CR - traumatic disorders

Question 1

What is the most appropriate diagnostic study in trauma patients with blood at the urethral meatus?

Answer 1

Retrograde urethrogram

Question 2

In the setting of acute trauma in a hemodynamically stable patient, this test should be performed if renal artery injury is suspected or needs to be excluded

Answer 2

CT scanning with 3-D reconstruction and IV contrast

Question 3

What are the classic signs of compartment syndrome?

Answer 3

The 6 P’s
Pain out of proportion
Pallor
Poikilothermic
Pulselessness
Paresthesia
Paralysis

Question 4

What is the role of hyperventilation in the management of elevated intracranial pressure secondary to trauma?

Answer 4

The role is very limited. Hyperventilation should only be considered for herniation or clinical deterioration despite adequate resuscitation and mannitol; if used, the pCO2 should be maintained between 35-40 mm Hg

Question 5

What is the immediate cause of death from an untreated tension pneumothorax?

Answer 5

Obstructive shock

The tension pneumothorax severely impedes venous return which results in a fatal reduction in cardiac output

Question 6

In a patient presenting with a periorbital hematoma or a hyphema, what diagnosis should be excluded?

Answer 6

Orbital fracture

Question 7

At what age can surgical cricothyroidotomy be performed on a child?

Answer 7

When the cricothyroid membrane is palpable, around 10 years

Question 8

When viewing cervical spine films in a child with possible injury, what are normal variants?

Answer 8

Wedging of the anterior cervical bodies (especially C3 which is seen up to age 12)

Anterior pseudosubluxation of C2 over C3 or C3 on C4

Pseudosubluxation is common in children <7 year old. Swischuk’s line drawn from the anterior aspect of posterior arch of C1 to anterior aspect of posterior arch of C3. Anterior aspect of posterior arch of C2 should be within 1-2mm of this line

Question 9

A patient with a head injury is unresponsive to both verbal and painful stimuli. There is no eye opening whatsoever.

What is the Glasgow Coma score?

Answer 9

3

The patient scores a one for each eye opening, speech, and best motor

Question 10

What is the leading cause of death in patients sustaining pelvic fractures?

Answer 10

Hemorrhagic shock

Question 11

Children (<11 years old) with cervical spine injuries are most commonly injured in what region of the cervical spine?

Answer 11

The upper C-spine

Question 12

What is the most common cause of sudden death following a MVC or fall from a great height?

Answer 12

A traumatic aortic rupture

Question 13

Clinical presentation: a patient has a facial laceration that requires suturing. He claims an allergy to procaine. Which of the following is the safest choice for local anesthesia?

Benoxinate HCl
Benzocaine
Cocaine
Tetracaine
Mepivicaine

Answer 13

Mepivicaine

Procaine is the prototype “ester” local anesthetic. All of the anesthetics listed are chemically related to procaine except mepivicaine which is an “amide”

The amide anesthetics are associated with far fewer allergic reactions. The other amides are lidocaine, bupivacaine, etidocaine, and prilocaine

Question 14

Pelvic fractures are associated with bladder injury. What should you check for?

Answer 14

Hematuria

The greater the degree of hematuria, the greater the risk of significant intra-abdominal injury. Pelvic fractures are associated with posterior urethral injury (above urogenital diaphragm) and bladder injury.

Question 15

How does on differentiate pulmonary contusion from adult respiratory distress syndrome (ARDS) on chest x-ray

Answer 15

Pulmonary contusion occurs within minutes to hours of the injury and is seen on x-ray as an infiltrate or consolidation that is usually localized to a pulmonary segment or lobe.

ARDS is associated with delayed onset (12-72 hours after injury) with diffuse patchy infiltrates seen on chest x-ray (24-72 hours after injury)

Question 16

Death from drowning is due to ___

Answer 16

Hypoxia

Question 17

What is the most common cause of fetal death following blunt trauma?

Answer 17

Second only to maternal death, abruptio placentae is the most common cause of fetal death.

Question 18

What are the NEXUS criteria?

Answer 18

No posterior midline cervical tenderness

No evidence of intoxication

Normal level of alertness

No focal neurological deficit

No distracting painful injuries

Question 19

What is the most common ureteral injury in the setting of blunt trauma

Answer 19

Ureteropelvic disruption

Should be suspected with fractures of the lumbar spine: urinalysis may be normal

Question 20

What are the most common sequela following blunt abdominal trauma during pregnancy?

Answer 20

Preterm contractions

Any pregnant woman at 24 weeks or more gestation who suffers blunt trauma should undergo at least 4 hours of fetal monitoring even if she looks well

Question 21

What is the most common site of penetrating trauma to the heart?

Answer 21

The right ventricle

Question 22

A patient with no head injury and multiple long-bone fractures undergoes a dramatic worsening of his neurological status. What diagnosis should be considered in this scenario?

Answer 22

Fat embolism syndrome

The classic triad of symptoms is: acute respiratory failure, global neurologic dysfunction an da petechial rash.

Usual cause of death is ARDS and 20% mortality rate. May occur 1-2 days after injury or intramedullary nailing.

Question 23

When assessing indications for thoracotomy in trauma arrest patients, signs of life in the field or on arrival in the ED include:

Answer 23

Blood pressure
Pulse
Cardiac rhythm
Respiratory effect
Echo cardiac activity or tamponade

Others include reactive pupils and spontaneous movement

Question 24

Sensory loss on the chest or abdomen is presumptive evidence of ___

Answer 24

Spinal cord injury / involvement

Question 25

What percent of patients with a c-spine fracture have a second, noncontiguous vertebral fracture?

