atls_copy_copy_20210630221308

Question 1

<p>The "Initial Assessment" includes the following 10 elements:</p>

Answer 1

<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>

Question 2

<p>What are the 2 different phases of trauma preparation?</p>

Answer 2

<p>Prehospital and hospital</p>

Question 3

<p>What are the 4 emphases of the Pre-hospital phase?</p>

Answer 3

<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>

Question 4

<p>What information should be taken from the ambulance crew?</p>

Answer 4

<p>1/ Time of injury2/ Events related to the injury (mechanism of injury etc.)3/ Patient history</p>

Question 5

<p>What course addresses prehospital care of injured patients that is similar to the ATLS course?</p>

Answer 5

<p>Prehospital Trauma Life Support (PHTLS)</p>

Question 6

<p>What 3 things should be made made immediately accessible in the prehospital phase?</p>

Answer 6

<p>1/ Airway equipment2/ Warmed IV Crystalloids3/ Monitoring devices</p>

Question 7

<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>

Answer 7

<p>1/Mask2/ Eye protection3/ Water Impervious Gown.4/ Gloves</p>

Question 8

<p>What is the definition of triage?</p>

Answer 8

<p>"Sorting of patients based on their needs for treatment and the resources available to provide that treatment."</p>

Question 9

<p>What is the definition of <strong>Multiple Casualties</strong>?</p>

Answer 9

<p>"The number of patients and the severity of their injuries do not exceed the capability of the facility to render care."</p>

Question 10

<p>What is the definition of "<strong>Mass Casualties</strong>?"</p>

Answer 10

<p>"The number of patients and the severity of their injuries exceed the capability of the facility and staff"</p>

Question 11

<p>How do you act if their are <strong>multiple casualties</strong>?</p>

Answer 11

<p>First treat those with with life threatening problems andmultiple-system injuries.</p>

Question 12

<p>How do you act if there are <strong>mass casualties</strong>?</p>

Answer 12

<p>First treat the patients with the greatest chance of survival and who require the least expenditure of time, equipment, supplies and personnel.</p>

Question 13

<p>What does A stand for?</p>

Answer 13

<p>Airway maintenance and cervical spine protection</p>

Question 14

<p>What does B stand for?</p>

Answer 14

<p>Breathing and ventilation</p>

Question 15

<p>What does C stand for?</p>

Answer 15

<p>Circultation and haemorrhage control</p>

Question 16

<p>What does D stand for?</p>

Answer 16

<p>Disability: Neurological status</p>

Question 17

<p>What does <strong>E</strong> stand for?</p>

Answer 17

<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>

Question 18

<p>Describe the quick 10 second way to assess a patient?</p>

Answer 18

<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>

Question 19

<p>Describe the 5 specialist populations and why?</p>

Answer 19

<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>

Question 20

<p>What is included in airway management?</p>

Answer 20

<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>

Question 21

<p>When can you most likely need definitve airway management?</p>

Answer 21

<p>GCS < 8 or nonpurposeful motor response.</p>

Question 22

<p>If there is history of a traumatic event or altered level of conciousness what should be assumed & done?</p>

Answer 22

<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>

Question 23

<p>If you take off the collar what must be done?</p>

Answer 23

<p>Inline mobilization techniques should be used in order to manually stabilise the C-spine.</p>

Question 24

<p>When assessing breathing in the primary survey what do you look for?</p>

Answer 24

<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>

Question 25

What breathing injuries should be assessed during the primary survey?

Answer 25

1/ Tension pneumothorax

2/ Flail chest with pulmonary contusion

3/ Massive haemothorax

4/ Open pneumothorax

Question 26

What is the main goal of inital ventilatory management?

Answer 26

To prevent secondary brain injury by maintaining adequate oxygenation and perfusion.

Question 27

What are the 3 main circulatory issues to consider in C on your primary survey?

Answer 27

Is there:

1. Blood volume
2. Poor cardiac output
3. Bleeding - Internal or external?

 

Question 28

What are the 3 clinical elements that assist with assessing blood volume & cardiac output?

Answer 28

1/ Level of conciousness - cerebral perfusion can indicate low circulating volume.

2/ Skin colour

3/ Pulse - assess bilaterally. A rapid thready pulse indicates hypovolaemia. If absent central pulses then immediately resuscitate with fluid.

Question 29

If someone is bleeding what do you do in the primary survey?

Answer 29

1/ Identify the bleed - physical, radiology or FAST

2/ Apply direct manual pressure

3/ Tourniquets for massive bleeding in limbs.

4/ Management - either chest decompression, pelvic binders, splint application, clamps or surgical intervention.

Question 30

What are the 5 most common sites of internal haemorrhage?

Answer 30

1/ Chest

2/ Abdomen

3/ Retroperitoneum

4/ Pelvis

5/ Long Bones.

Question 31

Describe the rapid neurological examination in the primary survey?

Answer 31

1/ Quick GCS

2/ Pupillary size and reaction

3/ Lateralizing signs

4/ Spinal cord injury level.

Question 32

What can cause a reduce level of conciousness?

Answer 32

1/ Decreased cerebral oxygenation.

2/ Direct cerebral injury.

3/ Hypoglycaemia

4/ Drugs - alcohol, narcotics and other drugs.

Question 33

What does the acronym AMPLE stand for and when should it be used?

 

Answer 33

• A- Allergies
• M- Medications currently used
• P- Past illnesses/Pregnancy
• L- Last meal
• E- Events/Environment related to the injury.

It should be used just prior to the secondary examination & can be obtained from patient, family or paramedics.

Question 34

What must be given to all trauma patients?

Answer 34

Supplemental oxygen

Question 35

Describe the importance of "the talking patient?" (p. 32)

Answer 35

The talking patient gives a positive, appropriate verbal response which indicates that their airway is patent, ventilation is intact and brain perfusion is adequate.

Question 36

If someone has an altered level of consciousness what do they require? (p. 32)

Answer 36

A definitive airway

Question 37

What is the definition of a definitive airway? (p.32)

Answer 37

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.

Question 38

What sort of patients may require a definitive airway due to compromised ventilatory effort? (p. 32)

Answer 38

1/ Unconscious patients with head injuries2/ Obtunded from alcohol & Drugs3/ Thoracic injuries

Question 39

What is the purpose of endotracheal intubation? (p.32)

Answer 39

1/ Provide an airway2/ Deliver supplementary oxygen3/ Support ventilation4/ Prevent aspiration

Question 40

Maintaining (blank) and preventing (blank) are critical in managing trauma patients, especially those who have sustained head injuries. (p.32)

Answer 40

1/ oxygenation2/ preventing hypercarbia

Question 41

If a patient is unconscious and vomits or has gastric contents in his/her airway, what should you do? (p.32)

Answer 41

1/ Immediate suctioning2/ Rotation of the entire patient to the lateral position.

Question 42

What 3 things can facial fractures be associated with? (p.32)

Answer 42

1/ Haemorrhage2/ increased secretions3/ Dislodged teeth

Question 43

What can fractures of the mandible cause (especially bilateral body fractures?) (p.32)

Answer 43

Loss of normal airway structural support.

Question 44

A fractured larynx manifests itself with a triad of clinical signs. What are they? (p.33)

Answer 44

1/ Hoarseness2/ Subcutaneous emphysema3/ Palpable fracture

Question 45

If noisy breathing suggests partial airway obstruction, what does absence of breathing suggest? (p.33)

Answer 45

It suggests complete airway obstruction

Question 46

What investigation would be useful if a fractured larynx is suspected? (p.33)

Answer 46

A CT

Question 47

What are the 4 objective ways of finding signs of airway obstruction? (p. 33)

Answer 47

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.

Question 48

In what 3 ways can a patients ability to ventilate be compromised? (p. 34)

Answer 48

1/ Airway obstruction2/ Altered ventilatory mechanics - chest trauma, c-spine injury (diaphragmatic breathing).3/ CNS depression - intracranial injury or drugs.

Question 49

If someone has abdominal breathing and a probable spinal injury, what might have happened? (p. 34)

Answer 49

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)

Question 50

What is this airway device called and how does it work?

Answer 50

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. 

Question 51

What type of airway device is this?

Answer 51

This is a Laryngeal Mask Airway (LMA). It is a type of Extraglottic/Supraglottic airway device.

Question 52

What airway device is this and how does this work?

Answer 52

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)

Question 53

Name 3 Supraglottic/Extraglottic airway devices?

Answer 53

1/ Layngeal Mask Airway (LMA)

2/ Laryngeal Tube Airway (LTA)

3) Multilumen eosophageal airway .

Question 54

Are Extraglottic and supraglottic airway devices definitive airways?

Answer 54

NO!! They are used when intubation attempts have failed or are unlikely to suceed.

Question 55

How do you you know if ventilation is inadequate? (p.34)

Answer 55

1/ Look for:

• Asymmetrical chest expansion- (i.e. penumothorax or flail chest.)
• Labored breathing

2/ Listen for:

• Decreased or absent breath sounds.

3/ Use a pulse oximeter.

Question 56

Describe the 4 step process of removing a helmet in a trauma patient?

Answer 56

1/ One person provides manual, inline stabilization of the head and neck.

2/ The other person expands the helmet laterally and removes it.

3/The first person then supports the weight of the patient's head.

4/ The second person then takes over inline stabilization.

Question 57

What factors predict a potentially difficult airway?

Answer 57

1/ C-spine injury

2/ Severe arthritis of the c-spine

3/ Significant maxillofacial or mandibular trauma.

4/ Limited mouth opening

5/ Obesity

6/ Anatomical variations (e.g. receding chin, overbite or a short muscular neck.)

