Title: Trauma

Q: What proportion of patients with thoracic trauma have missed injuries on CXR alone?
A: 50%

Q: What is the sensitivity of CXR for pneumothorax?
A: 50-80%

Q: What swallow study is recommended if suspicious for oesophageal injury?
A: Water-soluble contrast swallow study
Barium risks mediastinitis

Q: What is the DOPES mnemonic?
A: Post-intubation hypoxia
 - Displacement of ET
 - Obstruction of ET
 - Patient - PTX, PE, bronchospasm, APO, collapse
 - Equipment issues
 - Stacked breaths

Q: What proportion of blood volume can reside in one hemithorax?
A: 40%

Q: What is the definition of massive haemothorax?
A: >1500mL or >2/3 hemithorax

Q: How does a hemithorax cause death?
A: Hypovolaemic shock
Tamponade
Failure of lung to expand

Q: Who is at risk of systemic air embolism in trauma?
A: Penetrating chest wounds with subsequent PPV (esp. if haemoptysis)

Q: When can ICC be removed?
A: At least 24 hours, no bubbling, <200mL/24 hour fluid drainage or extubated (if on PPV)

Q: How soon are pulmonary contusions visible on CXR?
A: Within 6 hours (vs. aspiration pneumonitis or fat embolism)

Q: What is the risk of ARDS if >20% lung volume is contused?
A: 80%

Q: What limits haemothorax size?
A: Compressive effect of lung
High lung thromboplastin concentrations
Low PAP

Q: Why should small haemothoraces be drained?
A: Large clots act as a fibrinolytic
Bleeding from small vessels stops rapidly once haemothorax is drained
Reduces risk of empyema

Q: When is thoracotomy indicated after ICC placement?
A: >1500mL instant drainage
>150-200mL/hr for first 4 hours
Persistent blood product replacement

Q: What proportion of blunt chest trauma patients require iCC?
A: <5%

Q: What proportion of serious chest trauma suffer PTX?
A: 20%

Q: Do chest stab wound victims require repeat CXR's prior to discharge?
A: Yes. Can suffer delayed PTX (12% incidence). So need repeat CXR at 4-6 hours or prior if deteriorates

Q: What is the incidence of delayed PTX in chest stab wounds?
A: 12%

Q: What is the management for small (<1cm) pneumothoraces?
A: If unchanged on two CXR's 4-6hrs apart and otherwise well can observe only.
If PPV, enlarging, or long-distance travel - pigtail or small ICC

Q: What is the management of occult traumatic pneumothoraces?
A: Observation alone (unless MV)

Q: What is the complication rate of ICC's?
A: 22%

Q: What do you do if the lung does not inflate or persistent air leak occurs?
A: Check all connections and tube positioning then early bronchoscopy for tracheobronchial injury

Q: What is Hamman's sign?
A: Crunching sound over heart during systole indicative of pneumomediastinum

Q: What is the Macklin effect?
A: Alveolar rupture with air dissection along bronchoalveolar sheath into mediastinum

Q: What is the management of pneumomediastinum?
A: Intervene only if symptomatic.
Need to investigate for injury to aerodigestive tract

Q: Where do most tracheobronchial tree injuries occur?
A: Within 2cm of carina

Q: What are the long-term complications of tracheal tears that are not repaired?
A: Mediastinitis, severe bronchial stenosis, lung collapse and recurrent pulmonary infection

Q: What proportion of patients with diaphragmatic injury have CXR changes?
A: 25%

Q: Why are barium swallows recommended after negative water-soluble contrast swallow studies?
A: High false-negative rate

Q: What is the mortality rate of chylothorax?
A: 50%

Q: Where does the thoracic duct enter the circulation?
A: At junction of left subclavian and left internal jugular

Q: What proportion of rib fractures are visible on CXR?
A: 50%

Q: Define flail chest
A: Segmental fractures of 3 or more adjacent ribs

Q: Indications for early intubation in flail chest
A: Shock
Severe head injury
Comorbid pulmonary disease
8 or more ribs
Associated injuries
Age >65
PaO2 <80 despite supplemental O2

Q: Which patients with isolated sternal fractures can be discharged?
A: Otherwise normal CT chest
Normal echo (if performed)
Normal troponin at presentation and 6 hrs (if performed)
Normal ECG at presentation an 6 hours
No ongoing symptoms or signs suggestive of BCI

Q: What is the risk of arrhythmias with sternal fracture?
A: 1.5%

Q: What is the mortality of isolated sternal fractures?
A: 1%

Q: What part of the heart is most commonly involved in penetrating trauma?
A: RV (40%)

Q: Are gun shot wounds or stab wounds more likely to cause tamponade?
A: Stab wounds as gun shot wounds do not seal over

Q: What proportion of traumatic tamponade patients show Beck's triad?
A: 10%

Q: What is pulsus paradoxus?
A: Substantial fall in SBP >20mmHg during inspiration

Q: What is Kussmaul sign?
A: Raised JVP on inspiration indicative of tamponade

Q: What is the cardinal sign of tamponade?
A: Narrowed pulse pressure with elevated CVP

Q: Indications for removal of intracardiac missiles
A: Haemodynamic instability
Free or partially free in LV
Embolised
Embedded in or near coronary artery

Q: Indications for resuscitative thoracotomy
A: Refractory SBP <70 or arrest following blunt (signs of life in ED) or penetrating trauma (signs of life pre-hospital)

Q: ECG signs of blunt cardiac injury
A: Persistent tachycardia
New BBB
ST elevation
AF
Occasional PVC's
VF

Q: What is the most commonly injured coronary artery?
A: LAD

Q: How are blunt coronary injuries treated?
A: PCI with stenting

Q: What is the bruit de Moulin?
A: Mill-wheel sloshing murmur of cardiac rupture

Q: What is the NPV of normal ECG for blunt cardiac injury?
A: 80-90%

Q: What side of the heart is ECG most sensitive for BCI?
A: Left side as ECG predominantly views left heart

Q: When should troponin be performed in the setting of possible BCI?
A: Haemodynamic instability, signs of severe cardiac trauma, abnormal ECG or >60yo

Q: How can blunt cardiac injury be ruled out?
A: Repeated examination, serial ECG and cardiac monitoring for 4-6 hours +- troponin

Q: When is echo indicated in BCI?
A: Unexplained hypotension, high suspicion of injury, abnormal ECG, raised troponin

Q: What is pericardial inflammation syndrome?
A: Delayed hypersensitivity to damaged myocardium presenting 2-4 weeks post-blunt trauma. Treat as per pericarditis

Q: What is the brachiocephalic trunk?
A: Right subclavian and right common carotid

Q: What proportion of traumatic aortic injuries die pre-hospital?
A: 90%

Q: What is the overall survival of traumatic aortic injuries?
A: 1% at 4 months

Q: What is the mortality rate following traumatic aortic injuries per hour?
A: 1% per hour for 24 hours once they reach hospital

Q: What height or speed suggests risk of blunt aortic injury?
A: Fall >3m or MVA >50km/hr

Q: What proportion of thoracic great vessel injuries have external signs of injury?
A: 50%

Q: What defines 'wide mediastinum'?
A: >8cm or ratio > 0.38

Q: How sensitive is normal mediastinum width to rule out thoracic great vessel injury?
A: 95% if <65yo; 80% for all ages

Q: What is the most sensitive sign on CXR of thoracic great vessel injury?
A: Deviation of oesophagus >1cm to right of spinous process of T4

