Trauma Flashcards
(93 cards)
1
Q
Frequent findings in a patient with a traumatic basal skull fracture include all of the following, EXCEPT:
a) Bruising behind the ear.
b) Facial nerve palsy.
c) Otorrhea.
d) Severe epistaxis.
A
d) Severe epistaxis.
2
Q
What GCS score will typically require intubation?
A
8
3
Q
What hemorrhage classifications will require blood instead of crystalloid?
A
Class III and IV hemorraghic shock
4
Q
What is the leading cause of trauma-type mortality in pediatrics?
A
MVCs
5
Q
What is the first sign of hypovolemia?
A
Tachycardia
6
Q
What is the leading cause of trauma during pregnancy?
A
MVCs, falls, and assaults
7
Q
What to do when a pregnant mother experiences supine hypotensive syndrome?
A
This is caused by aortocaval compression by the uterus and as such, you should place the mother in left lateral decubitus position while keeping the spine neutral.
8
Q
What are the 3 trauma zones of the neck?
A
Zone 1: Horizontal zone between clavicles and cricoid cartilage
Zone 2: Cricoid cartilage to angle of mandible
Zone 3: Angle of mandible to base of skull
9
Q
What zone of the neck requires operative exploration?
A
Zone 2 which is the zone between cricoid cartilage to angle of mandible
10
Q
A 36-year-old man sustains blunt chest trauma after a fall. He is hemodynamically stable. Which of the following conditions is an indication for a thoracotomy?
A.
Flail chest
B.
Undrained hemothorax after tube thoracostomy
C.
Initial chest tube output of 1000 mL
D.
Continuous chest tube drainage of more than 200 mL/h of blood for 4 hours
E.
Pulmonary contusion
A
Correct answer: D
11
Q
A 22-year-old woman, at 30 weeks’ gestation, sustains a stab wound to the right upper chest. In the emergency department, blood pressure is 75/55 and breath sounds are diminished in the right chest. She is anxious and gasping for air. The most appropriate first step is to:
A.
Insert two large-caliber peripheral intravenous lines and start crystalloid infusion.
B.
Manually displace the gravid uterus to the left side of the abdomen.
C.
Perform a needle decompression of the right chest.
D.
Perform tracheal intubation.
E.
Obtain a chest x-ray
A
Correct answer: C
12
Q
Loss of 20% of a patient’s blood volume is associated with:
A.
Oliguria
B.
Hypotension
C.
Tachycardia
D.
Confusion
E.
Blood transfusion requirement
A
C
13
Q
In trauma, what is the most common cause of mortality within seconds to minutes?
A
This is often due to due to overwhelming injury involving the brain, spinal cord, heart, airway, and great vessels (aortic transection).
14
Q
In trauma, what is the most common cause of mortality within “golden hour”?
A
Typically due to organ injury.
Second peak: the “golden hour” after trauma, during which intervention has greatest impact. Deaths in this period result from intracranial hemorrhage, hemothorax, tension pneumothorax, ruptured spleen, severe liver lacerations, femur fractures, and other multiorgan injuries.
15
Q
In trauma, what is the most common cause of mortality within “golden hour”?
A
Third peak: This occurs several days to weeks after trauma due to sepsis and multiorgan failure.