Answer 25

10% If one fracture is present, complete radiographic screening of the entire spine is needed

Question 26

Which reversible conditions can mimic the appearance of brain death?

Answer 26

Hypothermia Barbiturate coma Baclofen and benzodiazepine OD

Question 27

What should you be looking ofr on AP and lateral films of the thoracic and lumbar spine in trauma patients?

Answer 27

AP: vertical alignment of the pedicles as well as the distance between them (unstable fractures commonly cause widening of the interpedicular distance) Lateral: subluxations, compression fractures and Chance fractures

Question 28

Patients in hypovolemic shock are usually ___ while those in neurogenic shock are typically ___

Answer 28

Hypovolemic shock = tachycardic Neurogenic shock = bradycardic

Question 29

CT scanning of the thoracic and lumbar spine is particularly useful for detecting which injuries?

Answer 29

Fractures of the posterior elements (pedicles, laminae + spinal processes) and the degree of canal compromise caused by burst fractures

Question 30

True or false: corticosteroids should not be used to treat head injury (whatever the severity)

Answer 30

True CRASH Trial - patients given steroids were 18% more likely to die within 14 days than those treated with placebo

Question 31

In mild traumatic brain injury and no loss of consciousness, a head CT is indicated for:

Answer 31

Focal neurological deficits Severe headache or vomiting Age >60 years Physical signs of basilar skull fracture CGS < 15 Coagulopathy Dangerous mechanism of injury Intoxication Short term memory deficits External signs of trauma above the clavicle Post-traumatic seizure

Question 32

Important factors for identifying children at low risk for traumatic brain injury after blunt head trauma include:

Answer 32

No loss of consciousness Normal mental status, GCS = 15 No clinical signs of skull fracture No history of vomiting and/or severe headache Fall less than 3 feet (<2 years old), 5 feet (>2 years old) No non-frontal scalp hematoma in children <2 years old No seizure

Question 33

What are the indications for emergent exploratory thoracotomy after initial chest tube is placed?

Answer 33

Blood loss >/= 1,500 mL in the initial chest tube drainage Blood loss >200 ml/hr for 2-4 hours Refractory hypotension or cardiopulmonary decompensation Persistent bleeding requiring serial blood transfusions >/= 50% pneumothorax

Question 34

Which odontoid fractures are considered unstable?

Answer 34

Type II and III are unstable Type I is considered stable

Question 35

What injuries are associated with lap seat belt restraint?

Answer 35

Tear/avulsion of bowel mesentery Rupture of small bowel or colon Thrombosis of iliac artery or abdominal aorta Chance fracture of lumbar vertebrae Pancreatic or duodenal injury

Question 36

What is the IOP indication for a lateral canthotomy

Answer 36

An intraocular pressure of 40 mmHg or higher

Question 37

What are the nexus C-spine rules

Answer 37

99.6% sensitive and 99.9% negative predictive value for presence of fractures if patient meets all the criteria below No neurological deficits No spinal midline tenderness No altered mental status No intoxication No distracting injuries If any criteria are met, consider obtaining CT imaging

Question 38

What are some physical exam findings that may suggest non-accidental trauma

Answer 38

Multiple injuries in various stages of healing Injuries in defensive pattern - nightstick fracture, hand injuries Injuries to protected body locations - inner thighs, genitalia, axilla Burns of entire hand or foot or buttocks Lighter or cigarette burns Bruises to thorax, ears, neck Bruises on any child less than 4 months Evidence of neglect, malnutrition, developmental delay

Question 39

A patient who fell from a ladder and presented with parasthesia and inability to move both upper and lower extremities, now has bradycardia and hypotension What is the suspected site of injury and treatment?

Answer 39

Patient has neurogenic shock Most likely cervical or upper thoracic cord injury Patient requires IV fluids, atropine for severe bradycardia, may need vasopressor support to improve perfusion

Question 40

In penetrating neck trauma, violation of the ___ muscle is indication for surgical consultation

Answer 40

Platysma

Question 41

True or false: penetrating abdominal GSW requires immediate operative intervention

Answer 41

False While transabdominal GSW is usually an indication for OR, stable patients may receive CT scans at surgeon's discretion for delineation of injuries

Question 42

What anatomical features place the pediatric population at an increased risk for significant thoracoabdominal organ injury?

Answer 42

The rib cage is more cartilaginous which may result in significant pulmonary contusion in the absence of rib fractures. Abdominal and pelvic organs are less well protected by ribs and pelvic bones. The liver and spleen extend beyond the lower costal margins

Question 43

Inclusion criteria for canadian c-spine rule

Answer 43

Alert (GCS 15) Stable Adult or child >8 years old

Question 44

hard signs of penetrating neck trauma which indicate need for immediate operative intervention

Answer 44

Airway compromise Expanding or pulsatile hematoma Active, brisk bleeding Hemorrhagic shock Hematemesis Neurological deficits Massive subcutaneous emphysema Air bubbling through wound

Question 45

What anatomical landmark separates neck zone I and zone II

Answer 45

Cricoid cartilage

Question 46

What anatomical landmark separates neck zone II and zone III

Answer 46

Angle of mandible

Question 47

A patient is complaining of severe chest pain after a high-speed MVC, and portable CXR shows a widened mediastinum. Vitals remain stable. What is the preferred imaging modality to diagnose great vessel injuries?

Answer 47

CT angiography

Question 48

Define spinal shock

Answer 48

The initial loss of spinal reflexes below the level of cord injury, which is followed by gradual recovery. Bulbo-cavernosis reflex is among the first to return with resolution of spinal shock (anal sphincter contraction with penis/clitoris stimulation)