ORALS - TRAUMA

Question 1

GENERAL TRAUMA SCRIPT

Answer 1

1. PPE/MOVID
   PPL: trauma team (trauma surgery, anesthesia, ortho, neurosurgery), 2nd ERP
   PPE
   Eqiup: US, rapid transfuser, chest tube, thoractomy tray, airway cart + difficult airway
2. On arrival - I will ask
   patient transfer, CR monitors (apply, titrate SpO2 >92%)
   BW: trauma + LFT, CK/Myo, INR (coags), T+S
   IVF x1 bolus, 2g ancef and 2g TDAP to be drawn and administered
   ensure patient is in a C collar +/- pelvic binder
   CXR +/- pelvis XR + XR of obvious limb deformity
3. Using ATLS - proceed with primary survery
   as part of exam, will perform an EFAST (FF, PTX, pericardial effusion)
   SAMPLE hx to complete survery
4. MGMT
   => Pain control
   => warm patient
   => control bleed +/- MTP, pelvic binder
   => axillary meds: TXA
   => SECONDARY Survey

FOLLOW UP QUESTIONS
1. Dosing of blood products for peds
blood 10cc/kg
FFP 10cc/kg
PLT 10cc/kg (goal 50)
cryo 1U/10kg (goal >1g/L - ADULT dose 10U)
MTP >40cc/kg of blood

2. Gustilo classification
   1 - wound, 1cm normal vasc
   2 - wound >1cm, no contamin, crush, vasc compromised
   3 - large open fracture, tissue loss, avulsion, B - extesion + large tissue loss C = major vascular injury [ancef + gent or just CTX]

Question 2

TBI CASE

Answer 2

1. general trauma script
2. MGMT
   Elevate HOB
   loosen C spine color
   osmotic agents: 1) mannitol 1g/kg / 20min 2) 3% saline
   hyperventilation PCO2 30-35 (if signs of herniation)
   avoid: hypoxia, fever, hypotension
   CT head
   seizure prophylaxis (1g dilantin load)
3. SPECIAL CONSIDERATIONS:
   intubation - neuroprotective RSI (etomidate 0.3mg/kg and rocuronium 1mg/kg)

ANTICOAGULATION:
=> WARFARIN = Octaplex 2000U, Vitamin K 10mg, TXA 1g
=> XA INHIBITOR = Octaplex 2000U or adnexanet alpha, TXA 1g
=> PRAXBIND 2.5mg x2 q15min, TXA 1g

HEMOPHILIA A
=> F8 50U/kg
=> cryoprecipitate
=> DDAVP 0.3mcg/kg
=> TXA 1g
consider: recombinant factor 7, FIEBA

HEMOPHILIA B
=> Factor 9 100U/kg
=> PCC, FFP
=> TXA 1g

4. Consults
   neurosurgery

follow up questions
1. list come indications for acute seizure (OLD LIST) prophylaxis in head trauma
depressed skull fracture
paralyzed + intaubted
seizure @ time of injury
seizure at ED presentation
penetrating brain injury
severe head injury
acute subdural
acute epidural
ICH

Question 3

ABDO TRAUMA CASE

follow up questions

Answer 3

1. Indications for laparotomy (BLUNT abdo)
   Unstable vital signs despite resus with positive e-fast
   Evidence of diaphragmatic injury
   Pneumoperitoneum
   Unequivocal peritoneal irritation on exam
2. Indications for laparotomy (PENETRATE abdo)
   Unstable vital signs
   Evisceration
   Evidence of diaphragmatic injury
   Pneumoperitoneum
   Peritoneal signs
3. Describe injuries associated with seatbelt sign
   Mesenteric lac
   Intestinal injury
   Ruptured diaphragm
   Abdominal aortic dissection
   Chance fracture