Question 58

What does LEMON stand for?

Answer 58

L- look externally

E-evaluate using the 3-3-2 rule

M-Mallampati

O- Obstructions?

N- Neck mobility

 

-

 

Question 59

Describe the 3-3-2 Rule.

Answer 59

3= the distance between the incisor teeth.

3= the distance between the hyoid bone and the chin

2= distance between the thyroid notch and the floor of the mouth

Question 60

Name and describe this maneouvre.

Answer 60

This is the chin lift maneuver. The fingers of one hand are placed under the mandible which is lifted gently upward.

 

It should NOT hyperextend the neck.

Question 61

What maneuvre is this and describe it?

Answer 61

This is the Jaw-Thrust Maneuver. The angles of the lower jaw are grasped and the mandible is displaced forward.

 

Do NOT hyperextend the spine.

Question 62

Name this airway and how do you insert it?

Answer 62

Oropharyngeal airway.

 

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.

 

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 .

Question 63

Who should Nasopharyngeal airways not be inserted in?

Answer 63

Cribiform plate fractures.

Question 64

Name the 3 types of definitive airways.

Answer 64

1/ Orotracheal tubes

2/ Nastoracheal tubes

3/ Surgical airways (cricothyroidotomy or tracheostomy).

Question 65

Regarding airway management, what is the quickest killer?

Answer 65

Inadequate delivery of oxygenated blood to the brain and other vital structures.

Question 66

Name the 5 types of shock.(p.63)

Answer 66

1/ Hypovolaemic (Most common)2/ Cardiogenic3/ Obstructive4/ Neurogenic5/ Septic

Question 67

Cardiac Output = (1) x (2)

Answer 67

1= Heart rate2= Stroke volume

Question 68

What is the definition of shock?

Answer 68

An abnormality of the circulatory system that results in inadequate organ perfusion and tissue oxygenation. (p.63)

Question 69

Preload (volume of blood flowing back to the heart) = (1)+(2)+(3)

Answer 69

1/ Venous capacitance2/ Volume status3/ The difference between mean venous systemic pressure and right atrial pressure.

Question 70

Stroke Volume = (1) + (2) + (3)

Answer 70

1/ Preload2/ Myocardial contractility3/ Afterload

Question 71

How does the body respond to blood loss?

Answer 71

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.

Question 72

What endogenous chemicals are released that cause vasoconstriction?

Answer 72

1/ Catecholamines2/ bradykinin3/ Histamin4/ B-endorphins5/ Cytokins6/ Prostanoids.

Question 73

What is the most effective way of restoring cardiac output and end organ perfusion?

Answer 73

Restore venous return by:1/ Stopping the source of bleeding.2/ Volume repletion

Question 74

Inadequately oxygenated & perfused cells compensate by shifting to (BLANK) respiration which results in the formation of (BLANK) and the development of (BLANK).

Answer 74

1/Anaerobic respiration2/ Lactic acid3/ Metabolic acidosis

Question 75

Name 2 proinflammatory mediators.

Answer 75

1/ Inducible nitric oxide synthase (INOS)2/ TNF

Question 76

Should vasopressors be given in shock?

Answer 76

No, they are contraindicated. Although they may increase BP. They worsen tissue perfusion by vasoconstriction.

Question 77

Who should be called if there is shock in an injured patient?

Answer 77

A surgeon.

Question 78

What should you assume if the patient is cool and has tachycardia?

Answer 78

They are in shock until proven otherwise.

Question 79

How is tachycardia diagnosed in children?

Answer 79

Infants= >160bpmPreschoolers = >140bpmSchool age = >120bpmAdults = >100bpm

Question 80

What may limited elderly patient's compensatory response to blood loss? (and thus they may not show signs of tachycardia)

Answer 80

1/ Drugs - diuretics, Beta blockers, CCB

2/PPM

(Look for a narrow pulse pressure in elderly patients who may have these factors in order to diagnose shock.)

3/ Relative decrease in sympathetic activity.

4/ Catecholamine receptor deficit

5 Reduced cardiac compliance.

6/ Pre-existing volume depletion

7/ Malnutrition

8/ Renal glomerular and tubular senescence - reduced responsiveness to aldosterone, catecholamines, vasopressin and cortisol.

Question 81

What should you not use to estimate blood loss? What should you use instead?

Answer 81

Do not use haemoglobin or haematocrit as they are unreliable in the acute setting.Use lactate and base excess.

Question 82

What is the most common cause of shock?

Answer 82

Haemorrhagic shock (after injury)

Question 83

Name the 4 types of non-haemorragic shock?

Answer 83

1/ Cardiogenic2/ Neurogenic3/ Obstructive4/Septic

Question 84

Name the causes of cardiogenic shock?

Answer 84

1/ MI2/ Cardiac tamponade3/ Air embolus4/ Blunt cardiac injury

Question 85

How do you identify and treat a cardiac tamponade?

Answer 85

1/ Identify -

• Tachycardia
• muffled heart sounds
• Dilated neck veins
• Hypotension resistant to fluid therapy.
• Most commonly seen after thoracic penetrating injury.

2/ Treatment

• Pericardiocentesis - temporarily
• Thoracotomy (Definitive)

 

Question 86

How do you identify and treat a tension pneumothorax?

Answer 86

1/ Identify

• Absent breath sounds
• Tracheal deviation
• Hyperresonant percussion note over the affected hemithorax
• Acute respiratory distress
• Subcutaneous emphysema

2/ Treatment

• Immediate thoracic decompression (See Chapter 4 for more details)

Question 87

How does neurogenic shock cause hypotension?

Answer 87

Cervical or upper thoracic spinal cord injury can produce hypotension due to loss of sympathetic tone. This compounds the effects of hypovolaemia.

Question 88

Do you get tachycardia in neurogenic shock?

Answer 88

No. Neurogenic shock is hypotension without tachycardia. A narrowed pulse pressure is not seen in neurogenic shock.

Question 89

What is the definition of haemorrhage?

Answer 89

An acute loss of circulating blood volume.

Question 90

What percentage of body weight is there of blood in a normal adult and in a normal child?

Answer 90

Adult = 7% (~5L in 70kg male)

Child 8-9% (80-90ml/kg)

Question 91

When should hemorrhage control and balanced fluid resuscitation be initiated?

Answer 91

When early signs and symptoms of blood loss are suspected NOT when blood pressure is falling or absent.

Question 92

Which patients will need pRBCs and blood products as an early part of resuscitation?

Answer 92

Class III and Class IV haemorrhage.

Question 93

What type of pRBC should females of childbearing age get and why? (p. 74)

Answer 93

Rh-negative cells in order to avoid sensitization and future complications.

Question 94

If someone has an exsanguinating haemorrhage, what type of blood should they get?

Answer 94

Type O.

Question 95

What temperature should we heat fluids to for hypotehermic patients in shock?

Answer 95

39C

This can be warmed in a microwave. 

Question 96

Can we warm blood products?

Answer 96

NO! They can be heated by passage through IV fluid warmers.

Question 97

What is the definition of a massive transfusion?

Answer 97

The need for >10 units of pRBC in the first 24 hours of admission.

Question 98

What does "balanced, hemostatic resucitation" (a.k.a. Damage control resuscitation) mean?

Answer 98

Th early administration of pRBC, plasma and platelts in order to minimize crystalloid administration.

Question 99

Coagulopathy is present in up to (BLANK) severely injured patients on admission.

Answer 99

30%

Question 100

What coagulation parameters should be used when deciding on the use of platelets, FFP, & cryoprecipitate?

Answer 100

1/ PT (prothrombin time)

2/ PPT (partrial prothrombin time)

3/ Fibrinogen.

4/ Platelet count

Question 101

Do most patients that have blood transfusions require calcium supplementation?

Answer 101

 NO

Question 102

In order to correct inadequate organ perfusion, what do we need to reverse?

Answer 102

We need to reverse shock.

(increase organ blood flow and tissue oxygenation.)

Remember the definition of shock is the opposite of the above.

 

 

Question 103

Who's law do we use increase blood pressure?

 

 

Answer 103

Ohm's law:

Blood pressure (V) = (I) Cardiac output x (R) Systemic vascular resistance.

REMEMBER: We care about in increase in cardiac output (I) NOT R. 

We do this by increasing stroke volume not heart rate. (stroke volume=preload+contractility+afterload)

Vasopressors can increase R by vasoconstriction but with no improvement to end organ perfusion.

Question 104

How much may blood volume increase by in athletes?

Answer 104

15 to 20%

Question 105

How much can cardiac output increase by in athletes?

Answer 105

6 times.

Question 106

How much can stroke volume increase in athletes?

Answer 106

50%

Question 107

Who is more likely to suffer from hypothermia as a result of vasodilation?

Answer 107

A trauma victim under the influence of alcohol or exposed to the cold.

Question 108

In mild to moderate hypothermia, how do you rewarm a patient?

Answer 108

Heat lamps, external warming devices, thermal caps, warmed IV fluids and warmed blood.

Question 109

In severe hypothermia, how is a patient rewarmed?

Answer 109

Core rewarming. (Irrigation of the peritoneal or thoracic cavity with crystalloid solutions warmed to 39C

OR

Extracorporeal bypass.

Question 110

Why is CVP useful?

Answer 110

The CVP allows us to evaluate appropriate volume replacement.

Question 111

What can cause pronounced increases in CVP?

Answer 111

1.  Overtransfusion
2. Cardiac dysfunction
3. Cardiac tamponade
4. Increased intrathoracic pressure from tension pneumothorax.
5. Catheter malposition.

