardial sac consistent with cardiac tamponade. The patient 4 Unanswered
suddenly deteriorates becoming profoundly hypotensive. As all of your colleagues,
including cardiothoracics, are tied up, you proceed to perform needle pericardiocentesis. 5 Unanswered
6 Unanswered
b. How could you monitor if the needle had been advanced too far? (1 mark) 7 Unanswered
c. Give three possible complications of this procedure. (1 mark)
8 Unanswered
9 Unanswered
10 Unanswered
11 Unanswered
Answer 12 Current Question
a. Puncture the skin 1 – 2 cm inferior to the left of the xiphochondral junction at a 45-degree angle to the skin
and advance the needle cephalad aiming towards the tip of the left scapula
b. If the needle is advanced too far (i.e. into ventricular muscle), an injury pattern appears on the ECG (e.g.
extreme ST-T wave changes or widened and enlarged QRS complex), indicating the needle should be
withdrawn until the previous baseline ECG tracing reappears
c. Any three of:
Aspiration of ventricular blood instead of pericardial blood
Laceration of ventricular epicardium/myocardium
Laceration of coronary artery or vein
New haemopericardium secondary to lacerations of above structures
Ventricular brillation
Pneumothorax secondary to lung puncture
Puncture of great vessel with worsening of tamponade
Puncture of oesophagus with subsequent mediastinitis
Puncture of peritoneum with subsequent peritonitis
Notes
Needle pericardiocentesis
Indications
Cardiac tamponade
Contraindications
Nil
Procedure
Monitor the patient’s vital signs and ECG before, during and after procedure
Surgically prepare and locally anesthetise the xiphoid and subxiphoid areas if time allows
Use a 16- to 18-gauge, 6 inch (15 cm) or longer cannula attached to an empty syringe
Puncture the skin 1 – 2 cm inferior to the left of the xiphochondral junction, at a 45-degree angle to the skin
Carefully advance the needle cephalad and aim towards the tip of the left scapula
When the needle tip enters the blood- lled pericardial sac, withdraw as much non-clotted blood as possible
If the needle is advanced too far (i.e. into ventricular muscle), an injury pattern appears on the ECG (e.g.
During the aspiration, the epicardium approaches the inner pericardial surface again, as does the needle tip,
and the ECG injury pattern may reappear
This indicates the needle should be withdrawn slightly
Should this injury pattern persist, the needle should be withdrawn completely
Once aspiration is complete, remove the syringe and attach a three-way valve, securing the cannula in place
Should the tamponade symptoms persist or worsen, the three-way valve may be opened and the
pericardial sac re-aspirated prior to de nitive treatment enroute to surgery or transfer to another care
facility
Complications
Aspiration of ventricular blood instead of pericardial blood

Laceration of ventricular epicardium/myocardium
Laceration of coronary artery or vein
New haemopericardium secondary to lacerations of above structures
Ventricular brillation
Pneumothorax secondary to lung puncture
Puncture of great vessel with worsening of tamponade
Puncture of oesophagus with subsequent mediastinitis
Puncture of peritoneum with subsequent peritonitis

Question Navigator
Major Trauma
A 30 year old is brought into ED by ambulance with reduced consciousness. He was playing 13 Current Question
rugby this morning where he sustained a head injury but was able to get up and play on. He has
14 Unanswered
been complaining of a headache for the last couple of hours and then suddenly became drowsy
and confused. You perform a CT which is shown below: 15 Unanswered
16 Unanswered
17 Unanswered
18 Unanswered
19 Unanswered
20 Unanswered
21 Unanswered
22 Unanswered
23 Unanswered
Courtesy of Hellerhoff (Own work) [CC BY-SA 3.0

(http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia
Commons

b. What anatomical structure has most likely been damaged to cause this diagnosis? (1
mark)
c. What is the de nitive management of this condition? (1 mark)
Answer
a. Extradural/epidural haematoma
b. Rupture of the middle meningeal artery
c. Surgical evacuation of haematoma
Notes
Extradural haematoma (EDH) is a collection of blood in the potential space between the dura and the skull. EDH is
most often due to a fractured temporal or parietal bone damaging the middle meningeal artery.
Clinical features
There is usually a history of trauma and head injury e.g. head strike in sport or RTC with loss of consciousness. There
may be a lucid interval of a few hours after the injury where the patient appears well but may have a headache and
subsequently deteriorates and loses consciousness.
Other features may include: nausea or vomiting, seizures, Cushing’s triad (re ex hypertension, bradycardia and
abnormal respiration), evidence of skull fracture, haematoma or lacerations, CSF leak (otorrhoea or rhinorrhoea),
unequal pupils or focal neurological de cit.
Imaging
CT demonstrates a high density biconvex/lenticular lesion, which occurs as the haematoma pushes the adherent
dura away from the inner table of the skull. The haematoma is most often located in the temporal or
temporoparietal region.
Management
The patient must be referred to neurosurgery urgently. Occasionally an alert patient with a small haematoma may
be treated conservatively but usually management is with surgical evacuation of haematoma. Complications include
neurological de cit or post-traumatic seizure.

