Term
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Definition
Coma is a state of profound unconsciousness caused by disease, injury or poison.
The patient is unresponsive and cannot be roused. |
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Term
| Name some neurological causes of unconsciousness (3) |
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Definition
1. epilepsy and status epileptics
2. raised ICP e.g. cerebral oedema
3. obstructive hydrocephalus |
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Term
| Give some toxic/drug induced causes of unconsciousness |
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Definition
Ethanol
Drug OD: opiates, BDZ, neuroleptics
Sedatives
Rec drugs: ecstasy, cocaine, gamma hydroxybutyrate
poisons: Carbon monoxide, solvents |
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Term
| Name some metabolic causes of unconsciousness |
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Definition
Hypo/hyperglycaemia
hypo/hypernatremia
Hypercapnia
hypercalcemia
hypoxia/anoxia
hypopituItarisms
hypothyroidism
liver/renal failure
acid base disturbances |
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Term
| Name some endocrine causes for unconsciousness |
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Definition
DKA
hyperthyroid
hypothyroid
hypo pituitary
hypercalcemia
hypoglycaemia |
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Term
| Give some e.gs of traumas that can result in unconsciousness |
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Definition
Subdural hematoma
depressed cranial fracture
intracerebral bleed
SAH |
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Term
| Name some ischemic causes to unconsciousness |
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Definition
CVA
cerebral hypo perfusion secondary to reduced CO
intracerebral bleed
hypertensive encephalopathy |
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Term
| Give some infections samples that can result in unconsciousness |
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Definition
Meningitis
encephalitis
septicemia
Abscess
malaria
toxoplasmosis |
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Term
| Are there any AI conditions that could lead to coma? |
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Definition
Yes: Vasculitis.
other causes include space occupying lesions with raised ICP |
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Term
| Glasgow coma scale. What is the significance of a score of 3, 8 or 15? |
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Definition
3 is the lowest score. It suggests deep coma or death
8 or less suggests a severe reduction in airway. The pt should be intubated and ventilated
15 is a normal scored for GCS |
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Term
| in GCS what is the eye component scored out of? What are the different levels? |
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Definition
4 levels for eye.
4 - normal eye opening
3- open to voice
2 - open to pain
1- eyes don't open at all |
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Term
| there are 5 levels to the verbal compartment of the GCS. name and score them all |
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Definition
5 = normal speech
4 = talks but is confused
3 = says words, no sentences
2 = makes noise, no words
1 = no speech |
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Term
| Name the 6 levels to the motor component of the GCS |
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Definition
6 = normal motor movement
5 = localises to stimuli
4 = withdraws from pain but can't localise
3 = decorticate posturing, arms flexed
2 = decerebrate posturing, arms extended
1= no movements |
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Term
| What does AVPU stand for? Who might use AVPU. |
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Definition
Alert
Voice - responds when spoken to
Pain - responds to pain e.g sternal rub
Unresponsive
ambulance crew use AVPU. if pt scores anything less than an A, they record GCS. |
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Term
| When surveying an unconscious pt what is cherry red discolouration suggestive of? |
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Definition
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Term
| in an unconscious pt, unilateral pupil dilation with a lack of response to light is suggestive of? |
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Definition
| Uncal herniation of temporal lobe over the tentorium trapping the 3rd CN |
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Term
| Brainstem reflexes are good for identifying lesions in which part of the brain? |
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Definition
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Term
| Pupils fixed in the mid position with loss of light reflex are typical of lesions where in the brain? |
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Definition
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Term
| If there were a lesion in the pons, describe the size and response of the pupils in the affected pt |
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Definition
| Pupils would be small and they would respond to light |
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Term
| Fixed dilatation of pupils in an unconscious pt is suggestive of? |
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Definition
| significant damage in the brainstem |
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Term
| In metabolic disease such as hepatic/renal failure how might the pupils be in an unconscious pt? |
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Definition
| small pupils reacting briskly to light |
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Term
| when might dolls eye movement be asymmetric or absent? |
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Definition
| when there is a brainstem lesion |
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Term
| state the 3 main aims of iniatally evaluating trauma pts |
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Definition
1. stabilise pt
2. ID life threatening in order of risk. Initiate supportive rx
3. Organise definitive rx or transfer for definitive rx |
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Term
| briefly list the 6 components of the pre hospital phase in trauma care |
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Definition
1 communicate with receiving hospital so trauma team can be activated
2 maintain airway
3 control of external bleeding shock
4 keep pt immobilised
5 information gathering including mechanism of injury
6 keep time at scene to a minimum |
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Term
| briefly list the 7 components in the hospital phase in trauma care |
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Definition
1. prepare resus area
2. get airway equipment ready
3. IV fluids and warming equipments
4. Monitoring equipment
5. methods of summoning extra help
6.prompt lab and radiology back up
7. Transfer arrangements with trauma centre |
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Term
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Definition
It is sorting pts according to their need for rx and the resources available.
