atls_copy_copy_20210630221308 Flashcards
<p>The "Initial Assessment" includes the following 10 elements:</p>
<ol> <li>Preparation</li> <li>Triage</li> <li>Primary Survey (ABCDEs)</li> <li>Resuscitation</li> <li>Adjuncts to primary survey and resuscitation</li> <li>Does the patient need transferring?</li> <li>Secondary survey (head-to-toe evaluation & history)</li> <li>Adjuncts to secondary survey</li> <li>Continued post-resuscitation monitoring and reevaluation</li> <li>Definitive care</li></ol>
<p>What are the 2 different phases of trauma preparation?</p>
<p>Prehospital and hospital</p>
<p>What are the 4 emphases of the Pre-hospital phase?</p>
<p>1/ Airway maintenance 2/ Control of external bleeding and shock 3/ Immobilization of the patient. 4/ Immediate transport to the closest appropriate facility.</p>
<p>What information should be taken from the ambulance crew?</p>
<p>1/ Time of injury2/ Events related to the injury (mechanism of injury etc.)3/ Patient history</p>
<p>What course addresses prehospital care of injured patients that is similar to the ATLS course?</p>
<p>Prehospital Trauma Life Support (PHTLS)</p>
<p>What 3 things should be made made immediately accessible in the prehospital phase?</p>
<p>1/ Airway equipment2/ Warmed IV Crystalloids3/ Monitoring devices</p>
<p>What does the Center for Disease Control and Prevention (CDC) recommend is worn as protection and the ACS COT say is the minimum precautionary equipment?</p>
<p>1/Mask2/ Eye protection3/ Water Impervious Gown.4/ Gloves</p>
<p>What is the definition of triage?</p>
<p>"Sorting of patients based on their needs for treatment and the resources available to provide that treatment."</p>
<p>What is the definition of <strong>Multiple Casualties</strong>?</p>
<p>"The number of patients and the severity of their injuries do not exceed the capability of the facility to render care."</p>
<p>What is the definition of "<strong>Mass Casualties</strong>?"</p>
<p>"The number of patients and the severity of their injuries exceed the capability of the facility and staff"</p>
<p>How do you act if their are <strong>multiple casualties</strong>?</p>
<p>First treat those with with life threatening problems andmultiple-system injuries.</p>
<p>How do you act if there are <strong>mass casualties</strong>?</p>
<p>First treat the patients with the greatest chance of survival and who require the least expenditure of time, equipment, supplies and personnel.</p>
<p>What does A stand for?</p>
<p>Airway maintenance and cervical spine protection</p>
<p>What does B stand for?</p>
<p>Breathing and ventilation</p>
<p>What does C stand for?</p>
<p>Circultation and haemorrhage control</p>
<p>What does D stand for?</p>
<p>Disability: Neurological status</p>
<p>What does <strong>E</strong> stand for?</p>
<p><strong>Exposure/Environmental control: </strong></p>
<p>1/ Completely undress the patient but prevent hypothermia.</p>
<p>2/ Warm with IV saline</p>
<p>3/ Warm environment.</p>
<p>Describe the quick 10 second way to assess a patient?</p>
<p>1/ Identify yourself,</p>
<p>2/ Ask the patient for his or her name</p>
<p>3/ Ask what happened.</p>
<p>(An appropriate response suggests no airway compromise, breathing is not severely compromised and is alert.)</p>
<p>Describe the 5 specialist populations and why?</p>
<p>1/ Children - anatomic and physiological differences (e.g. quantity of blood, fluids, medications, rapidity of heat loss and injury pattern difference)</p>
<p>2/ Pregnant females - anatomic and physiological difference. Ascertain pregnancy soon in females.</p>
<p>3/ Older adults - poor physiological reserve and multiple co-morbidities.</p>
<p>4/ Obese - difficult intubation, diagnostic difficulties and poor pulmonary reserve.</p>
<p>5/ Athletes - normally low BP and HR.</p>
<p>What is included in airway management?</p>
<p>1/ Clearing foreign bodies & suctioning</p>
<p>2/ Inspection of facial, mandibular or tracheal fractures that can cause airway obstruction.</p>
<p>3/ Administering oxygen</p>
<p>4/ Securying the airway.</p>
<p>When can you most likely need definitve airway management?</p>
<p>GCS < 8 or nonpurposeful motor response.</p>
<p>If there is history of a traumatic event or altered level of conciousness what should be assumed & done?</p>
<p>Assume there is loss of stability of the cervical spine.</p>
<p></p>
<p>Protect the patient's spinal cord with immobilization devices.</p>
<p>If you take off the collar what must be done?</p>
<p>Inline mobilization techniques should be used in order to manually stabilise the C-spine.</p>
<p>When assessing breathing in the primary survey what do you look for?</p>
<p>1/ Assess JVP</p>
<p>2/ Position of the trachea</p>
<p>3/ Chest wall excursion</p>
<p>4/ Auscultation</p>
<p>5/ Percussion.</p>
<p>What breathing injuries should be assessed during the primary survey?</p>
<p>1/ Tension pneumothorax</p>
<p>2/ Flail chest with pulmonary contusion</p>
<p>3/ Massive haemothorax</p>
<p>4/ Open pneumothorax</p>
<p>What is the main goal of inital ventilatory management?</p>
<p>To prevent secondary brain injury by maintaining adequate oxygenation and perfusion.</p>
<p>What are the 3 main circulatory issues to consider in C on your primary survey?</p>
<p>Is there:</p>
<ol> <li>Blood volume</li> <li>Poor cardiac output</li> <li>Bleeding - Internal or external?</li></ol>
<p></p>
<p>What are the 3 clinical elements that assist with assessing blood volume & cardiac output?</p>
<p>1/ Level of conciousness - cerebral perfusion can indicate low circulating volume.</p>
<p>2/ Skin colour</p>
<p>3/ Pulse - assess bilaterally. A rapid thready pulse indicates hypovolaemia. If absent central pulses then immediately resuscitate with fluid.</p>
<p>If someone is bleeding what do you do in the primary survey?</p>
<p>1/Identify the bleed - physical, radiology or FAST</p>
<p>2/ Apply direct manual pressure</p>
<p>3/ Tourniquets for massive bleeding in limbs.</p>
<p>4/ Management - either chest decompression, pelvic binders, splint application, clamps or surgical intervention.</p>
<p>What are the 5 most common sites of internal haemorrhage?</p>
<p>1/ Chest</p>
<p>2/ Abdomen</p>
<p>3/ Retroperitoneum</p>
<p>4/ Pelvis</p>
<p>5/ Long Bones.</p>
<p>Describe the rapid neurological examination in the primary survey?</p>
<p>1/ Quick GCS</p>
<p>2/ Pupillary size and reaction</p>
<p>3/ Lateralizing signs</p>
<p>4/ Spinal cord injury level.</p>
<p>What can cause a reduce level of conciousness?</p>
<p>1/ Decreased cerebral oxygenation.</p>
<p>2/ Direct cerebral injury.</p>
<p>3/ Hypoglycaemia</p>
<p>4/ Drugs - alcohol, narcotics and other drugs.</p>
<p>What does the acronym AMPLE stand for and when should it be used?</p>
<p></p>
<ul> <li>A- Allergies</li> <li>M- Medications currently used</li> <li>P- Past illnesses/Pregnancy</li> <li>L- Last meal</li> <li>E- Events/Environment related to the injury.</li></ul>
<p>It should be used just prior to the secondary examination & can be obtained from patient, family or paramedics.</p>
<p>What must be given to all trauma patients?</p>
<p>Supplemental oxygen</p>
<p>Describe the importance of "the talking patient?" (p. 32)</p>
<p>The talking patient gives a positive, appropriate verbal response which indicates that their airway is patent, ventilation is intact and brain perfusion is adequate.</p>
<p>If someone has an altered level of consciousness what do they require? (p. 32)</p>
<p>A definitive airway</p>
<p>What is the definition of a definitive airway? (p.32)</p>
<p>A tube placed in the trachea with the cuff inflated below the vocal cords, the tube connected to some form of oxygen-enriched assisted ventilation, and the airway secured in place with tape.</p>
<p>What sort of patients may require a definitive airway due to compromised ventilatory effort? (p. 32)</p>
<p>1/ Unconscious patients with head injuries2/ Obtunded from alcohol & Drugs3/ Thoracic injuries</p>
<p>What is the purpose of endotracheal intubation? (p.32)</p>
<p>1/ Provide an airway2/ Deliver supplementary oxygen3/ Support ventilation4/ Prevent aspiration </p>
<p>Maintaining (blank) and preventing (blank) are critical in managing trauma patients, especially those who have sustained head injuries. (p.32)</p>
<p>1/ oxygenation2/ preventing hypercarbia</p>
<p>If a patient is unconscious and vomits or has gastric contents in his/her airway, what should you do? (p.32)</p>
<p>1/ Immediate suctioning2/ Rotation of the entire patient to the lateral position.</p>
<p>What 3 things can facial fractures be associated with? (p.32)</p>
<p>1/ Haemorrhage2/ increased secretions3/ Dislodged teeth</p>
<p>What can fractures of the mandible cause (especially bilateral body fractures?) (p.32)</p>
<p>Loss of normal airway structural support.</p>
<p>A fractured larynx manifests itself with a triad of clinical signs. What are they? (p.33)</p>
<p>1/ Hoarseness2/ Subcutaneous emphysema3/ Palpable fracture</p>
<p>If noisy breathing suggests partial airway obstruction, what does absence of breathing suggest? (p.33)</p>
<p>It suggests complete airway obstruction</p>
<p>What investigation would be useful if a fractured larynx is suspected? (p.33)</p>
<p>A CT</p>
<p>What are the 4 objective ways of finding signs of airway obstruction? (p. 33)</p>
<p>1/ OBSERVE- the patient may be agitated, fingers may be cyanotic, circumoral skin and nail beds may be poorly perfumed. The person may be using accessory muscles when breathing.2/ LISTEN- The patient may have noisy breathing, stridor which would indicate partial occlusion of the larynx or pharynx. Hoarseness implies laryngeal obstruction.3/ FEEL - for the location of the trachea to see if midline or deviated.4/ EVALUATE - Abusive or belligerent patients may be intoxicated.</p>
<p>In what 3 ways can a patients ability to ventilate be compromised? (p. 34)</p>
<p>1/ Airway obstruction2/ Altered ventilatory mechanics - chest trauma, c-spine injury (diaphragmatic breathing).3/ CNS depression - intracranial injury or drugs.</p>
<p>If someone has abdominal breathing and a probable spinal injury, what might have happened? (p. 34)</p>
<p>They have had a complete C-spine transaction, the intercostal muscles are paralysed but the phrenic nerves (C3-C4) are spared.(Remember C3, C4, C5 keep the diaphragm alive)</p>
<p>What is this airway devicecalled and how does it work?</p>
<p>A Multilumen esophageal airway. One of the ports communicates with the oesophagus whislt the other communicates with the trachea. The oesophagus port is then occluded with a balloon and the other ventilated.</p>
<p>What type of airway device is this?</p>
<p>This is a Laryngeal Mask Airway (LMA). It is a type of Extraglottic/Supraglottic airway device.</p>
<p>What airway device is this and how does this work?</p>
<p>This is a laryngeal tube airway. (LTA). It is placed without viewing the glottis and does not require significant manipulation of the head and neck. (Just like an LMA)</p>
<p>Name 3 Supraglottic/Extraglottic airway devices?</p>
<p>1/ Layngeal Mask Airway (LMA)</p>
<p>2/ Laryngeal Tube Airway (LTA)</p>
<p>3) Multilumen eosophageal airway .</p>
<p>Are Extraglottic and supraglottic airway devices definitive airways?</p>
<p>NO!! They are used when intubation attempts have failed or are unlikely to suceed.</p>
<p>How do you you know if ventilation is inadequate? (p.34)</p>
<p>1/ <strong>Look for:</strong></p>
<ul> <li>Asymmetrical chest expansion- <em>(i.e. penumothorax or flail chest.)</em></li> <li>Labored breathing</li></ul>
<p>2/<strong>Listen for:</strong></p>
<ul> <li>Decreased or absent breath sounds.</li></ul>
