Trauma Flashcards
Indications for laparotomy in stab wound
Evisceration<div>Peritonitis</div><div>Hemodynamic instability</div><div>Impalement</div><div>Frank blood on NG/rectal</div>
<p>Name 3 patient or wound characteristics that would decrease the reliability of Local wound exploration (LWE) for anterior stabs.</p>
<ul> <li>Small puncture wounds (eg - ice pick)</li> <li>Significant obesity</li> <li>Multiple stab wounds</li> <li>Lack of patient co-operation</li> <li>Long tangential stab wounds</li> </ul>
<p>There is no commercial binder available. What else can you do? Describe.</p>
<p>What is a common pitfall to avoid?</p>
<p>‣Use a folded bedsheet centered over the <em>trochanters </em>secure with towel clips.</p>
<p>‣Internal rotation of legs and taping the ankles.</p>
<p>‣Avoid placing over the iliac crests.</p>
What non-abdominal injuries are associated with seat belt inj
L-Spine Chance #
“<img></img><div>What is this #</div><div>Stable vs unstable?</div><div>Why?</div>”
<p>Chanse # (Transverse # through vertebral body with posterior element involvement/splaying - involves PLL. Misdiagnosed as compression # )</p>
<div>Unstable</div>
<div>3 column involvement</div>
<p><strong>Hard and Soft Signs of Major Aerodigestive or Neurovascular Injury </strong></p>
“<p><img></img></p> <strong>Anatomical</strong> <strong>Hard Sign</strong> <strong>Soft Sign</strong> <span><strong>Airways</strong></span> <span>Airways compromise</span> <span>Hemoptysis</span> <span>Air bubbling through the wound</span> <span>Dyspnea, Dysphonia</span> <span>Massive SC emphysema</span> <span>Chest tube air leak</span> <span><strong>Vascular</strong></span> <span>Expanding/pulsating hematoma</span> <span>Non expanding hematoma</span> <span>Active/brisk bleeding</span> <span>Oroparyngeal blood</span> <span>Hemorrhagic shock</span> <span><strong>GIT</strong></span> <span>Hematemesis</span> <span>Dysphagia</span> <span><strong>Neuro</strong></span> <span>Neuro deficit</span> <span><strong>Others</strong></span> <span>Subcut or mediastinal air</span> <span>Crepitus</span> “
Brown-Sequard syndrome
Hemisection of SC<div>Ipsilateral loss of vibration/properioception</div><div>Ipsilateral motor loss (lat corticospinal tr)</div><div>Contralateral loss of pain/temp</div>
Can you remove C-collar after nefgative CT in blunt trauma in obtunded patient?
Yes if the patient can grossly move all 4 limbs (normal motor exam)
Name potential 4 harms of C-Spine immoblization
Increased ICP due to decrease venous return<div>Pressure ulcers</div><div>Increased aspiration risk</div><div>Impaired airway access</div><div>Pain</div><div>Potential for missed injuries</div>
<p>Explain the anatomic reason for the clinical findings of UE weakness in central cord syndrome</p>
<p>Fibers controlling UE are central</p>
<p></p>
<p>Tight spinal canal + hyperextension injury results in bleeding/edema into central part of cord - not always any acute bony abnormality</p>
<p><b>What should your next management steps be?</b></p>
<p>Switch to an Aspen collar, consult neurosurgery, MRI</p>
<div></div>
DOPE
Dislodgement of EET<div>Obstruction of ETT</div><div>PTX</div><div>Equipment failure</div><div><br></br></div><div>Others:</div><div>Temponade</div><div>air embolism</div><div>air trapping</div>
2018 ATLS updates
“<img></img><div><img></img><br></br></div><div><img></img><br></br></div>”
Anticoagulation reversal guidleines
“<img></img>”
PECARN
“<img></img>”
Canadian C-Spine rule in trauma
“<img></img>”
What is meant by (Dangerous Mechanisms) in trauma?