 

Question 112

What does a declining CVP suggest?

Answer 112

Fluid loss.

Question 113

In what scenarios can you have an initial high CVP but actually have significant volume loss?

Answer 113

1. COPD
2. Generalised vasoconstriction
3. Rapid fluid replacement

Question 114

In what way can we misinterpret/over rely on CVP (central venous pressure)?

Answer 114

The precise measure of cardiac function is the relationship between ventricular end diastolic volume and stroke volume

NOT

Right atrial pressure (CVP) and cardiac output are insensitive measures.

CVP is just a guide.

Question 115

What are some complications of inserting a CVP line?

Answer 115

1. Infections
2. Vascular injury
3. Nerve injury
4. Embolization
5. Thrombosis
6. Pneumothorax

Question 116

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?

Answer 116

1/ Closed reduction by extending the arm.

2/ Grasping the clavicle with a pointed instrument (e.g. a towel clamp) and manually reducing it.

Question 117

What major thoracic injuries should be picked up on and addressed during the primary survey?

Answer 117

1. Tension pneumothorax
2. Open pneumothorax
3. Flail Chest
4. Pulmonary Contusion
5. Massive haemothorax

Question 118

What type of shock is a tension pneumothorax?

Answer 118

Obstructive shock

Question 119

How does a tension penumothorax develop?

Answer 119

1. A "one way valve" air leak occurs from the lung or through the chest wall.
2. Air is forced into the pleural space without any means to escape.
3. The mediastium is displaced to the opposite side, decreasing venous return and compressing the opposite lung.

Question 120

After intubation what is one of the common reasons for loss of breath sounds in the left thorax?

Answer 120

A right mainstem intubation.

 

(Be aware that this can happened and don't mistake it for a pneumothorax/haemothorax)

Question 121

What are some causes of a tension pneumothorax?

Answer 121

1) Mechanical ventilation with positive-pressure ventilation in patients with a visceral pleural injury. (Most common)

2) Blunt/penetrating chest trauma where the lung parenchyma injury fails to seal.

3) Post subclavian/Internal jugular venous catheter insertion.

4) Traumatic defects in the chest wall.

Question 122

What signs and symptoms are seen with a tension pneumothorax?

Answer 122

1. Chest pain
2. Air hunger
3. Respiratory distress
4. Tachycardia
5. Hypotension
6. Tracheal deviation away from the side of injury
7. Unilateral absence of breath sounds over hemithorax.
8. Elevated hemithorax w/o respiratory movement.
9. Neck vein distension
10. Cyanosis (late manifestation)

Question 123

How does one manage a tension pneumothorax?

Answer 123

1/ Immediate decompression.- a large bore needle is inserted into the second intercostal space in the midclavicular line.

2/ Definition treatment - insertion of a chest tube into the fifth intercostal space (usually at the nipple level) just anterior to the mixaxillary line.

Question 124

What size needle should you use and what percentage chance will it be effective in chest decompression?

Answer 124

A 5cm needle will reach the pleural space >50% of the time.

An 8cm needle will reach the pleural space >90% of the time.

Question 125

In what circumstances does an open pneumothorax occur?

Answer 125

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.

Question 126

How is an open pneumothorax managed?

Answer 126

Temporary- A sterile occlusive dressing is placed over the wound with 3 sides taped down to provide a flutter valve.

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.

Definitive - surgery

Question 127

Describe how a flail chest occurs and its management.

Answer 127

1/ Trauma causing multiple rib fractures in two or more adjacent ribs in 2 or more places.

2/ Initial management -

• Adequate ventilation
• Administration of humidified oxygen
• Fluid resuscitation. (But fluid resuscitation should be used carefully so as not cause overload)
• IV morphine or intercostal blocks.

3/ Final management - surgery

Question 128

What is the definition of a massive haemothorax?

Answer 128

A rapid accumulation of more than 1500mL of blood or 1/3 or more of the patient's blood volume in the chest cavity .

Question 129

What are the common causes of a massive haemothorax?

Answer 129

1/ A penetrating injury that disrupts the systemic or hilar vessels.

2/ Blunt pulmonary trauma

Question 130

What are the signs of a massive hemothorax?

Answer 130

Shock associated with the abscence of breath sounds or dullness to percussion on one side of the chest.

Question 131

How should a massive haemothorax be managed?

Answer 131

1. A 36 or 40 French chest tube is inserted in the nipple line just anterior to the midaxillary line.
2. Continue to early thoracotomy if 1,500mL of fluid is immediately evacuated.
3. If patients continue to bleed or they require persistent transfusions, then they may also require a thoracotomy.

Question 132

What is the most common cause of cardiac tamponade?

Answer 132

Penetrating injury.

Question 133

How do you diagnose a cardiac tamponade?

Answer 133

Using Beck's Triad of 1/ Venous pressure elevation 2/ Decline in arterial pressure 3/ Muffled heart tones.

 

ECG - PEA is suggestive.

 

FAST Scan

Question 134

How accurate is a FAST scan in finding pericardial fluid? (if used by an experienced user)

Answer 134

90-95%

Question 135

How is a cardiac tamponade managed?

Answer 135

1/ Temporarily - pericardiocentisis

2/ Surgery - Pericardiotomy via thoracotomy. 

Question 136

What are some complications of a chest tube insertion?

Answer 136

1. Laceration or puncture of intrathoracic organs or abdominal organs.
2. Infection
3. Intercostal nerve damage
4. Incorrect tube position
5. Chest tube kinking or clogging
6. Persistent  pneumothorax - leak around the skin, leak in the underwater seal.
7. Subcutaneous emphysema
8. Recurrence of penumothorax upon chest drain removal.
9. Lung fails to expand due to plugged bronchus.
10. Anaphylactic or allergic reaction to prepartion.

Question 137

What are some complications of pericardiocentesis?

Answer 137

1. Aspiration of ventricular blood instead of pericardial blood.
2. Laceration of ventricular epicardium/myocardium
3. Laceration of coronary artery or vein.
4. New hemopericardium secondary 2-3.
5. Ventricular fibrillation (VF)
6. Pneumothorax
7. Puncture of esophagus with subsequent medistinitis.
8. Puncture of peritoneum with peritonitis.
9. Puncture of great vessels

Question 138

What does a "current of injury" mean?

Answer 138

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.

 

If the myocardium is irritated then premature ventricular contractions can occur.

Question 139

What maneuvers can be effectively accomplished with a resuscitative thoracotomy?

Answer 139

1/ Evacuation of pericardial blood causing tamponade

2/ Direct control of exsanguinating intrathoracic hemorrhage.

3/ Cross-clamping of the descending aorta to slow blood loss below the diaphragm and increase perfusion to the brain and heart.

Question 140

Who are NOT candidates for resuscitative thoracotomy?

Answer 140

Patients who sustain blunt injuries and arrive pulseless but with PEA.

Question 141

Who are candidates for immediate resuscitative thoracotomy?

Answer 141

Patients with penetrating thoracic injuries who arrive pulseless butwith myocardial electrical activity.

Question 142

What are the 8 thoracic injuries that should be identified during the secondary survey?

Answer 142

1. Simple pneumothorax
2. Hemothorax
3. Pulmonary contusion
4. Tracheobronchial tree injury
5. Blunt cardiac injury
6. Traumatic aortic disruption
7. Traumatic diaphragmatic injury
8. Blunt esophageal rupture

Question 143

What is the most common cause of simle pneumothorax?

Answer 143

Lung laceration with air leakage from blunt trauma.

Question 144

In what situation should you not transport someone to hospital who has a simple pneumothorax?

Answer 144

You should not transport them via air ambulance due to expansion of the pneumothorax at altitude. (even in a pressurized cabin)

Question 145

How much blood is lost in a hemothorax? (not a massive hemothorax)

Answer 145

<1500mL blood.

Question 146

What is the primary cause of hemothorax?

Answer 146

Lung laceration or laceration of the intercostal vessel or internal mammary artery due to either penetrating or blunt trauma.

Question 147

When is an operative exploration required for a hemothorax?

Answer 147

Guidelines for operative exploration are:

1. If 1500mL of blood is obtained immediately through the chest tube.
2. If drainage of more than 200mL/hr for 2 to 4 hours occurs
3. If blood transfusion is required.

Question 148

In what condition is pulmonary contusion most commonly seen?

Answer 148

Rib fractures.

Pulmonary contusion is the most common potentially lethal chest injury.

Question 149

If someone were to have chest trauma & subsequent pulmonary contusion, when would you think about intubating & ventilating them?

Answer 149

If they have significant hypoxia (PaO2 of <8.6kPa or SaO2 of <90% on room air.

Question 150

What is tracheobronchial tree injury?

Answer 150

Injury to the trachea or major bronchus.

Most injuries are within 1 inch of the carina.

Most patients die at the scene.

Question 151

What are the most common symptoms of tracheobronchial tree injury and how is it best diagnosed?

Answer 151

1. Hemoptysis
2. Subcutaneous emphysema
3. Tension pneumothorax
4. Incomplete expansion of the lung after placement of a chest tube.
5. Extreme breathlessness.

It is best diagnosed with a bronchoscopy

Question 152

Blunt cardiac trauma can result in:

Answer 152

1. Myocardial muscle contusion
2. Cardiac chamber rupture
3. Coronary artery dissection/thrombosis
4. Valvular disruption

Question 153

What are some of the msot common ECG findings in blunt cardiac injury?

Answer 153

1. Multiple premature ventricular contractions
2. Unexplained Sinus tachycardia
3. AF
4. BBB (usually right)
5. ST segment changes.