<p>3/<strong>Use a pulse oximeter.</strong></p>
<p>Describe the 4 step process of removing a helmet in a trauma patient?</p>
<p>1/ One person provides manual, inline stabilization of the head and neck.</p>
<p>2/ The other person expands the helmet laterally and removes it.</p>
<p>3/The first person then supports the weight of the patient's head.</p>
<p>4/ The second person then takes over inline stabilization.</p>
<p>What factors predict a potentially difficult airway?</p>
<p>1/ C-spine injury</p>
<p>2/ Severe arthritis of the c-spine</p>
<p>3/ Significant maxillofacial or mandibular trauma.</p>
<p>4/ Limited mouth opening</p>
<p>5/ Obesity</p>
<p>6/ Anatomical variations (e.g. receding chin, overbite or a short muscular neck.)</p>
<p>What does <strong>LEMON </strong>stand for?</p>
<p><strong>L</strong>- look externally</p>
<p><strong>E</strong>-evaluate using the 3-3-2 rule</p>
<p><strong>M-</strong>Mallampati</p>
<p><strong>O</strong>- Obstructions?</p>
<p><strong>N</strong>- Neck mobility</p>
<p></p>
<p>-</p>
<p></p>
<p>Describe the 3-3-2 Rule.</p>
<p>3= the distance between the incisor teeth.</p>
<p>3= the distance between the hyoid bone and the chin</p>
<p>2= distance between the thyroid notch and the floor of the mouth</p>
<p>Name and describe this maneouvre.</p>
<p>This is the chin lift maneuver. The fingers of one hand are placed under the mandible which is lifted gently upward.</p>
<p></p>
<p>It should NOT hyperextend the neck.</p>
<p>What maneuvre is this and describe it?</p>
<p>This is the Jaw-Thrust Maneuver. The angles of the lower jaw are grasped and the mandible is displaced forward.</p>
<p></p>
<p>Do NOT hyperextend the spine.</p>
<p>Name this airway and how do you insert it?</p>
<p>Oropharyngeal airway.</p>
<p></p>
<p>It is inserted into the mouth until it reaches the soft palate. It is then rotated 180 degrees and the device is slipped into place over the tongue.</p>
<p></p>
<p>NOTE: This method should NOT be used in children as it can damage the soft palate. In children, suppress the tongue and then insert it .</p>
<p>Who should Nasopharyngeal airways not be inserted in?</p>
<p>Cribiform plate fractures.</p>
<p>Name the 3 types of definitive airways.</p>
<p>1/ Orotracheal tubes</p>
<p>2/ Nastoracheal tubes</p>
<p>3/ Surgical airways (cricothyroidotomy or tracheostomy).</p>
<p>Regarding airway management, what is the quickest killer?</p>
<p>Inadequate delivery of oxygenated blood to the brain and other vital structures.</p>
<p>Name the 5 types of shock.(p.63)</p>
<p>1/ Hypovolaemic (Most common)2/ Cardiogenic3/ Obstructive4/ Neurogenic5/ Septic</p>
<p>Cardiac Output = (1) x (2)</p>
<p>1= Heart rate2= Stroke volume</p>
<p>What is the definition of shock?</p>
<p>An abnormality of the circulatory system that results in inadequate organ perfusion and tissue oxygenation. (p.63)</p>
<p>Preload (volume of blood flowing back to the heart) = (1)+(2)+(3)</p>
<p>1/ Venous capacitance2/ Volume status3/ The difference between mean venous systemic pressure and right atrial pressure.</p>
<p>Stroke Volume = (1) + (2) + (3)</p>
<p>1/ Preload2/ Myocardial contractility3/ Afterload</p>
<p>How does the body respond to blood loss?</p>
<p>1/ Vasoconstriction of cutaneous muscle and visceral circulation occurs to preserve blood flow to the kidneys, heart and brain. 2/ Increase in heart rate to preserve cardiac output.</p>
<p>What endogenous chemicals are released that cause vasoconstriction?</p>
<p>1/ Catecholamines2/ bradykinin3/ Histamin4/ B-endorphins5/ Cytokins6/ Prostanoids.</p>
<p>What is the most effective way of restoring cardiac output and end organ perfusion?</p>
<p>Restore venous return by:1/ Stopping the source of bleeding.2/ Volume repletion</p>
<p>Inadequately oxygenated & perfused cells compensate by shifting to (BLANK) respiration which results in the formation of (BLANK) and the development of (BLANK).</p>
<p>1/Anaerobic respiration2/ Lactic acid3/ Metabolic acidosis</p>
<p>Name 2 proinflammatory mediators.</p>
<p>1/ Inducible nitric oxide synthase (INOS)2/ TNF</p>
<p>Should vasopressors be given in shock?</p>
<p>No, they are contraindicated. Although they may increase BP. They worsen tissue perfusion by vasoconstriction.</p>
<p>Who should be called if there is shock in an injured patient?</p>
<p>A surgeon.</p>
<p>What should you assume if the patient is cool and has tachycardia?</p>
<p>They are in shock until proven otherwise.</p>
<p>How is tachycardia diagnosed in children?</p>
<p>Infants= >160bpmPreschoolers = >140bpmSchool age = >120bpmAdults = >100bpm</p>
<p>What may limited elderly patient's compensatory response to blood loss? (and thus they may not show signs of tachycardia)</p>
<p>1/ Drugs - diuretics,Beta blockers, CCB</p>
<p>2/PPM</p>
<p>(Look for a narrow pulse pressure in elderly patients who may have these factors in order to diagnose shock.)</p>
<p>3/ Relative decrease in sympathetic activity.</p>
<p>4/ Catecholamine receptor deficit</p>
<p>5 Reduced cardiac compliance.</p>
<p>6/ Pre-existing volume depletion</p>
<p>7/ Malnutrition</p>
<p>8/ Renal glomerular and tubular senescence - reduced responsiveness to aldosterone, catecholamines, vasopressin and cortisol.</p>
<p>What should you not use to estimate blood loss? What should you use instead?</p>
<p>Do not use haemoglobin or haematocrit as they are unreliable in the acute setting.Use lactate and base excess.</p>
<p>What is the most common cause of shock?</p>
<p>Haemorrhagic shock (after injury)</p>
<p>Name the 4 types of non-haemorragic shock?</p>
<p>1/ Cardiogenic2/ Neurogenic3/ Obstructive4/Septic</p>
<p>Name the causes of cardiogenic shock?</p>
<p>1/ MI2/ Cardiac tamponade3/ Air embolus4/ Blunt cardiac injury</p>
<p>How do you identify and treat a cardiac tamponade?</p>
<p>1/ Identify -</p>
<ul> <li>Tachycardia</li> <li>muffled heart sounds</li> <li>Dilated neck veins</li> <li>Hypotension resistant to fluid therapy.</li> <li>Most commonly seen after thoracic penetrating injury.</li></ul>
<p>2/ Treatment</p>
<ul> <li>Pericardiocentesis - temporarily</li> <li>Thoracotomy (Definitive)</li></ul>
<p></p>
<p>How do you identify and treat a tension pneumothorax?</p>
<p>1/ Identify</p>
<ul> <li>Absent breath sounds</li> <li>Tracheal deviation</li> <li>Hyperresonant percussion note over the affected hemithorax</li> <li>Acute respiratory distress</li> <li>Subcutaneous emphysema</li></ul>
<p>2/ Treatment</p>
<ul> <li>Immediate thoracic decompression (See Chapter 4 for more details)</li></ul>
<p>How does neurogenic shock cause hypotension?</p>
<p>Cervical or upper thoracic spinal cord injury can produce hypotension due to <strong>loss of sympathetic tone</strong>. This compounds the effects of hypovolaemia.</p>
<p>Do you get tachycardia in neurogenic shock?</p>
<p>No. Neurogenic shock is hypotension without tachycardia. <strong>A narrowed pulse pressure is not seen in neurogenic shock.</strong></p>
<p>What is the definition of haemorrhage?</p>
<p>An acute loss of circulating blood volume.</p>
<p>What percentage of body weight is there of blood in a normal adult and in a normal child?</p>
<p>Adult = 7% (~5L in 70kg male)</p>
<p>Child 8-9% (80-90ml/kg)</p>
<p>When should hemorrhage control and balanced fluid resuscitation be initiated?</p>
<p>When early signs and symptoms of blood loss are suspected NOT when blood pressure is falling or absent.</p>
<p>Which patients will need pRBCs and blood products as an early part of resuscitation?</p>
<p>Class III and Class IV haemorrhage.</p>
<p>What type of pRBC should females of childbearing age get and why? (p. 74)</p>
<p>Rh-negative cells in order to avoid sensitization and future complications.</p>
<p>If someone has an exsanguinating haemorrhage, what type of blood should they get?</p>
<p>Type O.</p>
<p>What temperature should we heat fluids to for hypotehermic patients in shock?</p>
<p>39C</p>
<p>This can be warmed in a microwave.</p>
<p>Can we warm blood products?</p>
<p>NO! They can be heated by passage through IV fluid warmers.</p>
<p>What is the definition of a massive transfusion?</p>
<p>The need for >10 units of pRBC in the first 24 hours of admission.</p>
<p>What does "<strong>balanced, hemostatic resucitation</strong>" (a.k.a. <strong>Damage control resuscitation</strong>) mean?</p>
<p>Th early administration of pRBC, plasma and platelts in order to minimize crystalloid administration.</p>
<p>Coagulopathy is present in up to (BLANK) severely injured patients on admission.</p>
<p>30%</p>
<p>What coagulation parameters should be used when deciding on the use of platelets, FFP, & cryoprecipitate?</p>
<p>1/ PT (prothrombin time)</p>
<p>2/ PPT (partrial prothrombin time)</p>
<p>3/ Fibrinogen.</p>
<p>4/ Platelet count</p>
<p>Do most patients that have blood transfusions require calcium supplementation?</p>
<p>NO</p>
<p>In order to correct inadequate organ perfusion, what do we need to reverse?</p>
<p>We need to reverse shock.</p>
<p>(increase organ blood flow and tissue oxygenation.)</p>
<p>Remember the definition of shock is the opposite of the above.</p>
<p></p>
<p></p>
<p>Who's law do we use increase blood pressure?</p>
<p></p>
<p></p>
<p><strong>Ohm's law:</strong></p>
<p><strong>Blood pressure (V)= (I)Cardiac outputx (R)Systemic vascular resistance.</strong></p>
<p>REMEMBER: <strong>We care about in increase in cardiac output (I) NOT R.</strong></p>
<p>We do this by <strong>increasing stroke volume</strong> not heart rate. (<em>stroke volume=preload+contractility+afterload</em>)</p>
<p><strong>Vasopressors</strong> can <strong>increase R</strong> by <strong>vasoconstriction</strong>but with no improvement to end organ perfusion.</p>
<p>How much may blood volume increase by in athletes?</p>
<p>15 to 20%</p>
<p>How much can cardiac output increase by in athletes?</p>
<p>6 times.</p>
<p>How much can stroke volume increase in athletes?</p>
<p>50%</p>
<p>Who is more likely to suffer from hypothermia as a result of vasodilation?</p>
<p>A trauma victim under the influence of alcohol or exposed to the cold.</p>
<p>In mild to moderate hypothermia, how do you rewarm a patient?</p>
<p>Heat lamps, external warming devices, thermal caps, warmed IV fluids and warmed blood.</p>
<p>In severe hypothermia, how is a patient rewarmed?</p>
<p>Core rewarming. (Irrigation of the peritoneal or thoracic cavity with crystalloid solutions warmed to 39C</p>
<p>OR</p>
<p>Extracorporeal bypass.</p>
<p>Why is CVP useful?</p>
<p>The CVP allows us to evaluate appropriate volume replacement.</p>
<p>What can cause pronounced increases in CVP?</p>
<ol> <li>Overtransfusion</li> <li>Cardiac dysfunction</li> <li>Cardiac tamponade</li> <li>Increased intrathoracic pressure from tension pneumothorax.</li> <li>Catheter malposition.</li></ol>
<p></p>
<p>What does a declining CVP suggest?</p>
<p>Fluid loss.</p>
<p>In what scenarios can you have an initial high CVP but actually have significant volume loss?</p>
<ol> <li>COPD</li> <li>Generalised vasoconstriction</li> <li>Rapid fluid replacement</li></ol>
<p>In what way can we misinterpret/over rely onCVP (central venous pressure)?</p>
<p>The <strong><u>precise measure</u> of <u>cardiac function</u></strong> is the <strong>relationship</strong> <strong>between</strong> <strong><u>ventricular end diastolic volume</u> and <u>stroke volume</u></strong></p>
<p><strong>NOT</strong></p>
<p><strong>Right atrial pressure (CVP) and cardiac output are insensitive measures.</strong></p>
<p>CVP is just a guide.</p>
<p>What are some complications of inserting a CVP line?</p>
