Trauma Flashcards
1
Q
Management of profuse bleeding liver
A
Pack liver and close abdomen with bagota bag
2
Q
Management of burn victim that complains of tingling of his leg and it appears dusky
A
Escharotomy
3
Q
Formula for fluid resuscitation for burn patient and which fluid
A
Harmtan or Ringer lactate
2 ml of lactated Ringers x patients body weight in kg x % TBSA for second- and third-degree burns
3ml if <14 or <30kg child
4ml if electrical burns
1/2 to be given in first 8 hrs
Remaining half in next 16 hrs
To maintain urine output of 30ml/hr
4
Q
Mx of very hypocalcaemic patient
A
10ml of 10% Ca gluconate over 10 mins
5
Q
Best access for bilateral haemopneumothoraces and a suspected haemopericardium
A
Clam shell thoracotomy
6
Q
Imaging for facial trauma planning
A
CT facial bones
7
Q
When to CT head in 1 hour
A
GCS of 12 or less on admission
GCS < 15 2 hours after admission
Suspected open or depressed skull fracture
Suspected skull base fracture (panda eyes, Battle’s sign, CSF from nose/ear, bleeding ear)
Focal neurology
Vomiting > 1 episode
Post traumatic seizure
?anticoagulants
8
Q
Best method for re-warming after hypothermia
A
Warmed Intra peritoneal
9
Q
Le Fort fractures
A
1- horizontal nasal septum through maxilla and backwards through pterygoid region, loose teeth
2-pyrimidal from nasofrotnal suture to process of maxilla, infraorbital parasthesia, palatal mobility, malocclusion fo teeth
3- horizontal across frontoethmoid, superior lateral orbit, craniofacial dislocation, haemotympani, flat face
10
Q
CVP 13 with reduced BP
A
Tamponade
11
Q
PE ECG changes
A
PRAT
Peaked p waves
RAD, RBBB
Atrial arrhythmia
TWI- V1-3
Tall R V1
S1,Q3,T3
12
Q
Haematemesis following burns cause
A
Curling ulcer
13
Q
Management of flail chest
A
If sats <90
Intubate and ventilate
14
Q
Calculate GCS
A
E- spontaneous
To speech
To touch
None
S- normal
Confused
Words
Sounds
None
M- normal
Localise to pain
Withdraws
Abnormal flexion to pain
Extension
None
15
Q
Presentation of aortic dissection
A
Tearing chest pain
Hypertensive /hypo
Pregnancy or connective tissue
Can compromise right CA- inferior ischaemia
- A blood pressure difference greater than 20 mm Hg
- Neurologic deficits (20%)
- Early Diastolic murmur may be found
16
Q
What meds worsen compartment syndrome
A
Anticoagulants
17
Q
Patient has raised ICP with CT showing increased oedema what tx
A
Mannitol
18
Q
CXR findings of diaphragm rupture
A
Hemidiaphragm is not visible
Bowel loops in the lower half of the hemi-thorax
Mediastinum is displaced
Often caused by A lateral blunt injury during a road traffic accident
19
Q
Massive PE management
A
Thrombolysis with alteplase
20
Q
Vertigo, dysarthria and collapse dx
A
Basillar artery occlusion
21
Q
Lateral medullary syndrome sx
A
ipsilateral ataxia, nystagmus, dysphagia, facial numbness, cranial nerve palsy with contralateral hemisensory loss §
22
Q
Youngster with left flank bruising ix
A
If harm-dynamically stable-First USS
23
Q
High K, Low Na, hypotensive tx
A
Hydrocortisone 100mg IV
24
Q
Patient with penetrating thorax trauma followed by an arrest mx
A
Thoracotomy
25
Ct shows cerebral contusion but no localising clinical signs
Intra cranial pressure device monitoring
26
Mx torsades de pointes
MgSO4
27
Dx of flail chest
> /= 2 rib fractures in more than 2 ribs
28
Test for CSF
Beta 2 transferrin assay
29
ECG changes for PCI or thrombolysis
ST elevation of > 2mm (2 small squares) in 2 or more consecutive anterior leads (V1-V6) OR
ST elevation of greater than 1mm (1 small square) in greater than 2 consecutive inferior leads (II, III, avF, avL) OR
New Left bundle branch block
30
Sudden anaemia and low reticulocytes
Parvovirus
31
Sick euthyroid biochem
Everything low with systemic illness
In the majority of cases however the TSH level is within the normal range (inappropriately normal given the low thyroxine and T3).
