The Ultimate Guide to Trauma - Part 2


The folks over at LifeintheFastLane have released a series of great posts on Trauma assessment and management. What I've provided here is a collated version of a selection of these posts, along with relevant resources from other sources, to create The Ultimate Guide to Trauma for Medical Students.

Most of the posts are done in a Q&A style so you can put your knowledge to test. In Part One we covered the basics (BLS & ALS, initial assessment & management), one step further (major haemorrhage, transfusions and intubation, considered abdominal and genitourinary trauma, chest trauma and trauma in pregnancy. In Part Two, we cover central nervous trauma, eye trauma and general radiology.

CNS Trauma

Spinal Injury
Spinal injuries most commonly arise as a result of motor vehicle accidents, falls, acts of violence and sporting activities. The most important part of the spine to be concerned about in an acute trauma situation, is the Cervical Spine.There are three major indications for c-spine precautions; Neck pain or neurological symptoms, Altered level of consciousness, and Significant blunt injury above the level of the clavicles. This post covers the differences between primary and secondary spinal injury, and how to localise and manage the trauma.

A useful mnemonic for potential spinal injury is SPINAL;  
S uspicious Mechanism of Injury (High speed MVA, roll over, patient ejected, fall, pedestrian, etc),  
P ain or bony tenderness around the spine,
I ntoxication with medications, alcohol or elicit drugs,
N umbness or tingling distally (below the area of injury),
A ny distracting pain,
L evel of consciousness altered.

Traumatic Brain Injury
Head injury accounts for one-third of all trauma deaths, so it's not something to be ignored (Kraus J, McArthur D: Epidemiology of Brain Injury 2000). The simplest way to categorise the severity of a head injury is the Glasgow Coma Scale (GCS). The GCS is a score out of 15, with 6 for motor, 5 verbal and 4 eyes. An even simpler alternative is the AVPU scale, which can be used by first aiders. Again you are concerned with identifying any primary (e.g. blunt trauma) or secondary (e.g. hypoxia, metabolic disturbances) injuries that may exist.

The use of imaging in Traumatic Brain Injuries is normally a key component in recognising the type of injury. Michelle has again created a Paucis Verbis’ card on Head CT Decision Rules in Trauma. The CT Evaluation of Head Trauma presentation by Dr Salauddin serves up several images and plenty of background material.

Testing Pupillary Response to Light in Head Trauma
In some patients with head and face trauma, it can be difficulty to check their pupillary response to light. Lucky for us, Michelle has shared this trick of the trade.

Trick: Check pupillary constriction using ultrasound.

Eye Trauma
There are several common eye injuries and presentations that you will see in the emergency department;  Scratched eyes, Penetrating injuries, Chemical burns, Swelling, Eye bleeding, Traumatic iritis, Hyphemas and orbital blowout fractures. Clinical examination of the eye, provides a nice overview of how to start approaching eye complaints. If the damage is severe enough, the treating doctor should refer to an ophthalmologist as soon as possible, if available.

Use a brief exam to assess eye trauma in children: I-ARM (Family Practice News, 2004).
  • I nspect
  • A cuity
  • R ed Reflex 
  • M otility
Checkout Common Eye Trauma on Orthobook by Dr Root for a succinct overview. 


My Trick of the Trade: If you need to irrigate an eye, but don't have a Morgan lens lying round (which is common in rural settings), grab a friendly clean cannula and attach it to a saline bag. It provides a bit more direction, than letting the bag gush over the patient.

Penetrating Eye Injury
Penetrating eye injuries can be split into four major groups - eye lid lacerations, corneal lacerations, scleral lacerations and perforating trauma. The first step in assessing an eye is taking a thorough history including components like; symptoms, mechanism of injury, type of projectile and velocity, previous trauma or surgery and use of eye protection, followed by an examination. Management typically involves supportive care until an ophthalmologist is available. CT scans can also be of use, looking for ocular or orbital foreign bodies.