<ol> <li>Infections</li> <li>Vascular injury</li> <li>Nerve injury</li> <li>Embolization</li> <li>Thrombosis</li> <li>Pneumothorax</li></ol>
<p>Injury to the upper chest can create a palpable defect in the region of the sternoclavicular joint, with posterior dislocation of the clavicular heads and upper airway obstruction. How do you reduce this injury?</p>
<p>1/ Closed reduction by extending the arm.</p>
<p>2/ Grasping the clavicle with a pointed instrument (e.g. a towel clamp) and manually reducing it.</p>
<p>What major thoracicinjuries should be picked up onand addressed during the primary survey?</p>
<ol> <li>Tension pneumothorax</li> <li>Open pneumothorax</li> <li>Flail Chest</li> <li>Pulmonary Contusion</li> <li>Massive haemothorax</li></ol>
<p>What type of shock is a tension pneumothorax?</p>
<p>Obstructive shock</p>
<p>How does a tension penumothorax develop?</p>
<ol> <li>A "one way valve" air leak occurs from the lung or through the chest wall.</li> <li>Air is forced into the pleural space without any means to escape.</li> <li>The mediastium is displaced to the opposite side, decreasing venous return and compressing the opposite lung.</li></ol>
<p>After intubation what is one of the common reasons for loss of breath sounds in the left thorax?</p>
<p>A right mainstem intubation.</p>
<p></p>
<p>(Be aware that this can happened and don't mistake it for a pneumothorax/haemothorax)</p>
<p>What are somecausesof a tension pneumothorax?</p>
<p>1) Mechanical ventilation with positive-pressure ventilation in patients with a visceral pleural injury. (Most common)</p>
<p>2) Blunt/penetrating chest trauma where the lung parenchyma injury fails to seal.</p>
<p>3) Post subclavian/Internal jugular venous catheter insertion.</p>
<p>4) Traumatic defects in the chest wall.</p>
<p>What signs and symptoms are seen with a tension pneumothorax?</p>
<ol> <li>Chest pain</li> <li>Air hunger</li> <li>Respiratory distress</li> <li>Tachycardia</li> <li>Hypotension</li> <li>Tracheal deviation away from the side of injury</li> <li>Unilateral absence of breath sounds over hemithorax.</li> <li>Elevated hemithorax w/o respiratory movement.</li> <li>Neck vein distension</li> <li>Cyanosis (late manifestation)</li></ol>
<p>How does one manage a tension pneumothorax?</p>
<p>1/Immediate decompression.- alarge bore needle is inserted into the second intercostal space in the midclavicular line.</p>
<p>2/ Definition treatment - insertion of a chest tube into the fifth intercostal space (usually at the nipple level) just anterior to the mixaxillary line.</p>
<p>What size needle should you use and what percentage chance will it be effective in chest decompression?</p>
<p>A 5cm needle will reach the pleural space >50% of the time.</p>
<p>An 8cm needle will reach the pleural space >90% of the time.</p>
<p>In what circumstances does an open pneumothorax occur?</p>
<p>It occurs when there is a large defect in the chest wall which allows atmospheric air to rush into the pleural space, thus equalizing atmospheric and intrathoracic pressure.</p>
<p>How is an open pneumothorax managed?</p>
<p>Temporary- A sterile occlusive dressing is placed over the wound with 3 sides taped down to provide a <strong>flutter valve</strong>.</p>
<p>As the patient breathes in the dressing occludes the wound and thus the lung expands. On breathing out, the open end of the dressing allows air to escape.</p>
<p>Definitive - surgery</p>
<p>Describe how a flail chest occurs and its management.</p>
<p>1/ Trauma causing multiple rib fractures in two or more adjacent ribs in 2 or more places.</p>
<p>2/ Initial management -</p>
<ul> <li>Adequate ventilation</li> <li>Administration of humidified oxygen</li> <li>Fluid resuscitation. (But fluid resuscitation should be used carefully so as not cause overload)</li> <li>IV morphine or intercostal blocks.</li></ul>
<p>3/ Final management - surgery</p>
<p>What is the definition of a massive haemothorax?</p>
<p>A rapid accumulation of more than 1500mL of blood or 1/3 or more of the patient's blood volumein the chest cavity .</p>
<p>What are thecommon causes of a massive haemothorax?</p>
<p>1/ A penetrating injury that disrupts the systemic or hilar vessels.</p>
<p>2/ Blunt pulmonary trauma</p>
<p>What are the signs of a massive hemothorax?</p>
<p>Shock associated with the abscence of breath sounds or dullness to percussion on one side of the chest.</p>
<p>How should a massive haemothorax be managed?</p>
<ol> <li>A 36 or 40 French chest tube is inserted in the nipple line just anterior to the midaxillary line.</li> <li>Continue to early thoracotomy if 1,500mL of fluid is immediately evacuated.</li> <li>If patients continue to bleed or they require persistent transfusions,then they may also require a thoracotomy.</li></ol>
<p>What is the most common cause of cardiac tamponade?</p>
<p>Penetrating injury.</p>
<p>How do you diagnose a cardiac tamponade?</p>
<p>Using Beck's Triad of 1/ Venous pressure elevation 2/ Decline in arterial pressure 3/ Muffled heart tones.</p>
<p></p>
<p>ECG - PEA is suggestive.</p>
<p></p>
<p>FAST Scan</p>
<p>How accurate is a FAST scan in finding pericardial fluid? (if used by an experienced user)</p>
<p>90-95%</p>
<p>How is a cardiac tamponade managed?</p>
<p>1/ Temporarily - pericardiocentisis</p>
<p>2/ Surgery - Pericardiotomy via thoracotomy.</p>
<p>What are some complications of a chest tube insertion?</p>
<ol> <li>Laceration or puncture of intrathoracic organs or abdominal organs.</li> <li>Infection</li> <li>Intercostal nerve damage</li> <li>Incorrect tube position</li> <li>Chest tube kinking or clogging</li> <li>Persistent pneumothorax - leak around the skin, leak in the underwater seal.</li> <li>Subcutaneous emphysema</li> <li>Recurrence of penumothorax upon chest drain removal.</li> <li>Lung fails to expand due to plugged bronchus.</li> <li>Anaphylactic or allergic reaction to prepartion.</li></ol>
<p>What are some complications of pericardiocentesis?</p>
<ol> <li>Aspiration of ventricular blood instead of pericardial blood.</li> <li>Laceration of ventricular epicardium/myocardium</li> <li>Laceration of coronary artery or vein.</li> <li>New hemopericardium secondary 2-3.</li> <li>Ventricular fibrillation (VF)</li> <li>Pneumothorax</li> <li>Puncture of esophagus with subsequent medistinitis.</li> <li>Puncture of peritoneum with peritonitis.</li> <li>Puncture of great vessels</li></ol>
<p>What does a "current of injury" mean?</p>
<p>In a pericardiocentesis, in the needle is advanced too far then on the ECG monitor one can see an extreme ST-T wave changes or widened & enlarged QRS complex.</p>
<p></p>
<p>If the myocardium is irritated then premature ventricular contractions can occur.</p>
<p>What maneuvers can be effectively accomplished with a resuscitative thoracotomy?</p>
<p>1/ Evacuation of pericardial blood causing tamponade</p>
<p>2/ Direct control of exsanguinating intrathoracic hemorrhage.</p>
<p>3/ Cross-clamping of the descending aorta to slow blood loss below the diaphragm and increase perfusion to the brain and heart.</p>
<p>Who are NOT candidates for resuscitative thoracotomy?</p>
<p>Patients who sustain blunt injuries and arrive pulseless but with PEA.</p>
<p>Who are candidates for immediate resuscitative thoracotomy?</p>
<p>Patientswith penetrating thoracic injuries who arrive pulseless butwith myocardial electrical activity.</p>
<p>What are the 8 thoracic injuries that should be identified during the secondary survey?</p>
<ol> <li>Simple pneumothorax</li> <li>Hemothorax</li> <li>Pulmonary contusion</li> <li>Tracheobronchial tree injury</li> <li>Blunt cardiac injury</li> <li>Traumatic aortic disruption</li> <li>Traumatic diaphragmatic injury</li> <li>Blunt esophageal rupture</li></ol>
<p>What is the most common cause of simle pneumothorax?</p>
<p>Lung laceration with air leakage from blunt trauma.</p>
<p>In what situation should you not transport someone to hospital who has a simple pneumothorax?</p>
<p>You should not transport them via air ambulance due to expansion of the pneumothorax at altitude. (even in a pressurized cabin)</p>
<p>How much blood is lost ina hemothorax? (not a massive hemothorax)</p>
<p><1500mL blood.</p>
<p>What is the primary cause of hemothorax?</p>
<p>Lung laceration or laceration of the intercostal vessel or internal mammary artery due to either penetrating or blunt trauma.</p>
<p>When is an operative exploration required for a hemothorax?</p>
<p>Guidelines for operative exploration are:</p>
<ol> <li>If 1500mL of blood is obtained immediately through the chest tube.</li> <li>If drainage of more than 200mL/hr for 2 to 4 hours occurs</li> <li>If blood transfusion is required.</li></ol>
<p>In what condition is pulmonary contusion most commonly seen?</p>
<p>Rib fractures.</p>
<p>Pulmonary contusion is the <strong>most common</strong> potentially lethal chest injury.</p>
<p>If someone were to have chest trauma & subsequent pulmonary contusion, when would you think about intubating & ventilating them?</p>
<p>If they have significant hypoxia (PaO2 of <8.6kPa or SaO2 of <90% on room air.</p>
<p>What is tracheobronchial tree injury?</p>
<p>Injury to the trachea or major bronchus.</p>
<p>Most injuries are within 1 inch of the carina.</p>
<p>Most patients die at the scene.</p>
<p>What are the most common symptoms of tracheobronchial tree injury and how is it best diagnosed?</p>
<ol> <li>Hemoptysis</li> <li>Subcutaneous emphysema</li> <li>Tension pneumothorax</li> <li>Incomplete expansion of the lung after placement of a chest tube.</li> <li>Extreme breathlessness.</li></ol>
<p>It is best diagnosed with a bronchoscopy</p>
<p>Blunt cardiac trauma can result in:</p>
<ol> <li>Myocardial muscle contusion</li> <li>Cardiac chamber rupture</li> <li>Coronary artery dissection/thrombosis</li> <li>Valvular disruption</li></ol>
<p>What are some of the msot common ECG findings in blunt cardiac injury?</p>
<ol> <li>Multiple premature ventricular contractions</li> <li>Unexplained Sinus tachycardia</li> <li>AF</li> <li>BBB (usually right)</li> <li>ST segment changes.</li></ol>
<p>Should we use troponins in diagnosing blunt cardiac injury?</p>
<p>Nope.</p>
<p>How long should someone be monitored if they have a blunt cardiac injury?</p>
<ol> <li>24 hours - after this the risk of dysrhythmia decreases dramatically.</li></ol>
<p>When is a traumatic aortic disruption commonly seen?</p>
<p>Automobile collisions or a fall from a great height.</p>
<p>In traumatic aortic disruption, when would patient's have the highest chance of survival?</p>
<p>If there is an incomplete laceration near the ligamentum arteriosum of the aorta.</p>
<p></p>
<p>Continuity is maintained by an intact adventitial layer or contained mediastinal hematoma and prevents immediate exsanguination and death.</p>
<p>Name some signs of traumatic aortic disruption that would appear on xray?</p>
<ol> <li>widened mediastinum</li> <li>obliteration of the aortic knob</li> <li>Deviation of the trachea to the right</li> <li>Depression of the left mainstem bronchus.</li> <li>Elevation of the right mainstem bronchus.</li> <li>Deviation of the esophagus</li> <li>Widened paratracheal stripe</li> <li>Widened paraspinal interfaces</li> <li>Presence of a pleural or apical cap</li> <li>Left hemothorax</li> <li>Fractures of the first or second rib or scapula.</li></ol>
<p>What has been shown to be an accurate screening method for a suspected blunt aortic injury?</p>
<p>Helical CT scan. (Sensitivity and specificity of ~100%)</p>
<p></p>
<p>If the results are equivocal then do an aortography.</p>
<p>What is the treatement for a traumatic aortic disruption?</p>