16
Q
What are the indications for a laparotomy? (5)
A
- Hemodynamic instability or peritoneal irritation
- Blunt trauma (with appropriate 4 criteria)
- Penetrating trauma (with appropriate previously described indications
- GSW penetrating the box (superior border: nipple line, inferior border: perineum and gluteal folds, flanks: posterio axillary line)
- Stab wounds that penetrate the anterior abdominal fascia
17
Q
For a blunt trauma, in what scenarios would a laparotomy be indicated? (4)
A
- Hypotension due to intraabdominal injury (do not waste time in the emergency department with more than a radiograph and type and crossmatch if hypotension persists)
- Positive focused assessment sonography in trauma (FAST) with hypotension
- Diaphragmatic rupture or free air
- Computed tomographic (CT) scan showing extravasation from liver or spleen injury, renal pedicle injury, pancreatic hematoma, mesenteric hematoma, or large amount of free fluid in pelvis not explained by solid organ injury (suggestive of small bowel injury)
18
Q
Stab wounds that penetrate the anterior abdominal wall fascia requires emergent laparotomy. How do you verify that the fascia has been violated? (4)
A
(1) Local wound exploration (although the false negative rate is nearly 30%)
(2) FAST, although if negative it does not exclude injury
(3) Diagnostic peritoneal lavage (DPL), which can be useful to identify injuries when patients have small amounts of free fluid without obvious injury
(4) Diagnostic laparoscopy
19
Q
What are the four interfaces for FAST?
A
FAST is used to look for free fluid in the
1. Pericardium
2. Hepatorenal fossa (Morrisson’s Pouch)
3. Splenorenal fossa
4. Pelvis/Pouch of Douglas
20
Q
What are the contraindications of Diagnostic Peritoneal Lavage?
A
Contraindications include
1. prior abdominal operations
2. coagulopathy
3. obesity
The stomach and bladder should be decompressed first to avoid injury.
21
Q
What is the greatest concern for trauma-related spleen injury?
A
Post-splenectomy infection from encapsulated bacteria
22
Q
What are the causative microorganisms post-splenectomy?
A
Streptococcus pneumoniae, Haemophilus influenzae, Neisseria mengitides
23
Q
What should be done as part of post-operative management post-splenectomy?
A
Vaccines should be given to cover encapsulated bacteria within 2 weeks of injury or immediately before patient is discharged.
24
Q
Which type of pancreatic injury can be managed non-operatively?
A
Contusions
25
A 28-year-old man was involved in a motor vehicle collision (MVC) requiring a splenectomy. He received 9 units of packed red blood cells (pRBCs) before arrival and 4 L of crystalloid. He was admitted to the intensive care unit (ICU) postoperatively, and now peak airway pressures are increasing. He is hypotensive to 82/46 mm Hg with a central venous pressure (CVP) of 15 mm Hg. He is no longer making urine and has a bladder pressure of 32 mm Hg. What is the most appropriate next step in this patient’s management?
A.
Computed tomography (CT) scan
B.
Continue volume resuscitation
C.
Decompressive laparotomy
D.
Add a vasopressor
Correct answer: C
26
A 32-year-old woman was involved in a high-impact MVC and arrived with a blood pressure of 78/46, heart rate of 130, and intubated. On primary survey she has multiple injuries, including an unstable pelvis and a distended abdomen. She has received 2 L of lactated Ringer’s solution (LR) and is now receiving blood with continued hypotension. What is the next step in this patient’s management?
A.
Exploratory laparotomy
B.
CT scan
C.
Focused assessment sonography in trauma (FAST) examination
D.
Angiogram
C
27
What is a pneumomediastinum a sign of?
Most commonly due to pulmonary injury with PTX, raises concern for esophageal or airway injury.
28
What is the definition of a flail chest?
At least two fractures per rib in two or more consecutive ribs.
29
What is the cardiac box?
Medial to the nipples, between the costal margin and clavicles
30
What are the three indications for a emergent thoracotomy in trauma patients?
1. Initial chest tube output exceeding 1500ml of blood
2. Bloody drainage exceeding 200 -250ml/h for 3 consecutive hours
3. Shock without other etiology
31
What is the immediate treatment for tension pneumothorax?
Needle thoacostomy. Insert a 14 gauge IV canula in the 2nd intercostal space until air is aspirated or gush of air is noted.
32
Whaat are the 5 principles of resuscitative thoracotomy?
