Dr. Pestana's Notes--Trauma Flashcards
(173 cards)
1
Q
In which cases will the airway most likely close?
A
expanding hematoma; emphysema in the neck
2
Q
When is an airway needed? (4 cases)
A
(a) if pt unconscious (GCS
3
Q
What do you need to do first before dealing with a cervical spine injury?
A
make sure the airway is secured
4
Q
How is an airway usually inserted?
A
orotracheal intubation using laryngoscope
5
Q
When an airway in inserted the patient is [awake/asleep].
A
awake
6
Q
In cervical spine injury, an orotracheal intubation can only be done IF _____.
A
the head is secured and not moved
7
Q
Use of a fiberoptic bronchoscope is mandatory when securing and airway IF there is _____ present.
A
subcutaneous emphysema in the neck [major disruption of tracheobronchial tree]
8
Q
If intubation cannot be done via orotracheal or nasotracheal intubation, the quickest and safest way to establish an airway before anoxic injury is to do a _________
A
cricothyroidostomy
9
Q
Why are docs reluctant to do a cricothyroidostomy in pts younger than 12yo?
A
risk of future laryngeal reconstruction
10
Q
What are the two requirements to make sure breathing is okay?
A
(1) bilat breath sounds
(2) satisfactory pulse oximetry
11
Q
Clinical signs of shock.
A
BP under 90mmHg systolic; fast feeble pulse; low urinary output in pt who is pale, cold, shivering, sweating, thirsty, apprehensive
12
Q
Traumatic shock is caused by [list 3].
A
(1) hemorrhage (2) pericardial tamponade (3) tension pneumothorax
13
Q
MCC traumatic shock?
A
Hemorrhagic (type of hypovolemic)
14
Q
List treatment of hemorrhagic shock in (a) big trauma center and (b) all other settings.
A
(a) surgical intervention + volume replacement
(b) other–volume replacement w/ 2L Ringer lactate w/o sugar + packed RBCs until urinary output reaches 0.5-2ml/kg/hr while not exceding CVP of 15mmHg
15
Q
(a) What is the preferred route of fluid resuscitation in trauma setting? (b) What is the next best? (c) In children under 6yo?
A
(a) 2 peripheral IV lines; 16 gauge
(b) percutaneous femoral vein catheter or saphenous vein cut-down
(c) intraosseus cannulation of proximal tibia
16
Q
Tx pericaridal tamponade (based on clinical dx and/or sonogram)
A
evacuation of pericardial sac (pericardiocentesis, tube, windo or open thoracotomy) + fluid + blood
17
Q
Tx tension pneumothorax (based on clinical dx)
A
big needle/IV catheter into pleural space + chest tub connected to underwater seal (both high in anterior chest wall)
18
Q
Types of hypovolemic shock.
A
hemorrhagic, burns, peritonitis, pancreatitis, massive diarrhea (fluid loss)
19
Q
Which type of shock has low CVP? High CVP?
A
hypovolemic/vasomotor; pericardial tamponade/tension pneumo/cardiogenic
20
Q
How do you distinguish pericardial tamponade from tension pneumothorax?
A
PT has no respiratory distress; TP does
21
Q
What causes cardiogenic shock?
A
massive MI or fulminating myocarditis
22
Q
Tx cardiogenic shock.
A
circulatory support
23
Q
Why is Ddx so important in shock?
A
If cardiogenic, increasing fluids + packed RBCs could be lethal
24
Q
Causes of vasomotor shock.
A
anaphylaxis, high spinal cord transection, high spinal anesthetic
25
Clinical signs vasomotor shock; tx
circulatory collapse (low CVP) in flushed, pink/warm pt; tx vasopressors + fluids
26
How do you tx a CLOSED linear skull fracture? OPEN?
Closed = leave it alone; Open = wound closure
27
What do all pts w/ head trauma + unconscious get?