Anaesthetic eyedrops may be required to facilitate the examination and for initial pain management but should not be used to allow return to the sporting field or for ongoing pain management (Moeller and Rifat, 2003).
 
Blunt Trauma to the Eye
Normally the eye is well protected by the rigid orbital bones, however high impact or targeted blunt trauma can bypass this defence mechanism. Again appropriate history taking and examination are important steps in assessing the eye. There are several eye injuries however which require the urgent attention of an ophthalmologist; chemical burns of the eye, perforation of the globe or cornea, lens dislocation, orbital haemorrhage with ↑ intraocular pressure, lacerations involving the lid margin, tarsal plate or nasolacrimal drainage system, and optic nerve injury.  

Hyphaema and traumatic iritis were considered in
LifeintheFastLane's Ophthalmology Befuddler 030 — A Poke in the Eye
.


Radiology
The chief principle behind trauma management is simple—treat the greatest threat to life first. Then we jump to our next device in our toolkit, imaging. ABC of Emergency Radiology does a quick refresher of our approach to trauma, and then carries as on to radiology territory. It is a good place to start, but if you want to delve right into it continue onwards.

Checkout the Quick Guide to Chest X-Ray Interpretation for some radiology gems.

The ABCDE approach makes a number of recurrences across the spectrum of medicine, and once again it rears its' head in radiology.

PELVIS XRAY (BMJ. 2005 May 14; 330(7500): 1136–1138.)
ABCs interpretation of pelvic radiographs Show
Alignment
• Check the pubic symphysis is symmetrical and not widened
• Carefully check that the sacroiliac joints are intact
Bones
• Check that all three pelvic rings are intact
• Use a bright light to check iliac crests and hips
• Look at the lumbar spine and hip joints separately
Cartilage
• Check the distance of the pubic symphysis
• Again check the sacroiliac joints
• Check both hips
Soft tissues
• Check the soft tissue planes are symmetrical
• Look for obturator internus
• Carefully delineate the perivesical fat plane
• Make sure the gluteus medius and psoas fat planes are intact


CHEST XRAY (CXR) (BMJ. 2005 May 14; 330(7500): 1136–1138.)
Interpretation of the supine chest radiograph (ABCDEs) Show
Airways
• Check trachea is clear and central
• Is airway patent?
• Check position of endotracheal tube
• Are there any teeth or foreign bodies?
• Check all lines and tubes
Breathing
• Exclude tension pneumothorax and haemothorax
• Check there is no radiological flail segment
• Exclude rib fractures
• Check lungs are clear
Circulation
• Check heart size and mediastinal contours are normal
• Make sure that the aortic arch is clearly seen
• Check the hila and vascular markings are normal
Diaphragm
• Check that diaphragms appear normal (size, shape, and position)
• Can both diaphragms be clearly seen?
• Check under each diaphragm
Edges
• Check the pleura and costophrenic recesses
• Exclude a subtle pneumothorax or effusion
Soft tissues and skeleton
• Look for surgical emphysema
• Check clavicles and shoulders and exclude rib fractures
• Look at the paraspinal lines and check the spine

Radiology MasterClass Trauma Series

LearningRadiology.com - Recognising a Pneumothorax

UK Radiology guidelines for trauma

Trauma.org - Radiology Images

Radiology Assistant

iMeducation

See Part 1 for the basics and information on
Abdominal and Genitourinary Trauma, Chest Trauma and Trauma in Pregnancy.

Further Reading

LifeintheFastLane.com - The majority of this guide originates from here, but there are many other great reads as well.
 
CrashingPatient.com provides a large body of knowledge on Trauma and Emergency Medicine.

Trauma.org is another useful resource. A selection of images used in this post are from Trauma.org.

A Simple Guide to Trauma by RL Huckstep (for the orthopods in the house). Covers the complete spectrum of musculoskeletal injuries.

Radiopedia.org - a free educational radiology resource with one of the web's largest collection of radiology cases and reference articles.

Got any resources that you would like to recommend? 
Comment below or message me on twitter @IVLINE

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