General Surgery - Trauma Flashcards
(159 cards)
1
Q
What widely accepted protocol does trauma care in the US follow?
A
ATLS precepts of the American College of Surgeons
2
Q
What are the three main elements of the ATLS protocol?
A
- Primary survey/resuscitation
- Secondary survey
- Definitive care
3
Q
How and when should the patient history be obtained?
A
It should be obtained while completing the primary survey; often the rescue squad, witnesses, and family members must be relied upon
4
Q
What are the five steps of the primary survey?
A
ABCDEs:
Airway/C-spine stabilization
Breathing
Circulation
Disability
Exposure and Environment
5
Q
What principles are followed in completing the primary survey?
A
Life-threatening problems discovered during the primary survey are always addressed before proceeding to the next step
6
Q
What are the goals during assessment of the airway?
A
Securing the airway and protecting the spinal cord
7
Q
In addition to the airway, what MUST be considered during the airway step?
A
Spinal immobilization
8
Q
What comprises spinal immobilization?
A
Use a full backboard and rigid cervical collar
9
Q
In an alert patient, what is the quickest test for an adequate airway?
A
Ask a question: If the patient can speak, the airway is intact
10
Q
What is the first maneuver used to establish an airway?
A
Chin lift, jaw thrust, or both; if successful, often an oral or nasal airway can be used to temporarily maintain the airway
11
Q
If these methods are unsuccessful, what is the next maneuver used to establish an airway?
A
Endotracheal intubation
12
Q
If all other methods are unsuccessful, what is the definitive airway?
A
Cricothyroidotomy, aka “surgical airway”: Incise the cricothyroid membrane between the cricoid cartilage inferiorly and the thyroid cartilage superiorly and place an endotracheal or tracheostomy tube into the trachea
13
Q
What must always be kept in mind during difficult attempts to establish an airway?
A
Spinal immobilization and adequate oxygenation; if at all possible, patients must be adequately ventilated with 100% oxygen using a bag and mask before any attempt to establish an airway
14
Q
What are the goals in assessing breathing?
A
Securing oxygenation and ventilation
Treating life-threatening thoracic injuries
15
Q
What comprises adequate assessment of breathing?
A
Inspection: for air movement, respiratory rate, cyanosis, tracheal shift, jugular venous distention, asymmetric chest expansion, use of accessory muscles of respiration, open chest wounds
Auscultation: for breath sounds
Percussion: for hyperresonance or dullness over either lung field
Palpation: for presence of subcutaneous emphysema, flail segments
16
Q
What are the life-threatening conditions that MUST be diagnosed and treated during the breathing step?
A
Tension pneumothorax, open pneumothorax, massive hemothorax
17
Q
What is pneumothorax?
A
Injury to the lung, resulting in release of air into the pleural space between the normally apposed parietal and visceral pleura
18
Q
How is pneumothorax diagnosed?
A
Tension pneumothorax is a clinical diagnosis: dyspnea, jugular venous distention, tachypnea, anxiety, pleuritic chest pain, unilateral decreased or absent breath sounds, tracheal shift away from the affected side, hyperresonance on the affected side
19
Q
What is the treatment of a tension pneumothorax?
A
Rapid thoracostomy incision or immediate decompression by needle thoracostomy in the second intercostal space midclavicular line, followed by tube thoracostomy placed in the anterior/ midaxillary line in the fourth intercostal space (level of the nipple in men)
20
Q
What is the medical term for a “sucking chest wound”?
A
Open pneumothorax
21
Q
What is a tube thoracostomy?
A
“Chest tube”
22
Q
How is an open pneumothorax diagnosed and treated?
A
Diagnosis:
usually obvious, with air movement through a chest wall defect and pneumothorax on CXR
Treatment in the ER:
tube thoracostomy (chest tube), occlusive dressing over chest wall defect
23
Q
What does a pneumothorax look like on chest X-ray?
A
Loss of lung markings (figure shows a right-sided pneumothorax; arrows point out edge of lung-air interface)
24
Q
What is Flail Chest?
A
Two separate fractures in three or more consecutive ribs
25
How is flail chest diagnosed?
Flail segment of chest wall that moves **paradoxically** (sucks in with inspiration and pushes out with expiration opposite the rest of the chest wall)
26
What is the major cause of respiratory compromise with flail chest?
