Crush Injury
Define crush injury.
A crush injury is compression of extremities or other parts of the body that causes muscle swelling and/or neurological disturbances in the affected area.
Describe the triple airway maneuver.
Chin lift/head tilt, jaw thrust, open mouth.
Consider suctioning, manual tongue manipulation, manual in line stabilisation, OPA/NPA if indicated. Avoid nasal devices unless airway not patent.
What is the difference between blast and ballistic injury?
Blast injury - a complex resulting from direct or indirect exposure to an explosion.
Ballistic - caused by penetration from projectiles.
What are the reversable "T's" of a traumatic cardiac arrest?
Tension pneumothorax
Tamponade (cardiac)
Toxins/tablets
Thromboembolism (coronary or pulmonary)
What would be your first line action for severe pain if you have IV access? (AV CPG A0501-1 Pain Relief)
Morphine IV (up to 5mg @ 5min intervals, consult after 20mg) OR Fentanyl IV (up to 50mcg @ 5min intervals, consult after 200mcg)
OR
Ketamine IN (75mg, repeat 50mg @ 20min intervals, no max dose. For Pts <60kg/elderly/frail, 50mg, repeat 25mg @ 20min intervals, no max dose)
Define compartment syndrome.
Compartment syndrome is a severe high pressure within a muscle fascia (tough membranes surrounding the muscles of the limbs) resulting in insufficient blood supply to the muscle and nerves. In effect, the fascia create multiple closed restricted volume spaces known as compartments. As an area of injury swells, pressure is transmitted into, and therefore compromise, the blood vessels and nerves. This can lead to crush syndrome and permanent localised damage.
Name some of the main bones of the skull and their location.
Zygomatic bone - cheek bones
Nasal bone - bridge of the nose
Mandible - jaw
Maxilla - middle of the face excluding the cheek bones and nasal bones
Frontal bone - forehead
What is "mushrooming"? (Ballistic injury mechanism)
Mushrooming describes controlled expansion of a bullet upon impact with the target. The bullet creates a larger area of damage in a shape that resembles a mushroom. The entry wound may be small, but the internal damage is significant.
What are the reversable "H's" on a traumatic cardiac arrest?
Hypoxia
Hypovolemia
Hypothermia
Hyperkalaemia
Hydrogen Ions (acidosis)
What are the contraindications of Fentanyl?
1. history of hypersensitivity
2. late second stage of labour
3. serotonin syndrome
4. monoamine oxidase inhibitors (MAOIs) within previous 14 days
Define crush syndrome.
In regards to fractures, which bones require high impact and which require low impact?
High impact - supraorbital rim, symphysis of the mandible, angle of the mandible, frontal.
Low impact - zygoma, nasal bone.
What is the difference between low energy (LE) explosions and high energy (HE) explosions?
LE - deflagration more gradual transformation, subsonic explosion, injuries characteristic of ballistic style injuries. E.g. gun power, pipe bomb, molotov cocktails, pyrotechnics.
HE - detonation causes instantaneous transformation, supersonic over-pressurisation shock wave, blast wave. E.g. TNT, oil, dynamite, C4, ammonium nitrate fuel.
According to AV CPG A0201-2, what correctable causes should be intervened in order of clinical need?
Prioritise major haemorrhage control over all other interventions!
1. Airway - ensure Pt airway, oxygenation and ventilation
2. Tension pneumothorax - where accredited, decompress chest bilaterally
3. Volume replacement - IV access, N/Saline 20mL/kg IV
What is the indications, presentation, onset, and duration of Paracetamol?
Indications - mild pain or pain relief in combination with other analgesics, or headache
Presentation - 500mg tablets OR 120mg in 5mL oral liquid
Onset - 30 minutes oral
Duration - 4 hours
What are the key medical interventions for crush syndrome?
1. Tourniquets will allow for controlled release of toxic metabolise into the circulation
2. Administer IV fluid
3. Analgesia will be required even though pain may be mild or not reported prior to removal of compressive force
4. Anticipate cardiac dysthymias and shock post release of compressive force
5. Administer additional fluid bolus during the release phase of compressive force
Describe the difference between Le Fort I, II, & III.
Le Fort I - horizontal fracture of the maxilla at the level of the nasal fossa
Le Fort II - pyramidal fracture (maxilla, nasal bones, medical aspect of orbits)
Le Fort III - also known as craniofacial dissociation. Fractures through the maxilla, zygoma, nasal bones, ethmoid bones, and bones of the base of the skull.
What injuries might you see secondary to blast injury?
Penetrating trauma due to shrapnel or fragmentation. This occurs at a distance. Intentional shrapnel may include nuts, bolts, nails, ball bearings, etc.
When would you suspect traumatic cardiac arrest over medical cardiac arrest?
Traumatic cardiac arrest Pts are usually young and healthy. If any doubt exists as to the cause of arrest, treat as per medical cardiac arrest.
Shockable rhythms (VT/VF) are more common in Medical cardiac arrest. PEA is most common in Traumatic cardiac arrest.
What patterns of injury contribute to the Trauma Time Critical Guidelines? (AV CPG A0105)
Penetrating and blunt trauma.
Specific injuries - limb amputation, suspected spinal cord injury or spinal fracture, burns >20% TBSA, suspected respiratory tract burns, high voltage (<1000 volts) burn injury, serious crush injury, major compound fracture or open dislocation, fracture to two or more of femur/tibia/humerus, fractured pelvis.
What is the pathophysiology of suspension trauma?
Gravity affects our blood pressure (orthostatic blood pressure) when we stand upright, directing blood flow into the legs and returning to the heart via venous valves and musculature contraction. When someone is immobile with suspension trauma and is not using their leg muscles, venous pooling occurs in the leg vessels due to gravity. Blood cannot return to the heart using physiological methods.
What are the grades/degree of hyphemia? (collection of blood in the anterior chamber of the eye)
Grade 1 - less than one third on the anterior chamber
Grade 2 - one third to one half of the anterior chamber
Grade 3 - greater than half of the anterior chamber
Grade 4 - total anterior chamber volume
What injuries might you see primary to blast injury?
Injury to gas containing body organs e.g. lung damage, rupture of tympanic membranes, pulmonary damage, globe rupture. These are attributed to the pressure wave.
Why would requesting MICA/HEMS be necessary in a TCA?
To perform a resuscitative thoracotomy to get rapid access to the heart and major thoracic vessels. Alternatively, transport rapidly to emergency department if within 10 minutes.
To provide blood products, crush injury medications, jugular vein and intraosseous insertion, endotracheal tube.
What factors may contribute to high risk TBI for adults?
LOC >5 mins, penetrating head injury, GCS <13, skull fracture, vomiting more than once, neurological deficit, seizure, worsening signs and symptoms.