<p>Treatment is either through:</p>
<ol> <li>Primary repair</li> <li>Resection of the torn segment and replacement with an interposition graft.</li> <li>Endovascular Repair (EVAR)</li></ol>
<p>Traumatic diaphragmatic injuries are most commonly seen on which side?</p>
<p>The left side because of the protective effect of the liver.</p>
<p>On CXR, what findingwould you see with a diaphragmatic injury?</p>
<p>An elevated right hemidiaphragm.</p>
<p>What is a complication of blunt esophageal rupture?</p>
<p>Mediastinitis and an empyema.</p>
<p>In what situation should a blunt esophageal rupture always be considered?</p>
<p>When a patient has a <strong>left pneumothorax</strong>, <strong>hemothorax</strong> <strong>w/o rib fractures</strong> or they received a s<strong>evere blow to the lower sternum or epigastrium</strong> and is in <strong>pain</strong>or <strong>shock</strong> that is <strong>out of proportion to their apparent injury</strong>.</p>
<p>What are the 3 significant manifestations of chest injury?</p>
<p>1/ Subcutaneous emphysema</p>
<p>2/ Crushing injury to the chest (Traumatic asphyxia)</p>
<p>3/ Rib, Sternum and Scapular Fractures</p>
<p>Young people have more flexible ribs, if there are multiple rib fractures in a young person what does this imply?</p>
<p>A greater transfer of force than in an older patient.</p>
<p>What dofractures of the lower ribs (10 to 12) imply?</p>
<p>Hepatosplenic injury</p>
<p>The upper ribs 1 to 3 are protected by the scapula, humerus and clavicle along with other muscular attachement. If you see fracutres of these ribs what does it imply?</p>
<p>A magnitude of injury that places the head, neck, spinal cord, lungs and great vessels at risk of injury.</p>
<p>What ribs sustain the majority of blunt trauma?</p>
<p>4 to 9. The middle ribs.</p>
<p>What should be assumed if a patient has sustained significant blunt torso trauma from a direct blow, deceleration or a penetrating injury?</p>
<p>Injury to the abdominal viscera, vasculature or pelvis until proven otherwise.</p>
<p>Define the landmarks of the anterior abdomen.</p>
<p>The area between the costal margins superiorly, the inguinal ligaments and the symphysis pubis inferiorly, and the anterior axillary lines laterally.</p>
<p>Define the landmarks of the thoraco-abdomen.</p>
<p>The area inferior to the trans-nipple line anteriorly and the infra-scapular line posteriorly, and superior to the costal margins. This area include the diaphragm, liver, spleen and stomach.</p>
<p>Define the landmarks of the flank.</p>
<p>The area between the anterior and posterior axillary lines from the sixth intercostal space to the iliac crest.</p>
<p>Define the landmarks of the back.</p>
<p>The area located posterior to the posterior axillary lines from the tip of the scapulae to the iliac crests.</p>
<p>Where are the retroperitoneal organs contained?</p>
<p>In the flank and the back.</p>
<p>What organs are in the retroperitoneum?</p>
<p>1/ Abdominal aorta2/ Inferior vena cava3/ Most of the duodenum4/ Pancreas5/ Kidneys6/ Ureters7/ The posterior aspects of the ascending and descending colons8/ The retroperitoneal composition of the pelvic cavity.</p>
<p>Why are injuries to the retroperitoneum hard to recognise?</p>
<p>The area is remote from physical examination and the injuries may not initially present with signs or symptoms of peritonitis.</p>
<p>What organs are in the pelvic cavity?</p>
<p>1/ Rectum</p>
<p>2/ Bladder</p>
<p>3/ Iliac vessels</p>
<p>4/ Internal reproductive organs (in females)</p>
<p>What is the definition of a deceleration injury?</p>
<p>It is an injury where the is a different movement of fixed and nonfixed parts of the body.</p>
<p>Give some examples of deceleration injuries?</p>
<p>1/ Lacerations of the liver and spleen.</p>
<p>2/ Bucket handle injuries to the small bowel.</p>
<p>What organs are most frequently injured in blunt trauma to the abdomen?</p>
<p>1/ Spleen (40-55%)</p>
<p>2/ Liver (35-45%)</p>
<p>3/ Small bowel (5% to 10%)</p>
<p>What kind of injuries can you get from a lap seat belt?</p>
<ol> <li>Tear of avulsion of the mesentery (Bucket Handle Tear)</li> <li>Rupture of the small bowel or colon.</li> <li>Thrombosis of the iliac artery or abdominal aorta</li> <li>Chance fracture of lumbar vertebrae.</li> <li>Pancreatic or duodenal injury</li></ol>
<p>What kind of injuries can you get from a shoulder harness?</p>
<ol> <li>Intimal tear or thrombosis in innominate, carotid,subclavian or vertebral arteries.</li> <li>Fractures or dislocations of the C-spine.</li> <li>Rib fractures.</li> <li>Pulmonary contusion.</li> <li>Rupture of upper abdominal viscera</li></ol>
<p>What kind of injuries can you get from an airbag?</p>
<ol> <li>Corneal abrasion</li> <li>Abrasions to the face, neck or chest.</li> <li>Cardiac rupture</li> <li>Cervical spine injury</li> <li>Thoracic spine fracture</li></ol>
<p>When can shearing injuries occur in the car?</p>
<p>When a restraint device is worn improperly</p>
<p>What general sort of injuries can a direct blow to the abdomen cause?</p>
<ol> <li>Compression/Crushing injuries</li> <li>Abdominal viscera and pelvis</li> <li>Organ rupture +/- secondary hemorrhage</li> <li>Contamination by visceral contents +/- peritonitis.</li></ol>
<p>What organs do stab wounds most commonly involve?</p>
<ol> <li>Liver (40%)</li> <li>Small bowel (30%)</li> <li>Diaphragm (20%)</li> <li>Colon (15%)</li></ol>
<p>What organs do gunshot wounds most commonly involve?</p>
<ol> <li>Small bowel (50%)</li> <li>Colon (40%)</li> <li>Liver (30%)</li> <li>Abdominal structures (25%)</li></ol>
<p>What two factors affect the injuries incurred by a gunshot wound?</p>
<ol> <li>The type of shot</li> <li>The distance from the gun.</li></ol>
<p>What is an overpressure injury?</p>
<p>This is an injury related to the <strong>blast </strong>from an <strong>explosion</strong></p>
<p>If in an <strong>enclosed space</strong>, the likelihood of overpressure <strong>injury increases</strong>..</p>
<p>There <strong>may be penetrating objects</strong> from the blast or <strong>purely from </strong>the <strong>barotrauma </strong>of the explosion.</p>
<p><strong>Pulmonary </strong>and <strong>hollow viscouses </strong>are commonly affected.</p>
<p>What sort of injuries can result from wearing a lap seat belt?</p>
<ol> <li>Bucket handle tear- Tear or avulsion of mesentery.</li> <li>Rupture of small bowel or colon</li> <li>Thrombosis of iliac artery or abdominal aorta</li> <li>Fracutred lumbar vertebrae</li> <li>Pancreatic or duodenal injury</li></ol>
<p>What injuries can result form wearing a shoulder harness?</p>
<ol> <li>Intimal tear or thrombosis in innominate, carotid, subclavian or vertebral arteries.</li> <li>Fracture or dislocation of cervical spine.</li> <li>Rib fractures</li> <li>Pulmonary contusion</li> <li>Rupture of upper abdominal viscera</li></ol>
<p></p>
<p>What injuries can result from an air bag?</p>
<ol> <li>Corneal abrasions</li> <li>Abrasions of face, neck and chest</li> <li>Cardiac rupture</li> <li>Cervical spine</li> <li>Thoracic spine fracture.</li></ol>
<p>What history should be taken when assessing a patient in a motor vehicle accident?</p>
<ol> <li>Speed of the vehicle</li> <li>Type of collision (frontal, lateral, sideswipe, rear impact or rollover)</li> <li>Vehicle intrusion into the passenger compartment.</li> <li>Types of restraints.</li> <li>Deployment of air bags.</li> <li>Patient's position in the vehicle</li> <li>Status of passengers.</li></ol>
<p>What history should be taken when assessing a patient who has fallen?</p>
<ol> <li>The height of the fall.</li></ol>
<p>What history should be taken when assessing a patient who has penetrating trauma?</p>
<p></p>
<ol> <li>Time of injury</li> <li>Type of weapon</li> <li>Distance from assailant. (Beyond 10 feet/3 metres the likelihood of major visceral injury decreases substantially.)</li> <li>Number of stab/shot sustained.</li> <li>Amount of external bleeding at the scene.</li></ol>
<p>What are the steps of the secondary abominal examination?</p>
<ol> <li><strong>Inspect </strong>for anterior & posterior abdomen for signs of blunt and penetrating inury & internal bleeding.</li> <li><strong>Auscultate for the presence of bowel sounds.</strong></li> <li><strong>Precuss </strong>the abdomen to elicit subtle rebound tenderness.</li> <li><strong>Palpate </strong>the abdomen for tenderness, involuntary muscle guarding, unequivocal revound tenderness and a gravid uterus.</li> <li>Assess for <strong>pelvic stability</strong> & obtain pelvic xray if required.</li> <li><strong>Perineal exam </strong>- contusions, hematomas, lacerations and urethral bleeding.</li> <li><strong>Rectal exam </strong>- blood, spinchter tone, bowel wall integrity, bony fragments, prostate position.</li> <li><strong>Gluteal exam</strong></li> <li><strong>Vaginal Exam</strong> - lacerations and blood in vaginal vault.</li></ol>
<ul> <li>Blood at the urethral meatus</li> <li>Scrotal haematoma</li> <li>Laceration of the perineum, vagina, rectum or buttocks</li> <li>A high riding prostate</li> <li>Limb length discrepancies/deformity</li></ul>
<p>Are all suggestive of what?</p>
<p>Open pelvic fracture.</p>
<p>If bowel sounds are absent on auscultation what could this signify?</p>
<p>Ileus secondary to Free GI contents or intraperitoneal blood.</p>
<p>On mild percussion, we are looking for signs of peritoneal irritation. If peritonism is seen should we also test for rebound tenderness?</p>
<p>NO!!! This will cause the pt more pain.</p>
<p>Why do we perform a manual manipulation of the pelvis only once?</p>
<p>To prevent further dislodging of clots and haemorrhage.</p>
<p>When should the manual manipulation of the pelvis NOT be performed?</p>
<p></p>
<ol> <li>Shock</li> <li>Obvious pelvic fracture</li></ol>
<p>Describe the compression distraction maneuver?</p>
<p>The Iliac crests are grasped and the unstable hemipelvis is pushed/rotated inward(internally) and then outward(externally).</p>
<p>When testing the pelvis for posterior ligamentous disruption (shear fracture), what manipulation can you do?</p>
<p></p>
<p>The hemipelvis can be pushed cephalad as well as pulled caudally. You simultaneously palpate the posterior iliac spine and tubercle</p>
<p>Blood at the urethral meatus strongly suggests what 2 injuries?</p>
<p></p>
<ol> <li>Urethral Meatus injury</li> <li>Pelvic fracture</li></ol>
<p>What are your goals when performing a rectal examination?</p>
<p></p>
<ol> <li>Assess spincter tone</li> <li>Assess rectal mucosal integrity</li> <li>Determine position of prostate (e.g. high riding)</li> <li>Identiy any fractures of the pelvic bone.</li> <li>Look for gross blood (especially if penetrating wound)</li></ol>
<p>If someone has a high riding prostate or a scrotal/perineal hematoma what should you NOT do?</p>
<p>DO NOT insert Foley catheters.</p>
<p></p>
<p>They may have a urethral injury.</p>
<p>Penetrating injuries of the gluteal area are associated with (?) incidence of significant intraabomdinal injury?</p>
<p>50%</p>
<p>What are the therapeutic goals of inserting gastric tubes?</p>
<ol> <li>Relieve acute gastric dilation</li> <li>Decompress the stomach before performing DPL</li> <li>Remove gastric contents.</li></ol>
<p>What does the presence of blood upon NG insertion suggest?</p>
<p></p>
<p>Injury to the oesophagus or upper GI tract.</p>
<p>What are the goals of <strong>Urinary Catheter </strong>insertion?</p>
<ol> <li>Relieve retention</li> <li>Decompress the bladder before performing DPL.</li> <li>Allow for monitoring urinary output (e.g. monitor tissue perfusion.)</li></ol>