Underlying pulmonary contusion!
27
What is the treatment of flail chest?
**Intubation** with positive pressure ventilation and PEEP PRN (let ribsheal on their own)
28
What is Cardiac Tamponade?
Bleeding into the pericardial sac, resulting in constriction of heart, decreasing inflow and resulting in decreased cardiac output (the pericardium does not stretch!)
29
Signs and symptoms of cardiac tamponade?
Tachycardia/shock with **Beck's triad,** pulsus paradoxus, Kussmaul's sign
30
Define Beck's triad
1. Hypotension
2. Muffled heart sounds
3. JVD
31
Define Kussmaul's sign
JVD with inspiration
32
How is cardiac tamponade diagnosed?
Ultrasound (echocardiogram)
33
Treatment of cardiac tamponade?
Pericardial window - if blood returns then median sternotomy to rule out and treat cardiac injury
34
How is Massive Hemothorax diagnosed?
Unilaterally decreased or absent breath sounds; dullness to percussion; CXR, CT scan, chest tube output
35
Treatment of massive hemothorax?
Volume replacement
**Tube thoracostomy** (chest tube)
Removal of the blood (which will allow apposition of the parietal and visceral pleura, sealing the defect and slowing the bleeding)
36
What are indications for emergent thoracotomy for hemothorax?
Massive Hemothorax =
1. \>1500 cc of blood on initial placement of chest tube
2. Persistent \>200 cc of bleeding via chest tube per hour x 4hrs
37
What are the goals in assessing circulation?
Securing adequate tissue perfusion; treatment of external bleeding
38
What is the initial test for adequate circulation?
Palpation of pulses: As a rough guide,
if a radial pulse is palpable, then systolic
pressure is at least 80 mm Hg; if a
femoral or carotid pulse is palpable, then
systolic pressure is at least 60 mm Hg
39
What comprises adequate
assessment of circulation?
Heart rate, blood pressure, peripheral
perfusion, urinary output, mental status,
capillary refill (normal \<2 seconds), exam
of skin: cold, clammy = hypovolemia
40
Who can be hypovolemic
with normal blood pressure?
Young patients; autonomic tone can
maintain blood pressure until
cardiovascular collapse is imminent
41
Which patients may not
mount a tachycardic
response to hypovolemic
shock?
Those with concomitant spinal cord
injuries
Those on ß-blockers
Well-conditioned athletes
42
How are sites of external
bleeding treated?
By direct pressure; +/- tourniquets
43
What is the best and
preferred intravenous (IV)
access in the trauma
patient?
“Two large-bore IVs” (14–16 gauge),
IV catheters in the upper extremities
(peripheral IV access)
44
What are alternate sites of
IV access?
Percutaneous and cutdown catheters in
the lower leg saphenous; central access
into femoral, jugular, subclavian veins
45
For a femoral vein catheter,
how can the anatomy of the
right groin be remembered?
Lateral to medial “NAVEL”:
Nerve
Artery
Vein
Empty space
Lymphatics
Thus, the vein is medial to the femoral
artery pulse (Or, think: “venous close
to penis”)
46
What is the trauma
resuscitation fluid of choice?
Lactated Ringer’s (LR) solution
(isotonic, and the lactate helps buffer the
hypovolemia-induced metabolic acidosis)
47
What types of decompression
do trauma patients receive?
Gastric decompression with an NG tube
and Foley catheter bladder decompression
after **normal rectal exam**
48
What are the
contraindications to
placement of a Foley?
Signs of urethral injury:
Severe pelvic fracture in men
Blood at the urethral meatus (penile
opening)
“High-riding” “ballotable” prostate
(loss of urethral tethering)
Scrotal/perineal injury/ecchymosis
49
What test should be
obtained prior to placing a
Foley catheter if urethral
injury is suspected?
Retrograde UrethroGram (RUG): dye in
penis retrograde to the bladder and x-ray
looking for extravasation of dye
50
How is gastric
decompression achieved
with a maxillofacial
fracture?
**Not** with an NG tube because the tube
may perforate through the cribriform
plate into the brain; place an **oral-gastric
tube (OGT)**, not an NG tube
51
What are the goals in
assessing disability?
Determination of neurologic injury
| (Think: neurologic disability)
52
What comprises adequate
assessment of disability?