it begins at the scene and continues at the receiving hospital. |
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Term
| in triage, which type of pts get the highest priority? |
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Definition
Those who are likely to deteriorate clinically.
triages takes into account vital signs, pre hospital course, mechanism of injury and other medical conditions. |
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Term
| How can trauma centres reduce the time to rx the injured pt? |
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Definition
| They should critically evaluate the pt whilst simultaneously running diagnostic tests. |
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Term
| Describe triage ABCDE with simultaneous assessment and rx. include c spine |
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Definition
Airway maintenance with C spine protection
Breathing and ventilation
Circulation with haemorrhage control
Disability and neuro status
Exposue and environmental control |
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Term
| What is a primary survey in trauma care? |
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Definition
| It is the first ABCDE at the scene. along with resucitation it allows life saving measures to be initiated as the problem is identified |
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Term
| what is a secondary survey in trauma care? |
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Definition
this begins after primary ABCDE survey once resus is underway and the pt is responding and vitals are normalising.
it is a head to toe examination with complete history, vital signs and reassessment of progress.
History AMPLE
Allergies
Medications in current use
Past illnesses/pregnancy
Last meal
Events related to injury
Physical exam
repeats some exams already done in primary survey.
Commonly repeat GCS score here
it aims to ID serious injuries like occult bleeding. |
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Term
| What are the colour codes and levels of triage? |
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Definition
Priority 1 or Trauma 1 = immediate life saving care. RED
P2/T2 = needs immediate/urgent care. YELLOW
P3/T3 = delayed care. rx can be safely delayed. GREEN
dead = BLACK |
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Term
| what tool is used to generate a triage score in pre hospital care? What are the 3 parameters? |
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Definition
the Revised trauma Score (RTS)
uses GCS score, SBP, RR
score of 1-10 = T1
11 = T2
12 = T3
0 = DEAD |
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Term
| What is the Gold standard for describing pt with multiple injuries and evaluating emergency care? |
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Definition
| (New) Injury Severity Score (NISS) |
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Term
| head trauma: where would you find the site of injury in a blunt or penetrating trauma? |
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Definition
| Direct injury at the impact site |
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Term
| head trauma: if there is an injury caused by movement of the brain in the skull which side would this injury be on? |
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Definition
| It would be on the opposite side of the head from the impact |
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Term
| what type of head injury results in damage to axons and blood vessels? |
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Definition
| In shear and rotational forces as the head is accelerated and decelerated after the impact. |
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Term
| An alerting call to the A and E destination hospital should be made for all patients with a GCS less than? |
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Definition
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Term
| What factors should prompt you to immobilise c spine in a pt with trauma? |
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Definition
GCS <15 anytime since injury
focal neuro deficit
paraesthesia in extremities
neck pain or tenderness
any other clinical suspicion that a cervical spine injury exists |
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Term
| name some indications for referring a head injury to the hospital (10) |
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Definition
GCS <15anytime since injury
amnesia for events before or after the event
persistant headache since injury
High energy head injury e.g. diving accident or car collision, ejection from car or drop from flights of stairs.