Q: CXR signs suggestive of great vessel injury
A: Wide mediastinum >8cm or ratio >0.38
Loss of normal aortic contour
Loss of aortopulmonary window
Depression of left mainstem bronchus >140 degrees
Loss of paravertebral stripe
Left pleural effusion
Double calcium line
Deviation of NG in oesophagus >1cm to right of T4 spinous process
Apical pleural haematoma
Diaphragm injury

Q: Treatment of thoracic great vessel injury
A: Urgent vascular surgery
HR control - Bisoprolol target 60
BP control target SBP 100-120

Q: Indications for MTP
A: SBP <90
HR >100
BE > -6
FAST/CT positive haemorrhage
Ongoing haemorrhage

Q: Dose of TXA in trauma
A: 1g in 100mL N/S over 10 minutes then 1g over 8 hours
15mg/kg in paediatrics

Q: How often should ROTEM be performed in MTP?
A: 10 minutes after each blood product intervention

Q: How often should FBC, Coags, Ca, ABG be performed in MTP
A: Every 30-60 min

Q: Targets in MTP
A: Temp 36-38
Hb >70
Plt >50
INR < 1.5
Fibrinogen >1.5
iCa >1.1
Lactate <4
pH >7.2, Lactate <4, BE -6 to +6

Q: Reversal of warfarin in acute trauma
A: Vit K 10mg IV + Prothrombinex 50IU/kg + FFP 300mL

Q: Reversal of dabigatran in trauma
A: Idarucizumab 5g bolus

Q: Reversal of apixaban/rivaroxaban in trauma
A: Prothrombinex 50IU/kg

Q: What is the INR of FFP?
A: 1.6

Q: What is in FFP?
A: All coagulation factors at physiological concentrations

Q: What is the usual dose of FFP?
A: 15mL/kg (20% increase in factors)

Q: Does rhesus matter for FFP?
A: No

Q: What is in cryoprecipitate?
A: Fibrinogen, vWF, Factor VIII, Factor XIII and fibronectin

Q: What is the volume of 1U cryo?
A: 30-40mL

Q: What is the usual dose of cryo?
A: 1U/10kg (increases fibrinogen by 0.5-1.0g/L)

Q: What is Novoseven?
A: Recombinant activated Factor VII

Q: What is EXTEM?
A: Tests extrinsic coagulation pathway (tissue factor)

Q: What is INTEM?
A: Intrinsic pathway testing. Heparin sensitive.

Q: What is FIBTEM?
A: EXTEM with platelet inhibitor. Comparison with EXTEM allows for quantification of fibrinogen effect

Q: What is APTEM?
A: EXTEM with aprotinin added (fibrinolysis inhibitor). Comparison with EXTEM identifies hyperfibinolysis

Q: What is HEPTEM?
A: INTEM with heparinase added. Comparison identifies heparin effect

Q: ROTEM Targets?
A: FIBTEM A5 > 10mm
EXTEM CT <80s
EXTEM A10 >40mm

Q: What is indicated if FIBTEM A5 <8?
A: Fibrinogen concentrate 4g or Cryo 20IU

Q: What is indicated if FIBTEM A5 8-10?
A: Cryo 10IU

Q: What is the trimodal distribution of trauma deaths?
A: 50% Immediate - Devastating head/vascular - Prevention only
30% Minutes to hours - Major head/torso - Rapid transport/trauma system improves this
20% ICU - SIRS/MODS - Improved by trauma systems and optimal care in first hours

Q: Mechanistic predictors of life-threatening injury
A: Ejection
MVA >60km/hr
Motorcycle accident >30km/hr
Fall >5m
Vehicle rollover
Fatality in same vehicle
Explosion
Pedestrian impact >30km/hr
Extrication >30 minutes

Q: Vital signs suggestive of life-threatening traumatic injury
A: SBP <100 (<75 in children)
GCS <15
SpO2 <90%
RR <10 or >30

Q: What are the most important variables to measure in trauma audit?
A: Injury severity score (anatomical)
Revised trauma score (physiological)
Age
Comorbidities
Outcome (death/GOS)

Q: What is Class I haemorrhage?
A: Up to 750mL
Up to 15% blood volume
HR <100
BP normal
Pulse pressure normal
Base excess 0 to -2

Q: What is Class II haemorrhage?
A: 750-1500mL
15-30% blood volume
HR 100-120
BP normal
Pulse pressure decreased
BE -2 to -6

Q: What is Class III haemorrhage?
A: 1500-2000mL
30-40% blood volume
HR >120-140
BP decreased
Pulse pressure decreased
BE - 6 to -10
Needs transfusion

Q: What is Class IV haemorrhage?
A: >2000mL
>40% blood volume
HR >140
BP decreased
Pulse pressure decreased
BE > -10
MTP

Q: What defines massive transfusion?
A: >10IU in 24 hours or >4U in one hour

Q: Target SBP in head injury?
A: >100mmHg if 50-69yo
>110mmHg if 15-49 or >70yo

Q: Where should needle decompression be performed?
A: 4th-5th ICS anterior axillary line NOW

Q: What is the traumatic arrest algorithm?
A: Usual ALS
If no ROSC - Bilateral thoracostomy
If no ROSC - Thoracotomy + pericardiotomy
 - Cardiac injury - Repair
 - Severe hypovolaemia - Clamp thoracic bleeding site or aorta if abdominal
Internal cardiac massage +- shock if ongoing arrest
Pronounce death if no ROSC at 30 min and temp >33

Q: Is there benefit to pre-hospital IVC or intubation for paediatric trauma?
A: No proven benefit. Transport is priority

Q: When volume of bleeding from ICC should lead to thoracotomy in paediatric cases?
A: ICC >15mL/kg instant or >4mL/kg/hr

Q: Do older patients have more or less total body water?
A: Less

Q: What is the incidence of falls in those over 65?
A: 35% per year

Q: What proportion of cases of elder abuse are recognised?
A: 15%

Q: What 5 conditions increase mortality in trauma by 2x?
A: Cirrhosis, COAD, Coagulopathy, IHD and DM

Q: How much higher is the risk of death in pelvic fractures in the elderly?
A: 4x

Q: What is the Baux score?
A: Age + BSA = % likelihood of mortality

Q: What Baux score suggests futility?
A: >160 (used to be 110)

Q: What is the mortality in elderly patients with SBP <90 following blunt trauma?
A: 82-100%

Q: Is FAST reliable in the elderly?
A: Yes

Q: What is the sensitivity of CT for pelvic fractures in the elderly?
A: 77% (therefore MRI if uncertain - especially posterior osteoporotic fractures)

Q: Mortality rate following hip fracture in the elderly?
A: 25% at 1 year

Q: Sensitivity of plain film for hip fracture?
A: 90%

Q: What proportion of occult hip fractures are missed on CT?
A: 17% (seen on MRI)

Q: What is the most common fracture in women up to age 75?
A: Colles

Q: Should platelets be given to ICH patients on aspirin or clopidogrel?
A: No PATCH study showed no benefit unless undertaking neurosurgical intervention immediately following

Q: What is the rate of delayed ICH in patients on warfarin?
A: 1-8%

Q: Do all patients on warfarin need to be admitted after head injury?
A: Can observe for 24 hours for delayed ICH or can send home if good family monitoring, lower INR and GP f/u

Q: What is the increase in maternal blood volume in pregnancy?
A: 50%. Peaks at week 28

Q: How much does Hct fall in pregnancy?
A: 33%

Q: How much does HR increase in pregnancy?
A: 10-20/min

Q: How much does BP drop in pregnancy?
A: 10-15mmHg in second trimester only

Q: How much blood volume can be lost in pregnant patient before deranged vital signs?
A: 33^

