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Flashcards in Exam 4 Deck (99):
1

Nexus National Emergency X-ray utilization Study

No Post. midline C-Spine Tenderness
No evidence of intoxication
Alert Mental Status
No focal Neuro deficits
No painful distracting injuries

2

If a patient is obtunded what can be assumed?

Assume a cervical spine injury until proven otherwise

3

Preferred study for Cervical Spine injury

CT Scan

Should not delay Urgent operative procedures

4

The following warrant immediate intervention

Tension pneumothorax needle D
36 French Chest tube for hemo-pneuo thorax
Occlusive dressing to sucking chest wound

5

Asymmetric or absent breath sounds in the intubated patient, what is the treatment

Partially withdraw ET tube from R main stem entubation

6

If no breath sounds and massive hemothorax or vascular injury suspected, what indicates a thoracotomy or video assisted thoracic surgery?

Chest tube output of > 1,000ml or >200ml/hr of blood

7

Class I Blood Loss

up to 750 ml

15%

<100 BPM

BP = Normal Pulse = Normal or increased

8

Class II Blood loss

750-1,500 ml

15-30%

Pulse 100-120

BP= Normal Pulse = Decreased

9

Class III Blood Loss

1,500-2,000 ml

30-40%

Pulse = 120-140

BP = Decreased Pulse Pressure = Decreased

10

Class IV Blood Loss

> 2,000 ml

> 40%

> 140

BP= Decreased Pulse Pressure= Decreased

11

Can Mask Early hemodynamic indicators of shock

B-Blockers

12

The following transfusion treatment showed decreased mortality when using

FFP: PRBCs 1:1 10 units

13

A patient with a GCS < 15 and appropriate MOI of head trauma has what?

Significant Head injury until proven otherwise

14

Monitor serum glucose for euglycemia and avoid _______ in head injury patients

Prophylactic hyperventilation/ Hyperventilation
of 25mmHg or less

15

Abdominal Tenderness or distention on palpation with hypotension indicates what?

Exploratory Laparotomy (Immediate OR transport)

16

Strongest recommendation for ED thoracotomy is?

Patients w/ penetrating trauma with witnessed signs of life during transport & at least Electrical activity upon arrival

17

Secondary survey consists of what?

Head to toe exam for injuries
(Do not start until basic functions are corrected)

18

If Meatal blood is present or prostate is displaced, suggesting urethral injury, what should be done prior to inserting a foley?

Perform a Retrograde Urethrography

(If vaginal= Bimanual exam)

19

Most frequently missed conditions in secondary survey?

Orthopedic Conditions

20

Patients who are not rapidly transported to the OR CT after initial assessment, what can be performed?

Standard Radiography imaging of C-spine, Chest and pelvis

21

FAST examination is an effective screening tool for ?

Intraperitoneal bleeding, Pericardial tamponade, and pneumo/Hemothorax

22

Obtunded patients get what imaging?

Entire spine if MOI warrants it

23

Routine labs for trauma include

Blood Type and screen, HgB, Urine Dipstick for blood, and ethanol level; Glucose for AMS; >55 =ECG and Cardiac markers

(HCG for child bearing age Females)

24

When transferring a patient what must be completed?

A rapid but thorough primary and secondary survey prior to transferring.

25

Which Injuries may not be readily apparent on initial CT?

What is required?

Pancreas, Bowel and head trauma

Repeated imaging and neurologic & LOC assessments

26

Most common herniation. Displaced Inferiorly through medial edge of tentorium

Leads to compression of CNIII Parasympathetic fibers

An ipsilateral fixed and dilated pupil due to unopposed sympathetic tone.

Results in contralateral motor paralysis

Uncal Herniation

27

Less common, occurs w/ midline lesions.

Lesions of the frontal or occipital lobes, or vertex

Bilateral pin point pupils, Bilateral Babinski's, and increased muscle tone. (Decorticate Posturing)

Central Transtentorial Herniation

28

Pinpoint pupils, flaccid paralysis, and sudden death.

Cerebellum portions herniates through foramen magnum.

Upwards transtentorial herniation leads to conjugate downward gaze w/ absent vertical eye movements

Cerebellotonsilar Herniation

29

GCS classified as Severe

GCS score 3-8

30

GCS classified as Moderate

GCS score of 9-13

31

GCS classified as Mild

GCS score of 14-15

32

Prior to intubating a patient what needs to be recorded?