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Major Trauma
A 40 year old man is brought into ED with an isolated head injury which he sustained during 13 Unanswered
a charity rugby match. His friends tell you he lost consciousness for about 30 seconds at the time
14 Current Question
of the injury.
15 Unanswered
a. Give four clinical signs that indicate a CT scan should be performed in this patient. (2
marks) 16 Unanswered
b. Give two history based indications that a CT scan should be performed in this patient. (1
17 Unanswered
mark)
18 Unanswered
19 Unanswered
20 Unanswered
21 Unanswered
a. Any four of:
23 Unanswered
Any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, cerebrospinal uid leakage from the ear
or nose, Battle’s
b. Any two of:
More than 1 episode of vomiting
Dangerous mechanism of injury (a pedestrian or cyclist struck by a motor vehicle, an occupant ejected
from a motor vehicle or a fall from a height of greater than 1 metre or 5 stairs)
More than 30 minutes’ retrograde amnesia of events immediately before the head injury
Warfarin therapy
Notes
Glasgow Coma Scale

Orientated (5)
Confused (4)
Obeys commands (6)




apply:



deterioration).
(PaCO2 > 6 kPa).
Seizures.
Admission

Observation
doctor.

movement.
Discharge
Discharge advice:


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Major Trauma
You are part of the trauma team caring for a 21 year old male who has been stabbed to the 13 Unanswered
left anterior chest wall. Your consultant has performed a FAST scan and notes uid in the
14 Unanswered
pericardial sac and diagnoses cardiac tamponade.
15 Current Question
a. Give the three features of Beck’s triad seen in cardiac tamponade. (1 mark)
b. Describe Kussmaul’s sign. (1 mark) 16 Unanswered
c. The patient suddenly deteriorates and you cannot detect a pulse. What rhythm would
17 Unanswered
you most expect to see in the context of this scenario? (1 mark)
18 Unanswered
19 Unanswered
20 Unanswered
21 Unanswered
a. Elevated JVP (distended neck veins), hypotension and muf ed heart sounds
23 Unanswered
b. Kussmaul’s sign = a paradoxical rise in jugular venous pressure on inspiration
c. Pulseless electrical activity (PEA)
Notes
Cardiac tamponade most commonly results from penetrating injuries (but may also occur following blunt cardiac
injury). The pericardial sac is a xed brous structure; a relatively small amount of blood can restrict cardiac activity
and interfere with cardiac lling.
Clinical features
Beck’s triad:
Venous pressure elevation (distended neck veins)
Decline in arterial pressure (hypotension)
Muf ed heart sounds
Kussmaul’s sign – a rise in venous pressure with inspiration when breathing spontaneously
PEA is suggestive of cardiac tamponade
Investigations
ECG
CVP monitoring
Echocardiogram
Focussed assessment sonography in trauma (FAST)
Pericardial window
Management
Restoration of intravascular volume

Emergency needle pericardiocentesis
Emergency thoracotomy with pericardiotomy
Surgery
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Major Trauma
You are part of the trauma team anticipating the arrival of a man who has received a single 13 Unanswered
stab wound to the chest. On arrival the patient is maintaining his own airway. His is tachypnoeic
14 Unanswered
with normal oxygen saturations whilst receiving 15L oxygen via non-rebreather mask. The
trachea is central and air entry equal on both sides. You note distended neck vasculature. The 15 Unanswered
patient is tachycardic (135 bpm) and hypotensive (80/57 mmHg).
16 Current Question
a. What is the most likely diagnosis? (1 mark)
17 Unanswered
b. What investigation should be performed urgently to con rm your suspected diagnosis?
(1 mark) 18 Unanswered
c. You diagnosis is con rmed, and the patient doesn’t respond to initial resuscitation. What
19 Unanswered
immediate treatment could be considered in ED? (1 mark)
20 Unanswered
21 Unanswered
22 Unanswered
23 Unanswered
Answer
a. Cardiac tamponade
b. Examination of the pericardial sac as part of focused assessment sonography in trauma (FAST)
c. Needle pericardiocentesis
Notes
Cardiac tamponade most commonly results from penetrating injuries (but may also occur following blunt cardiac
injury). The pericardial sac is a xed brous structure; a relatively small amount of blood can restrict cardiac activity
and interfere with cardiac lling.
Clinical features
Beck’s triad:
Venous pressure elevation (distended neck veins)
Decline in arterial pressure (hypotension)
Muf ed heart sounds
Kussmaul’s sign – a rise in venous pressure with inspiration when breathing spontaneously
PEA is suggestive of cardiac tamponade
Investigations
ECG
CVP monitoring
Echocardiogram
Focussed assessment sonography in trauma (FAST)
Pericardial window
Management
Restoration of intravascular volume

Emergency needle pericardiocentesis
Emergency thoracotomy with pericardiotomy
Surgery
Question Navigator
Major Trauma
A 23 year old cyclist is brought into the Emergency Department following a collision with a 13 Unanswered
car. The patient is poorly responsive, tachycardic, hypotensive and hypoxic. During the primary
14 Unanswered
survey you note distended neck veins and tracheal deviation towards the right side. There is
reduced air entry and hyperresonant percussion note over the left chest. 15 Unanswered
a. What is the most likely diagnosis? (1 mark) 16 Unanswered

b. Outline the basic pathophysiology of this diagnosis. (1 mark)
17 Current Question
c. What is the immediate management of this condition and at what site should this be
performed? (1 mark) 18 Unanswered
19 Unanswered
21 Unanswered
22 Unanswered
Answer
23 Unanswered
a. Left-sided tension pneumothorax
b. Development of a one-way valve air leak – air enters the pleural space but is unable to exit eventually
resulting in collapse of the affected lung, decreased venous return and obstructive shock
c. Needle thoracocentesis – second intercostal space midclavicular line
Notes
Causes
Clinical features
Symptoms
Chest pain
Dyspnoea
Signs
Tachycardia
Tachypnoea
Hypotension
Management