<p>What is gross haematuria a sign of?</p>
<p>Trauma to the genitourinary tract and non-renal intraabominal organs.</p>
<p>You <strong>would NOT </strong>insert a <strong>catheter </strong>and would do a urethrogram if you saw any of the following signs?</p>
<ol> <li>The inability to void</li> <li>Unstable pervlic fracture</li> <li>Blood at the meatus</li> <li>Scrotal haematoma</li> <li>Perineal ecchymoses</li> <li>High riding prostate on PR</li></ol>
<p>If you do have a disrupted urethra what procedure can you do to relieve the bladder?</p>
<p>Suprapubic catheter insertion.</p>
<p>What is the only contraindication to performing a FAST Scan or a DPL?</p>
<p>Existing indication for laparotomy</p>
<p>In what conditions may you need further studies?</p>
<ol> <li><strong>Change in sensorium</strong> (<strong>potential brain injury</strong>, alcohol intoxication or use of illicit drugs)</li> <li><strong>Change </strong>in <strong>sensation </strong>(potential injury to <strong>spinal</strong> <strong>cord</strong>)</li> <li><strong>Injury to adjacent structures</strong>, such as the lower ribs, pelvis or lumbar spine.</li> <li><strong>Equivocal physical examination</strong></li> <li><strong>Lap belt sign </strong>(<strong>abdominal wall contusion</strong>) with <strong>suspicion </strong>of <strong>bowel injury</strong>.</li></ol>
<p>With penetrating wounds, what should you put at all entrance and exit sites when performing an x-ray?</p>
<p>Marker rings/clips.</p>
<p>The FAST scan is used to obtain views of ?</p>
<ol> <li>Cardiac Tamponade</li> <li>Hepatorenal fossa</li> <li>Splenorenal Fossa</li> <li>Pelvis</li> <li>Puch of Douglas</li></ol>
<p>What does DPL stand for & how sensitive is it for detecting intraperitoneal bleeding?</p>
<p>Diagnostic peritoneal lavage. 98% sensitive</p>
<p>Name some relative contraindications to DPL?</p>
<ol> <li>Previous abdominal operations</li> <li>Morbid obesity</li> <li>Advvanced cirrhosis</li> <li>Preexisting coagulopathy</li></ol>
<p>If blood, GI contents, vegetable fibers or bile are obtained through DPL, what needs to be done?</p>
<p>Laparotomy.</p>
<p>Are DPL's usually done infrapubically or suprapubically?</p>
<p>Infrapubically.</p>
<p>However, if apelvic fracture is suspected then it can be done suprapubically.</p>
<p>If gross blood (>10mls) is not aspirated or GI contents are not aspirated what is the next step?</p>
<p>Perform lavage with 1L of warmed isotonic crystalloid solution. (10ml/kg in a child)</p>
<p>In DPL, when is it considered to be a positive test?</p>
<ol> <li>>100,000 red blood cells/mm3</li> <li>500 WBC/mm3</li> <li>Gram stain with bacteria present.</li></ol>
<p>When would you perform a urethrogram?</p>
<p>Before inserting a catheter when a urethral injury is suspected.</p>
<p>How is the urethrogram performed?</p>
<p>An <strong>8 French urinary catheter is secured in the meatal fossa</strong> by <strong>balloon inflation to 1.5 to 2mL</strong>. <strong>30 to 35 mL of undiluted contrast</strong> is <strong>instilled </strong>with gentle pressure. Radiographs are then taken.</p>
<p>What diagnostic tool is best used to diagnose an intraperitoneal or extraperitoneal bladder rupture?</p>
<p>Cystogram (XR) or CT cystogram.</p>
<p>How is a cystogram performed?</p>
<p>A s<strong>yringe barrel is attached to the indwelling bladder catheter</strong>, held <strong>40cm above the patient.</strong> <strong>350mL of water-soluble contrast is allowed to flow </strong>i<strong>nto the bladder until either flow stops</strong>, the <strong>patient voids </strong>or the <strong>patient</strong> is in <strong>discomfort</strong>. <strong>Contrast </strong>is then <strong>instilled</strong> into the bladder.AP and Post drainage images are taken. (XR)</p>
<p>What study is most useful if there are urinary system injuries?</p>
<p>A contrast-enhanced CT scan.</p>
<p></p>
<p>NOTE: If CT not available then an IVP (Intravenous pyelogram) is available.</p>
<p>On an Intravenous Pyelogram (IVP) what does a <strong>unilateral nonfunction </strong>indicate?</p>
<ol> <li>Absent kidney</li> <li>Thrombosis</li> <li>Avulsion of the renal artery</li> <li>Massive parenchymal disruption.</li></ol>
<p>If a non-function is seen on IVP what further ix is warranted?</p>
<p>Contrast-enhanced CT,renal arteriogram or surgical exploration.</p>
<p>What are some advantages & disadvantages of DPL?</p>
<p>Indication: Penetratinga nd blunt trauma</p>
<p>Advantages</p>
<ul> <li>Early diagnosis</li> <li>Performed rapidly</li> <li>98% sensitive</li> <li>Detects bowel injury</li></ul>
<p>Diadvantages</p>
<ul> <li>Invasive</li> <li>Low specificity</li> <li>Misses injuries to diaphragm and retroperitoneum</li></ul>
<p>What are some advantages & disadvantages of Fast Scan?</p>
<p>Indication: Unstable blunt trauma</p>
<p>Advantages</p>
<ul> <li>Early diagnosis</li> <li>Noninvasive</li> <li>Performed rapidly</li> <li>Repeatable</li> <li>86-97% sensitive</li></ul>
<p>Disadvantages</p>
<ul> <li>Operator dependent</li> <li>Bowel gas or subcutaneous air distortion</li> <li>Misses diaphragm, bowel or pancreatic injuries.</li></ul>
<p>What are some advantages & disadvantages of CT scan?</p>
<p>Indication: <strong>STABLE</strong>blunt trauma and penetrating back/flank trauma.</p>
<p>Advantages:</p>
<ul> <li>Most specific for injury</li> <li>92-98% sensitive</li> <li>Non-invasive</li></ul>
<p>Disadvantages</p>
<ul> <li>Cost and time</li> <li>Misses diaphragm, bowel and some pancreatic injuries</li> <li>Transport required.</li></ul>
<p>What percentage of gunshot wounds to the abdomen have intraperitoneal injury? What does this mean for management?</p>
<p>98%. Therefore gunshot wounds are always managed with anexploratory laparotomy.</p>
<p>What percentage of stab wounds have an intraperitoneal injury?</p>
<p>30%</p>
<p>What are the indications for laparotomy in patients with penetrating abdominal wounds?</p>
<ul> <li>Haemodynamically unstable</li> <li>Gunshot wound with a transperitoneal trajectory</li> <li>Signs of peritoneal irritation</li> <li>Signs of fascia penetration.</li></ul>
<p>?% of all patients with penetrating stab wounds to the anterior peritoneum have hypotension, ? or evisceration of ? or ?. This required an ?.</p>
<p>55-60%</p>
<p>Peritonitis</p>
<p>Omentum</p>
<p>Small Bowel</p>
<p>Emergency laparotomy</p>
<p>In flank and back injuries what kind of investigations is appropriate?</p>
<ol> <li><strong>Serial examinations </strong>(as accurate as CT scan)</li> <li><strong>Double </strong>or <strong>Triple Contrast CT</strong></li> <li><strong>DPL </strong>(invasive)</li> <li><strong>Laparotomy </strong>(invasive)</li></ol>
<p>NOTE: <strong>Early outpatient follow up after 24 hours </strong>is important due to <strong>subtle injuries </strong>that can manifest later. (i.e. <strong>colonic </strong>injuries)</p>
<p>What are the following 9 indications for laparotomy?</p>
<ol> <li><strong>Blunt abdominal trauma </strong>with <strong>hypotension</strong> wtih a <strong>positive FAST </strong>or clinical <strong>evidence </strong>of <strong>intraperitoneal bleeding</strong>.</li> <li><strong>Blunt </strong>or <strong>penetrating </strong>abdominal trauma with a <strong>positive DPL</strong>.</li> <li><strong>Hypotension </strong>with a <strong>penetrating abdominal</strong> wound.</li> <li><strong>Gunshot wounds </strong>in the <strong>peritoneal </strong>cavity or <strong>retroperitoneum</strong>.</li> <li><strong>Evisceration</strong>.</li> <li><strong>Bleeding </strong>from the <strong>stomach</strong>, <strong>rectum </strong>or <strong>genitourinary tract </strong>from penitrating trauma.</li> <li><strong>Peritonitis</strong></li> <li><strong>Free air</strong>, retroperitoneal air or rupture of the hemidiaphragm.</li> <li><strong>Contrast</strong>-<strong>enhanced CT </strong>that demonstrates <strong>ruptured GI tract</strong>, intraperitoneal <strong>bladder</strong> <strong>injury</strong>, <strong>renal </strong>pedicle <strong>injury </strong>or severe <strong>visceral</strong> <strong>parenchymal injury </strong>after <strong>blunt </strong>or <strong>penetrating</strong> trauma.</li></ol>
<p>Which hemidiaphragm is more commonly injured?</p>
<p><strong>Left</strong>.</p>
<p>Most common injury is 5 to 10cm in length and on the left posterior hemidiaphragm.</p>
<p>What Xray finding is seen with a diaphragm injury?</p>
<ul> <li>A raised hemidiaphragm</li> <li>"Blurring" of the hemidiaphragm</li> <li>hemothorax.</li></ul>
<p>In what 2 situations are duodenal rupture classically encountered?</p>
<ol> <li>Unrestrained drivers involved in frontal-impact motor vehicle collisions.</li> <li>Handlebar injuries.</li></ol>
<p>What situation causes pancreatic injuries?</p>
<p>Direct epigastric blows ...</p>
<p>that compress the pancreas against the thoracic column.</p>
<p>Is serum amylase always raised after pancreatic injury?</p>
<p></p>
<p>Nope.</p>
<p>What imaging should be done if pancreatic injury is suspected and what time period is it most useful in?</p>
<p>Double contrast CT.</p>
<p>Immediately postinjury (Up to 8 hours)</p>
<p>When contusions, hematomas or ecchymoses are seen over the back and flanks what should be done?</p>
<p>CT or IVP to investigate for renal/urinary tract injury.</p>
<p>What are the indications for further evaluation of the renal/urinary tract?</p>
<ol> <li>Gross hematuria</li> <li>Microscopic hematuria in patients with</li></ol>
<p>a) penetrating injury</p>
<p>b) an episode of hypotension and blunt abdo trauma</p>
<p>c) associated with intraabdominal injuries and blunt trauma.</p>
<p></p>
<p>What percentage of blunt renal injuries can be treated nonoperatively?</p>
<p>95%</p>
<p>In what two rare deceleration renal injuries can haematuria be absent?</p>
<ol> <li>Renal artery thrombosis</li> <li>Renal pedicle disruption</li></ol>
<p>What are anterior pubic fractures often associated with?</p>
<p>Urethral injuries.</p>
<p>How are urethral injuries classified?</p>
<p>Posterior (above the urogenital diaphragm)</p>
<ul> <li>usually occur in multisystem injuries</li> <li>Pelvic fractures.</li></ul>
<p>Anterior (below) the urogenital diaphragm.</p>
<ul> <li>Straddle impacts</li></ul>
<p>Describe the <strong>seatbelt sign</strong>?</p>
<p>The appearance of transverse, linear ecchymoses on the abdominal wall.</p>
<p>Indicates a possible intra-abdominal injury.</p>
<p>What is a <strong>Chance Fracture</strong>?</p>
<p>A flexion injury to the lumbar spinal cord when lap belts are used.</p>
<p>If a patient has a solid organ injury, what is the chance they will have a hollow viscus injury?</p>
<p>< 5%</p>
<p>What sort of pelvic fractures are associated with haemmorhage?</p>
<p><strong>Sacroiliac/Sacral fracture </strong>where the <u><strong>posterior</strong></u> <strong><u>osseous ligamentous complex </u></strong>is disrupted.</p>
<p></p>
<p>The <strong>pelvic ring tears </strong>the <strong>pelvic venous plexus </strong>and can <strong>disrupt </strong>the <strong>internal arterial system</strong>.</p>
<p>What sort of accidents can cause pelvic ring injuries?</p>
<ul> <li>Motorcycle accidents</li> <li>Pedestrian vehicle collisions</li> <li>Direct crush injuries</li> <li>Fall from a greater height than 12 feet (3.6 meters)</li></ul>
<p>1 in ? patients with pelvic fractures will die.</p>
<p>1 in ? patients with closed pelvic fractures & hypotension will die.</p>
<p>?% of patients with open pelvic fracture will die.</p>
<p>1 in 6</p>
<p>1 in 4</p>
<p>50%</p>