CT to look for intracranial hematomas [if negative + neuro intact, then can go home if family wakes them up during next 24hrs to eval for coma]
28
Clinical signs fracture at base of skull.
raccoon eyes, rhinorrhea, otorrhea, ecchymosis behind ear
29
How do you workup fracture at base of skull?
assess integrity of cervical spine (big trauma!!); CT
30
When should naso endotracheal intubation be avoided?
fracture at base of skull
31
What is neurologic damages (3) are caused from trauma? What are tx of each?
(1) initial blow [no tx] (2) devo of hematoma that displaces midline structures; tx surgery (3) increase ICP; tx mannitol/furosemide
32
What is progression of acute epidural hematoma?
trauma, unconsciousness, lucid interval and gradual relapsing into coma + ipsi fixed/dilated pupil + contra hemiparesis + decerebrate posture
33
Tx epidural hematoma
emergency craniotomy
34
Clinical sxs acute subdural hematoma.
big trauma, very sick pt who may be asxs at some point + severe neuro damage
35
Tx subdural hematoma w/ midline structure deviation
craniotomy
36
Tx subdural hematoma w/ no midline structure deviation
focus on preventing further damage from subsequent ICP
37
Tx ICP
ICP monitoring, elevate head, hyperventilate, avoid fluid overload, mannitol/furosemide; DO NOT diurese to point of lowering systemic BP; sedation or hypothermia [to dec brain activity/O2 demand]
38
Goal of tx hyperventilation w/ ICP is to get PCO2 to ____.
35mmHg
39
CT scan of diffuse axonal injury shows:
diffusing blurring of gray-white matter interface w/ multiple punctate hemorrhage
40
Tx DAI
prevent further damage from inc ICP [surgery if any hematoma]
41
Chronic subdural hematoma is seen in ____ or in _____
severely old; chronic alcoholics
42
Cause of chronic subdural hematoma
shrunken brain + tearing of venous sinuses
43
Dx and tx chronic subdural hematoma
CT; surgery
44
Hypovolemic shock ____ happen from intracranial bleeding. This is because ____
CANNOT; there isn't enough space inside head for amt blood loss to produce shock
45
Penetrating neck trauma requires surgical exploration in the following cases (4)
(1) expanding hematoma
(2) deteriorating vital signs
(3) signs of esophageal/tracheal injury [coughing/spitting blood]
(4) GSW of middle zone of neck
46
GSW Dx in (A) upper zone (B) middle zone (C) base of neck
(A) arteriography dx and appropriate tx
(B) surg exploration
(C) arteriography, esophagogram (+ barium if negative), bronchoscopy [all prior to surgery]
47
Stab wounds w/ asxs Tx (A) upper zone (B) middle zone
(A/B) safely observed
48
In ALL patients w/ severe blunt trauma to the neck, must do these 2 things
(1) check integrity of cervical spine
| (2) check neurological deficits
49
Must use CT imaging with severe blunt trauma to the neck in 2 scenarios
(1) signs of neuro deficits
| (2) neuro intact but pain to local palpation over cervical spine
50
Clinical sxs Brown-Sequard (typically from clean-cut injury, like a knife)
ipsi paralysis and proprioception loss; contra pain/temp loss
51
Clinical sxs Anterior Cord Syndrome (from burst fractures of vertebral bodies)
loss motor/pain/temp function distal to injury; vib/proprioception preserved
52
Clinical sxs Central Cord Syndrome (elderly w/ forced hyperextension of neck; MVA)
paralysis + burning pain in upper extremities w/ preserved most functions of LEs
53
Best imaging for spinal cord injuries; potential medical tx (besides surgery)
MRI; high-dose corticosteroids (dec inflammation post-trauma)
54
Describe progression of rib fracture in elderly, leading to death.
