Anaesthesia, Trauma & Critical Care

Topics covered in the manual:-

  • Primary Survey
  • Kinematics of Trauma
  • Airway Trauma
  • Cardio-Thoracic Trauma
  • Shock & Circulation Preservation (including fluid resuscitation, permissive hypotension &massive transfusion protocol)
  • Abdominal Trauma
  • Pelvic Trauma
  • Neuro Trauma
  • Spinal Trauma
  • Extremity Trauma
  • Burns & Thermal Injury
  • Bombs, Blasts & Ballistics
  • Drowning
  • Crush Injury & Suspension Trauma
  • Paediatric & Obstetric Trauma
  • Special Circumstances in Trauma
  • Damage Control Surgery
  • Emergency/Pre-Hospital Surgery
  • Management of Trauma Patients on ITU/Critical Care
  • Transfer of the Critically Ill Patient
  • Trauma Radiology
  • Pre-Hospital Care of the Trauma Patient
  • Mass casualty management/major civilian disasters
  • Casualty triage

 

Top 10 Posts of 2016

 

10. All Shock Explained

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9. Priapism

Priapism

Non-ischemic (high-flow) Ischemic (low-flow)
Physical Exam Typically painless, not fully tumescent Painful, fully tumescent with corpus cavernosa rigidity without involvement of corpus spongiosum and glans penis
Aetiology High-flow priapism is extremely rare and most commonly associated with antecedent trauma including blunt trauma, or resulting from needle injury of the cavernosal artery. Low-flow priapism is caused by impaired relaxation and/or paralysis of cavernosal smooth muscle and in sickle-cell disease
Management NOT Emergency Emergency

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8. 2016 Guidelines

 

 

 


7. Sepsis Six in 60 Minutes: World Sepsis Day – September 13th

Sepsis

NEW SEPSIS PATHWAY

FLUIDS

ANTIBIOTICS

…for every hour you delay, the patient has a 33% increased risk of death!

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LACTATE


6. Did you know about the RULE OF TENS for Fluid Resuscitation in Burns?

Burns Rule of TENS:

1. Estimate burn size (TBSA) to the nearest 10%.
2. Multiply %TBSA x 10 = Initial fluid rate in mL/hr (for adult patients weighing 40 kg to 80 kg).
3. For every 10 kg above 80 kg add 100 mL/hr to the rate.

 

 


5. New 2015 Resuscitation Guidelines Compedium

BLS

 

 

 

 


4. LFTs explained

LFTs Explained

  • LFTs = ‘hepatocellular’ or ‘cholestatic’ arrangement based on the pattern of elevation.
    • Hepatocellular pattern = transaminases >  ALK
  • ALT is generally considered to be more specific to liver damage
  • Magnitude of aminotransferase elevation => guide initial diagnosis: mild (<5x), moderate (5-10x), or marked elevation (>10x)
    • Mild = NAFLD, Drug Induced Liver Injury, Alcohol-Induced Liver Injury
    • Moderate = Alcoholic Hepatitis, Biliary Tract Disease
    • Severe = Acute Viral Hepatitis, Ischemic Injury, Acetaminophen Toxicity

 

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3. The GCS is out-of-stock

GCS

Contrary to common belief, The Glasgow Coma Scale (GCS) is NEVER out-of-stock and the lowest score possible is 3.

  • An intubated patient still gets 1 point for verbal meaning they score 3T…there is nothing like a 2T score (at least not in human beings)
  • The phrase ‘GCS of 11’ is essentially meaningless, and it is important to break the figure down into its components, such as E3V3M5 = GCS 11.
  • The Scale was described in 1974 by Graham Teasdale and Bryan Jennett (Assessment of coma and impaired consciousness. A practical scale. Lancet 1974; 2:81-4.) and is the most reference paper in medical literature

 

 


2. Nairobi Accident Hotspots

Accident Hotspots

The most dangerous time to walk on Nairobi’s streets is on a Friday, around 7am, particularly along  Mombasa Road.

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1. Salter-Harris Fracture (remember the mnemonic SALTR)

  1. Slipped (i.e., through growth plate and not involving bone) / Type I
  2. Above growth plate (i.e., through metaphysis) / Type II (most common)
  3. Lower growth plate (i.e., through epiphysis) / Type III
  4. Through (i.e., through metaphysis growth plate and epiphysis) / Type IV
  5. Rammed (i.e., Crush injury) / Type V (worst prognosis)

 

Burns Resuscitation

  • Signs of impending airway compromise include: stridor, wheezing, subjective dyspnea, and a hoarse voice.
  • Carbon monoxide (CO) poisoning may manifest with persistent neurologic symptoms or even as cardiac arrest.
  • Burns <15% TBSA generaly require only PO fluid resuscitation.
  • Do not include first degree burns in the calculation of % TBSA.
  • Generally crystalloid solutions should be infused during the initial 18-24 hrs of resuscitation. It is recommended that 5% dextrose be added to maintenance fluids for pediatric patients weighing < 20kg.
  • All resuscitation measures should be guided by perfusion pressure and urine output: Target a MAP of 60 mmHg, and urine output of 0.5-1.0ml/kg/hr for adults and 1-1.5mL/kg/h for pediatric patients.
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Inhalational Injury

Classically, the diagnosis of inhalation injury was subjective and made on the basis of clinical findings. Pertinent information includes exposure to flame, smoke, or chemicals (industrial and household), duration of exposure, exposure in an enclosed space, and loss of consciousness or disability. Pertinent physical exam findings include facial burns, singed facial or nasal hair, soot or carbonaceous material on the face or in the sputum, and signs of airway obstruction including stridor, edema, or mucosal damage. Older patients, and those with more extensive burns, are at increased risk of inhalation injury because of prolonged exposure to the fire environment.

With the cold comes fires, here’s a great resource for managing burns

 

The aim of these guidelines is to provide a consistent standard of management for burn injuries managed outside of a Burn Service, particularly in the early stages after injury, to improve patient care and outcomes. The guidelines are based on scientific evidence where available and consensus expert opinion

Minor burn treatment

Minor burn treatment includes cooling, cleansing, and debridement of the wounds upfront.

  • Blisters are usually left intact.
  • Povidone-iodine (Betadine) is cytotoxic and delays wound healing – DO NOT USE ON OPEN WOUNDS.
  • Chlorhexidine can be used in combination with a gauze dressing, and it does not interfere with wound re-epithelialization. It is also long-acting.

Pediatric Burn Resuscitation

  1. Take the time to estimate the TBSA involved. This will greatly influence the management!
  2. Initial fluid calculations for replacement (ex, using Parkland formula) should be ADDED to maintenance fluids.
  3. NEVER forget the sugar! You don’t need to add it to their resuscitation fluids, but their maintenance fluids need glucose.
  4. If the patient remains in your care for a prolonged period, don’t forget to monitor the glucose level.

Did you know about the RULE OF TENS for Fluid Resuscitation in Burns?

Burns Rule of TENS:

1. Estimate burn size (TBSA) to the nearest 10%.
2. Multiply %TBSA x 10 = Initial fluid rate in mL/hr (for adult patients weighing 40 kg to 80 kg).
3. For every 10 kg above 80 kg add 100 mL/hr to the rate.

It’s getting cold so here’s a review of carbon monoxide poisoning

“Symptoms are variable and physical exam and pulse-oximetry are unreliable. Maintain high level of suspicion with emphasis on historical factors. Start the patient on O2 as soon as the diagnosis is suspected.”