Question 154

Should we use troponins in diagnosing blunt cardiac injury?

Answer 154

Nope.

Question 155

How long should someone be monitored if they have a blunt cardiac injury?

Answer 155

1. 24 hours - after this the risk of dysrhythmia decreases dramatically.

Question 156

When is a traumatic aortic disruption commonly seen?

Answer 156

Automobile collisions or a fall from a great height.

Question 157

In traumatic aortic disruption, when would patient's have the highest chance of survival?

Answer 157

If there is an incomplete laceration near the ligamentum arteriosum of the aorta.

 

Continuity is maintained by an intact adventitial layer or contained mediastinal hematoma and prevents immediate exsanguination and death.

Question 158

Name some signs of traumatic aortic disruption that would appear on xray?

Answer 158

1. widened mediastinum
2. obliteration of the aortic knob
3. Deviation of the trachea to the right
4. Depression of the left mainstem bronchus.
5. Elevation of the right mainstem bronchus.
6. Deviation of the esophagus
7. Widened paratracheal stripe
8. Widened paraspinal interfaces
9. Presence of a pleural or apical cap
10. Left hemothorax
11. Fractures of the first or second rib or scapula.

Question 159

What has been shown to be an accurate screening method for a suspected blunt aortic injury?

Answer 159

Helical CT scan. (Sensitivity and specificity of ~100%)

 

If the results are equivocal then do an aortography.

Question 160

What is the treatement for a traumatic aortic disruption?

Answer 160

Treatment is either through:

1. Primary repair
2. Resection of the torn segment and replacement with an interposition graft.
3. Endovascular Repair (EVAR)

Question 161

Traumatic diaphragmatic injuries are most commonly seen on which side?

Answer 161

The left side because of the protective effect of the liver.

Question 162

On CXR, what finding would you see with a diaphragmatic injury?

Answer 162

An elevated right hemidiaphragm.

Question 163

What is a complication of blunt esophageal rupture?

Answer 163

Mediastinitis and an empyema.

Question 164

In what situation should a blunt esophageal rupture always be considered?

Answer 164

 When a patient has a left pneumothorax, hemothorax w/o rib fractures or they received a severe blow to the lower sternum or epigastrium and is in pain or shock that is out of proportion to their apparent injury.

Question 165

What are the 3 significant manifestations of chest injury?

Answer 165

1/ Subcutaneous emphysema

2/ Crushing injury to the chest (Traumatic asphyxia)

3/ Rib, Sternum and Scapular Fractures

Question 166

Young people have more flexible ribs, if there are multiple rib fractures in a young person what does this imply?

Answer 166

A greater transfer of force than in an older patient.

Question 167

What do fractures of the lower ribs (10 to 12) imply?

Answer 167

Hepatosplenic injury

Question 168

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?

Answer 168

A magnitude of injury that places the head, neck, spinal cord, lungs and great vessels at risk of injury.

Question 169

What ribs sustain the majority of blunt trauma?

Answer 169

4 to 9. The middle ribs.

Question 170

What should be assumed if a patient has sustained significant blunt torso trauma from a direct blow, deceleration or a penetrating injury?

Answer 170

Injury to the abdominal viscera, vasculature or pelvis until proven otherwise.

Question 171

Define the landmarks of the anterior abdomen.

Answer 171

The area between the costal margins superiorly, the inguinal ligaments and the symphysis pubis inferiorly, and the anterior axillary lines laterally.

Question 172

Define the landmarks of the thoraco-abdomen.

Answer 172

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.

Question 173

Define the landmarks of the flank.

Answer 173

The area between the anterior and posterior axillary lines from the sixth intercostal space to the iliac crest.

Question 174

Define the landmarks of the back.

Answer 174

The area located posterior to the posterior axillary lines from the tip of the scapulae to the iliac crests.

Question 175

Where are the retroperitoneal organs contained?

Answer 175

In the flank and the back.

Question 176

What organs are in the retroperitoneum?

Answer 176

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.

Question 177

Why are injuries to the retroperitoneum hard to recognise?

Answer 177

The area is remote from physical examination and the injuries may not initially present with signs or symptoms of peritonitis.

Question 178

What organs are in the pelvic cavity?

Answer 178

1/ Rectum

2/ Bladder

3/ Iliac vessels

4/ Internal reproductive organs (in females)

Question 179

What is the definition of a deceleration injury?

Answer 179

It is an injury where the is a different movement of fixed and nonfixed parts of the body.

Question 180

Give some examples of deceleration injuries?

Answer 180

1/ Lacerations of the liver and spleen.

2/ Bucket handle injuries to the small bowel.

Question 181

What organs are most frequently injured in blunt trauma to the abdomen?

Answer 181

1/ Spleen (40-55%)

2/ Liver (35-45%)

3/ Small bowel (5% to 10%)

Question 182

What kind of injuries can you get from a lap seat belt?

Answer 182

1. Tear of avulsion of the mesentery (Bucket Handle Tear)
2. Rupture of the small bowel or colon. 
3. Thrombosis of the iliac artery or abdominal aorta
4. Chance fracture of lumbar vertebrae.
5. Pancreatic or duodenal injury

Question 183

What kind of injuries can you get from a shoulder harness?

Answer 183

1. Intimal tear or thrombosis in innominate, carotid,subclavian or vertebral arteries.
2. Fractures or dislocations of the C-spine.
3. Rib fractures.
4. Pulmonary contusion.
5. Rupture of upper abdominal viscera

Question 184

What kind of injuries can you get from an airbag?

Answer 184

1. Corneal abrasion
2. Abrasions to the face, neck or chest.
3. Cardiac rupture
4. Cervical spine injury
5. Thoracic spine fracture

Question 185

When can shearing injuries occur in the car?

Answer 185

When a restraint device is worn improperly

Question 186

What general sort of injuries can a direct blow to the abdomen cause?

Answer 186

1. Compression/Crushing injuries
2. Abdominal viscera and pelvis
3. Organ rupture +/- secondary hemorrhage
4. Contamination by visceral contents +/- peritonitis.

Question 187

What organs do stab wounds most commonly involve?

Answer 187

1. Liver (40%)
2. Small bowel (30%)
3. Diaphragm (20%)
4. Colon (15%)

Question 188

What organs do gunshot wounds most commonly involve?

Answer 188

1. Small bowel (50%)
2. Colon (40%)
3. Liver (30%)
4. Abdominal structures (25%)

Question 189

What two factors affect the injuries incurred by a gunshot wound?

Answer 189

1. The type of shot
2. The distance from the gun.

Question 190

What is an overpressure injury?

Answer 190

This is an injury related to the blast from an explosion

If in an enclosed space, the likelihood of overpressure injury increases..

There may be penetrating objects from the blast or purely from the barotrauma of the explosion.

Pulmonary and hollow viscouses are commonly affected.

Question 191

What sort of injuries can result from wearing a lap seat belt?

Answer 191

1. Bucket handle tear- Tear or avulsion of mesentery.
2.  Rupture of small bowel or colon
3. Thrombosis of iliac artery or abdominal aorta
4. Fracutred lumbar vertebrae
5. Pancreatic or duodenal injury

Question 192

What injuries can result form wearing a shoulder harness?

Answer 192

1.  Intimal tear or thrombosis in innominate, carotid, subclavian or vertebral arteries.
2. Fracture or dislocation of cervical spine.
3. Rib fractures
4. Pulmonary contusion
5. Rupture of upper abdominal viscera

 

Question 193

What injuries can result from an air bag?

Answer 193

1. Corneal abrasions
2. Abrasions of face, neck and chest
3. Cardiac rupture
4. Cervical spine
5. Thoracic spine fracture.

Question 194

What history should be taken when assessing a patient in a motor vehicle accident?

Answer 194

1. Speed of the vehicle
2. Type of collision (frontal, lateral, sideswipe, rear impact or rollover)
3. Vehicle intrusion into the passenger compartment.
4. Types of restraints.
5. Deployment of air bags.
6. Patient's position in the vehicle
7. Status of passengers.

Question 195

What history should be taken when assessing a patient who has fallen?

Answer 195

1. The height of the fall.

Question 196

What history should be taken when assessing a patient who has penetrating trauma?

 

Answer 196

1. Time of injury
2. Type of weapon
3. Distance from assailant. (Beyond 10 feet/3 metres the likelihood of major visceral injury decreases substantially.)
4. Number of stab/shot sustained.
5. Amount of external bleeding at the scene.

Question 197

What are the steps of the secondary abominal examination?

Answer 197

1. Inspect for anterior & posterior abdomen for signs of blunt and penetrating inury & internal bleeding.
2. Auscultate for the presence of bowel sounds.
3. Precuss the abdomen to elicit subtle rebound tenderness.
4. Palpate the abdomen for tenderness, involuntary muscle guarding, unequivocal revound tenderness and a gravid uterus.
5. Assess for pelvic stability & obtain pelvic xray if required.
6. Perineal exam - contusions, hematomas, lacerations and urethral bleeding.
7. Rectal exam - blood, spinchter tone, bowel wall integrity, bony fragments, prostate position.
8. Gluteal exam
9. Vaginal Exam - lacerations and blood in vaginal vault.

Question 198

• Blood at the urethral meatus
• Scrotal haematoma
• Laceration of the perineum, vagina, rectum or buttocks
• A high riding prostate
• Limb length discrepancies/deformity

Are all suggestive of what?

Answer 198

Open pelvic fracture.

Question 199

If bowel sounds are absent on auscultation what could this signify?

Answer 199

Ileus secondary to Free GI contents or intraperitoneal blood.