Best score of GCS

33

Single fixed dilated pupil indicates what?

Intracranial hematoma- Uncal Herniation

34

Bilateral Fixed dilated pupils indicates what?

Increased ICP with poor brain perfusion, Bilat uncal herniation, Atropine drug effect or severe hypoxia

35

Bilateral pinpoint pupils indicates what?

Opiate exposure or Central Pontine lesion

36

Presentation of upper extremity flexion and lower extremity extension is what posturing?

Where is the intracranial injury?

Decorticate


Above the level of the midbrain

37

presentation of arm extension and internal rotation with wrist and finger flexion, and extension of lower extremities is what posturing?

Where is the intracranial injury?

Decerebrate




More Caudal to midbrain injury

38

Most important prehospital interventions for head trauma are?

Airway and BP management

39

Optimal Airway and BP management in head trauma

Capnometry PCO2@ 35-45

S BP> 90mmHg and Hypoxemia > 60
(<90mmHg & PAO2 < 60 = mortality 150%)

40

May decrease Baseline ICP and prevent transient rises in ICP elevation

Sedation and Analgesia

41

Appropriate early management of which conditions will have better outcomes ?

Hypotension, hypoxemia, Hypercarbia, and Hyperglycemia

42

Intubation agent may cause a lower ICP and may be neuro protective

Etomidate 0.3mg/kg IV

43

Intubation agent that has a rapid onset and anti-seizure properties. May cause hypotension if not adequately resuscitated

Propofol 1-3 mg/kg

44

Intubation agent that is short acting that may cause extensive muscle injury. Avoid in Burns

Succinylcholine 1-1.5 mg/kg

45

Intubation agent that is short acting and is safe in hyperkalemia

rocuronium (0.6-1.0 mg/kg

46

Maintain Sys BP and MAP at

> 90mmHg and MAP= 80mm Hg

47

hyperglycemia is associated with worse outcome. what is an adequate glycemic control?

100-180 mg/dL

48

Treatments that may lower ICP and improve cerebral blood flow

Elevate head 30 degrees

Mannitol &/or hypertonic saline 3% NaCl (250 ml over 30 min.)

49

If GCS < or = 8, this treatment can be used to monitor ICP and serve as extraventricular drain

What is the ICP monitoring criteria

Intracranial Bolt


> 40 y/o
Uni/Bilat motor posturing
Sys Bp < 90mmHg

50

An ICP of ______ mmHg increases morbidity and mortality. Monitor will be placed by neurosurgery

>20mmHg

51

Scalp Laceration can be treated with what, if direct pressure is not effective?

Locally infiltrate with Lidocaine and Epinephrine and clamp or ligate bleeding vessels

Galeal Lacerations tx with appropriate examination

52

Categorized linear fracture with an overlying laceration

Open fracture

53

Open or depressed skull fractures should be treated with

Vancomycin 1 Gm and Ceftriaxone 2 G

54

Decreased hearing or deafness and 7th nerve palsy.
Fluid collected that is sent for analysis. Found only in CSF

Basilar Skull Fx Beta Transferrin

55

Results from the disruptionof parenchyma and present with blood in the CSF

Present with Photophobia, headache, meningeal signs

MC CT abnormality

Subarachnoid Hemorrhage

56

have a three fold higher mortality and can be missed on early CT scans

Subarachnoid hemorrhage

Repeat CT after 6-8 hrs

57

Blunt trauma to temporal r temporoparietal area w associated skull fx

Middle meningeal arterial disruption

Significant blunt trauma with loss of consciousness or altered sensorium, followed by lucid period

Biconvex football shaped

Epidural Hematoma

58

The high-pressure arterial bleeding can lead to herniation within hours

Epidural Hematoma

59

Sudden acceleration-Deceleration of brain.

subsequent tearing Bridging Dural veins.

Tend to collect more slowly, than epidural because of venous nature. Crescent shaped lesion

Subdural Hematoma

60

Are more susceptible in elderly and alcoholics: < 2 y/o

Acute ______
Chronic _______

Subdural hematoma

W/I 14 days
After 2 weeks

61

Caused by sudden deceleration shearing forces.