affected hemithorax
midaxillary line

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Major Trauma
A 21 year is brought into ED with a stab wound. During the primary survey, your consultant 13 Unanswered
diagnoses a tension pneumothorax and advises you to perform an immediate needle
14 Unanswered
thoracocentesis.
15 Unanswered
b. Give two complications of this procedure. (1 mark) 16 Unanswered
c. What de nitive treatment should be performed after this procedure? (1 mark)
17 Unanswered
18 Current Question
19 Unanswered
20 Unanswered
a. Second intercostal space midclavicular line 22 Unanswered

b. Any two of:
23 Unanswered
Local haematoma
Creation of pneumothorax
Lung laceration
Failure of decompression due to obstruction by blood, tissue, or kinking, or due to the cannula
being too short to reach the pleural space

Other causes of failure include a localised tension pneumothorax in the patient with pre-existing
lung disease, or a large air leak in which the air collects in the pleural space quicker than can be
drained by the narrow bore of the cannula
c. Chest drain insertion ( fth intercostal space midaxillary line)
Notes
Needle thoracocentesis
Indications
Patient with suspected tension pneumothorax
Contraindications
Nil
Procedure
Identify second intercostal space in the midclavicular line

Locally anesthetise the area if patient is conscious and time permits
Insert needle over superior margin of lower rib perpendicular to skin
Listen for sudden escape of air when the needle enters the parietal pleura
Remove the needle, leaving the cannula in place and apply dressing over insertion site
Prepare for chest drain insertion (in the fth intercostal space, just anterior to the midaxillary line)
Complications
Local haematoma
Creation of pneumothorax
Lung laceration
Failure of decompression due to obstruction by blood, tissue, or kinking, or due to the cannula being too
short to reach the pleural space
Other causes of failure include a localised tension pneumothorax in the patient with pre-existing lung
disease, or a large air leak in which the air collects in the pleural space quicker than can be drained by
disease, or a large air leak in which the air collects in the pleural space quicker than can be drained by
the narrow bore of the cannula

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Major Trauma
A 18 year old is brought into ED after losing control of his car and crashing into a tree. It is 13 Unanswered
believed he was travelling approximately 50 miles per hour. He was restrained and the airbags
14 Unanswered
were deployed. He has bruising across his anterior chest and abdomen. He is tachycardic and
hypotensive. Your consultant performs a FAST scan. 15 Unanswered
a. What is an absolute contraindication for this procedure? (1 mark) 16 Unanswered

b. What four views should be obtained during a FAST scan? (1 mark)
17 Unanswered
c. Give one advantage and one disadvantage of this procedure as compared to other
methods of evaluating abdominal trauma. (1 mark) 18 Unanswered
19 Current Question
21 Unanswered
22 Unanswered
Answer
23 Unanswered
a. An existing indication for laparotomy
b. Views are obtained of the:
Right upper quadrant
Left upper quadrant
Pericardial sac
Pelvic cavity
c. Any two of:
Advantages
Early diagnosis
Noninvasive
Rapid and mobile
Repeatable
Disadvantages
Operator-dependent
Bowel gas and subcutaneous air distortion
Misses diaphragm, bowel and pancreatic injuries
Notes
Focussed Assessment Sonography in Trauma (FAST) provides a rapid, non-invasive, accurate and inexpensive means
of diagnosing haemoperitoneum which can be repeated frequently. Furthermore, FAST can detect one of the non
hypovolaemic causes of hypotension in trauma: cardiac tamponade.
Indications
Haemodynamically unstable patient with blunt trauma
Contraindications
Absolute contraindication to FAST:
An existing indication for laparotomy
Procedure
A negative FAST scan does not exclude intra-abdominal injury; it does however, make an abdominal source less
likely as the cause of heamodynamically signi cant bleeding.
FAST includes the following views:
Right upper quadrant

To include Morrison’s pouch and right costophrenic pleural recess
Left upper quadrant
To include splenorenal recess and left costophrenic pleural recess
Pericardial sac
From below or transthoracic
Pelvic cavity
After the rst scan is completed, a second scan may be performed after an interval of 30 minutes. This scan can
detect progressive haemoperitoneum.
Complications
Nil

trauma

Previous available
Advanced be sedated
Advanced be sedated
Pre-existing agent
coagulopathy

injury

Misses
diaphragm, bowel
and pancreatic
injuries

Question Navigator
Major Trauma
A 21 year old man is brought into the Emergency Department following a rugby match. His 13 Unanswered
team mates explain that he clashed heads with another player during a tackle. He did not lose
14 Unanswered
consciousness but seemed confused for a few minutes. He has no past medical history and takes
no regular medications. On examination you note a small laceration to the frontal scalp. 15 Unanswered
Otherwise examination is unremarkable.
16 Unanswered
a. Name, in order, the ve layers of scalp tissue. (1 mark)
17 Unanswered
b. Whilst suturing the laceration the patient vomits and becomes less responsive. The
nurse repeats his observations and notes he is hypertensive and bradycardic. His GCS is 18 Unanswered
10, E2 V3 M5. He is taking irregular breaths. Name this clinical nding and give the
19 Unanswered
underlying cause. (1 mark)
c. Give three treatment options for treating the above pathology that could be performed 20 Current Question
in ED. (1 mark)
21 Unanswered
22 Unanswered
23 Unanswered
Answer
a. Skin, connective tissue, aponeurosis, loose areolar tissue, periosteum (SCALP)