fracture-->pain-->hypoventillation-->atelectasis-->pneumonia-->death
55
Tx rib fracture
local nerve block or epidural catheter
56
Cause of pneumothorax; sxs
broken rib or penetrating weapon; SOB, absence breath sounds on affected side w/ hyperresonant to percussion
57
Workup of pneumothorax
CXR + chest tube (placed anterior, high) and connect to underwater seal
58
Tx hemothorax if (A) lung (most common) source of bleeding (B) intercostal artery/systemic vessel source of bleeding
(A) blood evacuated via chest tube (placed low); usually stops by itself (B) thoracotomy
59
Indication for surgery to tx hemothorax (2)
(1) >1500mL immediately post-chest tube placement
| (2) >600mL/6hrs post-chest tube placement
60
What are the three main "hidden injuries" and subsequent dx in severe blunt trauma to the chest?
(1) pulmonary contusion; CXR + blood gases
(2) MI; EKG + cardiac enzymes
(3) transection of aorta; CT angio (most common)
61
Clinical sxs of sucking chest wound (which can eventually develop into tension pneumothorax)
a flap that sucks air with inspiration and closes during expiration
62
Tx sucking chest wound
occlusive dressing that allows air out (taped 3 sides) but not in
63
Cause of flail chest; "paradoxical breathing"
w/ multiple rib fractures; segment of chest wall caves in during inspiration and bulges out during expiration
64
Underlying problems of flail chest
pulmonary contusion, possible transection of aorta
65
Basic tx pulmonary contusion
fluid restriction (lung sensitive to fluid overload) + diuretics + monitor blood gases
66
Tx if broken rib punctured lung, requiring respirator
bilateral chest tubes
67
Clinical sxs pulmonary contusion
deteriorating blood gases, "white out" on CXR
68
Pulmonary contusion can show up on CXR at two different times...
(1) right away (2) up to 48hrs later
69
Sternal fractures should make one suspect of ______, detected by ____
myocardial contusion; EKG/troponins
70
Tx of myocardial contusion
prevent complications, like arrhythmias
71
Signs of traumatic rupture of diaphragm; dx test for suspicious cases
bowel on LEFT side in chest; laparoscopy [CXR first]
72
MC location of traumatic rupture of aorta; MCC
junction of arch and descending aorta; deceleration injury
73
Sxs traumatic rupture of aorta
asxs until hematoma contained by adventitia ruptures; wide mediastinum
74
Fractures in chest bones that are "hard to break" (1st rib, scapula, sternum) suggest possible ____
traumatic rupture of aorta
75
Dx traumatic rupture aorta
CT angio (MC), transesophageal echo, MRI angio
76
Post-trauma subcutaneous emphysema in upper chest and lower neck or a large "air leak" from a chest tube suggests which morbidity?
traumatic rupture of trachea or major bronchus
77
Dx traumatic rupture of trachea or major bronchus
CXR (air in tissues), fiberoptic bronchoscopy (+ intubation to secure airway)
78
Tx traumatic rupture of trachea or major bronchus
fiberoptic bronchoscopy (+ intubation to secure airway) then surgery
79
Ddx of subcutantous emphysema
(1) traumatic rupture of trachea or major bronchus
(2) rupture of esopohagus (post-endoscopy)
(3) tension pneumothorax (+shock and respiratory distress)
80
Sudden death in a chest trauma pat who is intubated and on a respirator suggests ____, leading to ______.
air embolism; cardiac arrest
81
What happens when subclavian vein opened to air (supraclavicular node biopsies, CVP lines)
can cause air embolism
82
Tx/prevention possible air embolism
tx=cardiac massage w/ pt positioned w/ left side down; px = Trendelenburg position when entering great veins at base of neck
83
In a pt w/o chest trauma, a fat embolism can produce ______.