• Fall from > 1 meter/5 stairs<br></br>• Axial load of head<br></br>• MVC with ejection, rollover, > 60 mph<br></br>• Motorized recreational vehicle collision<br></br>• Bicycle collision
Low risk factors (prior to assessing ROM)
Simple rear-end MVC<br></br>Sitting position in ED<br></br>Ambulatory at any time<br></br>Delayed onset of neck pain<br></br>No midline cervical tenderness
CERVICAL SPINE TRAUMA<br></br>NEXUS Criteria
N - Neuro deficit<br></br>E - EtOH (alcohol)/intoxication<br></br>X - eXtreme distracting injury<br></br>U - Unable to provide history (altered LOC)<br></br>S - Spinal tenderness (midline)<br></br>Imaging indicated if any present
“<img></img><div>Name 3 potential vision threatening Dx ass with this trauma</div>”
Orbital floor / blowout #<div>Globe rupture</div><div>Retrobulbar hematoma</div><div>Hyphema</div><div><br></br></div><div>NB: No points for orbital rim # as it is not vision-threatening</div>
<p>What are some physical findings of an orbital blow-out fracture?</p>
<ul> <li>Enopthalmos</li> <li>Infraorbital paresthesia</li> <li>Impaired upward gaze</li> </ul>
“<img></img><div>Which eye is affected? Why?</div>”
Left eye<div>Inf rectus entrapment</div>
<p>Name 2 physical findings of a retrobulbar hematoma.</p>
“Exophthalmos<div>Decreased VA</div><div>Increased IOP</div><div><span>Relative Afferent Pupillary Defect (</span><b>RAPD</b><span>)</span><br></br></div><div>Subconjuctival hge</div>”
<p>What ultrasound finding rules-in a pneumothorax? Describe</p>
<p>Lung point - when you have lung slide and lack of lung slide in the same rib space.</p>
<p><strong>Name 3 limitations of FAST exam in blunt abdominal trauma</strong></p>
<ol> <li>Does not detect retroperitoneal injury</li> <li>Operator dependent (250-750cc)</li> <li>Can be negative early in trauma</li> <li>Does not detect perforated viscus (unless FF)</li> <li>False negatives - clotted blood, adhesions</li> <li>False positives - ascites, physiological FF</li> <li>Indeterminate scans (rib shadow etc)</li> </ol>
Restriction of volume replacement to:
- Avoid clot dislodgement
- Avoid dilution of clotting factors
- Avoid the triad of death (hypothermia, acidosis and coagulopathy)
- TBI with GCS < 8
- SCI
- No direct access to OR
What are the indications for imaging of blunt renal trauma in adults?
- Adults - imaging if gross hematuria or SBP <90 + any hematuria
- (Vs kids - anything >50 RBC/hpf requires imaging)
Name 3 risk factors that should prompt further screening for Blunt CerebroVascular Injury in asymptomatic patients?
- Severe facial trauma - especially Lefort II or III
- Basilar skull # with carotid canal involvement
- Any C1-C3 #
- Other C-spine #’s involving transverse foramen, subluxation or ligamentous injury
- Near-hanging with anoxic brain injury
- Severe TBI with GCS <6
- Clothesline-type injuries
In the ED setting, what vital sign parameters are most important in preventing secondary injury(2)?
- O2 >92%
- SBP >100-110 (>100 for 50-69 yo, >110 for 15-49/>70)
- EtCO2 - aim for eucapnia
- Normothermia
What are the indications for osmotic therapy (mannitol or HS) in the setting of severe TBI (in the ED)?
Clinical signs of impending herniation from ICP
Posturing, Cushing’s, fixed/dilated pupils
On advice from neurosurgery
Name 3 other things you can do in the ED to help prevent secondary brain
- Normothermia,
- elevate HOB,
- sedation, analgesia,
- loosen collar,
- glucose management
- Blunt trauma to head with
- LOC/amnesia/disorientation,
- initial GCS >13,
- <24 hours
What features increase the risk of ciTBI in kids <2 years with a scalp hematoma?