b. The triad of hypertension, bradycardia and irregular breathing is known as Cushing’s triad. It is a
physiological response to raised ICP.
c. Any three of:
Raising the head of the bed
Analgesia and sedation if pain or agitation present
Intubation and controlled hyperventilation
Hypertonic saline
Mannitol
Inducing a pentobarbital coma
Inducing hypothermia
Notes
Pathophysiology
The cranial cavity has a xed volume because the cranium is a rigid, non-expansive container. If cerebral oedema
worsens or if intracranial haematomas increase in size, the pressure within the cranium increases. Initial
compensatory mechanisms include diminution in the volume of CSF and venous blood within the cranial cavity.
When these mechanism fail, intracranial pressure (ICP) rises, resulting in a fall in cerebral perfusion pressure.
Cerebral perfusion pressure = mean arterial pressure (MAP) – mean intracranial pressure
A fall in cerebral perfusion pressure decreases cerebral blood ow, eventually producing ischaemia. This in turn
increases cerebral oedema, causing a further rise in ICP.
The normal ICP in the resting state is approximately 10 mmHg. Pressures greater than 20 mmHg, particularly if
sustained and refractory to treatment, are associated with poor outcomes.
Every effort should be made to enhance cerebral perfusion and blood ow by:
Reducing elevated ICP

Maintaining normal intravascular volume
Maintaining normal mean arterial blood pressure
Restoring normal oxygenation and normocapnia
Removing space occupying lesions
Clinical anatomy
Tough meningeal partitions separate the brain into regions. The tentorium cerebelli divides the intracranial cavity
into the supratentorial and infratentorial compartments. The midbrain passess through an opening called the
tentorial hiatus/notch.
A generalised increase in ICP in the supratentorial compartment initially causes the medial part of the temporal lobe
(uncus) to herniate through the tentorial hiatus.
In uncal herniation, the oculomotor nerve (CN III) is compressed against the free border of the tentorium, causing
ipsilateral pupillary dilatation secondary to loss of parasympathetic constrictor tone to the ciliary muscles; an
oculomotor nerve palsy may follow. Uncal herniation also causes compression of the corticospinal pyramidal tract in
the midbrain resulting in contralateral hemiparesis.
Eventually transforaminal (central) herniation will occur, leading to death. In central herniation (coning), the
cerebellar tonsils are forced through the foramen magnum. Neck stiffness may be noted. A slow pulse, raised blood
pressure and irregular respiration leading to apnoea are seen, usually preceded by signi cant tachycardia.
By Brain_herniation_types.svg: User:Delldot derivative work: RupertMillard

(Brain_herniation_types.svg) [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0), CC-
BY-SA-3.0 (http://creativecommons.org/licenses/by-sa/3.0/) or GFDL
(http://www.gnu.org/copyleft/fdl.html)], via Wikimedia Commons
Clinical features
Symptoms of raised ICP include:
Headache (worse in morning or when coughing/straining, relieved by standing)

Diplopia
Vomiting (in early stages without nausea)
Drowsiness and irritability
Signs of raised ICP include:
Reduced or uctuating consciousness

Pupillary signs (irregularity or dilatation in one eye)
Focal neurology
CN III palsy
Contralateral hemiparesis
Cushing’s triad: hypertension, bradycardia and irregular breathing
Cardiorespiratory arrest
Management
Primary options that can be used to lower ICP include raising the head of the bed to 30° and using the
reverse Trendelenburg position if spinal instability or injury is present.
Analgesics and sedation can be useful, as pain and agitation can increase the ICP.
Using paralytics in intubated patients can help to attenuate the effects of suctioning.
Hyperventilation to a goal pCO2 of 30 to 35 mmHg (4.0 – 4.7 kPa), monitored with serial ABGs, can be
bene cial.
Reduced PaCO2 causes cerebral vasoconstriction thus lowering ICP but also impairing cerebral
perfusion, thus hyperventilation should only be used in moderation and for as limited a time as possible
to avoid cerebral ischaemia.
Secondary treatment options to lower ICP include osmotic therapy with 3% hypertonic saline, with a dosing
limit based on an upper serum sodium limit of 155 mmol/L. Other studies using higher concentrations
including 7.2%, 20%, and 23.4% hypertonic saline have also shown signi cant treatment effect in lowering
ICP without reducing cerebral blood ow.
Osmotic diuretics such as mannitol can be used, but should be avoided if serum osmolality is > 320
mOsm/kg or in hypotensive patients (will not lower ICP in hypotension, and will worsen hypovolaemia and
cerebral ischaemia). The preparation most commonly used is a 20% solution (20 g of mannitol per 100 ml
solution), 1 g/kg bolus given rapidly over 5 minutes.
Other treatment options include maintaining the patient in a pentobarbital coma (requires continuous EEG
monitoring), inducing hypothermia by intravascular cooling or topical cooling blankets, and decompressive
hemicraniectomy.
For post-traumatic seizures, phenytoin or fosphenytoin are the agents used in the acute phase. For adults the
loading dose is 1 g phenytoin IV at a rate no faster than 50 mg/min (maintenance dose 100 mg/8 hours). Diazepam
or lorazepam is frequently used in addition to phenytoin until the seizure stops. Control of continuous seizures may
require general anesthesia.
Question Navigator
Major Trauma
A 36 year old scaffolder is brought to ED by ambulance after falling approximately 5 m on a 13 Unanswered

building site. His GCS is 10. You are performing a full neurological assessment when you note the
14 Unanswered
following abnormality shown below:
15 Unanswered
16 Unanswered
17 Unanswered
18 Unanswered
19 Unanswered
By Radomil talk (Own work) [GFDL (http://www.gnu.org/copyleft/fdl.html) or CC-BY-SA-3.0