Q: From what gestation is the uterus intra-abdominal?
A: 12 weeks

Q: Maximal uterine blood flow
A: 600mL/min

Q: How much does diaphragm rise in pregnancy?
A: 4cm (Consider for ICC)

Q: How much does Vt increase in pregnancy?
A: 40%

Q: How much does FRC reduce in pregnancy?
A: 25%

Q: How long should CTG monitoring be continued post-blunt trauma?
A: At least 4 hours

Q: How many contractions per hour suggest further Ix warranted?
A: >3/hour

Q: What is the most sensitive sign of placental abruption in trauma?
A: >3 contractions/hr

Q: After how many weeks gestation does right hip need wedging?
A: >20 weeks

Q: How much should volume resus be increased in pregnancy?
A: 50%

Q: Is FAST accurate in pregnancy?
A: Yes

Q: What is the radiation threshold for human teratogenesis?
A: >5rad = 0.05 Gray = 50mSv

Q: When is the foetus most at risk of death from radiation?
A: 0-2 weeks

Q: When is the foetus most at risk of malformation from radiation?
A: 2-8 weeks

Q: When is the foetus most at risk of CNS teratogenicity from radiation?
A: 8-15 weeks

Q: What are the two best predictors of fetal loss or adverse outcome in blunt pregnant trauma?
A: Severity of crash and not wearing, or inappropriate positioning of a seatbelt

Q: Dose of Anti-D
A: First trimester - 250IU
Second trimester - 625IU
Post-Kleihauer - 100IU per 1mL of fetal red cells (2mL whole blood)

Q: When is anti-D indicated in the first trimester?
A: Complete miscarriage, chorionic villus sampling, termination or ectopic pregnancy
NOT threatened miscarriage <12 weeks

Q: When is anti-D indicated in 2nd trimester?
A: Obstetric haemorrhage, amniocentesis, ECV, abdominal trauma

Q: Discharge criteria for pregnant trauma
A: Obstetric team agree
Reassuring status
Normal CTG >4 hours
No contractions
Bloods checked
Anti-D given if indicated
Social work referral

Q: Discharge info for pregnant trauma
A: PV loss, contractions, signs of preterm labour, abdominal pain, reduced foetal movements

Q: Normal FHR
A: 110-160/min

Q: From what gestation can FHR be identified with Doppler?
A: 12 weeks

Q: What is the lifetime risk of fatal cancer following a single CT scan of 10mSv?
A: 1/2000

Q: What is the annual background radiation in mSv?
A: 2.4

Q: How much radiation is a CT head in terms of annual background?
A: Less than 1 year

Q: How much radiation is a CT chest in terms of background radiation?
A: 2 years

Q: How much radiation is a CT abdo/pelvis in terms of background radiation?
A: Around 2 years

Q: How is minor head injury defined in Canadian CT head rule?
A: Witnessed LOC, amnesia or witnessed disorientation with GCS 13-15

Q: What are the indications for CT head in CCTHR?
A: GCS <15 at 2 hours
Suspected open or depressed fracture
Any sign of basal skull fracture
2 or more vomiting episodes
Age 65 or older
Dangerous mechanism (pedestrian hit by car, ejected, fall >3 feet or 5 stairs)
Retrograde amnesia >30 minutes

Q: Do epidural haematomas cross sutures?
A: No

Q: Do epidural haematomas cross the midline?
A: Yes

Q: Do subdural haematomas cross sutures?
A: Yes

Q: Do subdural haematomas cross the midline?
A: No

Q: What injury patterns are associated with blunt cerebrovascular injury?
A: LeFort 2 or 3
Attempted hanging with anoxic brain injury
Cervical spine subluxation, fractures extending into tranverse foramina or fractures of C1-3
Basilar skull fractures with carotid canal involvement
DAI with GCS <7

Q: What are the grades of BCVI?
A: Grade 1 - Intimal irregularity with <25% narrowing
Grade 2 - Dissection or intramural haematoma with >25% narrowing
Grade 3 - Pseudoaneurysm
Grade 4 - Occlusion
Grade 5 - Transection

Q: What is a blowout fracture?
A: Medial orbital wall or orbital floor fracture

Q: What proportion of cervical spine injuries are missed on plain imaging?
A: 15%

Q: What is the rate of cervical spine injury in traumatic brain injury?
A: 5-10%

Q: What is the sensitivity of NEXUS C-spine rule?
A: 99.6%

Q: What is the sensitivity of the Canadian CT C-spine rule?
A: 100%

Q: How specific is NEXUS C-spine?
A: 12%

Q: How specific is Canadian CT C-spine rule?
A: 42%

Q: How much subluxation of C2 on C3 is allowed in adults and children?
A: 1mm and 3mm respectively

Q: What thickness of prevertebral soft tissue is allowed in adults?
A: 7mm at C2 and 22mm at C6

Q: What prevertebral soft tissue thickness is allowed in children at C6?
A: 14mm

Q: What are Harris' measurements?
A: Basion to tip of dens (BDI)
Basion to posterior axial line (BAI)
Rule of 12's states these should add up to <12mm

Q: How large can space between odontoid peg and anterior arch of C1 be in adults and children?
A: <3mm and <5mm respectively on plain film

Q: Is the Denis three column theory used for cervical spine?
A: No

Q: What are the three Denis columns?
A: Anterior column: Anterior longitudinal ligament and anterior 2/3 of vertebral body
Middle column: Posterior 1/3 of vertebral body and posterior longitudinal ligament
Posterior column: Everything posterior to PLL

Q: Which Denis column injuries are unstable?
A: Anything involving middle column
Posterior + Middle or Anterior

Q: What is DISH?
A: Diffuse interstitial spinal hypertrophy (fused thoracic spine)

Q: What is a carrot stick fracture?
A: Fused thoracic spine fracture through multiple levels

Q: What is a Chance fracture?
A: Flexion/distraction injury around lap belt with horizontal fracture line through all three columns

Q: What volume of blood is required in chest to be seen on supine and erect CXR's?
A: 800-1000mL vs. 200-300mL

Q: What is this a picture of?
A: Right paratracheal stripe
>4mm suggests mediastinal mass/haematoma

Q: What does this indicate?
A: Thoracic great vessel haemorrhage

Q: What does the classic Boerhaave's CXR look like?
A: Pneumomedinastum, subcut emphysema, left pleural effusion

Q: What injuries are commonly missed on CT abdo/pelvis?
A: Small bowel injuries, pancreatic injury, diaphragm injuries and bladder injuries

Q: What is a Grade 1 splenic injury?
A: Subcapsular haematom <10% of surface area
Capsular tear <1cm in depth

Q: What is a Grade 2 splenic injury?
A: Subcapsular haematoma 10-50% or intraparenchymal haematoma <5cm diameter
Capsular tear 1-3cm deep not involving trabecular vessel

Q: What is a Grade III splenic injury?
A: Subcapsular haematoma >50% surface area or expanding or ruptured
Parenchymal haematoma >5cm or expanding or ruptured
Lacerations >3cm depth or involving trabecular vessel

Q: What is a Grade IV splenic injury
A: Segmental or hilar vessel laceration with >25% devascularisation

Q: What is a Grade V splenic injury
A: Completely shattered or devascularised spleen

Q: Sensitivity of FAST
A: 80-100%

Q: Specificity of fast
A: 88-100%

Q: What proportion of posterior pelvic fractures are missed on plain films?
A: 30%

Q: What are the three categories of pelvic fractures in the Young and Resnick classification?
A: AP compression
Lateral compression
Vertical shear

