1st peak for trauma deaths occur during what time period? Deaths due to lacerations of heart, aorta, brain, brainstem, spinal cord. Cannot really save these patients; death is too quick.
The 2nd peak in trauma deaths occurs in 30 min to 4 hrs. What classification of injury is the first and second most common cause? These are the patients you can save with rapid assessment (golden hour).
Head injury (#1) and hemorrhage (#2)
The 3rd peak for trauma deaths occurs in days to weeks. Deaths due to what two main reasons?
multisystem organ failure and sepsis
Blunt trauma accounts for 80% of all trauma; what is the most common injured organ?
liver (some texts say spleen)
What is the physics formula for kinetic entery?
What is the LD50 of height of fall.
What is the most commonly injured organ in penetrating injury?
small bowel (some texts say liver)
What is the most common cause of death in the 1st hour of trauma?
Blood pressure is usually OK until ___% of total blood volume is lost.
What is the most common cause of death after reaching the ER alive?
What is the most common cause of death long term in trauma patients?
What is the most common cause of upper airway obstruction? and what is the tx?
tongue, perform jaw thrust
What injuries are associated with seat belts?
small bowel perforations, lumbar spine fractures, sternal fractures
What is the best site for cutdown for access?
General indications for DPL or FAST?
hypotensive pt with blunt trauma
What is considered a positive DPL?
>10cc of blood, >100,000 RBCs/cc, food particles, bile, bacteria, >500 WBC/cc
What do you do if DPL is positive?
What location should DPL performed if pelvic fracture is present?
What 2 things can DPL miss?
retroperitoneal bleed, contained hematoma
What four places are checked for blood in FAST?
perihepatic fossa, perisplenic fossa, pelvis, pericardium
FAST can be obstructed by obesity and what amount of free fluid may not be detected?
Less than 50-80
What 2 things does FAST scan miss?
retroperitoneal bleeding, hollow viscus injury
Need a CT scan following blunt trauma in pts with ___, need for general anesthesia, closed head injury, intoxicants on board, paraplegia, distracting injury, hematuria.
Pt requiring DPL that turned out to be negative will need what?
abdominal CT scan
Name 2 injuries that CT scan misses.
hollow viscous injury, diaphragm injury
Peritonitis, evisceration, positive DPL, clinical deterioration, uncontrolled hemorrhage, free air, diaphragm injury, intraperitoneal bladder injury, positive contrast studies, specific renal, pancreas, and biliary tract injuries.
Possible penetrating abdominal injuries (knife or low-velocity injuries) - When would you just do local exploration and observation? What is the purpose of diagnostic laparoscopy?
fascia not violated; to see if fascia is violated
Name three situations that can cause abdominal compartment syndrome.
massive fluid resuscitation, trauma or abdominal surgery
What is the bladder pressure seen with abdominal compartment syndrome?
What is the final common pathway for decreased cardiac output in abdominal compartment syndrome?
How does abdominal compartment syndrome lead to decreased urine output?
renal vein compression
What is the treatment for abdominal compartment syndrome?
Pneumatic antishock garment is controversial; use in pts with SBP
ER thoracotomy: In what type of trauma is it used only if pressure/pulse lost ER? What type if lost on way to ER or in ER?
If ER thoracotomy is performed for cardiac injury, the pericardium is opened anterior to what structure?
In ER thoracotomy, for what type of injury is the aorta cross clamped? and what structure must you watch out for?
After cross clamping the aorta in ER thoractomy, at what BP level is further treatment futile?
if BP fails to reach 70 mmHg
When to catecholamines peak after injury?
What is the time it takes for type specific blood? type and screen? type and crossmatch?
Less than 10 minutes 20-30 min 45-60 min
Can you give nonscreened, noncrossmatched blood (Type specific)?
can be administered relatively safely but there may be effects from antibodies to minor antigens in the donated blood
Pt with head injury and GCS less than or equal to 14 what next? and 10? and 8?
head CT, intubation, ICP monitor
What is the most common artery injured with epidural hematoma?
middle meningeal artery
Head CT shows lenticular (lens-shaped) deformity?
Operation of epidural hematoma indicated for significant neurologic degeneration or significan mass effect (shift > ___)
Subdural hematoma is most commonly from tearing of what?
venous plexus (bridging veins) between dura and arachnoid
What is the head CT finding with subdural hematoma?
Chronic subdural hematoma is usually in elderly after minor fall. Need drainage if > ___ or causing significant symptoms.
In which 2 lobes are intracerebral hematoma usually found?
Traumatic intraventricular hemorrhage needs what procedure if causing hydrocephalus?