respiratory distress
84
MCC fat embolism
multiple trauma + several long bone fractures
85
Sxs fat embolism
petichial rashes in axillae and neck; fever, tachycardia, low plt; respiratory distress + hypoxemia + bilateral patchy infiltrates on CXR
86
Tx respiratory distress due to fat embolism
respiratory support
87
Dx fat embolism
CXR (bilateral patchy infiltrates), fat droplets in urine
88
GSW below level of nipple requires ____
exploratory laparotomy
89
In select cases involving low-caliber GSW to ____ quadrant, conservative therapy w/ close follow-up w/ [imaging] can be used
RUQ; serial abdominal CT scans
90
Penetrating stab wounds (with protruding viscera) require exploratory laparotomy; also if ____ or _____ develop
hemodynamic instability; peritoneal inflammation
91
When does blunt trauma to the abdomen require exploratory laparotomy?
with peritoneal inflammation [acute abdomen]
92
What main signs (3) indicate internal bleeding in blunt abdominal trauma?
hypovolemic shock, low CVP, no obvious external blood loss source; [lower BP, low UOP]
93
Clinically, what does a pt w/ internal bleeding look like? How much volume loss would cause this?
cold, anxious, shivering, thirsty, diaphoretic [lower BP, low UOP]; >1500mL (25-30%)
94
Which (4) places can accommodate >1500mL blood loss [causing hypovolemic shock] and can be unnoticed grossly?
(1) abdomen (2) thighs (from femur fracture) (3) pelvis (4) pleural cavities (seen on CXR); UE/LE and neck can be noticed grossly
95
In the initial survey of a trauma pt, which 2 places are always checked as potential causes that could lead to hypovolemic shock?
femurs and pelvis
96
Dx intraabdominal bleeding from blunt abd trauma; most common injury sites (2)
CT scan; spleen (MC significant blood loss) or liver (MC bleeding overall)
97
Tx for pt w/ minor injuries that responds to fluid resuscitation.
watch
98
Tx pt w/ major injuries that DOES NOT respond to fluid resuscitation
surgery
99
Major limitation of a CT scan in injury
can only be done in HEMODYNAMICALLY STABLE pt (also takes about 45min)
100
Dx of hemodynamically UNSTABLE pt having blood in peritoneal cavity in ER/OR w/ resuscitation efforts underway (2 techniques)
(1) diagnostic peritoneal lavage (DPL)
(2) sonogram (FAST)
[both only give yes/no answer if blood present; if yes, do exploratory laparotomy]
101
Major limitation of Focused Abdominal Sonogram for Trauma (FAST)
operator-dependent
102
Hint that blunt abd trauma has ruptured spleen
fractures of lower ribs on LEFT side
103
Why make every effort to repair spleen; in which population in particular
has immunologic function; children
104
What do you give for prophylaxis in asplenic pts?
postoperative immunization against encapsulated bacteria [pneumococcus, HiB, meningococccus]
105
Empirical Tx of coaggulopathy during prolonged abd surgery for multiple trauma w/ multiple transfusions
platelet packs + FFP (about 10 units each)
106
Tx coaggulopathy + hypothermia or acidosis
laparotomy must be terminated; packing bleeding surfaces and temporary closure; must wait
107
Abdominal Compartment Syndrome (Occult Syndrome)
when lots of fluid/blood given during prolonged sx; tissues swollen so cannot close abd wound w/o tension
108
Tx Abdominal Compartment Syndrome
temporary cover over abd contents (absorbable mesh or nonabsorbable plastic) to be removed later
109
Pt SECOND day post abd operation w/ abd distention and retention sutures cutting through tissues can cause (2 things).