Question 200

On mild percussion, we are looking for signs of peritoneal irritation. If peritonism is seen should we also test for rebound tenderness?

Answer 200

NO!!! This will cause the pt more pain.

Question 201

Why do we perform a manual manipulation of the pelvis only once?

Answer 201

To prevent further dislodging of clots and haemorrhage.

Question 202

When should the manual manipulation of the pelvis NOT be performed?

 

Answer 202

1. Shock
2. Obvious pelvic fracture

Question 203

Describe the compression distraction maneuver?

Answer 203

The Iliac crests are grasped and the unstable hemipelvis is pushed/rotated inward(internally) and then outward(externally).

Question 204

When testing the pelvis for posterior ligamentous disruption (shear fracture), what manipulation can you do?

 

Answer 204

The hemipelvis can be pushed cephalad as well as pulled caudally. You simultaneously palpate the posterior iliac spine and tubercle

Question 205

Blood at the urethral meatus strongly suggests what 2 injuries?

 

Answer 205

1. Urethral Meatus injury
2. Pelvic fracture

Question 206

What are your goals when performing a rectal examination?

 

Answer 206

1. Assess spincter tone
2. Assess rectal mucosal integrity
3. Determine position of prostate (e.g. high riding)
4. Identiy any fractures of the pelvic bone.
5. Look for gross blood (especially if penetrating wound)

Question 207

If someone has a high riding prostate or a scrotal/perineal hematoma what should you NOT do?

Answer 207

DO NOT insert Foley catheters.

 

They may have a urethral injury.

Question 208

Penetrating injuries of the gluteal area are associated with (?) incidence of significant intraabomdinal injury?

Answer 208

50%

Question 209

What are the therapeutic goals of inserting gastric tubes?

Answer 209

1. Relieve acute gastric dilation
2. Decompress the stomach before performing DPL
3. Remove gastric contents.

Question 210

What does the presence of blood upon NG insertion suggest?

 

Answer 210

Injury to the oesophagus or upper GI tract.

Question 211

What are the goals of Urinary Catheter insertion?

Answer 211

1. Relieve retention
2. Decompress the bladder before performing DPL.
3. Allow for monitoring urinary output (e.g. monitor tissue perfusion.)

Question 212

What is gross haematuria a sign of?

Answer 212

Trauma to the genitourinary tract and non-renal intraabominal organs.

Question 213

You would NOT insert a catheter and would do a urethrogram if you saw any of the following signs?

Answer 213

1. The inability to void
2. Unstable pervlic fracture
3. Blood at the meatus
4. Scrotal haematoma
5. Perineal ecchymoses
6. High riding prostate on PR

Question 214

If you do have a disrupted urethra what procedure can you do to relieve the bladder?

Answer 214

Suprapubic catheter insertion.

Question 215

What is the only contraindication to performing a FAST Scan or a DPL?

Answer 215

Existing indication for laparotomy

Question 216

In what conditions may you need further studies?

Answer 216

1. Change in sensorium (potential brain injury, alcohol intoxication or use of illicit drugs)
2. Change in sensation (potential injury to spinal cord)
3. Injury to adjacent structures, such as the lower ribs, pelvis or lumbar spine.
4. Equivocal physical examination
5. Lap belt sign (abdominal wall contusion) with suspicion of bowel injury.

Question 217

With penetrating wounds, what should you put at all entrance and exit sites when performing an x-ray?

Answer 217

Marker rings/clips.

Question 218

The FAST scan is used to obtain views of ?

Answer 218

1. Cardiac Tamponade
2. Hepatorenal fossa
3. Splenorenal Fossa
4. Pelvis
5. Puch of Douglas

Question 219

What does DPL stand for & how sensitive is it for detecting intraperitoneal bleeding?

Answer 219

Diagnostic peritoneal lavage. 98% sensitive

Question 220

Name some relative contraindications to DPL?

Answer 220

1. Previous abdominal operations
2. Morbid obesity
3. Advvanced cirrhosis
4. Preexisting coagulopathy

Question 221

If blood, GI contents, vegetable fibers or bile are obtained through DPL, what needs to be done?

Answer 221

Laparotomy.

Question 222

Are DPL's usually done infrapubically or suprapubically?

Answer 222

Infrapubically.

However, if a pelvic fracture is suspected then it can be done suprapubically.

Question 223

If gross blood (>10mls) is not aspirated or GI contents are not aspirated what is the next step?

Answer 223

Perform lavage with 1L of warmed isotonic crystalloid solution. (10ml/kg in a child)

Question 224

In DPL, when is it considered to be a positive test?

Answer 224

1. >100,000 red blood cells/mm3
2. 500 WBC/mm3
3. Gram stain with bacteria present.

Question 225

When would you perform a urethrogram?

Answer 225

Before inserting a catheter when a urethral injury is suspected.

Question 226

How is the urethrogram performed?

Answer 226

An 8 French urinary catheter is secured in the meatal fossa by balloon inflation to 1.5 to 2mL. 30 to 35 mL of undiluted contrast is instilled with gentle pressure. Radiographs are then taken.

Question 227

What diagnostic tool is best used to diagnose an intraperitoneal or extraperitoneal bladder rupture?

Answer 227

Cystogram (XR) or CT cystogram.

Question 228

How is a cystogram performed?

Answer 228

A syringe barrel is attached to the indwelling bladder catheter, held 40cm above the patient. 350mL of water-soluble contrast is allowed to flow into the bladder until either flow stops, the patient voids or the patient is in discomfort. Contrast is then instilled into the bladder.AP and Post drainage images are taken. (XR)

Question 229

What study is most useful if there are urinary system injuries?

Answer 229

A contrast-enhanced CT scan.

 

NOTE: If CT not available then an IVP (Intravenous pyelogram) is available.

Question 230

On an Intravenous Pyelogram (IVP) what does a unilateral nonfunction indicate?

Answer 230

1. Absent kidney
2. Thrombosis
3. Avulsion of the renal artery
4. Massive parenchymal disruption.

Question 231

If a non-function is seen on IVP what further ix is warranted?

Answer 231

Contrast-enhanced CT, renal arteriogram or surgical exploration.

Question 232

What are some advantages & disadvantages of DPL?

Answer 232

Indication: Penetratinga nd blunt trauma

Advantages

• Early diagnosis
• Performed rapidly
• 98% sensitive
• Detects bowel injury

Diadvantages

• Invasive
• Low specificity
• Misses injuries to diaphragm and retroperitoneum

Question 233

What are some advantages & disadvantages of Fast Scan?

Answer 233

Indication: Unstable blunt trauma

Advantages

• Early diagnosis
• Noninvasive
• Performed rapidly
• Repeatable
• 86-97% sensitive

Disadvantages

• Operator dependent
• Bowel gas or subcutaneous air distortion
• Misses diaphragm, bowel or pancreatic injuries.

Question 234

What are some advantages & disadvantages of CT scan?

Answer 234

Indication: STABLE blunt trauma and penetrating back/flank trauma.

Advantages:

• Most specific for injury
• 92-98% sensitive
• Non-invasive

Disadvantages

• Cost and time
• Misses diaphragm, bowel and some pancreatic injuries
• Transport required.

Question 235

What percentage of gunshot wounds to the abdomen have intraperitoneal injury? What does this mean for management?

Answer 235

98%. Therefore gunshot wounds are always managed with an exploratory laparotomy.

Question 236

What percentage of stab wounds have an intraperitoneal injury?

Answer 236

30%

Question 237

What are the indications for laparotomy in patients with penetrating abdominal wounds?

Answer 237

• Haemodynamically unstable
• Gunshot wound with a transperitoneal trajectory
• Signs of peritoneal irritation
• Signs of fascia penetration.

Question 238

?% of all patients with penetrating stab wounds to the anterior peritoneum have hypotension, ? or evisceration of ? or ?. This required an ?.

Answer 238

55-60%

Peritonitis

Omentum

Small Bowel

Emergency laparotomy

Question 239

In flank and back injuries what kind of investigations is appropriate?

Answer 239

1. Serial examinations (as accurate as CT scan)
2. Double or Triple Contrast CT
3. DPL (invasive)
4. Laparotomy (invasive)

NOTE: Early outpatient follow up after 24 hours is important due to subtle injuries that can manifest later. (i.e. colonic injuries)

Question 240

What are the following 9 indications for laparotomy?

Answer 240

1. Blunt abdominal trauma with hypotension wtih a positive FAST or clinical evidence of intraperitoneal bleeding.
2. Blunt or penetrating abdominal trauma with a positive DPL.
3. Hypotension with a penetrating abdominal wound.
4. Gunshot wounds in the peritoneal cavity or retroperitoneum.
5. Evisceration.
6. Bleeding from the stomach, rectum or genitourinary tract from penitrating trauma.
7. Peritonitis
8. Free air, retroperitoneal air or rupture of the hemidiaphragm.
9. Contrast-enhanced CT that demonstrates ruptured GI tract, intraperitoneal bladder injury, renal pedicle injury or severe visceral parenchymal injury after blunt or penetrating trauma.

Question 241

Which hemidiaphragm is more commonly injured?

Answer 241

Left.

Most common injury is 5 to 10cm in length and on the left posterior hemidiaphragm.

Question 242

What Xray finding is seen with a diaphragm injury?

Answer 242

• A raised hemidiaphragm
• "Blurring" of the hemidiaphragm
• hemothorax.

Question 243

In what 2 situations are duodenal rupture classically encountered?

Answer 243

1. Unrestrained drivers involved in frontal-impact motor vehicle collisions.
2. Handlebar injuries.

Question 244

What situation causes pancreatic injuries?