Diffuse axonal injury shows up better on MRI or CT?
Tx for diffuse axonal injury is supportive; may need what if ICP elevated?
Mean arterial pressure minus intracranial pressure = ? and what is the desired value
Cerebral perfusion pressure >60
What are the following signs of on brain imaging?: decreased ventricular size, loss of sulci, loss of cisterns
ICP monitors are indicated for (2)
1) Suspected increase in ICP 2) GCS 8
Normal ICP is ___; >___ needs treatment
Name three interventions that are tried first with elevated ICP
1) Sedation and paralysis 2) Raise head of bed 3) Relative hyperventilation
When hyperventilating a pt due to increased ICP. What is a target CO2 range? and what is the effect and what can happen if overhyperventilated?
30-35 cerebral vasoconstriction cerebral ischemia from too much vasoconstriction
What can be done with fluids to manage elevated ICP?
give hypertonic saline at times to draw fluid out of brain. (keep Na 140-150, serum Osm 295-310)
What medication can be given to pts with elevated ICP and what is the MOA?
mannitol, draws fluid from the brain
What are three procedural options for elevated ICP if other measures fail?
ventriculostomy w/CSF drainage; craniotomy decompression; Burr hole
What medication is given prophylactically to prevent seizures to most pts with traumatic brain injury?
Peak ICP levels occur after how long after head injury?
In traumatic brain injury, dilated pupil indicates temporal pressure on same side. Which CN is compressed?
Racoon eyes are a sign of fracture of what part of the basal skull?
Battle's sign indicates fracture of what part of the basal skull? What nerve can be injured?
middle fossa, facial
What is difference in tx for acute and delayed Battle's sign?
if acute need exploration, if delayed, likely secondary to edema and exploration not needed
Temporal skull fractures can injure what 2 cranial nerves?
CN VII and VIII
What is the most common site of facial nerve injury with temporal skull fractures?
Most skull fractures do not require surgical treatment. Operate if (3)
1) Significantly depressed by 8-10mm 2) Contaminated 3) CSF leak not responding to conservative therapy
What is a Jefferson fracture and what is the tx?
C-1 burst caused by axial loading. Tx: rigid collar
C-2 hangman's fracture is caused by distraction and extension. What is the tx?
traction and halo
What are the 3 types of C-2 odontoid fractures and what is their tx?
Type I - above base, stable Type II - at base, unstable (will need fusion or halo) Type III - extends into vertebral body (will need fusion or halo)
Cervical facet fractures or dislocations can cause injury to the___; usually associated with hyperextension and rotation and with disruption of ___ .
What are the three columns of the thoracolumbar spine?
1) anterior - anterior longitudinal ligament and anterior 1/2 of the vertebral body 2) middle - posterior 1/2 of the vertebral body and posterior longitudinal ligament 3) posterior - facet joints, lamina, spinous processess, interspinous ligament
What is the significance of more than one thoracolumbar spine column disruption.
What is the difference between compression (wedge) fractures and burst fractures of the thoracolumbar spine?
Compression fractures usually involve the anterior column only and are considered stable. Burst fractures are considered unstable and require spinal fusion.
Upright fall. Look for fractures of what 3 areas?
calcaneus, lumbar, wrist/forearm
Neurologic deficits without bony injury. What injury should you consider and how to dx?
Check for ligamentous injury with MRI
The following are indications for what? fracture or dislocation not reducible with distraction; acute anterior spinal syndrome; open fractures; soft tissue or bony compression of the cord; progressive neurological dysfunction
emergent surgical spine decompression
Facial nerve injuries need repair. Fracture of what bone is most common cause of facial nerve injury?
Try to preserve skin and not trime edges with lacerations in what part of the body
Maxillary fracture straight across is called what?
Le Fort type I
Maxillary fracture lateral to nasal bone underneath eyes, diagonal. ( / \ ) What is that called?
Le Fort type II
Fracture of lateral orbital walls ( - - ) is called what?
Le Fort type III
Nasoethmoidal orbital fractures, what percentage have a CSF leak? Try conservative therapy for how long? What can you try to decrease CSF pressure to help it close? May need surgical closure of dura to deal with leak.