focal neurological deficit
any LOC due to the injury
any vomiting or seizures since the injury
irritability or altered behaviour particularly in younger children and infants
any suspicion of skull fracture e.g. battle sign, panda/racoon eye, csf leaking through ear, unilateral deafness. |
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Term
| what factors in a pt's PMH with head trauma would make you refer them to A and E |
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Definition
If they were 65 or older
if they have had any cranial or neurosurgical interventions
if they have a history of bleeding or clotting disorder
if they are on warfarin or a new anticoagulant |
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Term
What are the indications for an urgent CT scan within 1 hour for adults with head trauma (6)
when should the radiology report be available? |
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Definition
GCS <13 on initial assessment or <15 two hours after injury
Suspected open or depressed skull fracture
Signs of base of skull fracture
Post traumatic seizure
Focal neurological deficit
>1 episode of vomiting
The written radiology report should be available within 1 hour of the scan |
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Term
| If patient with head trauma doesn't have factors that necessitate an urgent CT but have a bleeding disorder or are on oral anticoagulants what time limit should their CT be completed in? |
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Definition
Within 8 hours of the injury.
A written radiology report should be available within 1 hour |
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Term
| Give 4 signs for basal skull fracture |
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Definition
Hemotympanum - blood behind ear drum
Panda eyes - bruising around orbit w/o obvious eye trauma
CSF leakage through nose/ears
Battles sign - bruising that occurs behind the ears in base of skull fractures |
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Term
| In acute traumatic brain injury which medication has proved benficial in the pre-operative mx of pts with intracranial hematomas? |
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Definition
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Term
| outline some complications of severe head injury |
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Definition
Amnesia
raised ICP
cerebral herniation
CSF leak
intra/extra cranial haemorrhage
meningitis
diffuse axonal injuries
seizures
chronic daily headache
PTSD
vertigo |
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Term
| True or false: meningitis following skull fracture may occur weeks or years later |
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Definition
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Term
| In which type of haemorrhage is the middle meningeal artery classically torn beneath a temporal bone fracture? |
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Definition
Extradural. on CT you will see a biconcave pattern.
There is usually a lucid interval where the pt appears fine then they fall into a coma.
immediate evacuation of the hematoma is needed as 80% progress to uncial herniation. |
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Term
| Which type of haemorrhage typically affects birding veins and may be found in elderly, alcoholics and the children <2 years old? |
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Definition
Subdural haemorrhage.
caused by sudden acceleration-deceleration of brain parenchyma leading to tearing of bridging veins. |
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Term
| in moderate to severe head injury which type of intracranial haemorrhage is the most common? |
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Definition
SAH.
it can present with meningeal signs.
cerebral contusions are often associated with SAH |
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Term
| what type of forces/injury result in diffuse axonal injury? |
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Definition
Shearing/rotational forces. these are common in motor vehicle accidents and shaken baby syndrome.
the injury occurs immediately and there is a rapid increase in ICP. the pt will often be unresponsive.
CT scan may be normal. |
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Term
| Define a moderate and severe head injury by applying the GCS |
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Definition
Moderate head injury GCS 9-12
Severe head injury GCS <8 |
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Term
| How much morphine can you give pre hospital to a pt with injury to extremities, burns, crush injury, severe back/spinal pain; immobilised patients, abdominal pain, journey time >10 minutes? |
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Definition
IV morphine 2-5mg every 5 mins, titrated against pain OR
IM 5-10mg. may repeat after 20 mins.
Max 20mg |
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Term
| What is the max morphine given to critical trauma pts with thoracic or abdominal trauma pre-hospital? |
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Definition
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Term
| List contra indications for morphine use in pre hospital care |
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Definition
HTN pts with DBP >90 mmHg, DBP >80mmHg in school children or >70mmHg in preschool children
GCS <12
Pts taking MAOIs
those with phaeochromoytoma
previous anaphylactic reaction to morphine |
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Term
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Definition
| An injury caused by thermal, electrical, chemical or radiation energy. |
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Term
| How would you asses someone presenting with major burns? |
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Definition
ABCDE. prevent hypothermia and assess need for fluid resus.
assess severity, consciousness levels and cause.
establish time of burn injury
Burns sustained within an enclosed space suggest inhalation injury
establish tetanus immunisation status
assess depth and surface area of burns |
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Term
| In relation to assessing a burns pt explain the Rule of Nines |
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Definition
The adult body is divided into anatomical regions that represents 9% or multiples of 9% of the total body surface area.