Mental status—Glasgow Coma Scale
(GCS)
Pupils—a blown pupil suggests ipsilateral
brain mass (blood) as herniation of the
brain compresses CN III
Motor/sensory—screening exam for
lateralizing extremity movement,
sensory deficits
53
Describe the GCS scoring
system.
Eye opening (E)
4—Opens spontaneously
3—Opens to voice (command)
2—Opens to painful stimulus
1—Does not open eyes
(Think: Eyes = “four eyes”)
Motor response (M)
6—Obeys commands
5—Localizes painful stimulus
4—Withdraws from pain
3—Decorticate posture
2—Decerebrate posture
1—No movement
(Think: Motor = “6-cylinder motor”)
Verbal response (V)
5—Appropriate and oriented
4—Confused
3—Inappropriate words
2—Incomprehensible sounds
1—No sounds
(Think: Verbal = “Jackson 5”)
54
What is a normal human
GCS?
GCS 15
55
What is the GCS score for a
dead man?
GCS 3
56
What is the GCS score for a
patient in a “coma”?
GCS _\<_8
57
How does scoring differ if
the patient is intubated?
Verbal evaluation is omitted and replaced
with a “T”; thus, the highest score for an
intubated patient is 11 T
58
What are the goals in
obtaining adequate
exposure?
Complete disrobing to allow a thorough
visual inspection and digital palpation of
the patient during the secondary survey
59
What is the “environment”
of the E in ABCDEs?
Keep a warm Environment (i.e., keep the
patient warm; a hypothermic patient can
become coagulopathic)
60
What principle is followed
in completing the secondary
survey?
Complete physical exam, including all
orifices: ears, nose, mouth, vagina,
rectum
61
Why look in the ears?
Hemotympanum is a sign of basilar skull
fracture; otorrhea is a sign of basilar skull
fracture
62
Examination of what part of
the trauma patient’s body is
often forgotten?
Patient’s back (logroll the patient and
examine!)
63
What are typical signs of
basilar skull fracture?
Raccoon eyes, Battle’s sign, clear otorrhea
or rhinorrhea, hemotympanum
64
What diagnosis in the
anterior chamber must
not be missed on the eye
exam?
Traumatic hyphema = blood in the
anterior chamber of the eye
65
What potentially destructive
lesion must not be missed on
the nasal exam?
Nasal septal hematoma: Hematoma must
be evacuated; if not, it can result in
pressure necrosis of the septum!
66
What is the best indication
of a mandibular fracture?
Dental malocclusion: Tell the patient to
“bite down” and ask, “Does that feel
normal to you?”
67
What signs of thoracic
trauma are often found on
the neck exam?
Crepitus or subcutaneous emphysema from
tracheobronchial disruption/PTX; tracheal
deviation from tension pneumothorax;
jugular venous distention from cardiac
tamponade; carotid bruit heard with
seatbelt neck injury resulting in carotid
artery injury
68
What is the best physical exam
for broken ribs or sternum?
Lateral and anterior-posterior compression
of the thorax to elicit pain/instability
69
What physical signs are
diagnostic for thoracic great
vessel injury?
None: Diagnosis of great vessel injury
requires a high index of suspicion based
on the mechanism of injury, associated
injuries, and CXR/radiographic findings
(e.g., widened mediastinum)
70
What is the best way to
diagnose or rule out aortic
injury?
CT angiogram
71
What must be considered in
every penetrating injury of
the thorax at or below the
level of the nipple?
Concomitant injury to the abdomen:
Remember, the diaphragm extends to the
level of the nipples in the male on full
expiration
72
What is the significance of
subcutaneous air?
Indicates PTX, until proven otherwise
73
What is the physical exam
technique for examining the
thoracic and lumbar spine?
Logrolling the patient to allow complete
visualization of the back and palpation
of the spine to elicit pain over fractures,
step off (spine deformity)
74
What conditions must exist
to pronounce an abdominal
physical exam negative?
Alert patient without any evidence of
head/spinal cord injury or drug/EtOH
intoxication (even then, the abdominal
exam is not 100% accurate)
75
What physical signs may
indicate intra-abdominal
injury?