Q: What are the three subtypes of AP compression pelvic fractures?
A: Type I: Symphysis pubis <2.5cm diastasis. No posterior involvement
Type II: >2.5cm symphysis pubis diastisis with anterior SI joint diastasis due to disruption of sacrotuberous and sacrospinous ligaments.
Type III: Complete disruption of hemipelvis anteriorly and posteriorly with anterior and posterior SI joint ligament disruption

Q: What are the three subtypes of lateral compression pelvic fractures?
A: Type I: Oblique pubic ramus fracture with ipsilateral sacral ala compression fracture
Type II: Oblique pubic ramus fracture with ipsilateral posterior ileal fracture dislocation (crescent fracture)
Type III: Ipsilateral LC fracture with contralateral APC fracture (windswept pelvis)

Q: What are the predictors of arterial bleeding in pelvic fracture?
A: >65yo, absence of long-bone fractures with haemodynamic instability

Q: Success rate of angiographic embolisation for pelvic bleeding?
A: 90%

Q: Are open book (APC) fractures more likely to have venous or arterial bleeding?
A: Venous. So pelvic binder and X-fix are methods of choice for management

Q: What signs or symptoms suggest blunt cerebrovascular injury?
A: Carotid bruit, neck pain, arterial haemorrhage, focal neurology incongruous with CT, ischaemic stroke on secondary CT scan

Q: How good is CT angiography for blunt cerebrovascular injury?
A: 97.7% sensitive and 100% specific

Q: What is the medical therapy for blunt cerebrovascular injury?
A: Heparin with low target APTT or aspirin depending on other injuries

Q: Define mild TBI
A: GCS 13-15

Q: Define moderate TBI
A: GCS 9-12

Q: Define severe TBI
A: GCS 8 or less

Q: What proportion of moderate TBI have abnormal CT scan?
A: 40%

Q: What proportion of moderate TBI will need neurosurgical intervention?
A: 8%

Q: What is the mortality for severe TBI?
A: 40%

Q: What proportion of severe TBI have good neurological outcome?
A: <10%

Q: What proportion of head injuries are classified as mild/moderate/severe?
A: 80%/10%/10%

Q: What is the trimodal age distribution of head injury?
A: 0-4yo, 15-24yo and >75yo

Q: What is the lower limit of CPP allowing autoregulation?
A: 60mmHg

Q: What is normal ICP in adults?
A: <10-15cmH20

Q: What is normal ICP in children?
A: 3-7cmH20

Q: What are the three phases of cerebral blood flow following head injury?
A: Hypoperfusion phase (72hrs) - CPP directly proportional to MAP with loss of autoregulation
Hyperaemic phase (7-10 days) - Autoregulation recovers and targeted CPP results in vasogenic oedema
Vasospastic phase

Q: What different types of herniation can occur in head injury?
A: Subfalcine, central/descending transtentorial, ascending transtentorial, tonsillar

Q: What vessel is at risk from subfalcine herniation?
A: Anterior cerebral artery

Q: What is descending transtentorial herniation?
A: Uncus of temporal lobe herniats inferiorly through tentorium

Q: What structures are compressed by descending transtentorial herniation?
A: CN III Parasympathetics - Ipsilateral dilated pupil
Posterior cerebral artery - Visual defect
Cerebral peduncle - Contralateral paresis
Sylvian aqueduct - Hydrocephalus of 3rd and lateral ventricles

Q: What are Duret haemorrhages?
A: Midbrain and upper pons haemorrhages due to tearing of vessels in descending transtentorial herniation. Very poor prognosis

Q: What is central herniation?
A: Bilateral uncal and midbrain herniation through tentorium

Q: How does central herniation present?
A: Bilateral pinpoint pupils, Babinski and increased muscle tone

Q: How does upward transtentorial herniation occur?
A: Posterior fossa lesions

Q: How does upward transtentorial herniation present?
A: No localising signs OR bilateral pinpoint pupils, conjugate downward gaze and no vertical eye movements

Q: How does coning appear on CT?
A: Cerebellar tonsils >5mm below foramen magnum in adults (>7mm in children)

Q: How does coning present clinically?
A: Pinpoint pupils, flaccid paralysis, Cushing's triad and sudden death

Q: GCS Eyes
A: 4 - Spontaneous
3 - To speech
2 - To pain
1 - None

Q: GCS Verbal
A: 5 - Alert and oriented
4 - Disoriented
3 - Non-sensical words
2 - Incomprehensible sounds
1 - None

Q: GCS Motor
A: 6 - Follows commands
5 - Localises to pain e.g. hand crosses midline and gets above clavicle to supraorbital pressure
4 - Withdraws from pain
3 - Abnormal flexion
2 - Abnormal extension
1 - None

Q: What are the benefits and disadvantages of the New Orleans criteria?
A: 100% sensitive for CT finding and neurosurgical intervention but only 5% specific so results in overutilisation

Q: What are the high risk factors for neurosurgical intervention in the Canadian CT head rule?
A: Sign of basilar skull fracture
Open or depressed skull fracture
2 or more vomiting episodes
GCS <15 at 2 hours
Age >65

Q: What are the medium risk criteria for abnormal CT in the Canadian CT head rule and what difference does it make?
A: Retrograde amnesia >30 minutes and dangerous mechanism (>3ft or struck pedestrian).
If only medium risk factor can observe vs. CT

Q: What are the exclusion criteria for the Canadian CT head rule?
A: Age <16
>24 hours since injury
GCS <13 at any stage
No amnesia/LOC/disorientation at any stage
Focal neuro deficit
Unstable vital signs
Seizure
Bleeding disorder or use of antiplatelets/anticoagulants
Returned discharge
Pregnant

Q: What are the NEXUS CT head criteria?
A: Age >65, evidence of skull fracture, scalp haematoma, altered LOC, neuro deficit, abnormal behaviour, coagulopathy, persistent vomiting

Q: What is the mortality risk increase with hypotension or hypoxia in head injury?
A: 150%

Q: Which head injury patients warrant anticonvulsants?
A: GCS <11, acute seizure with injury or abnormal CT head (in liaison with Neurosurg)

Q: What is the prophylactic keppra dose in head injury?
A: 1g load then 500mg BD for 7 days

Q: What is the dose of Mannitol for raised ICP?
A: 1g/kg IV bolus targeting serum osmolality 300-320

Q: What is the dose of hypertonic saline for raised ICP?
A: 2-5mL/kg of 3% NaCl over 30 minutes repeated as necessary. Target Na 150-155 if raised ICP

Q: Above what PEEP may cerebral venous return be limited?
A: 15cmH20

Q: When does neurogenic pulmonary oedema usually occur?
A: 2-8 hours post-injury

Q: Target SBP in severe head injury
A: >100mmHg for 50-69yo and >110mmHg for 15-49 and >70yo

Q: What did the POLAR trial show?
A: Targeting 33-35 for at least 72 hours and up to 7 days in severe head injury vs. 37 showed no improvement in neurological outcome at 6 months

Q: Do prophylactic anticonvulsants prevent seizures in severe head injury?
A: Only for first week

Q: Phenytoin dose in seizure prophylaxis for severe head injury?
A: 20mg/kg IV

Q: What are risk factors for post-traumatic seizures?
A: GCS <10
Cortical contusion
Depressed skull fracture
Subdural/epidural/intracerebral haematoma
Penetrating wound
Seizure within first 24 hours

Q: What are first-tier interventions for raised ICP?
A: Head up 30, sedation, analgesia, NM blockade, vent CSF if drain in, PaCO2 35
 - All the normal primary interventions on admission