9% - Head
9% - each upper limb
18% - each lower limb
18% - front trunk
18% - back trunk |
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Term
| When do burn wounds need reassessing? |
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Definition
| In the first 24-72h. This is because they are dynamic and the depth can increase due to inadequate rx or superadded infection. |
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Term
| Describe characteristics and healing time of a superficial partial thickness (epidermal) burn |
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Definition
It is red and glistening
It is painful
there are no blisters
capillary refill is brisk.
non life threatening and normally heals within 1 week w/o scarring |
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Term
| describe characteristics and healing time of a superficial dermal burn |
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Definition
Pale pink or mottle colour
Swelling and small blisters
Weeping wet surface that is hypersensitive
brisk capillary refil
Heals in 2-3 weeks with minimal scarring and full fx recovery |
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Term
| describe the characteristics and healing time of a deep dermal burn |
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Definition
blistering and dry blotchy cherry red colour
It will not blanche
no capillary refill and reduced/absence sensation
healing in 3-8 weeks with scarring
you may need sx to recover best fx |
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Term
| describe a third degree burn. This is AKA a full thickness burn. |
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Definition
Colour is white or black
The burn is dry
There are no blisters
the capillary refill is absent so is sensation.
this needs surgical repair and grafting. |
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Term
| the initial rx of major burns need to include which possible injuries? (3) |
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Definition
1. Direct thermal injury causing upper airway oedema/obstruction
2. Inhalation of carbon particles/toxic fumes leading to chemical tracheobronchitis, oedema and pneumonia.
3. CO poisoning |
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Term
| Describe airway management in major burns pt |
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Definition
Stridor is an indication for immediate endotracheal intubation.
you should tube them if there are signs of upper airway damage e.g. horsiness of voice, burns around neck and chest. |
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Term
| In major burns, the baseline PO2 does not accurately predict CO poisoning. What levels should we monitor? |
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Definition
| We should get baseline Carboxyheamoglobin levels and administer 100% O2. |
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Term
| how can we reduce neck and chest wall oedema in a major burns pts? |
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Definition
| Elevate the head and chest by 20-30 degrees |
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Term
| If a full thickness burn of the chest wall leads to severe restriction of the chest wall motion what procedure can be done? |
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Definition
A chest wall escharotomy.
This does not need anaesthesia. |
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Term
| From oxygen and CO, which has a higher affinity for Hb? |
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Definition
CO has a higher affinity for hb. this is why it displaces O2.
assume CO exposure in pts who wee burnt in enclosed areas. |
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Term
| Pts with CO <20% usually have no symptoms. what signs/symptoms may a pt with high levels of CO display? |
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Definition
Headache
Nausea
Confusion
Coma
Death |
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Term
| CO dissociates vey slowly. How might we increase this? |
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Definition
| By breathing high flow O2 via a non rebreathing mask. |
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Term
| What % of burns in an adult suggest fluid replacement is needed? |
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Definition
15% of total body surface area in an adult
10% in children |
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Term
| How should we administer fluid replacement in an adult with burns? |
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Definition
4ml/kg body weight/% burns.
Give half the calculated volume in the 1st 8 hours and the remaining over the next 16 hours. |
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Term
| What is the maximum time you should tap water on burns for? why should you not use ice or freezing cold water? |
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Definition
Run water for 20 mins. Do not run longer than 1 hour.
Very cold objects cause vasoconstriction. This can worsen tissue ischemia and local oedema. |
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Term
| what pts should you refer to a burns unit? |
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Definition
age <5 and >60
site of injury: face, hands, perineum, any flexures
inhalation injury
mechanism of injury: chemical burns, exposure to IR,
high pressure steam, high tension electricity |
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