Flashcards in Exam 4 Deck (99):
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
If a patient is obtunded what can be assumed?
Assume a cervical spine injury until proven otherwise
Preferred study for Cervical Spine injury
Should not delay Urgent operative procedures
The following warrant immediate intervention
Tension pneumothorax needle D
36 French Chest tube for hemo-pneuo thorax
Occlusive dressing to sucking chest wound
Asymmetric or absent breath sounds in the intubated patient, what is the treatment
Partially withdraw ET tube from R main stem entubation
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
Class I Blood Loss
up to 750 ml
BP = Normal Pulse = Normal or increased
Class II Blood loss
BP= Normal Pulse = Decreased
Class III Blood Loss
Pulse = 120-140
BP = Decreased Pulse Pressure = Decreased
Class IV Blood Loss
> 2,000 ml
BP= Decreased Pulse Pressure= Decreased
Can Mask Early hemodynamic indicators of shock
The following transfusion treatment showed decreased mortality when using
FFP: PRBCs 1:1 10 units
A patient with a GCS < 15 and appropriate MOI of head trauma has what?
Significant Head injury until proven otherwise
Monitor serum glucose for euglycemia and avoid _______ in head injury patients
Prophylactic hyperventilation/ Hyperventilation
of 25mmHg or less
Abdominal Tenderness or distention on palpation with hypotension indicates what?
Exploratory Laparotomy (Immediate OR transport)
Strongest recommendation for ED thoracotomy is?
Patients w/ penetrating trauma with witnessed signs of life during transport & at least Electrical activity upon arrival
Secondary survey consists of what?
Head to toe exam for injuries
(Do not start until basic functions are corrected)
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)
Most frequently missed conditions in secondary survey?
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
FAST examination is an effective screening tool for ?
Intraperitoneal bleeding, Pericardial tamponade, and pneumo/Hemothorax
Obtunded patients get what imaging?
Entire spine if MOI warrants it
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)
When transferring a patient what must be completed?
A rapid but thorough primary and secondary survey prior to transferring.
Which Injuries may not be readily apparent on initial CT?
What is required?
Pancreas, Bowel and head trauma
Repeated imaging and neurologic & LOC assessments
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
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
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
GCS classified as Severe
GCS score 3-8
GCS classified as Moderate
GCS score of 9-13
GCS classified as Mild
GCS score of 14-15
Prior to intubating a patient what needs to be recorded?
Best score of GCS
Single fixed dilated pupil indicates what?
Intracranial hematoma- Uncal Herniation
Bilateral Fixed dilated pupils indicates what?
Increased ICP with poor brain perfusion, Bilat uncal herniation, Atropine drug effect or severe hypoxia
Bilateral pinpoint pupils indicates what?
Opiate exposure or Central Pontine lesion
Presentation of upper extremity flexion and lower extremity extension is what posturing?
Where is the intracranial injury?
Above the level of the midbrain
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?
More Caudal to midbrain injury
Most important prehospital interventions for head trauma are?
Airway and BP management
Optimal Airway and BP management in head trauma
Capnometry PCO2@ 35-45
S BP> 90mmHg and Hypoxemia > 60
(<90mmHg & PAO2 < 60 = mortality 150%)
May decrease Baseline ICP and prevent transient rises in ICP elevation
Sedation and Analgesia
Appropriate early management of which conditions will have better outcomes ?
Hypotension, hypoxemia, Hypercarbia, and Hyperglycemia
Intubation agent may cause a lower ICP and may be neuro protective
Etomidate 0.3mg/kg IV
Intubation agent that has a rapid onset and anti-seizure properties. May cause hypotension if not adequately resuscitated
Propofol 1-3 mg/kg
Intubation agent that is short acting that may cause extensive muscle injury. Avoid in Burns
Succinylcholine 1-1.5 mg/kg
Intubation agent that is short acting and is safe in hyperkalemia
rocuronium (0.6-1.0 mg/kg
Maintain Sys BP and MAP at
> 90mmHg and MAP= 80mm Hg
hyperglycemia is associated with worse outcome. what is an adequate glycemic control?
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.)
If GCS < or = 8, this treatment can be used to monitor ICP and serve as extraventricular drain
What is the ICP monitoring criteria
> 40 y/o
Uni/Bilat motor posturing
Sys Bp < 90mmHg
An ICP of ______ mmHg increases morbidity and mortality. Monitor will be placed by neurosurgery
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
Categorized linear fracture with an overlying laceration
Open or depressed skull fractures should be treated with
Vancomycin 1 Gm and Ceftriaxone 2 G
Decreased hearing or deafness and 7th nerve palsy.