70%, 2 weeks, epidural catheter
What is the difference in tx for anterior vs posterior nose bleeds?
anterior is just packing; posterior is harder to dea with; try ballon tamponade 1st; may need angioembolization of internal maxillary artery or ethmoidal artery
Orbital blowout fractures - pts with impaired upward gaze or diplopia with upward vision need what?
repair with restoration of orbital floor with bone fragments or bone graft
What is the number one indicator of mandibular injury?
malocclusion (misaligned teeth)
What are two imaging modalities to assess mandibular injury?
panorex film and fine-cut facial CT scan with reconstruction
Most mandibular injuries are repaired with (2)
1) IMF (intermaxillary fixation): metal arch bars to upper and lower dental arches, 6-8 weeks 2) ORIF
What is the tx for tripod fracture (zygomatic bone)?
ORIF for cosmesis
Pts with maxillofacial fractures are at high risk for what other injury?
Asymptomatic blunt trauma to the neck. What is the best next step?
neck CT scan
What are the delineations between the zones of the neck?
Zone I is clavicle to cricoid cartilage Zone II is cricoid to angle of mandible Zone III is angle of mandible to base of the skull
Asymptomatic penetrating trauma to Zone I of the neck. What is the best next step?
Zone I needs angiography, bronchoscopy, rigid esophagoscopy, barium swallow, pericardial window may be indicated. May need sternotomy to reach these lesions
Asymptomatic penetrating trauma to Zone II of the neck. What is the best next step?
Exploration in OR.
Asymptomatic penetrating trauma to Zone III of the neck. What is the best next step?
Need angio, laryngoscopy. May need jaw subluxation/digastric and sternocleidomastoid muscle release/mastoid sinus resection to reach vascular injuries in this location.
What is the important implication of neck Zone I injuries?
greater potential for intrathoracic great vessel injury
What is the tx for symptomatic blunt or penetrating trauma to the neck? (shock, bleeding, expanding hematoma, losing or lost airway, subcutaneous air, stridor, dysphagia, hemoptysis, neurologic deficit)
Injury to what structure is the hardest to find in neck trauma?
What is the best combined modality for diagnosing esophageal injury (find essentially 95% of injuries when using both methods)
rigid esophagoscopy and esophagogram
What is the tx for a contained injury to the esophagus?
Noncontained esophageal injury - if small, less than 24 hours, without significant contamination, and patient is stable
primary closure, otherwise make spit fistula and drain leak with chest tube
What is the surgical approach to repairing esophageal injury in the neck? Upper 2/3 of thoracic esophagus? Lower 1/3 of thoracic esophagus?
left side, right thoracotomy, left thoracotomy
Laryngeal fracture and tracheal injuries are airway emergencies. Secure airway in ER. Tx: primary repair, can use ___ for airway support; ___ necessary for most to allow edema to subside and to check for stricture.
strap muscle, tracheostomy
Recurrent laryngeal nerve injury - can try to repair or reimplant in ____ (hoarseness)
Management for shotgun injury to neck
1) Angiogram 2) Neck CT (esophagus/tracheal evaluation)
Can vertebral artery bleeds be ligated or embolized without sequela?
What are the relative indications for thoracotomy in the OR based on chest tube output quantity? (there are 3 of them, bleeding with instability is another indication)
>1,500 cc after initial insertion >250 cc/h for 3 hours 2,500 cc/24 h
Chest trauma and hemothorax - all blood needs to be drained in what timeframe and why?
Less than 48 hrs, to prevent fibrothorax, pulmonary entrapment, infected hemothorax
Unresolved hemothorax after 2 well placed chest tubes. What next?
thoracoscopic or open drainage
Sucking chest wound needs to be at least 2/3 the diameter of the trachea to be significant. What is the tx and explain the concern with just plugging the hole?
Cover wound with dressing that has tape on three sides. This prevents development of tension pneumothorax while allowing lung to expand with inspiration
Patient has worse oxygenation after chest tube placement. What should you think of?
tracheobronchial injury (one of the very few indications in which clamping the chest tube may be indicated)
Bronchial injuries are more common on which side?
How should you intubate a pt with bronchial injury?
may need to mainstem intubate pt on unaffected side
How do you diagnose tracheobronchial injury?
Blunt trauma injuries to the diaphragm are more common on which side?
How can the diagnosis of diaphragm injury be made?
CXR shows air-fluid level in chest from stomach herniation through hole
What are the following signs of? widened mediastinum, 1st rib fractures, apical capping, loss of aortopulmonary window, loss of aortic contour, left hemothorax, trachea deviation to right
The tear in aortic transection is usually at the ____ (just distal to subclavian takeoff). Other areas include near the aortic valve and where the aorta traverses the diaphragm.
What percentage of patients with an aortic tear have a normal CXR?
Indications for aortic evaluation include head on mva > ___ mph or fall >___ ft
Name the two diagnostic modalities for aortic transection.
aortogram or CT angiogram of chest
Name two medications used to control BP in pts with aortic transection.