<p>What are the types of Pelvic fracture and what are their frequency rates?</p>
<ol> <li>Lateral compression (60-70%) - lateral force to pelvis. Rarely bleeds.</li> <li>Anterior-posterior compression (open book - sacroiliac dislocation and disruption of posterior osseous ligamentous complex occurs.) (15-20%) Often bleeds. Very dangerous.</li> <li>Vertical shear. (5-15%) Commonly from fall. Force applied from bottom.</li></ol>
<p>How are pelvic fractures managed?</p>
<ol> <li>Early haemorrhage control - using a sheet, pevlic binder around greater trochanters.</li> <li>Fluid resuscitation</li> <li>Surgery</li></ol>
<ul> <li>If intraperitoneal gross blood --> Laparotomy</li> <li>If NO intraperitoneal gross blood --> Angiography and probably embolization.</li></ul>
<p>What % of prehospital trauma-related deaths involved head trauma?</p>
<p>90%</p>
<p>What is the primary goal of someone who has a TBI (traumatic brain injury)?</p>
<p>To prevent secondary brain injury from inadequate oxygenation and hypoperfusion.</p>
<p>The anterior fossa houses what?</p>
<p>The frontal lobes</p>
<p>The middle fossa houses what?</p>
<p>The temporal lobes.</p>
<p>The posterior fossa houses what?</p>
<p>The lower brainstem and cerebellum.</p>
<p>Name the 3 layers of the meninges. (outside to in)</p>
<ol> <li>The <strong>dura mater </strong>- tough and fibrous. 2 <strong>sublayers </strong>- the <strong>Periosteal Layer </strong>and <strong>Meningeal Layer</strong>.The large venous sinuses are housed in between these sublayers.</li> <li><strong>Arachnoid mater</strong></li> <li><strong>Pia Mater </strong>(covers the brain)</li></ol>
<p>When consulting a neurosurgeon about a patient with TBI what information needs to be relayed?</p>
<ol> <li><strong>Age </strong>of patient</li> <li><strong>Mechanism </strong>and <strong>time </strong>of <strong>injury</strong></li> <li><strong>Respiratory</strong> and <strong>cardiovascular</strong> status (<strong>Blood pressure </strong>and <strong>oxygen sats</strong>)</li> <li>Results of the <strong>neurological</strong> <strong>examination</strong>, including <strong>GCS </strong>score (with particular emphasis on the <strong>motor</strong> <strong>response</strong>, <strong>pupil size </strong>and <strong>reaction</strong> to <strong>light</strong>.</li> <li><strong>Focal neurological deficits</strong></li> <li><strong>Presence </strong>and <strong>type </strong>of <strong>associated injuries</strong></li> <li><strong>Results </strong>of <strong>diagnostic</strong> <strong>studies</strong>, particularly <strong>CT scan</strong><strong> </strong>(if available)</li> <li><strong>Treatment </strong>of <strong>hypotension </strong>or <strong>hypoxia</strong></li></ol>
<p>Meningeal arteries are located between what two surfaces?</p>
<p>Meningeal arteries lie between the dura and the internal surface of the skull (Epidural space)</p>
<p>Describe the the anatomy of a epidural hematoma.</p>
<p>Skull fractures can lacerate middle meningeal arteries (most commonly the middle meningeal artery). An epidural hematoma will form.</p>
<p>What two injuries can cause epidural hematomas?</p>
<ol> <li>Skull fractures</li> <li>Injury to Dural sinuses (Sagital sinus etc.)</li></ol>
<p>How do you manage an epidural hematoma?</p>
<p>URGENTLY!!! They need to be evacuated by a neurosurgeon ASAP.</p>
<p>How do subdural hematomas form?</p>
<p><strong>Bridging</strong> <strong>veins </strong>that travel from the surface of the brain to the venous sinuses within the dura may tear. These then fill the <strong>subdural space </strong>(<strong>between </strong>the <strong>dura</strong> <strong>mater </strong>and the <strong>arachnoid mater</strong>).</p>
<p>Subarachnoid hemorrhages are frequently caused by ?</p>
<ol> <li>Brain contusion</li> <li>Injury to the vessels at the base of the brain.</li></ol>
<p>The brain consists of what 3 structures?</p>
<ol> <li><strong>Cerebrum </strong>- right and left hemispheres and seperated by the <strong>falx cerebri</strong>.</li> <li><strong>Cerebellum - responsible for coordination and balance.</strong></li> <li><strong>Brain stem -<strong></strong></strong> <ul> <li><strong>Midbrain</strong></li> <li><strong>Pons</strong></li> <li><strong>Medulla.</strong></li> </ul> </li></ol>
<p>Which cerebral hemisphere contains the <strong>language centers</strong> in virtually all right handed people and 85% of left handed people?</p>
<p>The <strong>left </strong>hemisphere</p>
<p>What functions does the <strong>frontal lobe control</strong>?</p>
<p><strong>Executive</strong> <strong>functions</strong>, <strong>emotions</strong>, <strong>motor</strong> <strong>function </strong>and, on the <strong>dominant</strong> <strong>side</strong>, <strong>expression </strong>of <strong>speech</strong>.</p>
<p>What functions does the parietal lobe control?</p>
<p>Sensory function and spatial orientation.</p>
<p>What function does the temporal lobe control?</p>
<p>Memory functions</p>
<p>What functiondoes the occipital lobe control?</p>
<p>Vision.</p>
<p>The midbrain and upper pons contain the ? activating system which is responsible for ?</p>
<ol> <li>Reticular</li> <li>the state of alertness</li></ol>
<p>Where does the vital cardiorespiratory center preside?</p>
<p>In the medulla</p>
<p>Where is CSF produced and reabsorbed?</p>
<p>It is <strong>produced</strong> in the <strong>choroid plexus</strong> in the <strong>lateral ventricles </strong>and is <strong>reabsorbed</strong> in the <strong>dural</strong> <strong>venous</strong> <strong>sinuses</strong> through the <strong>arachnoid</strong> <strong>granulation</strong> <strong>tissue</strong>.</p>
<p></p>
<p><strong>NOTe: Blood in the CSF can inhibit reabsorption and can cause increased ICP</strong></p>
<p>Which cranial nerve runs along the edge of the tentorium and can be compressed against it during temporal lobe herniation?</p>
<p>Cranial Nerve III</p>
<p>What is the physiological mechanism to explain a <strong>blown</strong> <strong>pupil</strong>?</p>
<p><strong>Parasympathetic</strong> <strong>fibers </strong>from the <strong>3rd</strong> <strong>cranial nerve constrict</strong> the <strong>pupil</strong>. If these are compressed (e.g. herniation, hematoma) then they cannot act and you get <strong>unopposed sympathetic</strong> <strong>activity</strong>. i.e. <strong>pupillary dilation</strong>.</p>
<p>What's going on here?</p>
<p>The <strong>tentorial notch </strong>is <strong>opening </strong>that allows <strong>passage</strong> of the <strong>brainstem </strong>through the <strong>tentorium</strong>. The <strong>Uncus </strong>(medial part of the temporal lobe) is <strong>herniating </strong>(<strong>uncal</strong> <strong>herniation</strong>) through the <strong>tentorial notch</strong> and <strong>compressing </strong>the <strong>corticospinal </strong>(<strong>pyramidal</strong>) <strong>tract </strong>in the <strong>midbrain, </strong>which <strong>crosses </strong>at the <strong>brainstem</strong>. Therefore you will getin a <strong>contralateral hemiparesis</strong>.</p>
<p>What is the classic sign of <strong>uncal</strong> <strong>herniation</strong>?</p>
<p>Ipsilateral pupillary dilatation associated with contralateral hemiparesis.</p>
<p>What 3 physiological conepts related to head trauma?</p>
<ol> <li>Intracranial pressure - if elevated it can reduce cerebral perfusion and exacerbate ischaemia.</li> <li>The Monro-Kellie Doctrine</li> <li>Cerebral Blood Flow -cerebral blood flow can be reduced after comatose inducingTBI. This can lead to cerebral ischaemia.</li></ol>
<p>What is the normal ICP at resting stage?</p>
<p>~10mmHg</p>
<p>What ICP is related to poor outcomes?</p>
<p>20mmHg</p>
<p>What is the Monro-Kellie Doctrine?</p>
<p>The <strong>total volume </strong>of the <strong>intracranial</strong> <strong>contents </strong>must <strong>remain</strong> <strong>constant </strong>because the <strong>cranium </strong>is a <strong>rigid</strong>, <strong>nonexpansile </strong>container.</p>
<p><strong>Venous blood </strong>and <strong>cerebrospinal</strong> <strong>fluid </strong>may be <strong>compressed</strong> <strong>out </strong>of the <strong>container</strong>, <strong>providing </strong>a <strong>degree</strong> of <strong>pressure buffering</strong>.</p>
<p></p>
<p>Once, the <strong>limit of displacement</strong> of CSF and intravascular blood has been <strong>reached</strong>, <strong>ICP</strong> <strong>rapidly increases</strong>.</p>
<p>How is cerebral perfusion pressure (CPP) defined?</p>
<p>CPP = MAP - ICP</p>
<p></p>
<p>Mean arterial pressure</p>
<p>Incracrainal Pressure</p>
<p>What level of MAP (Mean arterial pressure) maintains a constant CBF? (a.k.a. <strong>Pressure</strong> <strong>autoregulation)</strong></p>
<p></p>
<p>What will happen if the MAP is too low?</p>
<p>What will happen if the MAP is too high?</p>
<p>50 to 150mmHg</p>
<p></p>
<p>If the MAP is too low then ischaemia and infarction can occur.</p>
<p>If the MAP is too high, marked brain swelling will occur with elevated ICP.</p>
<p>What 4 factors can induce secondary brain injury?</p>
<ol> <li>Hypotension - need to maintain MAP</li> <li>Hypoxia</li> <li>Hypercapnia</li> <li>Iatrogenic hypocapnia.</li></ol>
<p>Does CPP always equate with or assure adequate CBF?</p>
<p>NO. Once ICP increases dramatically then blood flow to the brain can be compromised.</p>
<p>What are the classifications of head injury?</p>
<ol> <li>Minor = GCS 13-15</li> <li>Moderate = GCS 9-12</li> <li>Severe = GCS 3-8</li></ol>
<p><strong>True </strong>or <strong>False</strong>, we use the <strong>worst motor response </strong>to calculate the GCS score, because this is the most reliable?</p>
<p><strong>FALSE</strong>. We use the <strong>BEST </strong>motor response score.</p>
<p>Describe the Glasgow Coma Score?</p>
<p>Remember Equation <strong>E4V5M6</strong></p>
<p>Eye opening =</p>
<ul> <li>4 to sponteously</li> <li>3 to speech</li> <li>2 to pain</li> <li>1 none</li></ul>
<p>Verbal response</p>
<ul> <li>5 Oriented</li> <li>4 Confused Speech</li> <li>3 Inappropriate words</li> <li>2 Incomprehensible sounds</li> <li>1 None</li></ul>
<p>Motor response</p>
<ul> <li>6 Obeys commands</li> <li>5 Localizes pain</li> <li>4 Withdrawal to pain</li> <li>3 Abnormal flexion (decorticate)</li> <li>2 Abnormal extension (decerebrate)</li> <li>1 None (flaccid)</li></ul>
<p></p>
<p>Skull fractures are divided into what two regions?</p>
<p>1/ Vault</p>
<ul> <li>Linear or stellate</li> <li>Depressed/Non-depressed</li> <li>Open/closed</li></ul>
<p>2/Basilar</p>
<ul> <li>With/without CSF leak</li> <li>With/without 7th Nerve Palsy.</li></ul>
<p>What are the clinical signs of a basilar skull fracture?</p>
<ol> <li><strong>Periorbital ecchymosis </strong>(<strong>racoon eyes</strong>)</li> <li><strong>Retroauricular ecchymosis </strong>(<strong>Battle</strong>'s <strong>sign</strong>)</li> <li><strong>CSF leakage </strong>from <strong>nose </strong>or <strong>ear</strong> (<strong>Rhinorrhea</strong>/<strong>Otorrhoea</strong>)</li> <li><strong>7th </strong>and <strong>8th nerve disfunction </strong>(<strong>Facial paralysis</strong> and <strong>hearing loss</strong>.</li></ol>
<p>Fractures that traverse the carotid canals can cause what?</p>
<p></p>
<p>What investigation can be useful?</p>
<ol> <li>Damage to <strong>carotid arteries </strong>(<strong>dissection</strong>, <strong>pseudoaneurysm</strong>, <strong>thrombosis</strong>)</li> <li><strong>Cerebral angiography</strong></li></ol>
<p>A linear vault fracture in concious patients increasese th elikelihood of an intracranial hematoma by roughly how many times?</p>