Reversible with illness recovery
32
When do patients with burns require fluid resuscitation
Adults >15% BSA
Children >10%
33
When should burns patients be transferred to burn centre
All full thickness
>2% in children, 5% adults
Partial >5 in <16 or >20 in adults
Hands, feet, perineum,
extreme of ages,
circumferential burns,
NAI
Not healed in 2w
Signs of inhalation injury
34
Major haemorrhage transfusion in trauma
Packed red cells, FFP and platelets are administered in a ratio of 1:1:1.
35
Most common area for aortic rupture
Distal to subclavian artery
36
Rib fracture with pneumothorax mx
Chest drain
37
Ix of trauma in pregnancy
FAST scan (high false negs in pregnancy)
if neg - CT
38
Colon trauma mx
If unstable- Resection and colostomy
39
Definitive mx of reduced gcs and unilateral dilated pupil
Parietaltemporal craniotomy
Rural units or no neurosurgery- Burr hole
40
CT head immediate in paeds
* Loss of consciousness lasting more than 5 minutes (witnessed)
* Amnesia (antegrade or retrograde) lasting more than 5 minutes
* Abnormal drowsiness
* Three or more discrete episodes of vomiting
* Clinical suspicion of non-accidental injury
* Post-traumatic seizure but no history of epilepsy
* GCS less than 14, or for a baby under 1 year GCS (paediatric) less than 15, on assessment in the emergency department
* Suspicion of open or depressed skull injury or tense fontanelle
* Any sign of basal skull fracture (haemotympanum, panda' eyes, cerebrospinal fluid leakage from the ear or nose, Battle's sign)
* Focal neurological deficit
* If under 1 year, presence of bruise, swelling or laceration of more than 5 cm on the head
* Dangerous mechanism of injury
41
Mx of spleen trauma
Conservative- grade 1-3
Resection
Hilar injuries- grade 4 or 5
Major haemorrhage
Major associated injuries
42
Tx of VT and drug CI in VT
Tx- amiodarone
CI- verapamil
43
Parasthesia, tinnitus and drowsy after LA mx
Intralipid 20%
44
Metoclopramide SE and tx
Oculogyric crisis- Restlessness, agitation
Involuntary upward deviation of the eyes
Mx- Procyclidine
45
Full thickness burns to torso and increasing ventilation pressure mx
Escharotomy
46
Orbital apex syndrome
Extension of superior orbital fissure syndrome and includes compression of the optic nerve passing through the optic foramen. It is indicated by features of superior orbital fissure syndrome and ipsilateral afferent pupillary defect.
47
If burn patient has soot in oropharyngeal and burn nasal hairs- management?
Intubation
48
How short gut syndrome causes broad VT
Hypomagnesaemia
49
Latest sign in compartment syndrome
Loss of pulse
50
Prilocaine SE and mx
methaemoglobinaemia
Cyanosis and dyspnoea. This disorder occurs because of the change haemoglobin to a ferric subtype rather than ferrous (Fe2+)
Give methylene blue
51
Mx of mediastinal travelling trauma
o All patients should undergo CT angiogram and Oesophageal Contrast Swallow. o Indications for thoracotomy are largely related to blood loss.
52
Mx of haemothroax
A wide bore 36F chest drain.
o Indications for thoracotomy include:
→ loss of more than 1.5L blood initially
→ ongoing losses of >200ml per hour for >2 hours.
53
When to use large vs small chest drains
* Large bore chest drains -trauma and haemothorax drainage.
* Smaller diameter chest drains - pneumothorax or pleural effusion drainage.
54
Mx of aortic dissection
Beta-blockers: aim HR 60-80 bpm and systolic BP 100-120 mm Hg.