Fluid collected that is sent for analysis. Found only in CSF
Basilar Skull Fx Beta Transferrin
Results from the disruptionof parenchyma and present with blood in the CSF
Present with Photophobia, headache, meningeal signs
MC CT abnormality
have a three fold higher mortality and can be missed on early CT scans
Repeat CT after 6-8 hrs
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
The high-pressure arterial bleeding can lead to herniation within hours
Sudden acceleration-Deceleration of brain.
subsequent tearing Bridging Dural veins.
Tend to collect more slowly, than epidural because of venous nature. Crescent shaped lesion
Are more susceptible in elderly and alcoholics: < 2 y/o
W/I 14 days
After 2 weeks
Caused by sudden deceleration shearing forces.
Disruption of axonal fibers in the white matter and brainstem
MVC and Shaken Baby Syndrome
Diffuse axonal Injury
Most frequently damaged abdominal organ
Most frequently damaged abdominal organ from sports accidents
Most common mechanism for blunt abdominal trauma
Considered a penetrated abdominal cavity injury until proven otherwise
Lower chest, pelvis, flank, or back
Mimic intra-abdominal injury
Rectus abdominis hematomas
hemoperitoneum is quickly detected with a single view up to 90% of patients at?
The fast cannot evaluate the______ the ______ imaging is more ideal for this area
Non invasive gold standard imaging study
CT with contrast
Gold standard therapy for significant intra-abdominal injury
60 minutes of resuscitative endovascular balloon occlusion is tolerated
REBOA endovascular Balloon of Aorta
Anatomically unique designed for rotation of spine, held by the transverse ligament
C1 Atlas & C2 Odontoid
Most commonly injured region of the spine
Cervical C5-C7 and C2 level
(C1-C7) most flexible--> most injured
2nd MC injured region of spine
Thoracolumbar transition zone
Rigid segment and enhanced reinforcement with rib articulation. Spinal canal also narrower--> complete transection
Can produce bowel or bladder dysfunction
Sacral Fractures that involve central canal
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)
Defined as the absence of sensory and motor function below the level of injury
Complete Neurologic Lesion
Defined as sensory and motor or both functions are partially present below the neurologic level of injury
Incomplete Neurologic Lesion
Patients in spinal shock lose all reflex activities below the area of injury, lesions cannot be deemed truly complete until
Spinal shock has resolved
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 _________
Loss of pain and temperature sensory on the contralateral half of body
Cross the midline immediately and ascend to thalamus via the________
Vibration, position loss in ipsilateral half
light touch not lost unless damage to both________&______ and cross at the medulla
Dorsal columns and spinothalamic tracts
Damage to_______Can cause immediate respiratory arrest
Any patient with damage to______ or above should have their airway secured by ET tube
_______ denotes an incomplete spinal cord level injury even if patient has complete motor sensory motor loss
Cremasteric reflex: stoking the medial thigh with a blunt instrument causes what?
The scrotum to rise= spinal cord integrity exists
Loss of motor function ad pain temperature sensation do distal lesion.
Only vibration, position and tactile sensation preserved
Decreased strength, decreased pain and temperature sensation: more in upper than lower extremities
Ipsilateral loss of motor function, proprioception, and vibratory sensation
loss of pain and contralateral and temperature sensation
Brown sequard syndrome (Penetrating MC)
Not a true spinal cord syndrome:
Bowel and Bladder dysfunction, saddle anesthesia, variable loss of lower extremity reflexes
present with warm skin, peripherally vasodilated and hypotensive bradycardia.
(HyTN Presumed to be other than Neuro R/O)
Standard Radiographic ID of cervical injury includes
Lateral (90% ID)
(Swimmers view for C spine junction)
Persistent neck pain/ midline tenderness, extremity paresthesia, or neurologic findings despite normal CT or radiographs indicate what?
SOC for Ligament injuries
Reliable patients with persistent CT and normal CT= DC with firm foam collar and F/U in 3-5 days
The two type of fractures amenable to outpatient therapy
Wedge or Anterior compression fractures
<40% loss of height
>50% loss of height= unstable
Fractures may result in retropulsed fragments that can impinge the spinal canal
SOmetimes misdiagnosed as wedge compression fractures
occurs via flexion distraction mechanism- involves significant distraction of the middle and posterior ligamentous structure