Answer 244

Direct epigastric blows ...

that compress the pancreas against the thoracic column.

Question 245

Is serum amylase always raised after pancreatic injury?

 

Answer 245

Nope.

Question 246

What imaging should be done if pancreatic injury is suspected and what time period is it most useful in?

Answer 246

Double contrast CT.

Immediately postinjury (Up to 8 hours)

Question 247

When contusions, hematomas or ecchymoses are seen over the back and flanks what should be done?

Answer 247

CT or IVP to investigate for renal/urinary tract injury.

Question 248

What are the indications for further evaluation of the renal/urinary tract?

Answer 248

1. Gross hematuria
2. Microscopic hematuria in patients with

a) penetrating injury

b) an episode of hypotension and blunt abdo trauma

c) associated with intraabdominal injuries and blunt trauma.

 

Question 249

What percentage of blunt renal injuries can be treated nonoperatively?

Answer 249

95%

Question 250

In what two rare deceleration renal injuries can haematuria be absent?

Answer 250

1. Renal artery thrombosis
2. Renal pedicle disruption

Question 251

What are anterior pubic fractures often associated with?

Answer 251

Urethral injuries.

Question 252

How are urethral injuries classified?

Answer 252

Posterior (above the urogenital diaphragm)

• usually occur in multisystem injuries
• Pelvic fractures.

Anterior (below) the urogenital diaphragm.

• Straddle impacts

Question 253

Describe the seatbelt sign?

Answer 253

The appearance of transverse, linear ecchymoses on the abdominal wall.

Indicates a possible intra-abdominal injury.

Question 254

What is a Chance Fracture?

Answer 254

A flexion injury to the lumbar spinal cord when lap belts are used.

Question 255

If a patient has a solid organ injury, what is the chance they will have a hollow viscus injury?

Answer 255

< 5%

Question 256

What sort of pelvic fractures are associated with haemmorhage?

Answer 256

Sacroiliac/Sacral fracture where the posterior osseous ligamentous complex is disrupted.

 

The pelvic ring tears the pelvic venous plexus and can disrupt the internal arterial system.

Question 257

What sort of accidents can cause pelvic ring injuries?

Answer 257

• Motorcycle accidents
• Pedestrian vehicle collisions
• Direct crush injuries
• Fall from a greater height than 12 feet (3.6 meters)

Question 258

1 in ? patients with pelvic fractures will die.

1 in ? patients with closed pelvic fractures & hypotension will die.

?% of patients with open pelvic fracture will die.

Answer 258

1 in 6

1 in 4

50%

Question 259

What are the types of Pelvic fracture and what are their frequency rates?

Answer 259

1.  Lateral compression (60-70%) - lateral force to pelvis. Rarely bleeds.
2. Anterior-posterior compression (open book - sacroiliac dislocation and disruption of posterior osseous ligamentous complex occurs.) (15-20%) Often bleeds. Very dangerous.
3. Vertical shear. (5-15%) Commonly from fall. Force applied from bottom.

Question 260

How are pelvic fractures managed?

Answer 260

1. Early haemorrhage control - using a sheet, pevlic binder around greater trochanters.
2. Fluid resuscitation
3. Surgery

• If intraperitoneal gross blood --> Laparotomy
• If NO intraperitoneal gross blood --> Angiography and probably embolization.

Question 261

What % of prehospital trauma-related deaths involved head trauma?

Answer 261

90%

Question 262

What is the primary goal of someone who has a TBI (traumatic brain injury)?

Answer 262

To prevent secondary brain injury from inadequate oxygenation and hypoperfusion.

Question 263

The anterior fossa houses what?

Answer 263

The frontal lobes

Question 264

The middle fossa houses what?

Answer 264

The temporal lobes.

Question 265

The posterior fossa houses what?

Answer 265

The lower brainstem and cerebellum.

Question 266

Name the 3 layers of the meninges. (outside to in)

Answer 266

1. The dura mater - tough and fibrous. 2 sublayers - the Periosteal Layer and Meningeal Layer.The large venous sinuses are housed in between these sublayers.
2. Arachnoid mater
3. Pia Mater (covers the brain)

Question 267

When consulting a neurosurgeon about a patient with TBI what information needs to be relayed?

Answer 267

1. Age of patient
2. Mechanism and time of injury
3. Respiratory and cardiovascular status (Blood pressure and oxygen sats)
4. Results of the neurological examination, including GCS score (with particular emphasis on the motor response, pupil size and reaction to light.
5. Focal neurological deficits
6. Presence and type of associated injuries
7. Results of diagnostic studies, particularly CT scan (if available)
8. Treatment of hypotension or hypoxia

Question 268

Meningeal arteries are located between what two surfaces?

Answer 268

Meningeal arteries lie between the dura and the internal surface of the skull (Epidural space)

Question 269

Describe the the anatomy of a epidural hematoma.

Answer 269

Skull fractures can lacerate middle meningeal arteries (most commonly the middle meningeal artery). An epidural hematoma will form.

Question 270

What two injuries can cause epidural hematomas?

Answer 270

1. Skull fractures
2. Injury to Dural sinuses (Sagital sinus etc.)

Question 271

How do you manage an epidural hematoma?

Answer 271

URGENTLY!!! They need to be evacuated by a neurosurgeon ASAP.

Question 272

How do subdural hematomas form?

Answer 272

Bridging veins that travel from the surface of the brain to the venous sinuses within the dura may tear. These then fill the subdural space (between the dura mater and the arachnoid mater).

Question 273

Subarachnoid hemorrhages are frequently caused by ?

Answer 273

1. Brain contusion
2. Injury to the vessels at the base of the brain.

Question 274

The brain consists of what 3 structures?

Answer 274

1. Cerebrum - right and left hemispheres and seperated by the falx cerebri.
2. Cerebellum - responsible for coordination and balance.
3. Brain stem - ​
   • ​​Midbrain
   • Pons
   • Medulla.

Question 275

Which cerebral hemisphere contains the language centers in virtually all right handed people and 85% of left handed people?

Answer 275

The left hemisphere

Question 276

What functions does the frontal lobe control?

Answer 276

Executive functions, emotions, motor function and, on the dominant side, expression of speech.

Question 277

What functions does the parietal lobe control?

Answer 277

Sensory function and spatial orientation.

Question 278

What function does the temporal lobe control?

Answer 278

Memory functions

Question 279

What function does the occipital lobe control?

Answer 279

Vision.

Question 280

The midbrain and upper pons contain the ? activating system which is responsible for ?

Answer 280

1. Reticular
2. the state of alertness

Question 281

Where does the vital cardiorespiratory center preside?

Answer 281

In the medulla

Question 282

Where is CSF produced and reabsorbed?

Answer 282

It is produced in the choroid plexus in the lateral ventricles and is reabsorbed in the dural venous sinuses through the arachnoid granulation tissue.

 

NOTe: Blood in the CSF can inhibit reabsorption and can cause increased ICP

Question 283

Which cranial nerve runs along the edge of the tentorium and can be compressed against it during temporal lobe herniation?

Answer 283

Cranial Nerve III

Question 284

What is the physiological mechanism to explain a blown pupil?

Answer 284

Parasympathetic fibers from the 3rd cranial nerve constrict the pupil. If these are compressed (e.g. herniation, hematoma) then they cannot act and you get unopposed sympathetic activity. i.e. pupillary dilation.

Question 285

What's going on here?

Answer 285

The tentorial notch is opening that allows passage of the brainstem through the tentorium. The Uncus (medial part of the temporal lobe) is herniating (uncal herniation) through the tentorial notch and compressing the corticospinal (pyramidal) tract in the midbrain, which crosses at the brainstem. Therefore you will get in a contralateral hemiparesis. 

Question 286

What is the classic sign of uncal herniation?

Answer 286

Ipsilateral pupillary dilatation associated with contralateral hemiparesis.

Question 287

What 3 physiological conepts related to head trauma?

Answer 287

1. Intracranial pressure - if elevated it can reduce cerebral perfusion and exacerbate ischaemia.
2. The Monro-Kellie Doctrine
3. Cerebral Blood Flow -cerebral blood flow can be reduced after comatose inducing TBI. This can lead to cerebral ischaemia.

Question 288

What is the normal ICP at resting stage?

Answer 288

~10mmHg

Question 289

What ICP is related to poor outcomes?

Answer 289

20mmHg

Question 290

What is the Monro-Kellie Doctrine?

Answer 290

The total volume of the intracranial contents must remain constant because the cranium is a rigid, nonexpansile container.

Venous blood and cerebrospinal fluid may be compressed out of the container, providing a degree of pressure buffering.

 

Once, the limit of displacement of CSF and intravascular blood has been reached, ICP rapidly increases.

Question 291

How is cerebral perfusion pressure (CPP) defined?

Answer 291

CPP = MAP - ICP

 

Mean arterial pressure

Incracrainal Pressure

Question 292

What level of MAP (Mean arterial pressure) maintains a constant CBF? (a.k.a. Pressure autoregulation)

 

What will happen if the MAP is too low?

What will happen if the MAP is too high?

Answer 292

50 to 150mmHg

 

If the MAP is too low then ischaemia and infarction can occur.

If the MAP is too high, marked brain swelling will occur with elevated ICP.

Question 293

What 4 factors can induce secondary brain injury?

Answer 293

1. Hypotension - need to maintain MAP
2. Hypoxia
3. Hypercapnia
4. Iatrogenic hypocapnia.

Question 294

Does CPP always equate with or assure adequate CBF?

Answer 294

NO. Once ICP increases dramatically then blood flow to the brain can be compromised.