Urgent surgical intervention: type A dissections. This will usually involve aortic root replacement
55
Management of urethral trauma
Ascending urethrogram
Suprapubic catheter
56
Pelvic fracture and void inability
Suspect bladder or urethral injury
57
Mx of bladder injury
IVU or cystogram
If low grade- contusion, hamatoma- conservative
Extraperitoneal- catheterise for 10d
Laparotomy if intraperitoneal (direct blow)l, conservative if extra (pelvic fracture)
58
Mx of vascular trauma
Simple lacerations of arteries is directly closed
Transection of the vessel is treated by either end to end anastomosis (often not possible) or an interposition vein graft.
59
Superior orbital fissure syndrome
Complete opthalmoplegia and ptosis (Cranial nerves 3, 4, 6 and nerve to Levator Palpebrae Superioris)
→ Relative afferent pupillary defect
→ Dilatation of the pupil and loss of accommodation and corneal reflexes
→ Altered sensation from forehead to vertex (frontal branch of trigeminal nerve)
60
Nasal fracture mx
→ Control epistaxis
→ CSF rhinorrhoea implies that the cribriform plate has been breached and antibiotics will be required.
→ Usually best to allow bruising and swelling to settle and then review patient clinically.
→ Major persistent deformity requires fracture manipulation, best performed within 10 days of injury.
61
Retrobullar haemorrhage presentation
Pain (usually sharp and within the globe)
Proptosis
Pupil reactions are lost
Paralysis (eye movements lost)
Visual acuity is lost (colour vision is lost first)
62
Retrobullar haemorrhage mx
Mannitol 1g/Kg as 20% infusion, Osmotic diuretic, Contra-indicated in congestive heart failure and pulmonary oedema
Acetazolamide 500mg IV, (Monitor FBC/U+E) Reduces aqueous pressure by inhibition of carbonic anhydrase (used in glaucoma)
Dexamethasone 8mg orally or intravenously
In a traumatic setting an urgent cantholysis may be needed prior to definitive surgery.
63
Skull fracture types
Linear- line
Comminuted - multiple fragments
Diastasis - suture line
Basillar- base
64
Min cerebral perfusion pressure in adults and kids
70 adults
40-70 children
65
Interpretation of pupil size in head injury
Unilateral dilated- 3rd nerve compressed- tentorial hernia
Bilateral dilated- poor CNS, bilateral 3rd
Unilateral dilated -Marcus gunn pupil- optic nerve injury
66
Escahrotomy incisions
Lateral aspects
Neck, arms, torso, legs
67
Indication for throacotomy for haemothorax
>1500mls or >1/3 patients blood
Or continued >200ml/her for 2-4 hrs
Or ongoing transfusion required
68
What happens in ebb phase
Decreased body temp
Decreased oxygen
Lactic acidosis
Increase stress hormon
Decreased insulin
Hyperglycaemia
Insulin resistance
69
What happens in flow phase
Increased body temp
Increase o2 consumption
Negative nitrogen balance
Increase stress hormones
Hyperglycaemia - lipolysis and proteinolysis
Immunosuppresion
70
Type A vs B dissection
Type B- distal to subclavian artery
71
% BSA of palm
1%
72
Shock classes based of HR, RR, UO
1- No tachy
2- <120, RR>20, UO 20-30
3- HR 120-140, RR 30-40, 5-15
4- HR >140, RR >35, No urine
73
Grading splenic trauma
1- sub capsular haematoma >10% or laceration <1cm
2- laceration 1-3cm
Haem- 10-50%
3- >3cm or >50%
4- Laceration involving segmental or hilar vessels - major devasc
5- complete shattered spleen or hilarity injury- complete devasc
74
Neurogenic shock signs
Bradycardia, warm peripheries, hypotensive, BP not responding to IV fluids
75
Child pyrexia with an unhealed burn
Toxic shock syndrome
76
Normal compartment pressure and when to treat
3-4mmHg
>30 fasciotomy
Diastolic and compartment <30 difference- fasciotomy
77
Flexor tendon zone injuries
1- between DIP and middle phalanx
2- between 1 and distal palmar crease
3- DPC and distal margin of carpal tunnel
4- overlying carpal tunnel
5- forearm and wrist up
78
What should be given to partial thickness burns
Non adhesive dressing
79
GI changes with burns
Curling ulcer
Decrease acid production
Acute dilatation
Ileus
80
Ix of odontoid process
Open mouth
But usually a CT if suspected