<p>400 times.</p>
<p>What are the 2 categories of uintracranial lesions?</p>
<p>Diffuse or Focal.</p>
<p><strong>Concussion </strong>is a type of diffuse brain injury. What happens in concussion?</p>
<p>The patient will have a <strong>transient</strong>, <strong>nonfocal neurologic</strong> disturbance that often includes <strong>loss </strong>of <strong>conciousness</strong>. CT scan will often be normal.</p>
<p>What is a common cause of severe diffuse brain injury and how can it manifest on a CT scan?</p>
<p><strong>Hypoxic ischaemic insult secondary </strong>to <strong>prolonged</strong> <strong>apnea </strong>or <strong>shock</strong>.</p>
<p></p>
<p><strong>CT </strong>may initially appear normal but may appear <strong>diffusely swollen </strong>with <strong>loss </strong>of <strong>normal gray</strong>-<strong>white</strong> <strong>distinction</strong>.</p>
<p>What are <strong>Diffuse Axonal Injuries </strong>(<strong>DAI</strong>) and how do they manifest on CT?</p>
<p><strong>DAI </strong>is a <strong>severe </strong>form of <strong>diffuse brain injury</strong>. <strong>DAI </strong>is a result of a <strong>shearing injury </strong>where there is a <strong>high</strong> <strong>velocity </strong>impact or <strong>deceleration injury</strong>. <strong>Multiple</strong> <strong>punctate hemorrhages </strong>are often seen throughout the <strong>cerebral hemispheres inbetween </strong>the <strong>grey </strong>and <strong>white</strong> <strong>matter</strong>.</p>
<p>Focal lesions consists of 4 types. What are they?</p>
<ol> <li>Epidural hematoma</li> <li>Subdural hematoma</li> <li>Contusion</li> <li>Intracerebral hematoma</li></ol>
<p>How common are epidural hematomas?</p>
<p>Uncommon. They occur in 0.5% of patients with brain injury & 9% in TBI who are comatose.</p>
<p>What shape are epidural hematomas and where are they most commonly located?</p>
<p>They are biconvex and are most commonly located over the temporal or temporoparietal region.</p>
<p>What do epidural hematomas often result from?</p>
<p>Skull fractures that cause the middle meningeal artery to tear.</p>
<p>How do epidural hematomas clinically present</p>
<p>Head injury with a <strong>lucid interval </strong>after injury but then neurological deterioration.</p>
<p>What are more common, epidural hematomas or subdural hematomas?</p>
<p></p>
<p>Subdural hematomas. They occur in 30% of individuals with severe brain injury.</p>
<p>Is the brain damage of an epidural hematoma or a subdural hematoma usually more severe?</p>
<p>Subdural hematoma brain damage is usually more severe due to concomitant parenchymal injury.</p>
<p>How common are cerebral contusions?</p>
<p>Cerebral contusions are common.</p>
<p>(Present in 20 to 30% of severe brain injuries)</p>
<p>Where do the majority of contusions occur?</p>
<p>In the frontal and temporal lobes.</p>
<p>Why should patients with contusion have a repeat CT scan within 24 hours of the intial scan?</p>
<p>Contusions can form a coalscent contusion with enough mass effect to require immediate surgical evacuation.</p>
<p>Define Minor traumatic brain injury (MTBI)</p>
<p>A history of disorientation, amnesia or transient loss of conciousness in a patient who is currently concious and talking. They will have a GCS score between 13-15.</p>
<p>What are some important parts of the history to take from a patient with a MTBI. (minor traumatic brain injury)</p>
<ol> <li>Name, sex, age, race, occupation</li> <li>Mechanism of injury</li> <li>Time of injury</li> <li>Loss of conciousness - length of time unresponsive, any siezure activity and the subsequent level of alertness.</li> <li>Duration of amnesia - both retrograde and antegrade.</li> <li>Subsequent level of alertness</li> <li>Headache - mild, moderate, severe.</li></ol>
<p>What are the <strong>high risks</strong> for <strong>neurosurgical</strong> <strong>intervention</strong> that warrant a<strong>CT </strong>scan being done for<strong>MTBI</strong>?</p>
<ol> <li><strong>GCS</strong> score <strong>less than 15 at 2 hours</strong> after injury.</li> <li><strong>Suspected open </strong>or <strong>depressed</strong> <strong>skull</strong> <strong>fracture</strong>.</li> <li>Any sign of <strong>basilar</strong> <strong>skull</strong> <strong>fracture</strong> (e.g. hemotympanum, raccoon eyes, CSF otorrhea or rhinorrhea, Battle's sign)</li> <li><strong>Vomiting (more than 2 episodes)</strong></li> <li>Any more than <strong>65 years</strong>.</li></ol>
<p>What are the <strong>moderate</strong> <strong>risks </strong>for neurosurgical intervention that warrant a<strong>CT scan</strong> being done for<strong>MTBI</strong>?</p>
<ol> <li><strong>Loss</strong> of <strong>conciousness </strong>(<strong>>5</strong> <strong>minutes</strong>)</li> <li><strong>Amnesia </strong>before impact (<strong>>30 minutes</strong>)</li> <li><strong>Dangerous mechanism </strong>(e.g. pedestrian struck by motor vehicle, occupant ejected from vehicle, fall from heigh of more than 3 feet or 5 stairs)</li></ol>
<p>If someone with an MTBI is being sent home what should you make sure happens?</p>
<p>That they are <strong>sent home with a companion </strong>who can <strong>observe them for 24 hours</strong> OR <strong>advise them to return</strong> to ED if they <strong>develop</strong> <strong>headaches</strong>, <strong>decline</strong> in <strong>mental status </strong>or <strong>develp</strong> <strong>neurological deficits</strong>.</p>
<p>Define moderate brain injury./</p>
<p>GCS 9-12</p>
<p>How shoud you manage a patient with mildbrain injury?</p>
<ol> <li>Take a history (see other card)</li> <li>General examination</li> <li>Limited neuro exam</li> <li>Imaging</li> <li>Bloods - alcohol level and urine toxicology.</li> <li>CT scan of head if indicated.</li></ol>
<p>How should you manage someone with a moderate brain injury?</p>
<ol> <li><strong>History</strong> and <strong>examinations </strong>same as mild head injury.</li> <li><strong>CT scan</strong>.</li> <li><strong>Follow up CT scan within 24 hours</strong> if condition worsens.</li> <li><strong>90% of patients will improve</strong> - discharge and follow up in clinic.</li> <li><strong>10% will deteriorate</strong> - manage as per severe brain injury protocal</li></ol>
<p>What is the definition of a severe brain injury?</p>
<p>The patient will be unable to follow simple commands because of impaired consciousness (GCS score 3-8).</p>
<p>How do you manage someone with a severe brain injury?</p>
<ol> <li><strong>ABCDEs</strong></li> <li><strong>Primary</strong> <strong>survey</strong></li> <li><strong>Resuscitation</strong></li> <li><strong>Secondary Survey </strong>and <strong>AMPLE</strong></li> <li><strong>Admit</strong> to <strong>facility </strong>for <strong>definitive </strong>neurosurgical care.</li> <li><strong>Therapeutic</strong> <strong>agents </strong>(<strong>Mannitol</strong>, <strong>Moderate hyperventilation [PCO2 32-35mmHg],</strong> <strong>Hypertonic saline</strong>)</li> <li><strong>Neurologic reevaluation</strong></li> <li><strong>GCS</strong></li> <li><strong>Pupils</strong></li> <li>Focal neurology</li> <li><strong>CT Scan</strong></li></ol>
<p>If you have a severe brain injury, hypotension and hypoxia on admission, what is your relative risk of dying?</p>
<p>75%</p>
<p>In severe head injury, how do you manage the airway and breathing?</p>
<ol> <li><strong>Endotracheal intubation early.</strong></li> <li><strong>Ventilate</strong> with <strong>100% O2</strong> until blood gas done.</li> <li><strong>Oxygen</strong> <strong>Sats</strong> of <strong>>98% </strong>are desirable on pulse oximetry.</li> <li><strong>Ventilation parameters</strong>: <strong>maintain</strong> <strong>PCO2 </strong>of ~<strong>35mmHg</strong>. <strong>Normocarbia </strong>is generally <strong>preferred</strong>.</li> <li><strong>Hyperventilation </strong>(<strong>PCO2 <32mmHg</strong>) should be <strong>cautisouly</strong> <strong>used </strong>only when <strong>acute neurological</strong> <strong>deterioration </strong>has <strong>occured</strong>. <strong>Hyperventilation causes a reduction in pCO2</strong> and causes <strong>cerebral</strong> <strong>vasoconstriction</strong>. This can <strong>promote cerebral</strong> <strong>ischaemia</strong>. <strong>Hyperventilation </strong>will <strong>LOWER ICP</strong> until <strong>emergent</strong> <strong>craniotomy </strong>can be <strong>performed</strong>.</li></ol>
<p>When does hypotension occur in a brain injury?</p>
<p>ONLY in the final stages when the medulla fails or there is concomitant spinal cord injury.</p>
<p></p>
<p>NOTE: intracranial haemorrhage cannot cause hemorrhagic shock.</p>
<p>What type of fluids should be used in order to establish euvolaemia in severe brain injuresi: hypotonic,isotonic or hypertonic fluids?</p>
<p>Isotonic solutions like Ringer's lactate or normal saline.</p>
<p>Can 5% dextrose be used for fluid resucitation in patients with severe brain injury?</p>
<p>No because hyperglycaemia can occur. Hyperglycaemia has been shown to be harmful to brain injury.</p>
<p>What can hyponatraemia cause to the brain?</p>
<p>It can cause brain swelling.</p>
<p>If someone is intoxicated, what must you make sure you don't do.</p>
<p>Do not miss a head injury!!!</p>
<p>The postictal state after a traumatic seizure can last for roughly how long?</p>
<p><strong>Minutes</strong> to <strong>hours</strong>.</p>
<p>NOTES: this can make it <strong>difficult </strong>to <strong>assess neurological</strong> <strong>state</strong>.</p>
<p>How can motor response be ellicited in a comatose patient?</p>
<p>The <strong>trapezius</strong> <strong>muscles</strong> can be pinched, the <strong>nail</strong> <strong>bed </strong>can be pressed on or the <strong>supraorbital ridge </strong>can be presed on.</p>
<p>Should we test for doll;s eye movement or do the caloric test with ice water?</p>
<p>NO...leave that to a neurosurgeon.</p>
<p></p>
<p>NOTE: Doll's eye testing should never be tempted before a C-spine injury has been ruled out.</p>
<p>What neurological examination should be done before sedating a patient?</p>
<p><strong>GCS score</strong> and <strong>pupillary response</strong>.</p>
<p></p>
<p>This is because <strong>knowledge</strong> of the patient's <strong>clinical</strong> <strong>condition</strong> is important for <strong>determinding</strong> <strong>subsequent</strong> <strong>treatment</strong>.</p>
<p>Sedation, in head injuries, should be avoided except....?</p>
<p>EXCEPT <strong>when a patient's agitated state places him or her at risk. </strong>The <strong>shortest</strong> <strong>acting</strong> <strong>agents </strong>are recommended.</p>
<p>What is a sign of temporal lobe herniation (uncal herniation)?</p>
<p>Dilation of the pupil and loss of pupillary response to light.</p>
<p>What are the significant and what are the crucial findings of CT scan?</p>
<p><strong>Significant Findings</strong></p>
<ol> <li><strong>Skull</strong> <strong>fractures</strong></li> <li><strong>Subgaleal</strong> <strong>hematomas</strong>.</li> <li><strong>Scalp swelling</strong></li></ol>
<p><strong>Crucial Findings</strong></p>
<ol> <li><strong>Intracranial hematoma</strong></li> <li><strong>Contusions</strong></li> <li><strong>Shift of the midline (mass effect)</strong> - <strong>a shift of 5mm or greater is often indicative of the need for surgery to evacuate the blood clot or contusion.</strong></li> <li><strong>Obliteration of the basal cisterns</strong></li></ol>