20 Unanswered
(http://creativecommons.org/licenses/by-sa/3.0/)], via Wikimedia Commons
21 Current Question
22 Unanswered
a. What abnormality is seen in the above image and what is most likely cause of this 23 Unanswered
nding? (1 mark)
b. On repeat examination, you note the patient’s right pupil is pointing down and out. What
cranial nerve is most likely affected? (1 mark)
c. Give two drugs that could be given in ED to treat the underlying cause. (1 mark)
Answer
a. Dilatation of the right eye with unequal pupil – Raised intracranial pressure (N.B. leading to uncal herniation
with compression of the super cial parasympathetic bres that lie on the surface of the oculomotor nerve
against the free edge of the tentorium – loss of parasympathetic constrictor activity leads to unopposed
sympathetic dilator activity)
b. Oculomotor nerve (CN III)
c. Mannitol or hypertonic saline
Notes
Pathophysiology

Clinical anatomy

Clinical features

Diplopia

Focal neurology
CN III palsy
CN III palsy
Management
bene cial.
hemicraniectomy.
Question Navigator
Major Trauma
A 45 year old man is brought to ED after being hit by a bus while crossing the road. 18 Unanswered
Witnesses report seeing him knocked approximately 5 m down the road. During primary survey,
19 Unanswered
it is is noted he is hypotensive with a systolic blood pressure of 90, and tachycardic with a HR of
140. He has signi cant bruising around the lower abdomen and pelvis and due to the high 20 Unanswered
suspicion of pelvic injury, bedside pelvic injury is requested and shown below:
21 Unanswered
22 Current Question
23 Unanswered
24 Unanswered
25 Unanswered
26 Unanswered
27 Unanswered
28 Unanswered
© Nevit Dilmen [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0) or GFDL


b. Give two techniques to reduce bleeding in pelvic trauma that can be performed in the
ED. (1 mark)
c. Give a non-operative method that can be used to stop pelvic bleeding. (1 mark)
Answer
a. Open book pelvic fracture
b. Any two of:
Internally rotate the lower legs to close an open-book type fracture, pad bony prominences and tie the
rotated legs together
Apply a pelvic binder
Apply a pelvic external xation device
Apply skeletal limb traction
c. Embolise pelvic vessels via angiography
Notes
Pelvic fractures associated with haemorrhage commonly exhibit disruption of the posterior osseous ligamentous
complex (sacroiliac, sacrospinous, sacrotuberous, and the bromuscular pelvic oor) from a sacroiliac fracture
complex (sacroiliac, sacrospinous, sacrotuberous, and the bromuscular pelvic oor) from a sacroiliac fracture
and/or dislocation, or from a sacral fracture. Disruption of the pelvic ring tears the pelvic venous plexus and
occasionally disrupts the internal iliac arterial system.
Mortality in patients with all types of pelvic fractures is approximately one in six, rising to approximately one in four
in patients with closed pelvic fractures and hypotension and approximately one in two in patients with open pelvic
fractures. Haemorrhage is the major potentially reversible contributing factor to mortality.
Mechanism of injury
Pelvic ring injuries may be caused by:
Motorcycle crashes
Pedestrian-vehicle collisions
Direct crushing injury to the pelvis
Falls from heights greater than 12 feet (3.5 metres)
Mechanism of injury:
AP compression (open book): 15 – 20% frequency

Lateral compression: 60 – 70% frequency
Vertical shear: 5 – 15% frequency
Complex (combination pattern)
Recognition of pelvic fractures
Identify mechanism of injury which can suggest the possibility of pelvic fracture
Inspect pelvic area for ecchymosis, perineal or scrotal haematoma, and blood at the urethral meatus
Inspect legs for differences in length or asymmetry in rotation of the hips
Perform rectal exam, noting the position and mobility of the prostate gland, any palpable fracture or the
presence of gross or occult blood in the stool
Perform a vaginal exam, noting palpable fractures, the size and consistency of the uterus, or the presence of
blood
If any of the above are abnormal, or if the mechanism of injury suggests a pelvic fracture, obtain an AP x-ray
lm of the patient’s pelvis
Otherwise, palpate the bony pelvis to identify painful areas
Determine pelvic stability by gently applying anterior-posterior compression and lateral-medial

compression over the anterosuperior iliac crests; test for axial stability by gently pushing and pulling on the
legs to determine stability in a cranial-caudal direction
Cautiously insert a urinary catheter, if not contraindicated, or perform retrograde urethrography if urethral
injury is suspected
Management of pelvic fractures
Initial management of major pelvic disruption associated with haemorrhage requires haemorrhage control
and uid resuscitation.
Techniques to reduce blood loss from pelvic fractures:
Internally rotate the lower legs to close an open-book type fracture, pad bony prominences and tie the
rotated legs together
Apply a pelvic binder
Apply a pelvic external xation device
Apply skeletal limb traction
Embolise pelvic vessels via angiography
Place sandbags under each buttock (if no indication of spinal injury and other techniques to close pelvis
are not available)
Arrange for transfer for de nitive care