81
Ligaments of odontoid
Alar- occipital condyles
Apical- top of odontoid to foreamen magnum
82
Management of shoulder dislocation
Closed reduction under sedation and analgesia
Arm in sling until ortho review
Kocher- traction on adducted arm, externally rotated and adducted
Hippocratic- supine, heel in axilla while traction
83
Grade liver injuries
1- sub capsular haematoma <10% or laceration <1cm parenchymal depth
2- 10-50%, 1-3cm and <10cm long
3- >50% or >3mc depth
4- laceration 25-75% of hepatic lobe or 1-3 segments
5- >75% of lobe of >3 segments
84
pCO2 effects on blood blow and CSF
Reduced CO2 causes vasoconstriction
This reduces blood flow and reduces ICP
85
Full thickness burns appearance
Leathery white or charred black
86
Escharotomy timings and IV access in burns
Deep or full thickness around chest can cause resp arrest so may need to be done before transfer to burns unit
IV access can be done through burns skin
If percutaneous difficult can do IV cut down
87
When should tetanus be given in trauma
If penetrating injury
And not been immunised in past 10y
88
GCS to intubate
<8
89
Pregnant lady and hypovolaemic shock signs
Late due to big increase in circulation
Fetus first to suffer
90
Grading renal injuries
1- contusion, subcapsula haematoma, no laceration
2- perirenal haematoma, cortical laceration <1cm
3- >1cm without urinary
4- laceration through corticomedullary junction into collection or vascular,
Renal segmental artery or vein injury with contained haematoma
5- shattered kidney or vascular
91
Tranfusion in haemorrhage in trauma
Whole blood
Alternatively 1:1:1 abc, plts, plasma
92
Structure damaged on medial ankle twist
Deltoid:
Anterior tibiotalar, posterior tibiotalar, tibiocalcaneal, tibionavicular,
93
Structure damaged on lateral ankle twist
Anterior talofibular
Posterior talofibular
Calcaneofiubular
94
Cardiac tamponade effect on CVP, PAP and JVP
CVP PAP elevated
Increased JVP on inspiration- Kussmaul sign
Pulsus paradoxis- drop in systolic on inspiration
95
Penetrating abdo injuries usually involved
Small bowel
Then colon
then liver
96
Mx of colles fracture
Manipulation if significant displacement
Reduction
Dorsal back slab
Distal fragment in palmar flexion and ulnar deviation
97
Mx of hypothermia
Slow rewarming 1C per hour
AS may cause pul/cerebral oedema
Warming with IV fluid, blankets and bear hugger
98
Types of odontoid fracture
1- tip of peg
2- base of dens, commonest, extension
3- base of dens- extend into body of axis
99
Mx of odontoid fracture
1- usually stable
2- surgical reduction and halo and body cast
If no fusion by 12w - may need fusion
100
Hangman fracture and mx
From hyperextension
Peduncles of C2
External immobilisation
101
Jefferson fracture
Ant and post arches of C1
Caused by blow to back of the head
102
Le fort 3 fracture with unstable airway mx
Cricothyroidotomy
103
Most important thing to check with circumferential burns
Peripheral pulses and cap refill
104
Ix after sternal and rib fracture
CT
If concerned about cardio contusion- serial trops and ECG
105
Normal CVP range
3-8cmH20
106
Hypertrophic scar features
Normally regresses with time
Confined to margin Respond to steroids, compression therapy
Occur with deep dermal burns
Wounds by secondary intention
Crossing flexor or tension lines
107
Main function of menisci
Shock absorbers
108
Main cause of hypoxia with flail chest
Pulmonary contusion
109
Physiological response to shock
Vasoconsritciton
Haemodilution
Tachycardia
110
Supracondylar fracture, unable to flex thumb and do ok sign, no sensory defect
AIN damage
111
Types of joints
Synovial- hylaine capsule with synovial fluid
Fibrous- a fixed joint where collagenous fibrous connective tissue connects two bones. Fibrous joints (synarthroses) are usually immovable and have no joint cavity
Cranial suture, between ulnar and radius, tibia and fibular
Cartilaginous- bone meets cartilage
Primary- ribs and epiphyses
Secondary- union of bones with thin lamina of hyaline cartilage
112
Most common salter Harris
2
113
Ix for haematocele