[ACS] (1) hypoxia secondary to inability to breathe and (2) renal failure from pressure on vena cava
110
Tx up to SECOND day post abd operation w/ ACS
abd surgically opened and temporary cover provided
111
Any pt who is predisposed to consumption coagulopathy, hypothermia or ACS should be surgically tx w/ the following 4 steps before doing rest of resuscitation:
(1) clamp the bleeders
(2) temporarily occlude damaged viscera
(3) clean up contamination
(4) get out of there [can go back at later date]
112
Pelvic hematomas are typically left alone if they are ______
NOT EXPANDING
113
Which injuries must be ruled out in pelvic fracture pt (4)?
rectal, bladder, vagina/urethra (retrograde urethrogram)
114
Best tx pelvic hematoma w/ hypovolemic shock
pelvic fixators + IR for angiographic embolization of BOTH internal iliac arteries; also transfusion if necessary
115
_____ indicates a urologic injury
Blood in the urine
116
Tx Penetrating urologic injuries
surgically exploration + repair
117
If blunt injury affects the kidney, usually underlying cause is ______. If blunt injury affects the urethra or bladder, the underlying cause is ______.
lower rib fracture; pelvic fracture
118
Urethral injury is MC in [M/F]. Dx?
Men; retrograde urethrogram
119
What is 100% contraindicated in urethral injury?
Foley insertion
120
Clinical sxs of urethral injury
blood at meatus, scrotal hematoma (posterior), obstructive micturition, "high-riding" prostate
121
Dx bladder injury; what are you looking for?
retrograde cystogram w/ POSTVOID films; looking for extraperitoneal leaks at base of bladder [may be obstructed when bladder is full]
122
Tx bladder injury causing intraperitoneal leaks
sx repair + suprapubic cystostomy
123
Dx renal injuries; MC Tx
CT scan; medical tx only [no surgery]
124
Damage to the renal _____ can cause the development of a kidney AV-fistula, leading to congestive heart failure
pedicle
125
Fracture of the penis can consist of fracture of ____ or _____.
corpora cavernosa; tunica albuginea
126
Sxs of fracture of penis
large penile shaft hematoma w/ nml glans
127
Tx fracture of penis; why is this emergent?
emergency surgery; if not, AV shunts will develop, causing impotence
128
What is the main concern regarding penetrating injuries of extremities?
whether vascular injury has occurred or not
129
Tx penetrating injury of leg w/ NO vascular injury
tetanus prophylaxis + cleaning wound
130
Tx asxs pt w/ penetrating injury of leg NEAR major vessels
tetanus prophylaxis + cleaning wound + CT angio/US
131
In which sequence do you treat an injury w/ damaged arteries, nerves and bone?
(1) stabilize BONE
(2) delicate VASCULAR repair (otherwise would be damaged by bone movement)
(3) NERVES
132
Tx vascular injury of LE/UE causing hematoma
fasciotomy (prevent compartment syndrome)
133
______ can produce a large cone of tissue destruction requiring debridements/amputations
High-velocity GSWs [military, big-game hunting]
134
4 major concerns in crushing injury of LE/UE
(1) hyperkalemia
(2) myoglobinemia/myoglobinuria
(3) renal failure
(4) potential compartment syndrome
135
Tx of hyperkalemia and myoglobinemia-myoglobinuria-renal failure from crushing injury
fluids, osmotic diuretics (mannitol), alkalinization of urine
136
Tx for all Chemical Burns
massive irrigation
137
[acidic/alkaline] burns are worse than [acidic/alkaline] burns
ALKALINE (Drano, liquid plumber); ACIDIC (battery acid)
138
______ burns are always deeper and worse than they appear.
High-voltage electrical
139
4 main concerns of high-voltage electrical burns
(1) myoglobinemia-myoglobinuria-renal failure
(2) orthopedic injuries secondary to massive muscle contraction
(3) late development of cataracts
(4) late development of demyelinization syndromes
140
Most common orthopedic injuries secondary to massive muscle contraction
posterior shoulder dislocation; compression fractures of vertebral bodies
141
Dx of respiratory (inhalation) burns
clinical signs of soot around mouth/throat; fiberoptic bronchoscopy (see whether respirator needed); arterial blood gases & carboxyhemoglobin levels
142
Tx of respiratory (inhalation) burns
intubation if obstructed airway; 100% O2 (for inc carboxyhemoglobin); +/- respirator
143
______ burns can cause cutoff of blood supply as edema accumulates underneath unyielding eschar.
Circumferential
144
Tx circumferential burns
escharotomies (at bedside w/ no anesthesia)
145
Tx severely burned pt
fluid replacement
146
In severe burns, ____ moves from circulation and is trapped in the burn site.