Question 295

What are the classifications of head injury?

Answer 295

1. Minor = GCS 13-15
2. Moderate = GCS 9-12
3. Severe = GCS 3-8

Question 296

True or False, we use the worst motor response to calculate the GCS score, because this is the most reliable?

Answer 296

FALSE. We use the BEST motor response score.

Question 297

Describe the Glasgow Coma Score?

Answer 297

Remember Equation E₄V₅M₆

Eye opening =

• 4 to sponteously
• 3 to speech
• 2 to pain
• 1 none

Verbal response

• 5 Oriented
• 4 Confused Speech
• 3 Inappropriate words
• 2 Incomprehensible sounds
• 1 None

Motor response

• 6 Obeys commands
• 5 Localizes pain
• 4 Withdrawal to pain
• 3 Abnormal flexion (decorticate)
• 2 Abnormal extension (decerebrate)
• 1 None (flaccid)

 

Question 298

Skull fractures are divided into what two regions?

Answer 298

1/ Vault

• Linear or stellate
• Depressed/Non-depressed
• Open/closed

2/Basilar

• With/without CSF leak
• With/without 7th Nerve Palsy.

Question 299

What are the clinical signs of a basilar skull fracture?

Answer 299

1. Periorbital ecchymosis (racoon eyes)
2. Retroauricular ecchymosis (Battle's sign)
3. CSF leakage from nose or ear (Rhinorrhea/Otorrhoea)
4. 7th and 8th nerve disfunction (Facial paralysis and hearing loss.

Question 300

Fractures that traverse the carotid canals can cause what?

 

What investigation can be useful?

Answer 300

1. Damage to carotid arteries (dissection, pseudoaneurysm, thrombosis)
2. Cerebral angiography

Question 301

A linear vault fracture in concious patients increasese th elikelihood of an intracranial hematoma by roughly how many times?

Answer 301

400 times.

Question 302

What are the 2 categories of uintracranial lesions?

Answer 302

Diffuse or Focal.

Question 303

Concussion is a type of diffuse brain injury. What happens in concussion?

Answer 303

The patient will have a transient, nonfocal neurologic disturbance that often includes loss of conciousness. CT scan will often be normal.

Question 304

What is a common cause of severe diffuse brain injury and how can it manifest on a CT scan?

Answer 304

Hypoxic ischaemic insult secondary to prolonged apnea or shock.

 

CT may initially appear normal but may appear diffusely swollen with loss of normal gray-white distinction.

Question 305

What are Diffuse Axonal Injuries (DAI) and how do they manifest on CT?

Answer 305

DAI is a severe form of diffuse brain injury. DAI is a result of a shearing injury where there is a high velocity impact or deceleration injury. Multiple punctate hemorrhages are often seen throughout the cerebral hemispheres inbetween the grey and white matter.

Question 306

Focal lesions consists of 4 types. What are they?

Answer 306

1.  Epidural hematoma
2. Subdural hematoma
3. Contusion
4. Intracerebral hematoma

Question 307

How common are epidural hematomas?

Answer 307

Uncommon. They occur in 0.5% of patients with brain injury & 9% in TBI who are comatose.

Question 308

What shape are epidural hematomas and where are they most commonly located?

Answer 308

They are biconvex and are most commonly located over the temporal or temporoparietal region.

Question 309

What do epidural hematomas often result from?

Answer 309

Skull fractures that cause the middle meningeal artery to tear.

Question 310

How do epidural hematomas clinically present

Answer 310

Head injury with a lucid interval after injury but then neurological deterioration.

Question 311

What are more common, epidural hematomas or subdural hematomas?

 

Answer 311

Subdural hematomas. They occur in 30% of individuals with severe brain injury.

Question 312

Is the brain damage of an epidural hematoma or a subdural hematoma usually more severe?

Answer 312

Subdural hematoma brain damage is usually more severe due to concomitant parenchymal injury.

Question 313

How common are cerebral contusions?

Answer 313

Cerebral contusions are common.

(Present in 20 to 30% of severe brain injuries)

Question 314

Where do the majority of contusions occur?

Answer 314

In the frontal and temporal lobes.

Question 315

Why should patients with contusion have a repeat CT scan within 24 hours of the intial scan?

Answer 315

Contusions can form a coalscent contusion with enough mass effect to require immediate surgical evacuation.

Question 316

Define Minor traumatic brain injury (MTBI)

Answer 316

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.

Question 317

What are some important parts of the history to take from a patient with a MTBI. (minor traumatic brain injury)

Answer 317

1. Name, sex, age, race, occupation
2. Mechanism of injury
3. Time of injury
4. Loss of conciousness - length of time unresponsive, any siezure activity and the subsequent level of alertness.
5. Duration of amnesia - both retrograde and antegrade.
6. Subsequent level of alertness
7. Headache - mild, moderate, severe.

Question 318

What are the high risks for neurosurgical intervention that warrant a CT scan being done for MTBI?

Answer 318

1. GCS score less than 15 at 2 hours after injury.
2. Suspected open or depressed skull fracture.
3. Any sign of basilar skull fracture (e.g. hemotympanum, raccoon eyes, CSF otorrhea or rhinorrhea, Battle's sign)
4. Vomiting (more than 2 episodes)
5. Any more than 65 years.

Question 319

What are the moderate risks for neurosurgical intervention that warrant a CT scan being done for MTBI?

Answer 319

1. Loss of conciousness (>5 minutes)
2. Amnesia before impact (>30 minutes)
3. Dangerous mechanism (e.g. pedestrian struck by motor vehicle, occupant ejected from vehicle, fall from heigh of more than 3 feet or 5 stairs)

Question 320

If someone with an MTBI is being sent home what should you make sure happens?

Answer 320

That they are sent home with a companion who can observe them for 24 hours OR advise them to return to ED if they develop headaches, decline in mental status or develp neurological deficits.

Question 321

Define moderate brain injury./

Answer 321

GCS 9-12

Question 322

How shoud you manage a patient with mild brain injury?

Answer 322

1. Take a history (see other card)
2. General examination
3. Limited neuro exam
4. Imaging
5. Bloods - alcohol level and urine toxicology.
6. CT scan of head if indicated.

Question 323

How should you manage someone with a moderate brain injury?

Answer 323

1. History and examinations same as mild head injury.
2. CT scan.
3. Follow up CT scan within 24 hours if condition worsens.
4. 90% of patients will improve - discharge and follow up in clinic.
5. 10% will deteriorate - manage as per severe brain injury protocal

Question 324

What is the definition of a severe brain injury?

Answer 324

The patient will be unable to follow simple commands because of impaired consciousness (GCS score 3-8).

Question 325

How do you manage someone with a severe brain injury?

Answer 325

1. ABCDEs
2. Primary survey
3. Resuscitation
4. Secondary Survey and AMPLE
5. Admit to facility for definitive neurosurgical care.
6. Therapeutic agents  (Mannitol, Moderate hyperventilation [PCO₂ 32-35mmHg], Hypertonic saline)
7. Neurologic reevaluation
8. GCS
9. Pupils
10. Focal neurology
11. CT Scan

Question 326

If you have a severe brain injury, hypotension and hypoxia on admission, what is your relative risk of dying?

Answer 326

75%

Question 327

In severe head injury, how do you manage the airway and breathing?

Answer 327

1. Endotracheal intubation early.
2. Ventilate with 100% O₂ until blood gas done.
3. Oxygen Sats of >98% are desirable on pulse oximetry.
4. Ventilation parameters: maintain PCO2 of ~35mmHg. Normocarbia is generally preferred.
5. Hyperventilation (PCO2 <32mmHg) should be cautisouly used only when acute neurological deterioration has occured. Hyperventilation causes a reduction in pCO₂ and causes cerebral vasoconstriction. This can promote cerebral ischaemia. Hyperventilation will LOWER ICP until emergent craniotomy can be performed.

Question 328

When does hypotension occur in a brain injury?

Answer 328

ONLY in the final stages when the medulla fails or there is concomitant spinal cord injury.

 

NOTE: intracranial haemorrhage cannot cause hemorrhagic shock.

Question 329

What type of fluids should be used in order to establish euvolaemia in severe brain injuresi: hypotonic, isotonic or hypertonic fluids?

Answer 329

Isotonic solutions like Ringer's lactate or normal saline.

Question 330

Can 5% dextrose be used for fluid resucitation in patients with severe brain injury?

Answer 330

No because hyperglycaemia can occur. Hyperglycaemia has been shown to be harmful to brain injury.

Question 331

What can hyponatraemia cause to the brain?

Answer 331

It can cause brain swelling.

Question 332

If someone is intoxicated, what must you make sure you don't do.

Answer 332

Do not miss a head injury!!!

Question 333

The postictal state after a traumatic seizure can last for roughly how long?

Answer 333

Minutes to hours.

NOTES: this can make it difficult to assess neurological state.

Question 334

How can motor response be ellicited in a comatose patient?

Answer 334

The trapezius muscles can be pinched, the nail bed can be pressed on or the supraorbital ridge can be presed on.

Question 335

Should we test for doll;s eye movement or do the caloric test with ice water?

Answer 335

NO...leave that to a neurosurgeon.

 

NOTE: Doll's eye testing should never be tempted before a C-spine injury has been ruled out.

Question 336

What neurological examination should be done before sedating a patient?

Answer 336

GCS score and pupillary response.

 

This is because knowledge of the patient's clinical condition is important for determinding subsequent treatment.

Question 337

Sedation, in head injuries, should be avoided except....?