TeachMeAnatomy
Question Navigator
Major Trauma
You receive a pre-alert call from the local ambulance service. A light aircraft carrying a 18 Unanswered
family of four has crashed in a eld. A crew are bringing the pilot to your Emergency
19 Unanswered
Department. He is shocked, tachycardic and hypotensive. On arrival you note bruising over the
anterior chest. On examination, you note reduced air entry and stony dull percussion note on the 20 Unanswered
left side.
21 Unanswered
22 Unanswered
b. What are the two main principles of immediate management of this condition? (1 mark)
c. Give an indication for thoracotomy speci c to this diagnosis. (1 mark) 23 Current Question
24 Unanswered
26 Unanswered
27 Unanswered
Answer
28 Unanswered
a. Massive haemothorax
b. Simultaneous restoration of blood volume (with crystalloid, blood and autotransfusion) and decompression
of the chest cavity (with chest drain insertion)
c. Any one of:
Blood loss > 1500 mL or 1/3rd of blood volume

Blood loss > 200 mL/h (3 mL/kg/h) for 2 – 4 hours
Persistent need for blood transfusions
Notes
Massive haemothorax results from rapid accumulation of > 1500 mL of blood or one-third or more of the patient’s
blood volume in the chest cavity. It is most commonly caused by a penetrating wound that disrupts the systemic or
hilar vessels. However, it can also result from blunt trauma.
Clinical features
In patients with massive haemothorax, the neck veins may be at as a result of severe hypovolaemia, or distended if
there is an associated tension pneumothorax. A massive haemothorax is suggested when shock is associated with
the absence of breath sounds or dullness to percussion on one side of the chest.
Immediate management
Massive haemothorax is initially managed by the simultaneous restoration of blood volume and decompression of
the chest cavity. Large calibre intravenous lines and a rapid crystalloid infusion are begun and type-speci c blood
administered as soon as possible. Blood from the chest tube should be collected in a device suitable for
autotransfusion.
Thoracotomy
If 1500 mL is immediately evacuated, early thoracotomy is almost always required. Patients who have an initial
output of less than 1500 mL of uid but continue to bleed (> 200 mL/hr for 2 – 4 hours) may also require
thoracotomy. The persistent need for blood transfusions is an indication for thoracotomy. Penetrating anterior
chest wounds medial to the nipple line and posterior wounds medial to the scapula should alert the practitioner to
the possible need for thoracotomy because of potential damage to the great vessels, hilar structures, and the heart,
with the associated potential for cardiac tamponade.
Question Navigator
Major Trauma
A 21 year old man presents to the ED on Sunday morning. He tells you he was involved in a 18 Unanswered
ght the night before, during which, he believes he was hit around the head with a baseball bat.
19 Unanswered
This morning, he woke with a severe headache and noticed bruising as seen below:
20 Unanswered
21 Unanswered
22 Unanswered
23 Unanswered
24 Current Question
25 Unanswered
26 Unanswered
27 Unanswered
Public domain, via Wikimedia Commons
28 Unanswered
a. What abnormality is seen in the image and what is the most likely diagnosis? (1 mark)
b. Give two further signs that you might see in this type of injury. (1 mark)
c. Give one possible complication of this type of injury. (1 mark)
c. Give one possible complication of this type of injury. (1 mark)
Answer
a. Panda/Racoon eyes (bilateral periorbital ecchymosis) – basal skull fracture
b. Any two of:
Retroauricular bruising (Battle’s sign)
CSF rhinorrhoea
CSF otorrhoea
Hemotympanum or bleeding from auditory canal
Subconjunctival haemorrhage (no posterior border seen)
CN VII palsy (facial paralysis)
CN VIII palsy (hearing loss)
c. Any one of:
Pneumocephalus from mask ventilation
Inadvertent intracranial tube placement (nasogastric or nasal intubation)
Carotid artery damage (dissection, pseudoaneurysm, thrombosis)
Cavernous sinus thrombosis
CSF stula
Meningitis
Notes
Basilar skull fractures usually require CT scanning with bone-window settings for identi cation.
Clinical features
Bilateral periorbital bruising (Panda eyes)

Retroauricular bruising (Battle’s sign)
CSF rhinorrhoea
CSF otorrhoea
CSF otorrhoea
Hemotympanum or bleeding from auditory canal
Subconjunctival haemorrhage (no posterior border seen)
CN VII palsy (facial paralysis)
CN VIII palsy (hearing loss)
Complications
Pneumocephalus from mask ventilation

Inadvertent intracranial tube placement (nasogastric or nasal intubation)
Carotid artery damage (dissection, pseudoaneurysm, thrombosis)
Cavernous sinus thrombosis
CSF stula
Meningitis
Management
Treatment of skull fractures is primarily conservative. Most non-depressed (linear) fractures, including basilar skull
fractures, are treated conservatively as long as there is no suspicion or evidence of intracranial pathology,
neurological status is normal, and there is no evidence of cranial nerve damage or CSF leak.
However, a depressed fracture, an open fracture, or a fracture with associated intracranial pathology, cranial nerve
de cit, or CSF leak (most likely to be a basilar fracture) may require surgical intervention.