1. Evacuation of pericardial tamponade
2. Control of massive hemorrhage from the heart, lungs, or great vesseels
3. Performance of internal cardiac massage.
4. Cross-clamping of descending aorta to improve cerebral and coronary blood flow
5. Evacuation of bronchovenous air in air embolism
33
What are the traditional indications for resuscitative thoracotomy?
a. Penetrating trauma with loss of vital signs in the trauma bay; or less than 15 minutes of cardiopulmonary resuscitation (CPR) en route
b. Blunt trauma with loss of vital signs in the trauma bay; or less than 5 minutes, CPR en route
34
What are the 3 contraindications to resuscitative thoracotomy?
a. No signs of life in the field. Signs of life: pupillary reactivity, spontaneous respiration, palpable pulse, cardiac electrical activity, or spontaneous movement
b. Penetrating trauma with greater than 15 minutes of CPR en route
c. Blunt trauma with greater than 5 minutes of CPR en route
35
What are the 7 causes of limb compartment syndrome?
1. Fracture
2. Intracompartmental or extracompartmental hematoma
3. Cast or external compressive dressings
4. Crush injury
5. Reperfusion injury secondary to ischemia, vascular injury
6. Burns—increased fluid load and capillary permeability
7. Intravenous (IV) infiltration
36
What are the late findings of compartment syndrome?
a. Paresthesia and paralysis
b. Pulselessness
c. Pallor
d. Poikilothermia—limb cold to touch
37
How to diagnose limb compartment syndrome?
1. A compartment’s perfusion pressure (ΔP) is the difference between the diastolic pressure and the compartment pressure.
2. ΔP ≤30 mm Hg is diagnostic of compartment syndrome and is an indication for fasciotomy.
38
What are the indications for fasciotomy in limb compartment syndrome?
a. Clearly positive examination findings
b. Perfusion pressure less than 30 mm Hg
c. Mangled or crushed limb
d. Associated vascular injuries with significant ischemia time (>6 hours) or combined arterial and venous injuries
39
What are the components of the physical exam in a patient who presents with a pelvic trauma?
1. Rule out open fracture (perineal, vaginal, and digital rectal examinations on all applicable patients).
2. Inspect for hematoma, hemorrhage, and contusions over perineum and flanks.
3. Rule out bladder injury with evaluation for gross hematuria. Gross hematuria requires a cystogram.
4. Note leg length or rotational discrepancies.
5. Assess pelvic stability (done by one person, gently, once).
40
What is the leading cause of death in patients with pelvic trauma?
Pelvic hemorrhage
41
In trauma patients, what are the 6 hard signs of a vascular injury?
1. Absent distal pulse
2. Pulsatile bleeding
3. Expanding hematoma
4. Audible bruit
5. Palpable thrill
6. Ischemic limb
42
In patients with extremity injuries, what is an indication of immediate surgical exploration?
All patients with hard signs of arterial injury require surgical exploration immediately. These patients should be monitored closely postoperatively for compartment syndrome or undergo fasciotomy during index surgery.
43
What type of burn patients can be managed as an outpatient?
<5% of total body surface area
44
What % of total body surface area of burns should a patient be referred for evaluation?
> 5-10%
45
When should a patient be referred to a burn centre? (8 scenarios)
1. Partial-thickness burns of more than 10% TBSA in all patients
2. Burns that involve the face, hands, feet, genitalia, or major joints
3. Full-thickness burns in any age group
4. Electrical, chemical, or inhalation injury
5. Burn injury in patients with preexisting medical conditions that may complicate management, prolong recovery, or affect mortality
6. Any patient with burns and concomitant trauma in which the burn injury poses the greatest risk or morbidity and mortality
7. Children in hospitals without qualified personnel or equipment for appropriate pediatric care
8. Patients who will require special social, emotional, or rehabilitation intervention, including victims of abuse or neglect
46
When is prophylactic intubation/tracheostomy indicated in a BURN patient? (4)
(1) Loss of consciousness or decreased mental status with inability to protect airway
(2) Extensive burns greater than 60% TBSA
(3) Increasing stridor or hoarseness
(4) Evidence of posterior pharyngeal burn or injury
47
What is the major contributor to mortality in BURN patients?