Question 4

NECK TRAUMA

follow up questions

Answer 4

1. Describe hard / soft signs of penetrating neck injury
   HARD - AB3CDS3-H
   Airway compromise
   Bubbling air (wound)
   Bruit
   Blood ++
   Cerebral ischemia
   Decreased / absent radial pulse
   Stridor
   Subcut air ++
   Shock (no response to tx)
   Hemoptysis (massive)
   soft - MN2OPQ-HD
   Minor hemoptysis
   Neurologic findings
   Non expanding hematoma
   Oropharyngeal wound
   Proximity wound
   subQ air
   Hematemsis
   Dysphonia / dysphagia
2. Approach to patient with only SOFT signs of penetrating injury
   CTA neck
   directed angio
   directed endoscopy
   bronchoscopy
   local wound exploration
3. Describe the zones of the neck + structures in each
   Zone I= base of neck: sternal notch to cricoid
   => vert art, sub clavians, lung apices, esophagus, trachea, thyroid, spinal cord
   Zone II= cricoid to mandible
   => carotid artery, vert, larynx, esophagus, jugular vein, vagus nerve, spinal cord
   Zone III= angle of mandible to base of skull
   => carotid, vert, jugular, spinal cord, parotid

Question 5

SPINAL TRAUMA

Answer 5

1. Describe neurogenic shock = BRADY + hypotension
   impairment of descending sympathetic pathways in C spine / upper thoraic cord
   MGMT = MAP goal >80, IVF + pressors
2. Describe spinal shock
   not true shock => flaccid + loss of reflexes
   no bulbocaernosus reflex
3. Name 2 conditions that predispose to C spine injury
   Down syndrome => predisposition to atlanto occipital d/c
   RA => prone to rupture of transverse ligament (C2)
4. Describe cord syndromes
   Brown sequard => hemisection, IPSILAT (motor, vibration, proprioception), C/L (pain + temp)
   Central cord syndrome => hyperextension (MUDE)
   Anterior cord syndrome => motor paralysis, loss of pain + temp
5. Anatomical diff in peds c spine
   c spine fulcrum
   large head
   large occiput
   ligamentous injuries more common
   flatter facet joints
   incomplete ossification
   epiphysis of spinous process tips
   preodontoid space > in younger kids
   pseudosubluxation of C2 on C3
   prevertebral space size varies with respiration

Question 6

PEDS TRAUMA

Answer 6

Buckle fracture mgmt:
Removable immobilize device, GP f/u in 3-4 weeks (doesnt need ortho)
Greenstick # mgmt:
Call ortho in ED as they may need fracture to be completed for anatomically reduction to be achieved.
Immobilization and close ortho f/u
Please describe the salter harris class of this fracture and how you would manage this injury (in general terms):
Type 1 - Straight across
● non-displaced (pain over growth plate without radiologic evidence)
○ Immbolization and PCP follow up in a week for r/a
● Displaced
○ Closed reduction and ortho f/u within a few days
Type 2 - Above the epiphysis
● Closed reduction and ortho f/u within a few days
Type 3 - Lower (or beLow), through epiphysis
● ED ortho consult +/- ORIF
Type 4 - Two (or Through)
● ED ortho consult +/- ORIF
Type 5 - ERasure of growth plate (cRush)
● ED ortho consult +/- ORIF

Please describe the Gartland classification of this supracondylar fracture and how you would manage this injury? What are common complications of this fracture?

Extension-type
Most common
Pt presents with arm in extension and S-shaped elbow with prominent olecranon
MOI - hyperextension (FOOSH) = anterior cortex failure

Flexion-type:
Rare (5%)
Impacted flexed elbow = failure of posterior cortex
Presents with arm in flexion without olecranon visible

Gartland classification
Type 1 - non-displaced
● Splint and sling, outpt ortho f/u
Type 2 - displaced # but posterior cortex remains intact
● ED ortho consult for open vs closed reduction with pinning
Type 3 - complete fracture of the cortex
● ED ortho consult for open vs closed reduction with pinning

Measurements to assess for subtle #/displacement:
● Anterior humeral line → should bisect the capitellum
● Radiocapitellar line → radial neck (not shaft) should bisect the capitellum
● Baumann’s angle → line along the capitellum growth plate vs line along humerus shaft line, normal is 75-80 degrees.

ED reduction:
Only indicated if pale and cold without a pulse (no pulse but warm is fine to wait for ortho)
Traction-countertraction: pull to length and correct any rotation. Once at length, flex elbow (with MD thumb anteriorly over distal segment to keep in correct position) and immobilize with splint and sling.

Complications:
1. Vascular injury
2. Median (AIN) > radial nerve injury
3. Compartment syndrome
4. Gunstock deformity
5. Volkmann’s contracture (shortening, necrosis, and fibrosis of flexors in forearm)