Q: How often can mannitol be given?
A: q3h

Q: What is the final tier of raised ICP Rx?
A: Barbiturate coma
Therapeutic hypothermia
Aggressive hyperventilation to PaCO2 25-30
Decompressive craniectomy
Lumbar CSF drainage

Q: Indications for CPP monitoring
A: Abnormal CT and GCS <9
Normal CT with two or more:
 - Age >40
 - Unilateral or bilateral motor posturing
 - SBP<90

Q: Target CPP in head injury
A: 60-70mmHg

Q: What proportion of patients with severe head injury suffer a delayed secondary haemorrhage?
A: 10%

Q: Indications for antibiotics with skull fracture?
A: Open or depressed
Involving sinus
Pneumocephalus

Q: Antibiotic indicated in skull fracture?
A: Should be considered for open or depressed skull fractures and base of skull fractures.
Evidence is not clear on benefit in base of skull fracture.
Vancomycin 1g IV then 500mg BD and ceftriaxone 2g IV BD

Q: What is the most common CT finding in moderate-severe TBI?
A: Subarachnoid haemorrhage

Q: When is CT most sensitive for traumatic SAH?
A: 6-8 hours post-injury

Q: What proportion of epidural haemotoma patients have classic lucid period?
A: Only 20%

Q: Which patients have better outcomes: Epidural or subdural?
A: Epidural as typically underlying brain tissue is not significantly damaged vs. subdural

Q: Which has higher mortality: Epidural or subdural?
A: Subdural by 3x (75% vs. 25%)

Q: Classic CT findings of DAI?
A: Punctate haemorrhages along gray-white margin and in deep white matter +- oedema

Q: What is second impact syndrome?
A: Theorised rapid cerebral oedema and death in the setting of a second hit during recovery phase of concussion

Q: Discharge info for minor head injury
A: Rest (cognitive and physical)
Avoid aspirin/NSAID's/anticoagulants
Responsible adult/carer
Return for worsening symptoms, headache, abnormal behaviour, nausea, vomiting
Refer to OT for concussion monitoring/Rx
Athletes return to activity guided by symptoms

Q: What is the mortality of second-impact syndrome?
A: 60-80%

Q: What is the mortality rate of ICH on warfarin?
A: 89%

Q: What is the odds ratio for ICH in mild head injury while on antiplatelets?
A: 2.6

Q: Do patients on aspirin with ICH need desmopressin?
A: No

Q: What were the results of RESCUEicp?
A: Unilateral decompression for large mass lesion or bifrontal DC for diffuse oedema in the setting of raised ICP resulted in:
Reduced death
Increased vegetative state
Of 100 patients, 22 extra survivors( 6 vegetable, 8 lower severe disability and 8 upper severe disability or better)

Q: What proportion of facial traumas have visual loss?
A: 6%

Q: What proportion of severe facial trauma require intubation?
A: 44%

Q: What proportion of those with facial injuries have closed head injury?
A: 15%

Q: Screening questions in facial trauma
A: How is your vision?
Is your face numb?
Do your teeth fit together normally?

Q: What does monocular double vision indicate in facial trauma?
A: Lens dislocation

Q: When should hyphaema be checked for in facial trauma?
A: After sitting up for several minutes

Q: Clinical test for mandibular condyle fracture?
A: Finger in the ear and ask patient to open and close jaw

Q: What is the tongue-blade test?
A: If patient can bite down on tongue blade and allow physician to twist and break it = 96% sensitive to rule out mandibular fracture

Q: How sensitive is an OPG for mandibular fracture?
A: 80%

Q: Which part of mandible is least well visualised on OPG?
A: Condyle

Q: What is the management of non-displaced frontal sinus fractures without posterior table involvement?
A: PO cephalexin/augmentin, decongestants and suitable follow-up

Q: What is the management of depressed frontal bone fractures?
A: IV cephalexin +- vancomycin and admission for operative repair

Q: Management of isolated orbital fractures
A: Augmentin, decongestants, sinus precautions and d/w MaxFax re: timing of repair

Q: What is orbital fissure syndrome?
A: Fracture of superior orbital fissure with impaired fx of III IV VI and V1

Q: What is orbital apex syndrome?
A: Orbital fissure syndrome + optic nerve involvement

Q: Primary indications for lateral canthotomy
A: Decreased visual acuity
IOP >40
Proptosis

Q: Contraindication to lateral canthotomy
A: Globe rupture

Q: Steps in lateral canthotomy
A: Consent
Local anaesthetic
Compress lateral canthus with forceps for 1 minute to devascularise
Scissors to cut down laterally
Pull lower eyelid away and then cut inferior part of lateral canthal tendon then cut superior one if required

Q: What is a tripod fracture?
A: Zygomaticotemporal junction
Zygomaticofrontal junction
Inferior orbital rim

Q: Management of tripod fractures
A: IV Cephalexin 1g TDS, sinus precautions, inpatient repair

Q: What is a LeFort IV
A: LeFort III + frontal bone involvement

Q: What proportion of mandibular fractures are bilateral?
A: 64%

Q: What is an Andy Gump fracture?
A: Bilateral mandibular fracture with risk of airway occlusion from posterior displacement of tongue

Q: Borders of posterior triangle
A: Posterior border SCM, anterior border trap and middle third clavicle

Q: Borders of anterior triangle
A: Midline, mandible and anterior border SCM

Q: What are the three zones of the neck?
A: All anterior triangle
Zone 1 - Clavicles to cricoid cartilage
Zone 2 - Cricoid to angle of mandible
Zone 3 - Angle of mandible to base of skull

Q: Contents of Zone 1
A: Proximal carotid/vertebral arteries
Major thoracic vessels
Superior mediastinum
Lungs
Trachea
Oesophagus
Thoracic duct
Spinal cord

Q: Contents of zone 2
A: Carotid and vertebrals
Jugular veins
Oesophagus
Trachea
Larynx
Spinal cord

Q: Zone III contents
A: Distal carotid/vertebrals
Pharynx
Spinal cord
NO oesophagus or trachea

Q: Success rate of RSI in neck injuries?
A: 98%

Q: Can cricothyroidotomy be performed in children?
A: Yes but needle cric mandatory if <8 and advised if <12yo

Q: What proportion of penetrating neck trauma have pneumo- or haemothorax?
A: 20%

Q: Most common cause of death in penetrating neck injury?
A: Exsanguination

Q: In isolated penetrating neck injury, should the patient be kept in C-spine collar?
A: If gunshot yet, if stabbing no

Q: Screening tests for neck wounds
A: Ask to cough (haemoptysis), swallow (dysphagia) and speak (laryngeal fracture)

Q: How sensitive is careful examination for significant aerodigestive and vascular injuries in penetrating neck trauma?
A: 95%. Oesophageal and venous injuries most commonly missed

Q: What proportion of patients will have serious injury requiring repair in the presence of a hard sign?
A: 90%

Q: Hard signs of vascular injury
A: Refractory shock
Active arterial bleeding
Pulse deficit
Pulsatile/expanding haematoma
Thrill/bruit

Q: Hard signs of laryngotracheal injury
A: Stridor
Haemoptysis
Dysphonia
Air bubbling in wound
Airway obstruction

Q: Hard signs of oesophageal injury
A: None

Q: Soft signs of vascular neck injury
A: History of arterial bleed
Hypotension in the field
Haematoma (non-pulsatile/expanding)
Proximity wounds