Inhalation injury
48
What is the treatment for CO poisoning?
Treatment—100% O2 reduces half-life of CO
(a) Follow with carboxyhemoglobin levels and continue to treat until levels are 10%–15%.
(b) Persistent metabolic acidosis despite adequate volume resuscitation implies CO poisoning of cellular respiration.
Carboxyhemoglobin levels greater than 50% are potentially lethal.
49
Up to how many hours post-burn should one monitor for thermal injury of the upper airway?
Upper airway obstruction may occur up to 72 hours post injury. Maximal edema is seen between 12 and 24 hours.
Usually limited to upper airway due to heat absorptive capacity of oropharynx. Steam burns are the exception that may affect lower airways.
50
When should you suspect an inhalation injury in a BURN patient?
(a) Closed-space injury (e.g., house fire)
(b) Presence of facial burns, singed nasal hairs, bronchorrhea, carbonaceous sputum, wheezing and rales, tachypnea, progressive hoarseness, and difficulty clearing secretions
51
What is the initial treatment for an inhalation injury?
1. Immediate O2 supplementation
2. Ventilatory assistance
3. O2 sat monitor
4. Art line for ABG
5. Bronchodilators
6. BAL to remove debris, if necessary
52
What does first degree burn mean?
First degree—Only the epidermal layer is involved.
(1) Painful to palpation
(2) Pink in appearance without blistering
53
What does second degree burn mean?
Second degree (partial thickness)—The dermal layer is only partially involved, classified as superficial and deep partial thickness.
(1) Painful to palpation
(2) White to pink in appearance; blebs and blisters may be present.
(3) Epithelialization occurs from epithelial cells surrounding hair follicles or sweat glands (skin appendages) and from the wound edges and is markedly delayed with deeper injury.
(4) Deeper burns result in the destruction of epidermal appendages in reticular dermis and often require excision.
54
What are the four characteristics of a second degree burn?
(1) Painful to palpation
(2) White to pink in appearance; blebs and blisters may be present.
(3) Epithelialization occurs from epithelial cells surrounding hair follicles or sweat glands (skin appendages) and from the wound edges and is markedly delayed with deeper injury.
(4) Deeper burns result in the destruction of epidermal appendages in reticular dermis and often require excision.
55
What is third degree burn?
Third degree (full thickness)—The entire dermal layer is affected.
(1) All dermal appendages destroyed
(2) Insensate area
(3) White, black, or red in appearance with a dry and leathery (inelastic) texture
56
What does third degree burn look like?
(1) All dermal appendages destroyed
(2) Insensate area
(3) White, black, or red in appearance with a dry and leathery (inelastic) texture
57
What is fourth degree burn?
The estimate of the TBSA of the burn injury is the sum of second- and third-degree burns only.
58
Which degrees of burn can you estimate for the total body surface area of burn injury?
The estimate of the TBSA of the burn injury is the sum of second- and third-degree burns only.
59
How do you estimate the total body surface area that was burned? (i.e. what is the rule of 9's for adults)
(1) Head and neck: 9%
(2) Each upper extremity: 9%
(3) Each lower extremity: 18%
(4) Anterior trunk: 18%
(5) Posterior trunk: 18%
(6) Perineum: 1%
60
How do you estimate the PEDIATRIC total body surface area that was burned? (i.e. what is the rule of 9's for KIDS)
(1) Head and neck: 18%
(2) Each upper extremity: 9%
(3) Each lower extremity: 14%
(4) Anterior trunk: 18%
(5) Posterior trunk: 18%
(6) Perineum: 1%
61
What lines do you need in a patient who presents with significant burns?
