Flashcards in SR 38 - Trauma Deck (92):
First five steps of the primary survey?
Airway and C-spine stabilization
Exposure and environment
What are the steps of a cricothyroidotomy?
Incise the cricothyroid membrane between the cricoid cartilage inferiorly and the thyroid cartilage superiorly and place an ET or tracheostomy tube into the trachea
What are the parts of a good breathing assessment?
Inspection - air movement, respiratory rate, cyanosis, tracheal shift, JVD, asymmetric chest expansion, accessory muscle use, open chest wounds
Auscultation - breath sounds
Percussion - hyperresonance or dullness
Palpation - subcutaneous emphysema, flail chest
Life-threatening conditions that need to be identified and treated during the breathing stage?
Treatment of a tension pneumothorax?
Needle thoracostomy - 2nd ICS MCL
Followed by, tube thoracostomy in anterior/midaxillary line in 4th ICS
What does a pneumothorax look like on a CXR?
Loss of lung markings
What is the major cause of respiratory compromise with flail chest?
Underlying pulmonary contusion
What is the treatment for a flail chest?
Intubation with positive pressure ventilation
(Allows the ribs to heal)
Define Beck's Triad
Muffled heart sounds
Define Kussmaul's sign
JVD with inspiration
How do you diagnose cardiac tamponade?
Ultrasound - echocardiogram
What is the treatment of cardiac tamponade?
If blood returns, complete median sternotomy to R/O cardiac injury
What is the treatment of a massive hemothorax?
Removal of blood (allows apposition of parietal and virsceral pleura - seals the defect)
What is the initial assessment for adequate circulation?
Palpation of pulses
Radial - 80mmHg
Femoral/carotid - 60mmHg
What are the parts of a good circulation assessment?
Capillary refill (normal
Who won't mount a tachycardic response to hypovolemic shock?
Spinal cord injury
What is the trauma resuscitation fluid of choice?
Lactated Ringer's solution
Isotonic and the lactate helps buffer the hypovolemia-induced metabolic acidosis
What decompressions do trauma patient receive?
Gastric decompression - NGT
Bladder decompression - foley AFTER normal rectal exam
Contraindications to placement of a foley?
Signs of urethral injury:
- Severe pelvic fracture in men
- Blood at the urethral meatus
- 'High-riding' 'ballotable' prostate
- Scrotal/perineal injury/ecchymosis
What test do you do if urethral injury is suspected prior to placement of a foley catheter?
Retrograde UrethroGram (RUG)
Dye in penis retrograde to the bladder and E-ray to look for extravasation of dye
How do you get gastric decompression when a patient has maxillofacial fracture?
Use an OGT
Because an NGT may perforate through the cribiform plate into the brain
What are the parts of a good disability assessment?
- Mental status - GCS
What are the three parts of the GCS?
Eye opening (4)
Motor response (6)
Verbal response (5)
What are the stages in GCS - eye opening?
4 - opens spontaneously
3 - opens to voice command
2 - opens to painful stimuli
1 - does not open eyes
What are the stages in GCS - motor response?
6 - obeys commands
5 - localizes to painful stimulus
4 - withdraws from pain
3 - decorticate posture
2 - decerebrate posture
1 - no movement
What are the stages in GCS - verbal response?
5 - appropriate and oriented
4 - confused
3 - inappropriate words
2 - incomprehensible sounds
1- no sounds
Define decorticate posture
Define decerebrate posture
Why do you inspect the ears in trauma?
Hemotympanum and otorrhea is a sign of basilar skull fracture
What are typical signs of basilar skull fracture?
Clear otorrhea or rhinorrhea
What diagnosis in the anterior chamber must not be missed on the eye exam?
Blood in the anterior chamber of the eye
What potential destructive lesion must not be missed on the nasal exam?
Nasal septal hematoma
If not evacuated, it can cause pressure necrosis in the septum
What is the best indication of a mandibular fracture?
Tell the patient to 'bite down' and ask if it feels normal
Signs of thoracic trauma are found on the neck exam?
Crepitus or subcutaneous emphysema from tracheobronchial disruption/PTX
Tracheal deviation - tension PTX
JVD - cardiac tamponade
Carotid bruit - carotid artery injury
What is the best way to diagnose or rule-out aortic injury?
What must be considered in every penetrating injury of the thorax at or below the nipple?
Injury to the abdomen
Diaphragm extends to the level of the nipples on expiration
What conditions must exist to pronounce an abdominal physical exam negative?
Alert patient without evidence of head/spinal cord injury or intoxication
What is the seatbelt sign?
Ecchymosis on lower abdomen from wearing a seatbelt
10% will have small bowel perforation
What must be documented from the rectal exam?
Sphincter tone (indication of spinal cord function)
Presence of blood (colon or rectal injury)
Prostate position (urethral injury)
What patients can have their C-spine cleared during physical exam?
No neck pain on palpation
Full range of motion
No neurological injury - GCS 15
No distracting injury
No pain meds
CXR findings suggestive of thoracic aortic injury?
Apical pleural capping
Loss of aortic contour
Depression of left main stem bronchus
What is the most common site of thoracic aortic traumatic tear?