Nipride and esmolol
When repairing aortic transection. Which do you treat first other life-threatening injury (ie positive DPL) or the transection?
treat other injury first
What are the 2 most common causes of death after myocardial contusion?
v-tach and v-fib
What is the timeframe for the highest risk of death with myocardial contusion?
first 24 hours
What is the most common arrhythmia overall in patients with myocardial contusion?
What is the biggest pulmonary impairment in pts with flail chest?
the underlying pulmonary contusion
Will aspiration produce CXR findings immediately?
What defines the "box" in penetrating chest injury?
clavicles, xiphoid process, nipples
Name three traumatic causes of cardiogenic shock?
cardiac tamponade, cardiac contusion, tension pneumothorax
What exactly causes the cardiac compromise in tension pneumothorax?
decreased venous return
Pts with sternal fractures are at high risk for ___. Pts with 1st and 2nd rib fractures are at high risk for ___
cardiac contusion, aortic transection
Anterior vs Posterior pelvic fractures. Which is more likely to have venous vs arterial bleeding
Anterior - venous. Posterior - arterial
Which portion of the duodenum is most commonly injured in trauma?
2nd (descending portion near ampulla of Vater), can also get tears near ligament of treitz
Duodenal trauma - segmental resection with primary end-to-end closure possible with all segments except which one?
What is the major source of morbidity with duodenal trauma?
Paraduodenal hematomas usually occur with trauma to which portion of the duodenum and why?
usually third portion because it is overlying the spine in blunt injury
What is the most common organ injured with penetrating injury?
Abdominal CT scan showing intra-abdominal fluid not associated with a solid organ injury, bowel wall thickening, or a mesenteric hematoma is suggestive of what injury?
occult small bowel injury
Initial tx for occult small bowel injury?
close observation and possibly repeat abdominal CT after 8-12 hours to make sure finding is not getting worse.
Pt with non occlusive small bowel injury from trauma, what do you need to make sure of before they are discharged?
can tolerate diet
How do you repair small lacerations to small bowel? and large (>50% of circumference or results in lumen diameter 1/3 normal)?
transversely to avoid stricture; perform resection and reanastomosis
When do you open a mesenteric hematoma?
if expanding or large (>2 cm)
What is the difference in repair of trauma between right/transverse colon vs left colon?
right and transverse can perform primary reanastomosis; left colon it is safest to preform colostomy and Hartman's pouch or mucus fistula
What is approach to repairing low rectal trauma (less than 5 cm)
Does the pringle maneuver stop bleeding from hepatic veins?
no, clamping of portal triad only
If possible, clamp time intervals in the pringle maneuver should be limited to what?
Do portal triad hematomas need to be explored?
What type of graft can be placed in liver laceration to help with bleeding and prevent bile leaks?
In blunt liver injury or spleen trauma, what are the indications for OR?
1) Active blush on abdominal CT 2) Pseudoaneurysm
How long will pt with blunt liver injury or splenic trauma need bed rest with conservative mgmt?
How long does it take for splenic trauma to fully heal?
What age range is postsplenectomy sepsis most common? How long after splenectomy is the greatest risk of sepsis?
1st 5 years of life. Within 2 years of splenectomy.
Splenic salvage is associated with increased ___.
Is the threshold for splenectomy in children higher or lower?
much higher; hardly any children undergo splenectomy
Are immunizations after trauma splenectomy necessary?
What is more common blunt or penetrating pancreatic trauma?
What is necessary in a distal pancreatic duct injury? How much of the gland can you take?
distal pancreatectomy, 80%
What test is useful in evaluating a missed pancreatic injury?
When there is vascular and orthopedic trauma, which is repaired first?
Major signs of vascular trauma are pulse deficit, expanding or pulsatile hematoma, distal ischemia, bruit, thrill. Moderate/soft signs are deficit of anatomically related nerve, large stable/nonpulsatile hematoma. What is the difference in tx between the two?
Major signs go to OR for exploration (some say angio 1st) Moderate/soft signs go to angio
Name 6 veins that need repair if injured.
vena cava, femoral, popliteal, brachiocephalic, subclavian, and axillary
Limb ischemia > 4 hours, what tx should you consider and why?
fasciotomy to prevent compartment syndrome
Consider compartment syndrome with pressures > __ mmHg
What are the "Ps" of compartment syndrome?
pain -> parathesias -> anathesia -> paralysis -> poikilothermia -> pulselessness (late finding)
Compartment syndrome most commonly occurs with what type of injuries?
supracondylar humeral fractures, tibial fractures, crush injuries or other injuries that result in a disruption and then restoration of blood flow
How is bleeding of IVC best controlled?
with proximal and distal pressure, not clamps -> can tear it
How much blood loss is possible from a femur fracture?