plasma
147
Explain the "Rule of 9s" in aldult burn patients
9% body surface area each to head, each UE, 2x for each LE, 4x for trunk
148
How do you calculate amt (mL) RL infused in first 8hrs in severely burned patients using the "Rule of 9s"?
("Rule of 9s" burned body surface area) x (wt in kg) x (about 5) = mL RL
149
In severely burned pts, no fluids are needed on the ____ day because plasma trapped in burn edema is reabsorbed, causing a large diuresis.
third
150
What are the 2 goals for fluid tx in severely burned pts?
approximately hourly UOP 1-2mL/kg/h and CVP ≥ 15mmHg
151
A predetermined rate of 1000mL/h RL (w/o sugar) is given to adults whose burns exceed greater than _____ of body surface, then adjusted to meet UOP demands.
20%
152
Sugar is avoided in RL because it could cause ____, invalidating the hourly UOP.
osmotic diuresis (from glycouria)
153
Explain the "Rule of 9s" in baby burn pts. Why is this different?
9% body surface area-- 2x for head, 3x for 2 legs, one per arm, 4x for trunk; babies have big heads!
154
Explain appearance of third-degree burns in (A) babies and (B) adults
(A) deep bright red (B) leathery, dry, gray
155
Because babies need more fluid than adults, the appropriate initial rate of fluid admin is _______ if the burn exceeds _____ of body surface area.
20mL/kg/hr; 20%
156
Topical agents for burn patients include ___ for more superficial burns and ___ for deeper ones.
silver sulfadiazine; mafenide acetate (can hurt and produce acidosis)
157
Tx burns near eyes
triple abx ointment
158
High-cal/high-nitrogen diets [NG or TPN] for a couple of days. After _____ wounds that haven't regenerated are grafted. Rehab starts on ____ day.
2-3 weeks; FIRST
159
Normally, early excision and grafting of wound of extreme burn pt has a burn that is [2 characteristics]
(1)
160
Tx for ALL BITES
tetanus prophylaxis + wound care
161
When might it be good to start rabies immunization for a dog bite?
When it bites you near your face (if you are at all unsure it has rabies)
162
When is rabies prophylaxis mandatory? What does it consist of?
unprovoked dog bite/wild animal bite where animal cannot be killed and brain examined; immunoglobulin + vaccine
163
How do you know a snakebite was poisonous?
local pain, swelling and discoloration w/in 30 min of bite
164
Labs needed if someone got snakebite
blood typing, crossmatch, coagulation studies, LFT, RFT
165
Tx if rattlesnake [crolatid] bites you
CROFAB
166
Antivenin dosage related to size of ______. If no antivenin, first aid is to _____.
envenomation; splint extremity during transport
167
_____ snakes have a neurotoxin that needs specific antivenin stat!
Coral ["red on yellow, kill a fellow"]
168
Bee stings can kill via ______. Tx w/ ____.
anaphylaxis and hypotension caused by vasomotor shock (pink and warm); epinephrine
169
Sxs from Black Widow Spider bite
nausea, emesis, severe generalized muscle cramps
170
Tx Black Widow Spider bite
IV calcium gluconate +/- muscle relaxants
171
Sxs Brown Recluse Spider bite
next day--skin ulcer w/ necrotic center and surrounding erythema
172
Tx Brown Recluse Spider bite
Dapsone +/- surgical excision if >1wk (also skin grafting)
173
______ bites are the dirtiest bites and require extensive irrigation, debridement and specialized orthopedic care.
Human [sharp cut over knuckles after punch in mouth]