Q: Soft signs of laryngotracheal injuries
A: Subcutaneous emphysema
Hoarseness
Neck tenderness
Tracheal deviation/step
Laryngeal oedema/haematoma
Restricted vocal cord mobility

Q: Soft signs of aerodigestive tract injury
A: Dysphagia
Odynophagia
Subcut emphysema
Haematemesis
Blood in mouth
Saliva from wounds
Severe neck tenderness
Prevertebral air
Transmidline trajectory

Q: Management of stable penetrating neck trauma violating platysma with hard signs
A: OT or interventional radiology

Q: Management of stable penetrating neck trauma violating platysma without hard signs
A: MDCTA +-
Suspicion of pharyngo-oesophageal - Water-soluble contrast swallow study +- barium swallow study if negative +- oesophagoscopy
Suspicion of laryngotracheal injury - Bronchoscopy
Suspicion of vascular injury - OT or interventional radiology

Q: Management of penetrating neck injury with venous damage
A: Usually non-operative

Q: Management of laryngotracheal hard signs
A: Urgent OT

Q: Which laryngotracheal injuries need operative repair?
A: Any with hard signs
Any displaced laryngeal fractures
Exposed cartilage
Vocal cord immobility
Complete separation

Q: Management of pharyngeal and oesophageal perforations
A: Pharyngeal perforations >2cm and all oesophageal perforations need operative repair, IV antibiotics (ampicillin 2g q6h, gent 5mg/kg IV stat and metronidazole 500mg BD IV) and NBM

Q: Management of asymptomatic patients post-attempted hanging
A: CXR, CT head +- neck CTA if concern, laryngobronchoscopy if any airway concern
Observe 24 hours for delayed airway compromise or respiratory/neurological dysfunction

Q: What proportion of benign initial abdominal examinations have injuries?
A: 45%

Q: How can duodenal injuries not be missed?
A: Low threshold for CT of abdominal trauma then repeated examination even if negative CT

Q: Management of penetrating abdominal stab wounds
A: Stable - CT + local exploration of anterior stab wounds for peritoneal violation
Unstable - Red blanket

Q: Absolute indications for laparotomy in blunt abdominal trauma
A: Anterior abdominal wall injury with hypotension
Abdominal wall disruption
Peritonitis
Free air
Positive FAST and unstable
CT diagnosed injury requiring surgery

Q: Relative indications for laparotomy in blunt abdominal trauma
A: Positive FAST and stable
Free fluid on CT of unclear source
Solid visceral injury on CT and stable

Q: Absolute indications for laparotomy in penetrating abdominal trauma
A: Injury with hypotension
Abdominal tenderness
Evisceration
High-suspicion of trans-abdominal trajectory of gunshot
CT-diagnosed injury requiring surgery
Free air

Q: Relative indication for laparotomy in penetrating abdominal trauma
A: Positive wound exploration

Q: Which solid organ injuries are best managed non-operatively?
A: Non-vascular injuries in younger patients

Q: Why is physical examination insensitive in flank injuries?
A: Retroperitoneal injuries may not produce peritonism

Q: Management of penetrating flank trauma
A: If unstable or peritonitic - urgent laparotomy
If stable - Triple contrast (PO/IV/PR) CT (in reality probably just IV +- PR)

Q: Examination in penetrating buttocks trauma
A: PR
Evaluate for haematuria
Assess peripheral pulses
Assess peripheral neurology

Q: What proportion of pelvic fractures have urethral injuries?
A: 5-10%

Q: Does microscopic haematuria make genitourinary trauma more likely?
A: No

Q: Does gross haematuria make genitourinary trauma more likely?
A: Yes

Q: Which patients need scanning with microscopic haematuria?
A: Transient hypotension
Rapid deceleration mechanism
Obvious flank/back tenderness
Scanning for other reason

Q: What does early contrast extravastation around genitourinary structures suggest?
A: Active haemorrhage

Q: What does late (10min) contrast extravasation around genitourinary structures suggest?
A: Urinary extravasation

Q: What is a Grade 1 renal injury?
A: Haematuria with contusion
Subcapsular non-expanding haematoma
No laceration

Q: What is a Grade 2 renal injury?
A: Peri-renal non-expanding haematoma
<1cm cortical laceration
No urinary extravasation

Q: What is a Grade III renal injury?
A: >1cm cortical laceration with no collecting system involvement or urinary extravasation

Q: What is a Grade IV renal injury?
A: Laceration through to collecting system or segmental vessel injury with haematoma

Q: What is a Grade V renal injury?
A: Shattered. 82% nephrectomy rate

Q: When is operative renal exploration indicated?
A: Grade V injury
Life-threatening haemorrhage
Expanding, pulsatile or non-contained retroperitoneal haemorrhage of renal source

Q: Management of urinary extravasation
A: Usually observed unless other indication for nephrectomy/exploration

Q: What are the long-term complications of renal injuries?
A: Urinomas
Delayed bleeding (25% of Grade III/IV injuries)
Perinephric abscess formation
HTN
Renal failure

Q: Disposition of renal injuries
A: Class I injury - Urology consult and likely d/c
Gross haematuria without Class I - Observe until resolved
Grade II or higher - Admit under trauma service

Q: What proportion of patients with ureteral injury have micro- or macroscopic haematuria?
A: Only 70%

Q: Which ureteral injuries need operative intervention?
A: All

Q: Which patients typically suffer bladder rupture in MVA?
A: Typically intoxicated patients (full bladder)

Q: How do bladder injuries present?
A: Gross haematuria with lower abdominal pain
Abdominal distension
Scrotal swelling from urinary extravasation

Q: Is a delayed contrast CT suitable for assessment of bladder integrity?
A: No. Not sensitive enough. Need at least 350mL retrograde cystourethrogram to rule out bladder injury

Q: How are bladder injuries classified?
A: Extra/Retroperitoneal (55%)
 - Typically bladder drainage alone with observation (unless bladder neck involved, other injuries)
Intraperitoneal (38%)
 - All need operative repair

Q: What is the classic triad of posterior urethral injuries?
A: High-riding prostate, urinary retention and haematuria

Q: When should retrograde cystourethrogram be timed compared to other imaging?
A: Only after CT as may obscure images

Q: Management of males with posterior urethral injury
A: Immediate SPC with endoscopic repair

Q: What is the salvage rate of testicular rupture?
A: Up to 90% if treated promptly

Q: Management of penile fractures?
A: Immediate urology consult to maintain erectile function

Q: Management of penile trauma in presence of prosthetics
A: Early urology consult for even minor trauma

Q: What is the primary blast injury?
A: Direct effect of blast wave pressure on air-filled structurs

Q: What is spalling?
A: Displacement of dense medium in to less dense medium e.g. lung tissue into alveolar space

Q: What is shearing injury?
A: Primary blast wave travels through different density mediums at different velocities

Q: What is implosion blast injury?
A: Primary blast wave causes less dense medium to enter more dense medium e.g. air embolism. Opposite of spalling

Q: What are three mechanisms of primary blast wave injury?
A: Spalling, shearing and implosion

Q: What are secondary blast injuries?
A: Collateral damage from flying objects

Q: What are tertiary blast injuries?
A: Victim thrown against stationary objects

Q: What are quaternary blast injuries?
A: Burns and smoke inhalation

Q: What is the most common fatal primary blast injury?
A: Pulmonary barotrauma

Q: Can perforation of TM be used to prognosticate blast injuries?
A: No. Misses 50% of lung injuries

Q: What is crush syndrome?
A: Systemic manifestation of muscle cell damage with/without compartment syndrome

Q: 5P's of compartment syndrome
A: Pain, pulseless, pain with passive stretch, paraesthesia, pressure