Tenderness; guarding; peritoneal signs;
progressive distention (always use a
gastric tube for decompression of air);
seatbelt sign
76
What is the seatbelt sign?
Ecchymosis on lower abdomen from
wearing a seatbelt (10% of patients with
this sign have a small bowel perforation!)
77
What must be documented
from the rectal exam?
78
What is the best physical
exam technique to test for
pelvic fractures?
Lateral compression of the iliac crests
and greater trochanters and anteriorposterior
compression of the symphysis
pubis to elicit pain/instability
79
What is the “halo” sign?
Cerebrospinal fluid from nose/ear will form
a clear “halo” around the blood on a cloth
80
What physical signs indicate
possible urethral injury, thus
contraindicating placement
of a Foley catheter?
**High-riding ballotable prostate** on
rectal exam; presence of blood at the
meatus; scrotal or perineal ecchymosis
81
What must be documented
from the extremity exam?
Any fractures or joint injuries; any open
wounds; motor and sensory exam,
particularly distal to any fractures; distal
pulses; peripheral perfusion
82
What complication after
prolonged ischemia to the
lower extremity must be
treated immediately?
Compartment syndrome
83
What is the treatment for
this condition?
Fasciotomy (four compartments below
the knee)
84
What injuries must be
suspected in a trauma
patient with a progressive
decline in mental status?
Epidural hematoma, subdural hematoma,
brain swelling with rising intracranial
pressure
But **hypoxia/hypotension must be
ruled out!**
85
What are the classic blunt
trauma ER x-rays?
1. AP (anterior-to-posterior) chest film
2. AP pelvis film
86
What are the common
trauma labs?
Blood for complete blood count,
chemistries, amylase, liver function tests,
lactic acid, coagulation studies, and type
and crossmatch; urine for urinalysis
87
Will the hematocrit be
low after an acute massive
hemorrhage?
No (no time to equilibrate)
88
How can a C-spine be
evaluated?
1. Clinically by physical exam
2. Radiographically
89
What patients can have
their C-spines cleared by a
physical exam?
No neck pain on palpation with full range
of motion (FROM) with no neurologic
injury (GCS 15), no EtOH/drugs, no
distracting injury, no pain meds
90
How do you rule out a
C-spine bony fracture?
With a CT scan of the C-spine
91
What do you do if no bony
C-spine fracture is apparent
on CT scan and you cannot
obtain an MRI in a
COMATOSE patient?
This is controversial; the easiest answer is
to leave the patient in a cervical collar
92
Which x-rays are used for
evaluation of cervical spine
LIGAMENTOUS injury?
MRI, lateral flexion and extension
C-spine films
93
What findings on chest film
are suggestive of thoracic
aortic injury?
**Widened mediastinum (most common
finding)**, apical pleural capping, loss
of aortic contour/KNOB/AP window,
depression of left main stem bronchus,
nasogastric tube/tracheal deviation,
pleural fluid, elevation of right mainstem
bronchus, clinical suspicion, high-speed
mechanism
94
What study is used to rule
out thoracic aortic injury?
Spiral CT scan of mediastinum looking
for mediastinal hematoma with CTA
Thoracic arch aortogram (gold standard)
95
What is the most common
site of thoracic aortic
traumatic tear?
Just distal to the take-off of the left
subclavian artery
96
What studies are available to
evaluate for intra-abdominal
injury?
FAST, CT scan, DPL
97
What is a FAST exam?
Ultrasound: Focused Assessment with
Sonography for Trauma = FAST
98
What does the FAST exam
look for?
Blood in the peritoneal cavity looking at
Morison’s pouch, bladder, spleen, and
pericardial sac
99
What does DPL stand for?
Diagnostic Peritoneal Lavage
100
What diagnostic test is the
test of choice for evaluation
of the unstable patient with
blunt abdominal trauma?
FAST
101
What is the indication for
abdominal CT scan in blunt
trauma?
Normal vital signs with abdominal
pain/tenderness/mechanism
102
What is the indication for
DPL or FAST in blunt
trauma?
Unstable vital signs (hypotension)
103
How is a DPL performed?
Place a catheter below the umbilicus (in
patients without a pelvic fracture) into
the peritoneal cavity
Aspirate for blood and if \<10 cc are
aspirated, infuse 1 L of saline or LR
Drain the fluid (by gravity) and analyze
104
What is a “grossly positive”
DPL?