<p>If someone has a head injury and is either anticoagulated or is on antiplatelet therapy, what should be done?</p>
<ol> <li>INR</li> <li>Rapid normalization of the anticoagulation.</li></ol>
<p>Medical therapies for brain injury include...?</p>
<ol> <li>Intravenous fluids</li> <li>Temporary Hyperventilation</li> <li>Mannitol</li> <li>Hypertonic saline</li> <li>Barbiturates</li> <li>Anticonvulsants.</li></ol>
<p>What PCO2 levels correspond with normocarbia, hypocarbia and hypercarbia?</p>
<ul> <li><u><strong>Normocarbia - PCO2~35mmHg (4.7kPa)</strong></u></li> <li><u><strong>Hypocarbia/Hyperventilation</strong>- <strong>PCO2 25-30mmHg (3.3 to 4.7kPa) but aim for 28 to 32mmHg to be safer.</strong></u>- Promotes vasoconstriction and thus used in acute increases of ICP)</li> <li><strong>Hypercarbia </strong>- <strong>PCO2 >45</strong> (promotes vasodilation & increases ICP)</li></ul>
<p>What is mannitol used for?</p>
<p>To decrease ICP</p>
<p>How do you secondarily manage a severe head injury? (not diagnostic)</p>
<ol> <li><strong>Frequent</strong> <strong>serial</strong> <strong>neuro examination</strong>.</li> <li><strong>Normocarbia -PCO2 35+/- 3</strong></li> <li><strong>Mannitol</strong> and <strong>PCO2 28-32 if deterioration.</strong></li> <li><strong>Avoid PCO2 <28</strong></li> <li><strong>Address</strong> <strong>intracranial lesions </strong>appropriately.</li></ol>
<p>What preparation of mannitol is most commonly used?</p>
<p>20% solution (20g in 100ml solution).</p>
<p>When should mannitol NOT be given?</p>
<p><strong>In patients with hypotension.</strong></p>
<p></p>
<p><strong>Mannitol</strong> <strong>does </strong>not <strong>lower ICP in hypovolaemia </strong>and is a potent <strong>osmotic</strong> <strong>diuretic</strong>.</p>
<p>How do you administer mannitol in a deteriorating euvolaemic patient with a severe head injury?</p>
<ol> <li>Give a bolus of 1g/kg rapidly over 5 minutes</li> <li>Then transported immediately to CT scanner.</li></ol>
<p>What is hypertonic saline used for?</p>
<p>To reduce ICP</p>
<p>How do mannitol and hypertonic saline compare when it comes to lowering ICP?</p>
<p><strong>They are just as effective.</strong></p>
<p></p>
<p><strong>Neither </strong>will <strong>adequately lower ICP </strong>in <strong>hypovolaemic</strong> <strong>patients</strong>. HOWEVER, <strong>hypertonic saline </strong>is <strong>preferred in</strong> patients with <strong>hypotension </strong>because it <strong>does NOT </strong>act as a <strong>diuretic</strong>.</p>
<p>When should barbiturates NOT be used?</p>
<p>In severe head injury patients who have hypotension and hyopvolaemia.</p>
<p></p>
<p>NOTE: Hypotension can result from their use.</p>
<p>Why are barbiturates used and when should they not be used?</p>
<p>They are useful in reducing ICP refractory to other measures. They are not to be used in the acute resuscitative phase.</p>
<p>Why should barbiturates probably not be used if the patient will die?</p>
<p>They have a long half life and will prolong brain death.</p>
<p>What are the 3 factors that are linked to a high incidence of late epilepsy?</p>
<ol> <li>Seizures occuring in the first week.</li> <li>Intracranial hematoma</li> <li>A depressed skull fracture.</li></ol>
<p>What effect does early anticonvulsant use have on long term traumatic seizure outcome?</p>
<p>None whatsoever. Purely used to control seizures.</p>
<p>What effect do anticonvulsants have on brain recovery?</p>
<p>They inhibit it. So use them carefully.</p>
<p>What anticonvulsants and in what doses are they used in patients with traumatic seizures?</p>
<p><strong>Phenytoin </strong>and <strong>Fosphenytoin</strong>.</p>
<p>For <strong>phenytoin</strong>, a <strong>loading dose </strong>of <strong>1 gram</strong> is <strong>given IV </strong>at a rate <strong>~50mg/min</strong>.</p>
<p>Then <strong>100mg/8 hours</strong> <strong>for maintenance </strong>but <strong>monitor</strong> <strong>serum levels </strong>for optimal dosing.</p>
<p>What else can be used in addition to phenytoin for traumatic seizures?</p>
<p><strong>Diazepam </strong>or <strong>lorazepam</strong>.</p>
<p></p>
<p><strong>GA </strong>may also be required if still not controlled.</p>
<p>Why is it important to gain control over seizures early?</p>
<p>If prolonged seizures occur (30-60minutes) they can cause secondary brain injury.</p>
<p>How do you diagnose brain death/</p>
<ol> <li>GCS score of 3</li> <li>Nonreactive pupils</li> <li>Absent brainstem reflexes (Doll's eyes, no gag reflex etc)</li> <li>No psontaneous ventilatory effort on formal apnea testing.</li></ol>
<p>What do you need to exclude before diagnosing brain death?</p>
<p></p>
<p>Reversible conditions like hypothermia and barbiturate coma.</p>
<p>What head wounds may require surgical management?</p>
<p></p>
<ol> <li><strong>Scalp wounds </strong>- clean and inspect. <strong>CSF</strong> <strong>leakage </strong>indicates a <strong>dural tear</strong>.</li> <li><strong>Depressed skull fractures </strong>- can be operated on to <strong>elevate the fracture if the degree of depression is greater than the thickness of the adjacent skull</strong> <strong>or </strong>it is <strong>open </strong>and <strong>contaminated</strong>.</li> <li><strong>Intracranial mass lesions </strong>- managed by neurosurgeon. May require emergency craniotomy if trained.</li> <li><strong>Penetrating brain injuries</strong> - <strong>CT/CT angiography is recommended</strong>. If non metalic then MRI can be useful. <u><strong>Prophylactic broad</strong>-<strong>spectrum</strong> <strong>antibiotics </strong>should be <strong>given</strong>.</u></li></ol>
<p>When is early ICP monitoring recommended in a penetrating brain injury?</p>
<ol> <li>When the clinician is <strong>unable </strong>to <strong>assess </strong>the <strong>neurologic examination accurately</strong>.</li> <li>The <strong>need to evacuate </strong>a <strong>mass lesion </strong>is <strong>unclear</strong>.</li> <li><strong>Imaging studies suggest elevated ICP</strong>.</li></ol>
<p>How should you treat someone with a small bullet entrance wound to the head?</p>
<p></p>
<p>Wound care and closure if there is no scalp devitalization and no major intracranial pathology.</p>
<p>If someone has a penetrating intracranial wound what should you do?</p>
<p>Leave it in place until the vascular surgeons review.</p>
<p>How is the primary survey performed for head injuries?</p>
<p></p>
<ol> <li>ABCDEs</li> <li>Immobilize and stabilize C spine</li> <li>Perform a brief neuro exam.</li></ol>
<ul> <li>Pupillary response</li> <li>GCS score</li> <li>Lateralizing signs.</li></ul>
<p>How is the secondary survey performed in a patient that has a potential brain injury?</p>
<ol> <li><strong>Inspect </strong>the <strong>entire head</strong>, <strong>face </strong>looking for <strong>lacerations</strong>, <strong>CSF leakage </strong>from <strong>nose </strong>and <strong>ears</strong>.</li> <li><strong>Palpate </strong>the entire head and face looking for <strong>fractures </strong>and <strong>lacerations</strong>.</li> <li><strong>Inspect </strong>the <strong>scalp </strong>lacerations for <strong>brain tissue, depressed skull fractures, debris and CSF leaks.</strong></li> <li><strong>Determine GCS score</strong>, <strong>pupillary response, best limb motor response, verbal response.</strong></li> <li><strong>Examine </strong>the <strong>C-spine.</strong></li> <li><strong>Document </strong>the neurological injury.</li> <li><strong>Reassess </strong>for deterioration.</li></ol>
<p>Describe the process of evaluating CT scans of the head?</p>
<p></p>
<ol> <li><strong>Confirm the patient.</strong></li> <li><strong>Assess the scalp for contusions</strong> or <strong>swelling</strong>.</li> <li><strong>Assess for skull fractures</strong> - <strong>depressed skull</strong> <strong>fractures</strong>, <strong>open fractures</strong>, <strong>missile wounds </strong>or <strong>tracts</strong>.</li> <li><strong>Assess the gyri and sulci for symmetry.</strong> If assymetrical consider subdural hematoma or epidural hematoma. (<strong>Subdural hematomas</strong> <strong>more frequent </strong>and can have associated <strong>contusions </strong>and <strong>hematomas</strong>. <strong>Epidural</strong> <strong>hematomas </strong>cause <strong>midline shift</strong>, <strong>biconvex </strong>and commonly over <strong>temporal region</strong>)</li> <li><strong>Assess the cerebral hemispheres</strong> - density, symmetry, <strong>cerebral contusions(punctate areas of high density)</strong>, <strong>DAI </strong>(diffuse axonal injury), intracerebral hematomas.</li> <li><strong>Assess the ventricles</strong> - decreased size if increased ICP.</li> <li><strong>Assess midline shift</strong> - <strong>>5mm or more requires surgical decompression.</strong></li> <li><strong>Assess maxfacs structures</strong> - <strong>facial bones</strong>, <strong>sinuses</strong>, <strong>mastoid </strong>air cells.</li> <li><strong>Look </strong>for the <strong>4 C's of increased density</strong>: <strong>Contrast</strong>, <strong>Clot</strong>, <strong>Cellularity </strong>(<strong>tumor</strong>), <strong>Calcification</strong> (<strong>pineal gland, choroid plexus</strong>)</li></ol>
<p>Why can patients have a worsening of spinal injury symptoms after arriving in hospital?</p>
<p>1/ Ischemia</p>
<p>2/ Worsening of spinal cord oedema.</p>
<p>3/ Inadequate immobilization</p>
<p>When can you exlude the presence of a significant spinal injury?</p>
<p>The patient is neurologically intact and there is no pain on palpation of the spine.</p>
<p>How many vertebrae are there in the C-spine, T-spine and the L-spine?</p>
<p>C-spine=7</p>
<p>T Spine=12</p>
<p>L spine=5</p>
<p>Is the cervical canal wide or narrow in the cervical spine?</p>
<p>Wide</p>
<p>What fraction of patients with cervical spine injuries die at the scene from apnea? Why do they die of apnea?</p>
<p>1/3.</p>
<p>This is because of loss of central innervation of the phrenic nerve and spinal cord injury above C3-C5 where the phrenic nerve arises.</p>
<p>How is the cervical spine different form children and adults?</p>
<p>The C-spine of children is:</p>
<p>1/ More flexible, (joint capsules and interspinous ligaments)</p>
<p>2/ Flat facet joints</p>
<p>3/ Vertebral bodies are wedged anteriorly and slide forward with flexion. These changes stop at about 12 years old.</p>
<p>What type of fracture are most thoracic spine fractures?</p>
<p>Wedge compression fractures. (not associated with spinal cord injury)</p>
<p>A fracture dislocation of the thoracic spine almost always results in (blank)?</p>
<p>Complete spinal cord injury.</p>
<p>What is the <strong>thoracolumbar junction </strong>and why is it <strong>more susceptible to injury</strong>?</p>
<p>The <strong>fulcrum </strong>between the inflexible thoracic region and the stronger lumbar levels. It is thus more <strong>prone to injuries 15% of all spinal injuries</strong> occur here.</p>
<p>Where does the spinal cord originate?</p>
<p>At the caudal end of the <strong>medulla oblongata </strong>at the <strong>foramen magnum</strong>.</p>
<p>Where does the spinal cord end?</p>
<p>Usually at the L1 boney level.</p>
<p>This is called the <strong>conus medullaris</strong>.</p>
<p>Below this is the <strong>cauda equina</strong>.</p>
<p>Name the 3 tracts of the spinal cord?</p>
<p><strong>Descending (Motor)</strong></p>
<ol> <li>Corticospinal tract</li></ol>
<p><strong>Ascending (Sensory)</strong></p>
<ol> <li>Spinothalamic tract</li> <li>Dorsal Column</li></ol>