- Age <3 months
- Non-frontal (ie - parietal or temporal)
- >3cm
- Associated symptoms
What subgroup of <2 year olds with isolated hematoma have the highest risk of TBI?
< 3 months - highest risk of TBI on CT (but low risk of needing surgery)
- PECARN - of 111 patients with isolated hematoma <3 most - 21% had TBI on CT, but only 2% required surgery
- Full thickness >10%
- Partial thickness >25% if between 10-50 yo, otherwise >20%
- Inhalational, chemical or high-voltage electrical burns
- Major trauma
- Patients with underlying co-morbidites
- Involvement of face, ears, hand, feet or perineum.
Wide mediastinum (>6cm on PA, >8cm on AP)
Obscured aortic knob
Displaced NG tube
Widened paratracheal stripe
Depression of right mainstem bronchus
Apical cap
Hemothorax (esp. left side)
Lateral displacement of trachea
1st/2nd rib #
Name 5 history or physical exam findings that would increase your suspicion of an aortic injury.
- Major chest trauma – on exam or history
- Ex – high speed MVC, seat belt sign, contusions
- Unequal BP’s in UE’s
- Hypertension in UE, hypotension in LE
- Hypotension/tachycardia
- Rib/sternal #’s – especially 1st/2nd rib
- Flail chest
- Intrascapular murmur/bruits
- Hemothorax
What clinical exam findings will support your diagnosis of a globe rupture? Name 5
- Pupil – irregular shape, non-reactive, RAPD
- Decreased vision
- Bloody chemosis or severe subconj hemorrhage*
- Hyphema
- Lens injury
- Flat/shallow anterior chamber
- Extrusion of contents
- FB
- Lens dislocation
If you were uncertain of the diagnosis of globe rupture, what bedside test could you do? Describe.
- Seidel test – fluorescein washed away by leaking aqueous
Globe rupture, What is your work-up (1) and management plan for this patient (5)?
- CT
- Protect eye
- Antibiotics
- Tetanus
- Ophthalmology
- Elevate HOB
- Antiemetics/analgesia
- NPO
What bedside test is CI in this patient?
- IOP measurement
Jefferson
Bilateral facet dislocation
Odontoid
Atlanto-occipital dissociation
Hangmans
Teardrop"
Anterior :
Flexion injury 🔜direct ink to ant cord ➡️ complete paralysis and sensory loss below level of injury
Central:
Hyperextension 🔜mostly motor function in UE more LE
Brown - Sequard
Hemisection or unilateral SC compression 🔜 ipsilateral loss of motor, properioception and vibration and contralateral loss of pain and temp
3 Types
Types 2&3 are unstable
Bilateral facet dislocation anterior displacement greater than 50% diameter of vertebral body. "Transport checklist
ABCDEFGHIJKLMN
Airway: Secured endotracheal tube verified on CXR
Breathing: Oxygen saturation +/- ETCO2, chest tube(s) functioning and secured
Circulation: Documentation of serial BP and HR, timing of tourniquets, volume/type blood products given, pelvic binder for suspected or confirmed pelvic injury
Disability: Documentation of serial GCS or AVPU, neurologic exam prior to paralysis, timing of paralytic
Exposure: Splint fractures, dress wounds, then cover patient and keep them dry
Fluids: Measure urine output, chest tube output, IV fluids given
Gut: NG tube placed and confirmed
Heme: Tranexamic acid or prothrombin complex concentrates given, INR drawn
Infusions: Sedation and analgesia
JVP: Signs of tension pneumothorax/tamponade
Kelvin: Initial and current temperature. Keep patient warm.
Lines: Two lines minimum, check all lines (IV, IO, foley, chest tubes)
Micro: antibiotics and tetanus as needed
Next of Kin: Family made aware of plan, contact information documented
- Retrobulbar hematoma with orbital compartment syndrome
- Hyphema
- Retinal detachment and
- Globe rupture
Gown in appropriate PPE
Prepare necessary equipment including airway equipment/chest tube tray/rapid transfuser
Prepare warmed fluids
Draw up medications for pain, TXA, intubation, etc.