Question Navigator
Major Trauma
A 21 year old is brought into ED by ambulance with a stab wound to his left upper back. You 18 Unanswered
notice bubbling of blood at the site of the wound. He is tachycardic and tachypnoeic. On
19 Unanswered
examination you note decreased chest expansion and reduced air entry on the left side. There is
no tracheal deviation. 20 Unanswered
a. What is the most likely diagnosis? (1 mark) 21 Unanswered

b. What immediate treatment step should be performed in this patient? (1 mark)
22 Unanswered
c. What life-threatening complication can occur if the above treatment is not performed
correctly? (1 mark) 23 Unanswered
24 Unanswered
You did not answer this question 25 Current Question
26 Unanswered
27 Unanswered
Answer
28 Unanswered
a. Open pneumothorax
b. Promptly closing the defect with a sterile occlusive dressing; the dressing should be large enough to overlap
the wound’s edges and then taped securely on three sides in order to provide a utter-type valve effect.
c. Securely taping all edges of the dressing can cause air to accumulate in the thoracic cavity, resulting in a
tension pneumothorax.
Notes
Large defects of the chest wall that remain open can result in an open pneumothorax.
Equilibrium between intrathoracic pressure and atmospheric pressure is immediate. Air tends to follow the path of
least resistance; as such, if the opening in the chest wall is approx. two-thirds of the diameter of the trachea or
greater, air passes preferentially through the chest wall defect with each respiratory effort. Effective ventilation is
thereby impaired, leading to hypoxia and hypercarbia.
In open pneumothorax (sucking chest wound), initial management is accomplished by promptly closing the defect
with a sterile occlusive dressing. The dressing should be large enough to overlap the wound’s edges and then taped
securely on three sides in order to provide a utter-type valve effect. As the patient breathes in the dressing
occludes the wound, preventing air from entering. During exhalation, the open end of the dressing allows air to
escape from the pleural space. Securely taping all edges of the dressing can cause air to accumulate in the thoracic
cavity, resulting in a tension pneumothorax.
A chest tube remote from the wound should be placed as soon as possible. Subsequent surgical closure of the defect
is frequently required.

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Question Navigator
Major Trauma
A 85 year old woman is brought to ED complaining of neck pain following a fall. She has a 18 Unanswered
history of chronic neck pain. She is complaining of muscle weakness bilaterally, particularly in her
19 Unanswered
arms and hands and a burning sensation in her upper limbs. On examination you note
symmetrical motor loss, greater in the distal upper limb than the proximal upper limb, and 20 Unanswered
greater in the upper limb than the lower limb.
21 Unanswered
22 Unanswered
b. What is the most likely mechanism of injury? (1 mark)
c. What investigation should be performed in this patient? (1 mark) 23 Unanswered
24 Unanswered
26 Current Question
27 Unanswered
Answer
28 Unanswered
a. Central cord syndrome
b. Hyperextension injury of cervical spine in patient with pre-existing cervical stenosis (e.g. frontal fall with
facial impact)
c. MRI spine
Notes
The spinal cord extends from the base of the skull and terminates near the lower margin of the L1 vertebral body as
the conus medullaris). Below L1, the spinal canal contains the lumbar, sacral and coccygeal spinal nerves that
comprise the cauda equina.
By Polarlys and Mikael Häggström [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0) or GFDL

Spinal cord tracts
Of the many spinal cord tracts, only three can be readily assessed clinically:
Tract Location Function
Dorsal column Posteromedial aspect Transmits ipsilateral proprioception, vibration and light-
of cord touch sensation
Spinothalamic tract Anterolateral aspect of Transmits contralateral pain, temperature and crude-touch
cord sensation
Lateral corticospinal Posterolateral aspect Controls ipsilateral motor power

tract of cord
Spinal cord syndromes
Spinal cord Mechanism Tracts affected Clinical features

syndrome
Complete Major trauma All tracts Death (C1 – C3), paralysis of

cord voluntary/automatic breathing (above
transection C5), quadriplegia (C1 – C8), paraplegia
(below T1), complete UMN paralysis
below lesion, complete sensory loss
below lesion, urinary and faecal
incontinence, anhidrosis and loss of
vasomotor tone
Brown- Hemi-transection e.g. All tracts on Ipsilateral UMN paralysis below lesion,
Sequard penetrating trauma or one side ipsilateral loss of
syndrome unilateral compression of the proprioception/vibration/ ne touch
(hemisection) cord sensation below lesion, contralateral
loss of crude touch/pain/temperature
sensation below lesion
Central cord Hyperextension injury of Lateral Bilateral UMN motor loss below lesion
syndrome cervical spine in patient with corticospinal and varying degrees of sensory loss
pre-existing cervical stenosis tract, below lesion with greater loss in upper
e.g. frontal fall with facial spinothalamic limbs than lower limbs and greater loss
impact tract of motor function than sensory
function
Anterior cord Occlusion of anterior spinal Corticospinal, Bilateral UMN motor loss below lesion,
syndrome artery with infarction of spinothalamic bilateral loss of crude
anterior cord by direct and touch/pain/temperature sensation
anterior cord by direct and touch/pain/temperature sensation
anterior cord compression, spinocerebellar below lesion, (dorsal column spared),
exion injuries of the cervical tracts cerebellar incoordination
spine, or thrombosis of
anterior spinal artery
Posterior Penetrating trauma to the Dorsal column Bilateral loss of proprioception,

cord
Spinal cord back or hyperextension injury
Mechanism Tracts affected vibration and light-touch sensation,
Clinical features
syndrome
syndrome associated with vertebral arch (motor and pain/temperature/crude
fractures (very rarely occurs in touch sensation preserved)
isolation)
by Fpjacquot, via Wikimedia Commons
Spinal shock
Immediate accidity, paralysis, are exia and loss of sensation below the level of the acute spinal cord injury.
Some re exes return after a few days and hyperre exia typical of an upper motor neurone lesion in weeks.
Neurogenic shock
Results from impairment of the descending sympathetic pathways in the cervical or upper thoracic spinal
cord.
Rare in spinal cord injuries below T6.
Loss of vasomotor tone causes vasodilation in visceral and lower-extremity blood vessels, pooling of blood
and hypotension.
Loss of sympathetic innervation to the heart results in bradycardia (or lack of appropriate tachycardia).
Hypotension may be refractory to uid resuscitation which may instead result in uid overload and
pulmonary oedema – blood pressure instead may be restored by vasopressors after moderate uid
replacement.
Atropine may be used to counteract haemodynamically signi cant bradycardia.