Distal to the take-off of the left subclavian artery
What studies do you use to evaluate intra-abdominal injury?
FAST (focused assessment with sonography for trauma)
DPL (Diagnostic Peritoneal Lavage)
What does the FAST exam look for?
Blood int eh peritoneal cavity
You look at Morison's pouch, bladder, spleen and pericardial sac
Indication for CT scan in blunt abdominal trauma?
Stable with abdominal pain/tenderness/mechanism
Indication for DPL or FAST in blunt abdominal trauma?
Indicators of a positive peritoneal lavage in blunt trauma?
- Inability to read newsprint through the lavage fluid
- RBC >100,000
- WBC >500mm3
- Lavage fluid drained from chest tub, foley, NGT
- Bile present
- Bacteria present
- Feces present
- Food matter present
- Elevated amylase level
What must be placed before a DPL is performed?
NGT and foley catheter
What injuries does CT scan miss?
What injuries does DPL miss?
What are the most emergent orthopedic injuries?
Hip dislocation (needs immediate reduction)
Exsanguinating pelvic fracture (binder or external fixator)
What findings would require a celiotomy in a blunt trauma victim?
Free air on CXR/CT scan
Unstable patient with positive FAST or DPL
Approach to GSW to the belly?
Evaluation of stab wound to the belly?
Exploratory laparotomy - peritoneal signs, heavy bleeding, shock
Otherwise, observe, or local wound exploration to rule out fascial penetration or DPL
What depth of neck injury must be further evaluated?
Penetrating injury through the platysma
Anatomy of the neck by trauma zones - zone III
Angele of the mandible and up
Anatomy of the neck by trauma zones - zone II
Angle of the mandible to the cricoid cartilage
Anatomy of the neck by trauma zones - zone I
Below the cricoid cartilage
How do you treat penetrating neck injuries to zone III?
How do you treat penetrating neck injuries to zone II?
Dependent on status - surgical exploration vs. selective exploration
How do you treat penetrating neck injuries to zone I?
What is selective exploration?
Based on diagnostic studies - A-gram or CT a-gram, bronchoscopy, esophagoscopy
What are the indications for surgical exploration in all penetrating neck wounds?
Hard signs of significant neck damage
- Exsanguinating hemorrhage
- Expanding hematoma
- Pulsatile hematoma
- Neurologic injury
- SubQ emphysema
What is the Le Forte fracture arrangement?
III - orbital fracture
II - mandible/nasal
I - mandible/oral
What is the '3-for-1' rule?
For every 1 L blood loss - 3 L crystalloids
How much blood can be lost into the thigh with a closed femur fracture?
What population is a surgical cricothyroidotomy not recommended?
Patient younger than 12yo
Perform a needle cricothyroidotomy
What are the signs of a laryngeal fracture?
SubQ emphysema in the neck
Palpable laryngeal fracture
What is the treatment of a rectal penetrating injury?
Diverting proximal colostomy
Closure of the perforation
What is the treatment of extraperitoneal minor bladder rupture?
Bladder catheter and observation
(Intraperitoneal or large bladder rupture requires operative closure)
What intra-aobdominal injuries are associated with seatbelt use?
Small bowel injury
Bleeding from a pelvic fracture is caused by arterial or venous bleeding?
If patient has a laceration through their eyebrow - do you shave the eyebrow before suturing?
No - it may not grow back (20%)
What is the treatment for extensive irreparable biliary, duodenal, and pancreatic head injury?
What is the most common intra-abdominal organ injured with penetrating trauma?
If you can only run one blood test for a trauma patient, what would you do?
Type and cross for blood transfusion
What is the treatment of penetrating injury to the colon?
In shock - resection and colostomy
Stable - primary anastomosis/repair
What is the treatment of small bowel injury?
Primary closure or resection and primary anastomosis
What is the treatment of minor pancreatic injury?
What is the most commonly injured abdominal organ with blunt trauma?
What is the treatment for significant duodenal injury?
- Close duodenal injury
- Staple off pylorus
What is the treatment for massive tail of pancreas injury?
Distal pancreatectom with splenectomy
What is 'damage control' surgery?
Stop major hemorrhage and GI soilage
Pack and get out of the OR ASAP - bring patient to the ICU to warm, correct coags and resuscitate
Return patient to OR when stable, warm and not acidotic
What is the lethal triad?
What is the diagnosis if you see a NGT in the chest on a CXR?
Ruptured diaphragm with stomach in the pleural cavity
Take patient to OR - ex-lap
What finding on ABD/pelvic CT requires ex-lap in a blunt trauma patient with normal vital signs?
(No solid organ injury with lots of free fluid - to rule out hollow viscus injury)
Can you rely on a negative FAST in the unstable patient with a pelvic fracture?
No - perform DPL (above the umbilicus)
What lab tests are used to look for intra-abdominal injury in children?
LFT (increased AST or ALT)
What is the only indication for MAST trousers?
What is the treatment for human and dog bites?
Leave wound open
What is sympathetic ophthalmia?
Blindness in one eye that results in subsequent blindness in the contralateral eye (autoimmune)