1. 2 large bore IV (> 18 gauge)
2. Central venous access, especially if vasopressors are needed
3. Central venous pressure or pulmonary catheters are used in patients with cardiac or pulmonary disease, questionable fluid status, or hemodynamic instability.
62
What is the Parkland Formula for resuscitation of BURN patients?
Parkland formula:
This resuscitation scheme uses lactated Ringer (LR) solution at 3–4 mL/kg/% burn,
with half the total volume given over the first 8 hours (calculated from the time of burn),
and the other half over the following 16 hours.
63
At what % of TBSA should you consider enteral feeding?
TBSA > 20%
64
When will a burn patient require an escharotomy?
Patients with burns to extremities and chest to prevent compartment syndrome and respiratory compromise.
Extremity burns should be managed with elevation of the affected extremity
65
What type of burns are at increased risk of compartment syndrome?
Compartment syndrome is especially important to look for with electrical burns.
66
When should an escharotomy be performed in a patient with a circumferential chest burn?
Escharotomies should be performed in the presence of increased peak pressures, increased partial pressure of carbon dioxide (PaCO 2), and decreased compliance.
67
Which type of medication is contraindicated in a BURN patient?
Prophylactic antibiotics are contraindicated.
68
What are the three medications required for the management of a BURN patient?
1. Tetanus prophylaxis—unless received booster within last 5 years
2. Ulcer prophylaxis—may use proton pump inhibitor or H2 blocker, should attempt at enteral administration as soon as is safe for the patient and a route for enteral administration has been established
3. Multivitamins (particularly vitamin C and the other antioxidants) in tube feedings
69
What happens to the metabolism of a BURN patient?
Metabolism—There is a state of wound–, central nervous system–, and stress hormone–induced hypermetabolism.
a. Begins at 48 hours after burn
b. Caloric needs increased 1.3–2 times normal
c. Characterized by increased oxygen consumption, heat production, increased body temperature, hypoproteinemia caused by catabolism and wound exudate, gluconeogenesis, and hyperglycemia
d. Gradually returns to normal after wound is closed and the inflammation is resolved
70
What happens to the immune function of a burn patient?
All aspects of the immune function are initially depressed, including:
(1) Cellular-mediated immunity (T cells), humoral-mediated immunity (B cells), opsonization caused by decreased complement and antibodies, decreased phagocytosis and bactericidal activity by macrophages and neutrophils, and loss of natural barrier function of the skin
b. Predisposes the patient to infections and multiorgan failure
71
What is the goal of topical agents in a BURN patient?
Goal is to decrease wound sepsis, not prevent colonization of eschar.
72
How do you manage the area of burn in patients with a 1st degree burn?
Treat with minor care and symptomatic pain control
73
How do you manage the area of burn in patients with partial thickness burn?
Partial-thickness burns—Initially wash with antiseptic soap (e.g., chlorhexidine gluconate), remove debris, unroof vesicles.
Apply topical agents (bacitracin/Silvadene/Sulfamylon) wrapped with a nonadherent dressing.
74
How do you manage the area of burn in patients with deep thickness burn?
Deep partial-thickness, full-thickness burns—Initially treat as for partial-thickness burns. If there is no healing after 2 weeks, grafting is required.
75
When should early excision and grafting should be performed in a BURN patient?
Perform within 2–7 days of admission for obvious deep second- and third-degree burns. Should not be performed less than 24 hours after admission due to interference with resuscitation and wound evolution.
76
How do you estimate the metabolic rate of a patient with at least partial thickness burn?
The metabolic rate is proportional to burn size up to 40%–50% TBSA burns. Total body O2 consumption and water loss are proportional to burn size.
77
How much are the nitrogen losses in a BURN patient?
Nitrogen losses may be as great as 150–200 g/day and are calculated with 24-hour urine blood urea nitrogen (BUN) measurements, as well as estimates for insensible losses.
78
When should enteral feeding be started in a BURN patient?