_\>_10 cc blood aspirated
105
Where should the DPL
catheter be placed in a
patient with a pelvic
fracture?
Above the umbilicus
Common error: If you go below the
umbilicus, you may get into a pelvic
hematoma tracking between the fascia
layers and thus obtain a false-positive
DPL
106
What constitutes a positive
peritoneal tap?
Prior to starting a peritoneal lavage, the
DPL catheter should be aspirated; if
\>10 mL of blood or any enteric contents
are aspirated, then this constitutes a
positive tap and requires laparotomy
107
What are the indicators of a
positive peritoneal lavage in
blunt trauma?
Classic:
Inability to read newsprint through
lavaged fluid
RBC _\>_100,000/mm3
WBC _\>_500/mm3 (Note: mm3, not
mm2)
Lavage fluid (LR/NS) drained from
chest tube, Foley, NG tube
Less common:
Bile present
Bacteria present
Feces present
Vegetable matter present
Elevated amylase level
108
What must be in place
before a DPL is performed?
NG tube and Foley catheter (to remove
the stomach and bladder from the line
of fire!)
109
What injuries does CT scan
miss?
110
What injuries does DPL
miss?
Retroperitoneal injuries
111
What study is used to
evaluate the urethra in cases
of possible disruption due to
blunt trauma?
Retrograde urethrogram (RUG)
112
What are the most emergent
orthopaedic injuries?
1. Hip dislocation—must be reduced
immediately
2. Exsanguinating pelvic fracture (binder
or external fixator)
113
What findings would require
a celiotomy in a blunt trauma
victim?
114
What is the treatment of a
gunshot wound to the belly?
Exploratory laparotomy
115
What is the evaluation of a
stab wound to the belly?
If there are peritoneal signs, heavy
bleeding, shock, perform exploratory
laparotomy; otherwise, many surgeons
either observe the asymptomatic stab
wound patient closely, use local wound
exploration to rule out fascial
penetration, or use DPL
116
What depth of neck injury
must be further evaluated?
Penetrating injury through the platysma
117
# Define the anatomy of the
neck by trauma zones:
Zone III
Zone II
Zone I
Zone III-Angle of the mandible and up
Zone II-Angle of the mandible to the cricoid
cartilage
Zone I-Below the cricoid cartilage
118
How do most surgeons treat
penetrating neck injuries
(those that penetrate the
platysma) by neck zone:
Zone III
Zone II
Zone I
Zone III - Selective exploration
Zone II - Surgical exploration vs. selective
exploration
Zone I - Selective exploration
119
What is selective
exploration?
Selective exploration is based on diagnostic
studies that include A-gram or CT A-gram,
bronchoscopy, esophagoscopy
120
What are the indications for
surgical exploration in all
penetrating neck wounds
(Zones I, II, III)?
**“Hard signs”** of significant neck damage:
**shock**, exsanguinating hemorrhage,
expanding hematoma, pulsatile
hematoma, neurologic injury, subQ
emphysema
121
How can you remember the
order of the neck trauma
zones and Le Forte
fractures?
In the direction of carotid blood flow
122
What is the “3-for-1” rule?
Trauma patient in hypovolemic shock
acutely requires 3 L of crystalloid (LR)
for every 1 L of blood loss
123
What is the minimal urine
output for an adult trauma
patient?
50 mL/hr
124
How much blood can be lost
into the thigh with a closed
femur fracture?
Up to 1.5 L of blood
125
Can an adult lose enough
blood in the “closed” skull
from a brain injury to cause
hypovolemic shock?
Absolutely not! But infants can lose
enough blood from a brain injury to
cause shock
126
Can a patient be hypotensive
after an isolated head injury?
Yes, but rule out hemorrhagic shock!
127
What is the brief ATLS
history?
“AMPLE” history:
Allergies
Medications
PMH
Last meal (when)
Events (of injury, etc.)
128
In what population is a
surgical cricothyroidotomy
not recommended?
Any patient younger than 12 years; instead
perform needle cricothyroidotomy
129
What are the signs of a
laryngeal fracture?
Subcutaneous emphysema in neck
Altered voice
Palpable laryngeal fracture
130
What is the treatment of
rectal penetrating injury?