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Radiopaedia
Question Navigator
Major Trauma
A 32 year old female cyclist is brought into the Emergency Department with reduced 18 Unanswered
consciousness following a collision with a car, she was not wearing a helmet. She has been
19 Unanswered
intubated and trauma CT has revealed a right sided subdural haematoma. She has no signi cant
chest, abdominal or pelvic trauma. 20 Unanswered
a. Give three signs on examination that are suggestive of raised ICP. (1 mark) 21 Unanswered
b. Outline the mechanism of the bene cial effect of hyperventilation in treating raised ICP,
22 Unanswered
and give a complication of this treatment. (1 mark)
c. What clinical feature would preclude the use of mannitol in treating raised ICP? (1 mark) 23 Unanswered
24 Unanswered
26 Unanswered
27 Current Question
Answer
28 Unanswered
a. Any three of:
Focal neurology
CN III palsy
b. Hyperventilation = reduced PaCO2 = cerebral vasoconstriction = decreased cerebral perfusion = decreased
ICP. However there is a risk of cerebral ischaemia.
c. Hypotension (N.B. will not lower ICP in view of hypotension, but will worsen hypotension and cerebral
ischaemia)
Notes
Pathophysiology

Clinical anatomy

Clinical features

Diplopia

Focal neurology
CN III palsy
Management
bene cial.
hemicraniectomy.

Advanced Life Support Group
Question Navigator
Major Trauma
You receive a pre-alert from the ambulance service regarding a 17 year old male who has 18 Unanswered
received multiple stab wounds to the chest. The paramedics have diagnosed a tension
19 Unanswered
pneumothorax and performed needle thoracocentesis to good effect.
20 Unanswered
a. Give three signs on examination that would distinguish a diagnosis of tension
pneumothorax from cardiac tamponade. (1 mark) 21 Unanswered
b. Give two iatrogenic causes of a tension pneumothorax. (1 mark)
22 Unanswered
c. What is the de nitive management of this condition and at what site should this be
performed? (1 mark) 23 Unanswered
24 Unanswered
26 Unanswered
27 Unanswered
Answer
28 Current Question
a. Any three of:
Hyperresonant note on percussion
Deviated trachea
Reduced/absent breath sounds
Reduced chest expansion

b. Any two of:
Inappropriate application of occlusive dressing over an open chest wall defect
c. Chest drain insertion – fth intercostal space just anterior to the midaxillary line
Notes
Causes
Clinical features
Symptoms
Chest pain
Dyspnoea
Signs
Tachycardia
Tachypnoea
Hypotension
Management

affected hemithorax
midaxillary line
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7/31/2017 Major Trauma - FRCEM Success

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You did not answer this question 9 Unanswered

Assessment for cervical spine injury

Assessment for thoracic or lumbosacral spine injury

has any signi cant distracting injuries

Perform CT in adults (16 or over) if:

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Blunt abdominal trauma with a positive DPL

Most commonly injured in blunt trauma:

Spleen (40 – 55%)

Most commonly injured in stab wounds:

Most commonly injured in gunshot wounds:

Small bowel (50%)

Focussed Assessment Sonography in Trauma (FAST)

speci c investigation for injury.

Procedure FAST DPL CT

Indications Unstable blunt Unstable blunt Stable blunt trauma

Contraindications An existing An existing Hemodynamically

Time 2 – 4 mins 10 – 15 mins Variable

Sensitivity Medium High High

Speci city High Low High

Advantages Early diagnosis Early diagnosis Most speci c

Procedure FAST DPL CT

Disadvantages Operator- Invasive Cost and time

Indications for laparotomy in patients with trauma

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a. Any three of:

Suspected open or depressed skull fracture

Glasgow Coma Scale

The eye opening response (scored out of 4)

Obeys commands (6)

Criteria for performing a CT head scan

GCS less than 13 on initial assessment in the emergency department

Age 65 years or older

Criteria for performing a CT cervical spine in patients with head injury

GCS less than 13 on initial assessment.

It is not considered safe to assess the range of movement in the neck.

was involved in a simple rear-end motor vehicle collision.

Involving the neurosurgical department

Persisting coma (GCS 8 or less) after initial resuscitation.

Indications for intubation and ventilation

Intubate and ventilate the patient immediately in the following circumstances:

Use intubation and ventilation before transfer in the following circumstances:

Patients with new, clinically signi cant abnormalities on imaging.

Development of agitation or abnormal behaviour.

Details of the nature and severity of the injury.

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Courtesy of 2007-06-24 17:16 Glitzy queen00 (Wikipedia Commons

a. What is the diagnosis? (1 mark)

You did not answer this question

The patient should be referred urgently to neurosurgery.

Death due to cerebellar herniation

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a. An existing indication for laparotomy