Disruption of axonal fibers in the white matter and brainstem

MVC and Shaken Baby Syndrome

Diffuse axonal Injury

62

Most frequently damaged abdominal organ

Liver

63

Most frequently damaged abdominal organ from sports accidents

Spleen

64

Most common mechanism for blunt abdominal trauma

MVC

65

Considered a penetrated abdominal cavity injury until proven otherwise

Lower chest, pelvis, flank, or back

66

Mimic intra-abdominal injury

Rectus abdominis hematomas

67

hemoperitoneum is quickly detected with a single view up to 90% of patients at?

Morrison's pouch

68

The fast cannot evaluate the______ the ______ imaging is more ideal for this area

retroperitoneum: CT

69

Non invasive gold standard imaging study

CT with contrast

70

Gold standard therapy for significant intra-abdominal injury

Laparotomy

71

60 minutes of resuscitative endovascular balloon occlusion is tolerated

REBOA endovascular Balloon of Aorta

72

Anatomically unique designed for rotation of spine, held by the transverse ligament

C1 Atlas & C2 Odontoid

73

Most commonly injured region of the spine

Cervical C5-C7 and C2 level
(C1-C7) most flexible--> most injured

74

2nd MC injured region of spine

Thoracolumbar transition zone

75

Rigid segment and enhanced reinforcement with rib articulation. Spinal canal also narrower--> complete transection

T1-T10

76

Can produce bowel or bladder dysfunction

Sacral Fractures that involve central canal

77

Spine injury is considered unstable when?

At least 2 columns of a particular region are involved
(assume any spine fx is unstable until spine surgeon confirms it is stable)

78

Defined as the absence of sensory and motor function below the level of injury

Complete Neurologic Lesion

79

Defined as sensory and motor or both functions are partially present below the neurologic level of injury

Incomplete Neurologic Lesion

80

Patients in spinal shock lose all reflex activities below the area of injury, lesions cannot be deemed truly complete until

Spinal shock has resolved

81

Damage results in ipsilateral findings muscle weakness, spasticity, increased tendon reflexes, and babinski's sign

Descending motor pathway originates from the cortex and 90% cross to the opposite side of origin at medulla through the _________

corticospinal tract

82

Loss of pain and temperature sensory on the contralateral half of body

Cross the midline immediately and ascend to thalamus via the________

spinothalamic Tract

83

Vibration, position loss in ipsilateral half

light touch not lost unless damage to both________&______ and cross at the medulla

Dorsal columns and spinothalamic tracts

84

Damage to_______Can cause immediate respiratory arrest

C-3

85

Any patient with damage to______ or above should have their airway secured by ET tube

C5

86

_______ denotes an incomplete spinal cord level injury even if patient has complete motor sensory motor loss

Anogenital Reflex

87

Cremasteric reflex: stoking the medial thigh with a blunt instrument causes what?

The scrotum to rise= spinal cord integrity exists

88

Loss of motor function ad pain temperature sensation do distal lesion.

Only vibration, position and tactile sensation preserved

Anterior Cord

89

Decreased strength, decreased pain and temperature sensation: more in upper than lower extremities

Central cord

90

Ipsilateral loss of motor function, proprioception, and vibratory sensation

loss of pain and contralateral and temperature sensation

Brown sequard syndrome (Penetrating MC)

91

Not a true spinal cord syndrome:

Bowel and Bladder dysfunction, saddle anesthesia, variable loss of lower extremity reflexes

Cauda Equina

92

present with warm skin, peripherally vasodilated and hypotensive bradycardia.

Neurogenic shock
(HyTN Presumed to be other than Neuro R/O)

93

Standard Radiographic ID of cervical injury includes

Lateral (90% ID)

Ant-Posterior

Odontoid

(Swimmers view for C spine junction)

94

Persistent neck pain/ midline tenderness, extremity paresthesia, or neurologic findings despite normal CT or radiographs indicate what?

Ligamentous injury

95

SOC for Ligament injuries

MRI

Reliable patients with persistent CT and normal CT= DC with firm foam collar and F/U in 3-5 days

96

The two type of fractures amenable to outpatient therapy

Wedge or Anterior compression fractures

<40% loss of height
>50% loss of height= unstable

97

Fractures may result in retropulsed fragments that can impinge the spinal canal

Burst fractures

98

SOmetimes misdiagnosed as wedge compression fractures

occurs via flexion distraction mechanism- involves significant distraction of the middle and posterior ligamentous structure

Chance Fracture

99

Coccygeal fractures assessment do not include

Imaging