Answer 337

EXCEPT when a patient's agitated state places him or her at risk.  The shortest acting agents are recommended.

Question 338

What is a sign of temporal lobe herniation (uncal herniation)?

Answer 338

Dilation of the pupil and loss of pupillary response to light.

Question 339

What are the significant and what are the crucial findings of CT scan?

Answer 339

Significant Findings

1. Skull fractures
2. Subgaleal hematomas.
3. Scalp swelling

Crucial Findings

1. Intracranial hematoma
2. Contusions
3. Shift of the midline (mass effect) - a shift of 5mm or greater is often indicative of the need for surgery to evacuate the blood clot or contusion.
4. Obliteration of the basal cisterns

Question 340

If someone has a head injury and is either anticoagulated or is on antiplatelet therapy, what should be done?

Answer 340

1. INR
2. Rapid normalization of the anticoagulation.

Question 341

Medical therapies for brain injury include...?

Answer 341

1. Intravenous fluids
2. Temporary Hyperventilation
3. Mannitol
4. Hypertonic saline
5. Barbiturates
6. Anticonvulsants.

Question 342

What PCO2 levels correspond with normocarbia, hypocarbia and hypercarbia?

Answer 342

• Normocarbia - PCO₂ ~35mmHg (4.7kPa)
• Hypocarbia/Hyperventilation - PCO2 25-30mmHg (3.3 to 4.7kPa) but aim for 28 to 32mmHg to be safer. - Promotes vasoconstriction and thus used in acute increases of ICP)
• Hypercarbia - PCO2 >45 (promotes vasodilation & increases ICP)

Question 343

What is mannitol used for?

Answer 343

To decrease ICP

Question 344

How do you secondarily manage a severe head injury? (not diagnostic)

Answer 344

1. Frequent serial neuro examination.
2. Normocarbia - PCO₂ 35+/- 3
3. Mannitol and PCO₂ 28-32 if deterioration.
4. Avoid PCO₂ <28
5. Address intracranial lesions appropriately.

Question 345

What preparation of mannitol is most commonly used?

Answer 345

20% solution (20g in 100ml solution).

Question 346

When should mannitol NOT be given?

Answer 346

In patients with hypotension.

 

Mannitol does not lower ICP in hypovolaemia and is a potent osmotic diuretic.

Question 347

How do you administer mannitol in a deteriorating euvolaemic patient with a severe head injury?

Answer 347

1. Give a bolus of 1g/kg rapidly over 5 minutes
2. Then transported immediately to CT scanner.

Question 348

What is hypertonic saline used for?

Answer 348

To reduce ICP

Question 349

How do mannitol and hypertonic saline compare when it comes to lowering ICP?

Answer 349

They are just as effective.

 

Neither will adequately lower ICP in hypovolaemic patients. HOWEVER, hypertonic saline is preferred in patients with hypotension because it does NOT act as a diuretic.

Question 350

When should barbiturates NOT be used?

Answer 350

In severe head injury patients who have hypotension and hyopvolaemia.

 

NOTE: Hypotension can result from their use.

Question 351

Why are barbiturates used and when should they not be used?

Answer 351

They are useful in reducing ICP refractory to other measures. They are not to be used in the acute resuscitative phase.

Question 352

Why should barbiturates probably not be used if the patient will die?

Answer 352

They have a long half life and will prolong brain death.

Question 353

What are the 3 factors that are linked to a high incidence of late epilepsy?

Answer 353

1. Seizures occuring in the first week.
2. Intracranial hematoma
3. A depressed skull fracture.

Question 354

What effect does early anticonvulsant use have on long term traumatic seizure outcome?

Answer 354

None whatsoever. Purely used to control seizures.

Question 355

What effect do anticonvulsants have on brain recovery?

Answer 355

They inhibit it. So use them carefully.

Question 356

What anticonvulsants and in what doses are they used in patients with traumatic seizures?

Answer 356

Phenytoin and Fosphenytoin.

For phenytoin, a loading dose of 1 gram is given IV at a rate ~50mg/min.

Then 100mg/8 hours for maintenance but monitor serum levels for optimal dosing.

Question 357

What else can be used in addition to phenytoin for traumatic seizures?

Answer 357

Diazepam or lorazepam.

 

GA may also be required if still not controlled.

Question 358

Why is it important to gain control over seizures early?

Answer 358

If prolonged seizures occur (30-60minutes) they can cause secondary brain injury.

Question 359

How do you diagnose brain death/

Answer 359

1. GCS score of 3
2. Nonreactive pupils
3. Absent brainstem reflexes (Doll's eyes, no gag reflex etc)
4. No psontaneous ventilatory effort on formal apnea testing.

Question 360

What do you need to exclude before diagnosing brain death?

 

Answer 360

Reversible conditions like hypothermia and barbiturate coma.

Question 361

What head wounds may require surgical management?

 

Answer 361

1. Scalp wounds - clean and inspect. CSF leakage indicates a dural tear.
2. Depressed skull fractures - can be operated on to elevate the fracture if the degree of depression is greater than the thickness of the adjacent skull or it is open and contaminated.
3. Intracranial mass lesions - managed by neurosurgeon. May require emergency craniotomy if trained.
4. Penetrating brain injuries - CT/CT angiography is recommended. If non metalic then MRI can be useful. Prophylactic broad-spectrum antibiotics should be given.

Question 362

When is early ICP monitoring recommended in a penetrating brain injury?

Answer 362

1. When the clinician is unable to assess the neurologic examination accurately.
2. The need to evacuate a mass lesion is unclear.
3. Imaging studies suggest elevated ICP.

Question 363

How should you treat someone with a small bullet entrance wound to the head?

 

Answer 363

Wound care and closure if there is no scalp devitalization and no major intracranial pathology.

Question 364

If someone has a penetrating intracranial wound what should you do?

Answer 364

Leave it in place until the vascular surgeons review.

Question 365

How is the primary survey performed for head injuries?

 

Answer 365

1. ABCDEs
2. Immobilize and stabilize C spine
3. Perform a brief neuro exam.

• Pupillary response
• GCS score
• Lateralizing signs.

Question 366

How is the secondary survey performed in a patient that has a potential brain injury?

Answer 366

1. Inspect the entire head, face looking for lacerations, CSF leakage from nose and ears.
2. Palpate the entire head and face looking for fractures and lacerations.
3. Inspect the scalp lacerations for brain tissue, depressed skull fractures, debris and CSF leaks.
4. Determine GCS score, pupillary response, best limb motor response, verbal response.
5. Examine the C-spine.
6. Document the neurological injury.
7. Reassess for deterioration.

Question 367

Describe the process of evaluating CT scans of the head?

 

Answer 367

1. Confirm the patient.
2. Assess the scalp for contusions or swelling.
3. Assess for skull fractures - depressed skull fractures, open fractures, missile wounds or tracts.
4. Assess the gyri and sulci for symmetry. If assymetrical consider subdural hematoma or epidural hematoma. (Subdural hematomas more frequent and can have associated contusions and hematomas. Epidural hematomas cause midline shift, biconvex and commonly over temporal region)
5. Assess the cerebral hemispheres - density, symmetry, cerebral contusions(punctate areas of high density), DAI (diffuse axonal injury), intracerebral hematomas.
6. Assess the ventricles - decreased size if increased ICP.
7. Assess midline shift - >5mm or more requires surgical decompression.
8. Assess maxfacs structures - facial bones, sinuses, mastoid air cells.
9. Look for the 4 C's of increased density: Contrast, Clot, Cellularity (tumor), Calcification (pineal gland, choroid plexus)

Question 368

Why can patients have a worsening of spinal injury symptoms after arriving in hospital?

Answer 368

1/ Ischemia

2/ Worsening of spinal cord oedema.

3/ Inadequate immobilization

Question 369

When can you exlude the presence of a significant spinal injury?

Answer 369

The patient is neurologically intact and there is no pain on palpation of the spine.

Question 370

How many vertebrae are there in the C-spine, T-spine and the L-spine?

Answer 370

C-spine=7

T Spine=12

L spine=5

Question 371

Is the cervical canal wide or narrow in the cervical spine?

Answer 371

Wide

Question 372

What fraction of patients with cervical spine injuries die at the scene from apnea? Why do they die of apnea?

Answer 372

1/3.

This is because of loss of central innervation of the phrenic nerve and spinal cord injury above C3-C5 where the phrenic nerve arises.

Question 373

How is the cervical spine different form children and adults?

Answer 373

The C-spine of children is:

1/ More flexible, (joint capsules and interspinous ligaments)

2/ Flat facet joints

3/ Vertebral bodies are wedged anteriorly and slide forward with flexion. These changes stop at about 12 years old.

Question 374

What type of fracture are most thoracic spine fractures?

Answer 374

Wedge compression fractures. (not associated with spinal cord injury)

Question 375

A fracture dislocation of the thoracic spine almost always results in (blank)?

Answer 375

Complete spinal cord injury.

Question 376

What is the thoracolumbar junction and why is it more susceptible to injury?

Answer 376

The fulcrum between the inflexible thoracic region and the stronger lumbar levels. It is thus more prone to injuries 15% of all spinal injuries occur here.

Question 377

Where does the spinal cord originate?

Answer 377

At the caudal end of the medulla oblongata at the foramen magnum.

Question 378

Where does the spinal cord end?

Answer 378

Usually at the L1 boney level.

This is called the conus medullaris.

Below this is the cauda equina.

Question 379

Name the 3 tracts of the spinal cord?

Answer 379

Descending (Motor)

1. Corticospinal tract

Ascending (Sensory)

1. Spinothalamic tract
2. Dorsal Column