Femoral neck fractures are at high risk for ___
Long bone fracture or dislocations with loss of pulse (or weak pulse). What next? And if pulse does not return?
immediate reduction and reassessment of pulse Go to OR for vascular bypass or repair (some say angio)
Name the concomitant nerve or artery injury associated with anterior shoulder dislocation. and posterior?
axillary nerve axillary artery
Name the concomitant nerve or artery injury associated with proximal humerus fracture.
Name the concomitant nerve or artery injury associated with midshaft humerus (or spiral humerus fracture).
Name the concomitant nerve or artery injury associated with distal (supracondylar) humerus fracture.
Name the concomitant nerve or artery injury associated with elbow dislocation.
Name the concomitant nerve or artery injury associated with distal radius fracture.
Name the concomitant nerve or artery injury associated with anterior hip dislocation? and posterior?
femoral artery; sciatic nerve
Name the concomitant nerve or artery injury associated with distal (supracondylar) femur fracture.
Name the concomitant nerve or artery injury associated with posterior knee dislocation.
Name the concomitant nerve or artery injury associated with fibular neck fracture.
common peroneal nerve
All knee dislocations need to go to ___, unless pulse is absent, in which case some would just go to ___
What is the best indicator of renal trauma? And what is the diagnostic study needed with the finding?
Hematuria, CT scan
With renal trauma what is the study that is useful if going to the OR without abdominal CT, to identify presence of functional contralateral kidney, which could affect intraoperative decision making?
Why is it possible to ligate the left renal vein near the IVC while this cannot be done on the right?
Left has adrenal and gonadal vein collaterals
From anterior to posterior, what are the renal hilum structures?
vein, artery pelvis
What percentage of renal trauma is treated nonoperatively?
Do all urine extravasation injuries require operation?
Indications for operation in renal trauma include
1) acute ongoing hemorrhage with instability 2) after acute phase - major collecting system disruption, unresolved urine extravasation, hematuria
In operation for renal trauma, with exploration, what do you get control of first?
vascular renal hilum
How do you check for a leak at the end of an operation for renal trauma?
methylene blue dye
What is the best indicator of bladder trauma?
>95% of bladder trauma is associated with what other injury?
How is the diagnosis of bladder trauma made?
In what type of bladder rupture does cystogram show starbursts?
extraperitoneal bladder rupture
What is the tx for extraperitoneal bladder rupture?
Foley 7-14 days
What does the cystogram show in intraperitoneal bladder rupture?
leak (as opposed to starbursts seen with intraperitoneal)
What type of bladder rupture is more likely in kids?
What is the tx of intraperitoneal bladder rupture?
operation and repair of defect, followed by foley drainage
Hematuria is unreliable indicator of what type of trauma?
ureteral (best for renal and bladder)
What are the two best tests for ureteral trauma?
IVP and retrograde urethrogram (RUG)
What direction does the blood supply come from for the ureter?
medially in the upper 2/3, laterally in the lower 1/3
Hematuria or blood at meatus best sign; free-floating prostate gland; usually associated with pelvic fractures. What is the injury?
You suspect urethral injury. Do you insert a foley? What is the best test?
What are the possible problems with early urethral injury repair as opposed to the recommended 2-3 months?
High stricture and impotence rate if repaired early
Testicular trauma - order ___ to see if ___ is violated then repair if necessary.
ultrasound, tunica albuginea
___ is not a good indicator of blood loss in children - last thing to go.
What are the best indicators of shock in children (4)
HR, RR, mental status and clinical exam
In an infant less than 1 yr what is a normal pulse, SBP and RR?
160, 80, 40
In a preschool age child (1-5 yrs) what is a normal pulse, SBP and RR?
140, 90, 30
In an adolescent (>10 yr) what is a normal pulse, SBP and RR?
120, 100, 20
What fraction of total blood volume loss can occur in a pregnant pt without signs?
In trauma during pregnancy estimate age based on ___
fundal height (20 cm = 20 wk = umbilicus)
What is the most common mechanism of placental abruption?
What is the Kleihauer-Betke test?
tests for fetal blood in maternal circulation, sign of placental abruption
What location is uterine rupture with trauma in pregnancy most likely to occur?
If uterine rupture occurs after delivery of child. What intervention leads to the best outcome?
Aggressive resuscitation even in the face of shock, uterus will eventually clamp down after delivery.