Q: Definition of compartment syndrome
A: Absolute pressure >30mmHg or Delta <30mmHg

Q: How often should labs be done on possible crush injured patients?
A: q2-4h UEC, CMP, CK, VBG, FBC

Q: Target UO in crush syndrome
A: 200-300mL/hr

Q: Indications for fasciotomy
A: Absent peripheral pulses, debridement of necrotic wounds, compartment pressure >30

Q: What proportion of burns centre admissions are due to chemical burns?
A: 10%

Q: What proportion of burns deaths are due to chemical burns?
A: 30%

Q: Which chemical burns cases should not receive immediate copious irrigation?
A: Sodium metals, dry chemical particles e.g. lime and phenol (carbolic acid) should all be removed first as water induces exothermic reaction

Q: What sort of necrosis occurs by acids?
A: Coagulative necrosis

Q: What sort of necrosis is caused by alkalis?
A: Liquefactive necrosis

Q: How are phenol burns managed initially?
A: Dilution of phenol with water increases penetration and water does not reach phenol trapped under eschar. Can use undiluted PEG or isopropyl alcohol

Q: How does hydrofluoric acid causes burns?
A: Hydrogen ions cause direct cellular damage
Free fluoride ions scavenge Ca and Mg to disrupt cellular membranes and inhibit Na/K ATPsae

Q: What is the best indicator of ongoing damage in fluoric acid burns?
A: Ongoing pain

Q: Management of hydrofluoric acid burns
A: Water irrigation for 30 minutes
Topical calcium gluconate (25m 10% calcium gluconate in 75mL lubricant)
Intra-dermal calcium gluconate (0.5mL/cm2 of 10% calcium gluconate)
Intra-arterial calcium gluconate via arterial line proximal to site (10mL 10% calcium gluconate + 40mL 5% dextrose over 4 hours)

Q: Management of hydrofluoric acid burns under nailbeds?
A: Removal of nail and direct intradermal injection of 10% calcium gluconate 0.5mL/cm2 to nailbed

Q: Management of inhalational injury from hydrofluoric acid
A: Nebulised 10% calcium gluconate 1.5mL in 4.5mL sterile water

Q: Management of intraocular HFl acid contamination
A: 30 minutes water and urgent ophthal
No calcium-containing substance

Q: Management of VF secondary to HFl acid toxicity
A: 10mL 10% IV calcium chloride + 5mmol MgSO4 stat repeated q5min until ROSC

Q: Management of embedded burning metal fragments
A: Do not use water and can spontaneously ignite.
Mineral oil is best and then excise

Q: Management of ocular chemical burns
A: At least 30 minutes irrigation. If no obvious injury, can cease when pH 7.4
If injury exists, continue for at least 2-3 hours to ensure anterior chamber neutralisation

Q: What defines high-voltage?
A: >600V

Q: What is more dangerous: AC or DC?
A: AC at same voltage is more dangerous as risk of tetany (cannot let go) and risk of VF

Q: Which patients need ongoing cardiac monitoring following electrical injury?
A: >1000V, symptomatic or abnormal initial ECG

Q: How sensitive is MRI for spinal cord injuries in electrical trauma?
A: Can have normal MRI with permanent spinal cord injury in this situation

Q: What proportion of patients have spinal cord injuries following high-voltage electrical trauma?
A: 8%

Q: What are risk factors for significant tissue damage from electrical trauma?
A: >1000V, full-thickness skin burns, prehospital cardiac arrest, crush injury

Q: How far away should one stay from downed power lines?
A: 10m

Q: Disposition of low-voltage injuries (<600V)
A: If <240V, asymptomatic and normal ECG - Discharge
If 240-600V, symptomatic or abnormal eCG - Monitor for 4-6 hours and reassess

Q: Disposition of high-voltage (>600V) electrical injuries
A: Admit all for observation with cardiac monitoring if >1000V, symptomatic or abnormal ECG

Q: What are children at risk of after mouth burns?
A: Labial artery necrosis and haemorrhage

Q: When does labial artery eschar separate after mouth burn in child?
A: Day 5

Q: Mortality rate of lightning injuries
A: 10-30%

Q: What proportion of survivors of lightning strikes will have permanent sequelae
A: 75%

Q: What is keraunoparalysis?
A: Lower limb > upper limb paralysis and sensory abnormalities following lightning strike

Q: What rhythm do lightning strike victims go into?
A: Complete asystole with potential for spontaneous reversion of sinus rhythm (vs. VF with lower voltage AC injuries)

Q: What is reverse triage?
A: Lightning strike victims should be reverse triaged...that is, those that appear dead should be treatedfirst

Q: What prognostic significance does mydriasis and anisocoria have in lightning strike victims?
A: None

Q: What are Lichtenberg figures?
A: Superficial feathering/ferning pattern due to electron showering over skin. Resolve in 24 hours

Q: What proportion of thermal burn victims are male?
A: 70%

Q: Overall mortality rate of thermal burns?
A: 4%

Q: What are the three zones of thermal burns?
A: Zone of coagulation: Irreversibly destroyed
Zone of stasis: Stagnant microcirculation. Resus aims at preserving this
Zone of hyperaemia: Increased blood flow

Q: What percentage does head make up in rule of 9's?
A: 9%

Q: What percentage does front of torso make up in rule of 9's?
A: 18%

Q: What percentage does back make up in rule of 9's?
A: 18%

Q: What proportion does whole leg make up in rule of 9's?
A: 18%

Q: What proportion does whole arm make up in rule of 9's?
A: 9%

Q: What proportion does back of patients hand equate to?
A: 1%

Q: Which burns are included in BSA calculation?
A: Partial and full thickness burns only

Q: How long do superficial burns take to heal?
A: Up to 7 days

Q: How long do superficial partial thickness burns take to heal?
A: 14-21 days

Q: How do superficial partial thickness burns appear?
A: Erythematous, moist, blisters with brisk capillary return

Q: How do deep partial thickness burns appear?
A: Pale exposed dermis, blisters, sluggish capillary refill

Q: How do full thickness burns appear?
A: Pale, non-blanching, leathery. Insensate.

Q: How long do deep partial thickness burns take to heal?
A: 3-8 weeks

Q: What are fourth degree burns?
A: Those involving bone and muscle

Q: What defines a major burn by BSA
A: BSA >25% if 10-50yo
BSA >20% if <10 or >50yo
Full thickness >10% BSA

Q: What is the primary cause of mortality in burn injured patients?
A: Inhalational injury

Q: Physical signs of inhalational injury
A: Soot at nares, hoarse voice, carbonaceous sputum, intra-oral burns, hair loss around mouth/nose, expiratory wheeze

Q: What proportion of intubated burns patients suffer ARDS?
A: 50%

Q: Indications for intubation post-thermal burn
A: Full thickness burns to face
Circumferential neck burns
Acute respiratory distress
Progressive dyspnoea/hoarseness
Respiratory depression
Reduced LOC
Supraglottic oedema/inflammation on laryngoscopy
Anticipated clinical course
High pain relief requirements (humane)

Q: Which patients require NG insertion after thermal burns?
A: Intubated and those with partial thickness >20% as highly likely to suffer ileus

Q: Which patients require modified Parkland's resuscitation?
A: Adults >20% deep partial thickness and full thickness
Children >10% BSA deep partial and full thickness

Q: Modified Parkland's formula in adults
A: 2mL/kg/BSA over 24 hours Hartmann's
4mL/kg/BSA for electrical burns
Half in first 8 hours and next half over next 16
Target UO 0.5mL/kg/hr