US
114
Signs of teste rupture on US
Hetegeneous pattern of testicular parenchyma and disruption fo tunica albuingea
115
Control of poorly controlled diabetes with infected burn
VRII until infection improves
116
What should an amputated digit be kept in
Wrapped in saline soaked gauge
Plastic bag chilled in ice water
117
Specific placing of chest drain
Use US
4th 5th ICS
In between anterior and mid axillary below axilla
118
Abdo trauma, pregnant, no free fluid on FAST scan, what next
CT
119
BSA of perineum and arms
Arms- front 4.5% back 4.5%
Perineum 1%
120
ml required for fluid resuscitations in electrical burns
4ml x BSA x weight
121
Open fracture, severe bleeding, HR 220 what should you do
Apply direct pressure to control bleeding
122
Which shoulder dislocation causes axillary nerve damage
Anterior
123
What does Le fort 3 fracture go through
Nasofrontal suture
Maxilla frontal suture
Orbital wall
Zygomatic arch
124
Irrigation amount for open fracture
3L guistillo 1
6L for 2
9L for 3
125
What should be monitored in electrical burns
Myoglobin
Renal failure- urinary output
If myoglobin detected- fluid resuscitations to aim for 100ml/h of urine
126
Hydrofluroic acid burn effects on electrolytes
Hypocalcaemia
127
Blow to lateral knee can cause
Unhappy triad
ACL, MCL, MM
MM as attaches to Mcl
128
Primary intention process
Occurs when wound is closed between 12-24 hrs
Wound edges meet
Epithelisaition occurs within 48 hrs
Immediate inflammatory
Prolif phase- migration of fibroblast and capillaries into wound lasting 3w
Collagen detected day 4
129
Main cells involved in soft callus formation
Osteoblasts and fibroblasts
130
Most common fracture in direct blow to patella
Stellate
Comminuted
131
Mx of patella fracture
Undisplaced - cylinder cast
Displaced transverse- internal fixation
132
X ray signs for aortic injury
Wide mediastinum
Obliteraated aortic knuckle
Depressed left bronchus
Large left haemothorax
Plerural cap
Depressed right bronchus
133
Best method for monitoring fluid requirements in trauma and what it should be kept at
Urine output
>0.5ml/kg/hr
134
Fat embolism feeatures
Hypoxic
Petechial rash on trunk axilla and conjunctiva
Confusion
135
Excessive crystalloids in trauma patients can cause
ARDS
136
Structure most likely damaged in tracheostomy
Thyroid ima
Anterior jugular retracted laterally
137
Area of incision for trachy
Midway from cricoid to sternum
138
Fluids used in hypovolaemic shock
Hartman for 1 or 2 may be enough
Hartmann plus blood products for 3
139
Symptoms and signs of orbital floor fracture
Structure may herniate through ethmoidal or maxillary sinus
Trapdoor appearance on x ray
Occular injury- enopthalmos and diplopia especially on upward gaze
140
Burn types and symptoms
Superficial- red and painful no blister
Superficial partial thickness- superficial dermis- blisters, painful- papillary dermis
Deep partial- most of dermis- pale some blisters, not much pain- reticular dermis
No eschar
Both can look lobster red with mottling
Full thickness- subcutaneous fascia, waxy, painless
Eschar
141
Most common organ damaged with blunt trauma
Spleen
142
Mortality of open pelvic fractures
50%
143
Traumatic AV fistula features
AV fistula forms after trauma to artery and vein
If large can cause ischamia, left to right shunt can cause heart failure
144
When to immobilise C spine and with what
Unconsious with traum a
Blunt injury above clavicle
Multi systemic trauma
Initially immobilised in line position - no traction- if resistance don't
Use rigid collar, sandbags and tape
145
Hypovolaemic shock on pulse pressure
Narrows
146
Patient with neck wound- stable, mx
CT angio head and neck then theatre
147
Cause of absent left breath sounds after intubation
Intubation of right mainstream bronchus
148
Cushing response
Decreased HR
Increased BP
Increased PP
Decreased RR
149
Most common complication of urinary extravasation of kidney
Urinoma
150
Physiological effects of burns
Hyperthermia
Hypermetabolic state
Immunosuppression
151
Arms in supine position in surgery- which nerve at most risk of damage