Enteral (nasoduodenal) route is preferred and should be started during first 12 hours after injury. Leads to decreased infection, complication rates, and decreased cost. Lower rates of stress ulcers and ileus
79
What is the most common infection in BURN patients?
Pneumonia
1. Early pneumonia—commonly the result of gram-positive organisms
2. Later pneumonia (>7 days after hospitalization)—typically the result of gram-negative organisms
3. May occur in up to 50% of burn patients. More common in intubated patients, although can occur in nonintubated patients
80
What is the most common causative microorgonism of EARLY pneumonia in BURN patients?
Early pneumonia—commonly the result of gram-positive organisms
81
What is the most common causative microorgonism of LATER pneumonia pneumonia in BURN patients?
Later pneumonia (>7 days after hospitalization)—typically the result of gram-negative organisms
82
How does wound sepsis occur in an untreated burn wound?
Surface bacteria proliferate, migrate through nonviable tissue, pause at the subeschar space, and when microbial invasiveness “outweighs” host defense capability, invade viable tissue with microvascular involvement and systemic dissemination.
83
Why are systematic antibiotics ineffective against sepsis in a patient with full-thickness burn?
Avascularity and ischemia of full-thickness burn wound allow microbial proliferation and prevent delivery of systemic antibiotics and cellular components of host defense.
84
Are culture of burn wound helpful in bacterial colonization?
Cultures of burn wound surface do not accurately predict progressive bacterial colonization or incipient burn wound sepsis. Bacterial growth is best monitored by semiquantitative burn wound biopsy.
85
What are the 5 most common causative pathogens in nosocomial burn infection?
1. Staphylococcus aureus
2. Pseudomonas aeruginosa
3. Acinetobacter baumanii
4. Enterococcus spp.
5. Candida albicans
6. BONSU: other gram negative rods
86
How to prevent burn infections (3)
1. Daily dressing changes and application of topical agents
2. No indication for prophylactic antibiotics
3. Strict hand washing
87
What tissue has the least electrical resistance?
Electrical resistance of tissues—(from least to most) nerve, blood, blood vessel, muscle, skin, tendon, fat, and bone
88
At what voltage does electricity cause ventricular fibrillation as opposed to cardiac arrest?
High-voltage currents usually cause cardiac arrest, whereas low-voltage (<440 volts) currents usually produce ventricular fibrillation.
89
Why do you need to put the patient with an electrical injury in a cervical spine collar?
Protect against neurologic damage caused by fractures of the spine.
a. Place in cervical spine collar and on a long backboard to immobilize the entire spine.
b. Tetanic contraction of muscle may cause fractures of the cervical and lumbosacral spine and long bones.
90
27) All of the following are principles of the management of severe frostbite, EXCEPT?
a. rapid rewarming
b. limb elevation
c. early amputation for frank gangrene
d. antibiotics
C
91
41) A 39 year old man develops hypovolemic shock due to splenic rupture caused by a motor vehicle crash. Which of the following treatments will help treat his hypovolemia as he is brought to the operating room?
a. use of the pneumatic anti-shock garment (MAST pants)
b. use of Trendelenburg position (elevation of the lower extremities above the level of the heart)
c. use of epinephrine infusion to raise blood pressure
d. rapid infusion of normal saline
d. rapid infusion of normal saline
92
45. A 23 year old man sustains a closed right midshaft tibia-fibula fracture in a motorcycle crash. He has no other injuries. His leg is severely painful, especially with passive stretching. He has decreased skin sensation in his right lower limb. Dorsalis pedes and posterior tibial pulses are nonpalpable but can be found with a Doppler ultrasound monitor. The most appropriate management now would be?
1) angiography
2) compartment pressure measurement
3) splint and elevate right leg and reassess in four hours
4) fasciotomy
4
93
What is bergmans triad?
Fat emboli syndrome
1. Mental status changes
2. Petechiae
3. Dyspnea