Q: Modified Parkland's formula for children
A: 3mL/kg/BSA over 24 hours (first in 8 hours then next over 16 hours) + maintenance targeting UO 1mL/kg/hr
Hartmann's

Q: How to perform escharotomy?
A: If suspicion of peripheral vascular compromise/ventilatory compromise
Scalpel to depth of fat along mid-lateral limbs
For trunk - 2nd to 12th ICS in anterior axillary line joined across chest wall

Q: Which blisters need debridement post-thermal burn?
A: Ruptured ones and large intact ones or those over joints

Q: Absorbant dressing post-burn
A: Mepilex

Q: Balanced dressing post-thermal burn
A: Mepitel

Q: Hydrating dressing post-thermal burn
A: Solusite with secondary dressing

Q: Absorbant antimicrobial dressing post-thermal burn
A: Acticoat 3 or 7

Q: Hydrating antimicrobial dressing post-thermal burn
A: Flamazine (1% silver sulfadiazine)

Q: Target SBP and MAP in paediatric resuscitation
A: MAP = 40+ Age x 1.5 (5th centile)
SBP = 70 + Age x 2 (5th centile)
*Best target is mentation/cap refill/UO

Q: When may subdural haematoma be treated conservatively?
A: Haematoma <10mm (even if coma)
No clinical or CT signs of hernation or raised ICP
Midline shift <5mm
GCS score not dropped by >=2 points from time of injury to admission
Clinically stable or improving
ICP <20mmHg

Q: Which patients with extradural haematomas can be managed conservatively?
A: Haematoma volume <30mm3
Clot thickness <15mm
Midline shift <5mm
No pupillary abnormalities
Mildly symptomatic only (GCS >8)
No focal neurological deficits

Q: Management of nasal septal haematoma
A: Topical lignocaine spray
Incision
Nasal packing
Flucloxacillin PO 500mg QID
Review in 24 hours (may recur)

Q: What is a naso-orbito-ethmoid complex fracture?
A: Squashed nasal bridge with avulsion of meial canthal ligaments
Intercanthal distance >3.5cm is suggestive and >4cm is diagnostic

Q: Management of TMJ dislocation
A: OPG if suspect fracture
If fractures of neck/head of mandible - MaxFax
Analgesia/light sedation
Place double-gloved thumbs on posterior lower molars and other fingers on anterior inferior body of mandible
Rapid downward pressure with thumbs and upward pressure with fingers on opposite side until clunks in
Repeat on other side (high failure rate if attempt to relocate both sides at once)
No need for XR unless suspect #
Soft, thin food for days and refer recurrent dislocators for repair

Q: Which orbital blowout fractures need repair?
A: Entrapment, diplopia in primary position, persistent symptoms or cosmetic reasons

Q: When should teeth not be reimplanted?
A: Primary teeth
Fractured root
Alveolar margin fracture

Q: Analgesia options in rib fractures
A: IV opiates
IV ketamine
Intercostal block 20mL 0.25% bupivacaine (Max 2mg/kg)
PCA

Q: Delta gap calculation
A: Change in AG (12) / Change in bicarb (24)

Q: Delta gap interpretation
A: <0.4 - Hyperchloraemic NAGMA
0.4-0.8 - Mixed HAGMA/NAGMA
0.8-2 - Pure HAGMA
>2 - HAGMA + Pre-existing metabolic alkalosis/compensation for respiratory acidosis

Q: Cannula used for decompression of tension PTX?
A: 16G

Q: 3/3/2 rule for airway assessment
A: 3 fingers mouth opening
3 fingers thyromental distance
2 fingers thyrohyoid distance

Q: Management of air embolism
A: 100% O2
Left lateral decubitus position
Trendelenberg

Q: Strangulated hernia
A: Ischaemic hernia

Q: Incarcerated hernia
A: Trapped but not ischaemic

Q: Which burns need referral to burns centre?
A: Suspected inhalational injury
Suspected infection
>10% TBSA
>5% full thickness
Special areas: Face, genitals, perineum, hands, feet, major joints
Circumferential
Chemical burns
Electrical burns
Children/elderly
Immunosuppressed/T2DM/Comorbidities
Pregnant
Associated trauma

Q: What did the DORM study show?
A: Droperidol 10mg vs. Midazolam 10mg vs. Combination 5/5
No difference in time security staff required
More additional sedation with midaz
More oversedation with midaz
No evidence of QT prolongation vs. midazolam

Q: What did DORM-II show?
A: 49 patients had ketamine rescue 50-500mg (median 300mg IM)
Safe with no obvious harms
Median time to sedation 20min
<200mg associated with treatment failure

Q: Target osmolarity with mannitol in raised ICP?
A: 300-320mOsm/L

Q: What did CRASH-I trial show?
A: Methylpred 2g load and 0.4g/hr infusion for clinically significant head injury (GCS 14 or less) in adults resulted in worsened mortality and severe disability. Strongly advised against.

Q: ED indications for placement of tourniquet
A: Alternative haemorrhage techniques ineffective
Unstable with ongoing haemorrhage requiring rapid control
Multitrauma with active arterial bleeding and other priorities

Q: Removal of pre-hospital tourniquet
A: Analgesia/sedation
Pneumatic tourniquet above (deflated initially)
Equipment for haemorrhage control prepared
Ensure appropriate surgical team present
If re-bleeds, trial other means but may require pneumatic inflation

Q: After how many hours is reperfusion injury a risk wth tourniquet use?
A: >2 hours

Q: Should tourniquet be left in place for CT-A?
A: If unstable - Yes
If stable - Attempt deflation and alternative haemorrhage control techniques prior

Q: What is the standardised concussion assessment tool?
A: SCAT-5

Q: Concussion advice
A: Rest for a few days with avoidance of behaviours that worsen symptoms
Avoid alcohol, drugs, aspirin/NSAID
Do not drive until cleared
Gradually increase ADL's after a few days and do not increase activity level if symptoms worsen
Gradual return to sport only once ADL's completed without issue

Q: ROTEM targets in trauma
A: Fibtem A5 >10mm
EXTEM CT < 80s
EXTEM A1 >40mm

Q: What did the PROMMTT trial show?
A: 1:1 ratios of PRBC:FFP and platelets reduced mortality at 24 hours in trauma patients receiving at least 3U of PRBC in first 24 hours vs. 1:2 or greater

Q: What is telecanthus?
A: Widened intercanthal distance = nasoethmoidal complex injury

Q: What is the most common localised disaster?
A: Chemical accident

Q: What is the most widely used anatomical trauma score?
A: Injury severity score

Q: How does the injury severity score work?
A: Sum of squares of abbreviated injury scale of three most severely injured body regions

Q: What is the most widely used physiological trauma score?
A: Revised trauma score

Q: How does the revised trauma score work?
A: Lower score = worse = GCS + SBP + RR

Q: Indications for REBOA
A: Traumatic life-threatening haemorrhage below the diaphragm in patients with haemorrhagic shock unresponsive or transiently responsive to resuscitation

Q: 2 contraindications to FAST in trauma?
A: More pressing issue e.g. airway obstruction
Obvious requirement for laparotomy e.g. penetrating trauma to abdomen

Q: Prognostic factors in hanging?
A: Downtime
Arrest at scene
Comorbidities
Current injury severity
Estimated height of fall

Q: Exclusion criteria for original Canadian CT C-spine rule?
A: Age <16
GCS <15
Chronic vertebral disease
Previous cervical spinal surgery
Paralysis
Penetrating trauma
Atraumatic
Return for assessment of same injury
Pregnant