Ulnar
152
Adequate urine output in children
1-2ml/kg/hr
153
Meds used in tx frostbite
Aspirin
154
Subaponeurotic haematoma symptoms
Between galea and pericranium
Large fluctuant mass
Gradually resolves by selfW
155
Which bones are difficult to break but if broken suggest high energy trauma and extensive soft tissue damage due to location
First rib
Sternum
Scapula
156
Mx of urethra trauma
Retrogrdae urethrography first
Then suprapubic cathete r
157
Mx of liver injury
If patient stable and low grade- conservative
Unstable- lapratoy and liver packing
158
What is a FAST scan likely to miss
Kidney injury as retroperitoneal
159
Ix for kidney injury
Delayed phase CT with contrast
160
Pain control of NOF
If uncontrollable on opioids and para
Fascia iliaca block
161
If elderly and non displaced NOF mx
If well- IF
If poor mobiliser, imapired- Hemi
162
When to intubate
Inadequate ventilation - ie RR >35 or low is asthma
Specific- head injury, GCS <8, raised ICP or burns
Chest injury- flail chest, pulmonary contusion
High spinal trauma
163
Mx of hip dislocations
Allis technique
flex knee to 90
Apply longitudinal traction
With someone applying counter traction at ASIS
Adduct and IR then extend
164
When may amputation by necessary
Uncontrollable haemorrhage in open fracture
165
Penile fracture
Break of tunica albuginea of penis (fibrous capsules of erectile bodies)
If bleeding in Bucks fascia- only in penis
If Bucks breaks- butterfly in perineum
166
Wound management of open pneumothorax
Wound dressing on 3 sides
Blocking entry when inhaling
Allowing exit when exhaling
167
Most effective preventative of fat embolisms
Early reduction
168
PP and peripheries in neurogenic shock
Warm peripheries
Widened pulse pressure
169
Types of blast injury
1- primary - direct pressure- damage to gas organs, tympanic
Secondary - fragments
Tertiary - impact With objects
Quaternary - related injuroes, illnesses not related to 1-3- burns
170
Mx of penile fracture
Surgical exploration
171
What burns are used in parkland formula
All part from superficial
Ie erythema without blisters
172
Chemical burns treatment, acid vs alkali
Flushed with large amounts of water
Of dry brushed first
Alkali penetrate deeper
Acid hurts more
Hydrofluric causes low calcium - require systemic Ca
173
Patient presents with hoarseness voice, subcutaneous emphysema, tender around neck - dx and mx
Laryngeal fracture
Endotracheal intubation with C spine immobilisation if unstable
174
Weber fracture
Fibular fracture
Look at level of syndesemosis where fibular joins tibia just above talus
175
How much of tibia should be kept for below knee amuptation
At least 8cm
15cm desirable
176
Flap vs graft
Graft only take on well vascularised surface- wouldn't on bone
Split- no limit, full smaller
Flap- limited by territory blood supply
177
Most common bladder injury
Extraperitoneal perf by pelvic fracture
178
Signs of cervical cord injiry
Flaccid areflexia
Diaphragmatic breathing - loss of intercostal muscles
Flex but not extend the elbow
Hypotension with bradycardia
Priapism
179
Movements unable to do if common fibular damage
Inversion, eversion and dorsiflexion
180
Trauamatic amputation haemorrhage mx
Tourniquet
181
Which areas to look in FAST scan
Looks for fluid in 4 areas (hepatorenal, splenorenal, pelvic, and pericardial spaces)
182
Determining bladder vs urethral injury
Bladder- CT cystogram
Urethral- retrograde uretrogram
183
Rhabdomyolysis electrolytes
Fluid and electrolyte abnormalities
Hypovolemia
Acidemia
Hyperkalemia
Hyperphosphatemia and hypocalcemia
184
Tetanus prophylaxis
Tetanus-prone wound: >6 hrs postinjury; stellate or avulsion; >1 cm deep, projectile or crush-type injury; devitalized, contaminated, or ischemic tissue
Unknown status in general or < 3 adsorbed tetanus toxoid doses or >5-10 years since last dose: administer tetanus toxoid 0.5 cc IM
With tetanus-prone wounds and above, administer tetanus immune globulin 250 units IM.
185
Witnessed arrest, suspicious of tamponade tx
Thoracotomy
186