```
**Diverting proximal colostomy**; closure
of perforation (if easy, and definitely if
intraperitoneal); and **presacral drainage**
```
131
What is the treatment of
EXTRAperitoneal minor
bladder rupture?
“Bladder catheter” (Foley) drainage and
observation; intraperitoneal or large
bladder rupture requires operative closure
132
What intra-abdominal injury is
associated with seatbelt use?
Small bowel injuries (L2 fracture,
pancreatic injury)
133
What is the treatment of a
pelvic fracture?
+/- pelvic binder until the external
fixator is placed; IVF/blood; +/- A-gram
to embolize bleeding pelvic vessels
134
Bleeding from pelvic fractures
is most commonly caused by
arterial or venous bleeding?
Venous (~85%)
135
If a patient has a laceration
through an eyebrow, should
you shave the eyebrow prior
to suturing it closed?
No—20% of the time, the eyebrow will
not grow back if shaved!
136
What is the treatment of
extensive irreparable biliary,
duodenal, and pancreatic
head injury?
Trauma Whipple
137
What is the most common
intra-abdominal organ
injured with penetrating
trauma?
Small Bowel
138
How high up do the
diaphragms go?
To the nipples (intercostal space #4);
thus, intra-abdominal injury with
penetrating injury below the nipples
must be ruled out
139
Classic trauma question:
“If you have only one vial of
blood from a trauma victim
to send to the lab, what test
should be ordered?”
Type and cross (for blood transfusion)
140
What is the treatment of
penetrating injury to the
colon?
If the patient is in shock, resection and
colostomy
If the patient is stable, the trend is
primary anastomosis/repair
141
What is the treatment of
small bowel injury?
Primary closure or resection and primary
anastomosis
142
What is the treatment of
minor pancreatic injury?
Drainage (e.g., JP drains)
143
What is the most commonly
injured abdominal organ
with blunt trauma?
Liver (in recent studies)
144
What is the treatment for
significant duodenal injury?
Pyloric exclusion:
1. Close duodenal injury
2. Staple off pylorus
3. Gastrojejunostomy
145
What is the treatment for
massive tail of pancreas
injury?
```
Distal pancreatectomy (usually perform
splenectomy also)
```
146
What is “damage control”
surgery?
Stop major hemorrhage and GI soilage
Pack and get out of the O.R. ASAP to
bring the patient to the ICU to warm,
correct coags, and resuscitate
Return patient to O.R. when stable,
warm, and not acidotic
147
What is the “lethal triad”?
“ACH”:
1. Acidosis
2. Coagulopathy
3. Hypothermia
(Think: ACHe = Acidosis, Coagulopathy,
Hypothermia)
148
What comprises the workup/
treatment of a stable
parasternal chest gunshot/
stab wound?
1. CXR
2. FAST, chest tube, +/- O.R. for subxiphoid
window; if blood returns, then
sternotomy to assess for cardiac injury
149
What is the diagnosis with
NGT in chest on CXR?
```
Ruptured diaphragm with stomach in
pleural cavity (go to ex lap)
```
150
What films are typically
obtained to evaluate
extremity fractures?
Complete views of the involved extremity,
including the joints above and below the
fracture
151
Basic workup for victim w/severe blunt trauma diagram
Enjoy
152
What finding on ABD/pelvic
CT scan requires ex lap in
the blunt trauma patient
with normal vital signs?
Free air; also strongly consider in the
patient with no solid organ injury but lots
of free fluid = both to rule out hollow
viscus injury
153
Can you rely on a negative
FAST in the unstable patient
with a pelvic fracture?
No—perform DPL (above umbilicus)
154
What lab tests are used to
look for intra-abdominal
injury in children?
Liver function tests (LFTs) = inc AST
and/or inc ALT
155
What is the only real indication
for MAST trousers?
Prehospitalization, pelvic fracture
156
What is the treatment for
human and dog bites?
Leave wound open, irrigation, antibiotics
157
What percentage of pelvic
fracture bleeding is
exclusively venous?
85%
158
What is sympathetic
ophthalmia?
Blindness in one eye that results in
subsequent blindness in the contralateral
eye (autoimmune)
159
What can present after blunt
trauma with neurological
deficits and a normal brain
CT scan?
Diffuse Axonal Injury (DAI), carotid
artery injury