Alert transfusion medicine for potential need for blood products
Alert surgical team that potential surgical patient
Note: This question asks how to prepare before a trauma patient arrives. No marks are given for any interventions done to the patient (who is 10 mins away)
List the indications for an ED (Trauma Room) Thoracotomy
Penetrating Trauma
- Cardiac Arrest with signs of life in the field
- SBP <50 mmHg after fluid resuscitation
- Severe Shock with clinical signs of tamponade
Blunt Trauma
- Arrest in ED
Theoretic
- Suspected Air Embolus (post-instrumentation)
List the indications for an urgent OR Thoracotomy
Initial Chest tube drainage > 20cc/kg
Ongoing chest tube drainage > 7cc/kg/hr
Increasing hemothorax on CXR
Pt remains hypotensive despite adequate blood replacement and other sources of blood loss have been ruled out
Pt decompensates after initial response to resuscitation
1.Is there a HIGH Risk factor that mandates an X-RAY? (No -> go to step 2)
2.Is there a LOW Risk factor present that allows a safe assessment of ROM? (Yes -> go to step 3)
3.Can the patient rotate 45° left & right?
HIGH RISK Factors
• > 65 years
•Parasthesias
•Dangerous mechanisms
•Fall > 5 stairs (or 3 ft)
•Axial load to head
•High speed (>100kph)
•Ejection
•Rollover
•ATV, Bike collision
•
LOW RISK Factors
•Simple rear end MVC (except bus, truck, highspeed, pushed into traffic, rollover)
•Ambulatory, sitting in ED
•Delayed onset of neck pain
•Absence of midline c-spine tenderness
100% sensitivity and 42.5% specificity for clinically important c-spine injury
"Prospective Cohort
Inclusion:
- Minor CHI
- Blunt Head trauma within 24 hours
- Witnessed LOC
- Amnesia or witnessed disorientation
- GCS 13 – 15
Exclusion:
- Pregnant
- On anti-coagulant
- Age , 16
- > 24 hours
- No history of trauma
- Obvious penetrating skull injury or depressed #
- Acute focal neuro definict
- Major trauma with unstable VS
- Seizure prior to ED visit
- A return visit to the ED for reassessment of the same injury
HIGH Risk for Neurosurgical intervention
1.Failure to reach GCS 15 within 2 hours
2.Suspected open skull#
3.Suspected basal skull#
4.Vomiting ≥2
5.Age ≥65
MEDIUM Risk for Clinically Important Head Injury
1.Amnesia before impact > 30 minutes
2.Dangerous mechanism
–Pedestrian struck
–Ejection from vehicle
–Fall from height (>3ft or 5 steps)
–
- 100% sensitive for HIGH risk
98.4% sensitive for MEDIUM risk
Definition of Massive Transfusion, complications, which are immune-mediated?
- Massive Transfusion > 10 U pRBC in a 24 hr period
- Acute complications:
Consumptive coagulopathy
Excessive fibrinolysis
Dilutional coagulopathy
Hypothermia
Acidosis, citrate, hypo Ca/Mg
Hyper K+ (on last week’s ER)
TRALI
Immune-mediated
Haemolytic transfusion reactions (e.g. ABO or Rh)
Non-haemolytic febrile reaction
Allergic Reaction (simple or severe/anaphylaxis)
"Indications for acute seizure prophylaxis in head injuries. What is the goal?
- Depressed Skull #
- Paralyzed & intubated pt
- Seizure at the time of injury
- Seizure in ED
- Penetrating Brain Injury
- Severe HI (GCS<8)
- Acute Subdural hematoma
- Acute Epidural hematoma
- Acute ICH
- Prior history of seizures
GOAL:
- To reduce the risk of early seizures (early prophylaxis) (decrease 66%) \prevents additional insult (increase ICP) to the brain -> does not prevent late post-traumatic seizures
