Trauma 2/28/17

Question 1

zones approach (old approach) to neck trauma
how new approach updates

Answer 1

III - toward head - worried about arteries - but tough to explore - get arteriogram
II - middle - arteries, trach, espophagus - go to surgery, easy to explore
I - toward thorax - arteries, trach, esophagus - scary to operate as things can retract / fall into thorax - get arteriogram, esophogram, bronchoscope

the above if pt stable
if unstable, to surgery regardless of zone

new approach - OR if unstable, CT angiogram if stable but symptomatic (evals arteries, esoph, trach), observe if asymptomatic or CT angio negative, to OR if CT angio positive, repeat CT angio if asymptomatic becomes symptomatic
…. all regardless of zone.

so basically CT angiogram changed things and is the first step in eval if stable symptomatic… to OR if unstable still… use zone method if CT angio unavailable

Question 2

define penetrating neck injury

Answer 2

platysma has been disrupted

Question 3

hard signs vs soft signs of instability w neck trauma

Answer 3

hard

• airway gurgle, stridor, loss of airway
• vascular expanding hematoma, pulsatile (arterial) bleeding, stroke, frank shock

soft
-signs of air digestive or vascular injury that are not that bad - dysphonia dysphasia, subq emphysema / crepitus, non-pulsatile bleeding non-expanding hematoma

Question 4

dorsal columns medial lemniscus system

where in spinal cord transverse cut
where decussate

function

Answer 4

posteromedial
decussates up in… brain or brainstem… not spinal cord

proprioception
(fin feels the way)
vibratory sense
(shivers down the back)

Question 5

ALS
aka aka aka

where in spinal cord transverse cut
where dessucate

function

Answer 5

anterolateral system
ventrolateral system
spinothalamic tract

anterolateral (and MEDIAL - DECUSSATES anterior to spinal canal)

pain
temperature
(vent the pain and temperature)
(spinoThermometer tract .. put thermometer in spine it will be painful)

Question 6

corticospinal tract

where in spinal cord transverse cut

function

Answer 6

lateral
(decussates way up in pyramids i think… not in spinal cord)

motor

Question 7

DCML
STT
CST

where in transverse cut of spinal cord
where decussate
what function

Answer 7

DCML posteromedial, up in brain/stem whatever not in spine, proprioception (fin) vibratory sense (chills)

STT anterolateral/ventrolateral but decussates at the level - pain and temp (put spinothermometer into spine will get pain and temp)

CST lateral slightly dorsal - decussates up in pyramids - motor

Question 8

brown sequard syndrome

Answer 8

hemisection of spinal cord
(almost always knife trauma to neck)

contralateral pain/temp loss below level, bilateral at level (STT/ALS/VLS)
ipsilateral motor loss… flaccid LMN at level, spastic UMN below level… (CST)
ipsilateral vib and prop loss below level (DCML)

Question 9

cord compression
sx
dx
tx

Answer 9

fnd
ed (erectile dysfunction)
u/b incontinence

dexamethasone (to reduce inflammatory edema, which is the cause of the compression… not the trauma itself)

MRI AFTER dex because want to treat asap, MRI takes a while uncomfortable maybe dangerous

Question 10

anterior cord syndrome

Answer 10

dcml spared (prop and vib)

LMN at level, UMN below level (CST)

loss of pain temp below (STT ALT VLT)

Question 11

central cord syndromes

Answer 11

syringomyelia (swelling of central canal)
hyperextension in elderly

Loss of pain/temp, LMN AT THE LEVEL ONLY…eg usually CAPE-LIKE distribution down back and arms from cervicle spine lesion
(other syndromes affect below the level too)

Question 12

posterior cord syndrome

Answer 12

lose dcmls
(sensation below the level)

motor (cst) pain and temp (stt als vls) preserved

Question 13

evaluate airway patency in emergency situation

Answer 13

speaking full sentences
no accessory muscle use
bilateral breath sounds
-patent

can see expanding hematoma
cutaneous emphysema
-urgent airway

GCS less than 8, intubate
gurgling, gasping, stridor
-emergent airway - INTUBATE

Question 14

what is the significance of inspiratory stridor

Answer 14

entrance to entire airway is collapsing

Question 15

evaluate breathing in emergency situation

Answer 15

full breaths, satting well on pulse-ox, probably ok

deeper look:

pCO2 on ABG measures ventilation (MV = TVxRR)

pO2 on ABG (or pulse ox is almost as good really) measures oxygenation (controlled with PEEP, FiO2)

*don’t be fooled by ETCO2 endotracheal capnography (40 is normal) just tells you that ET tube is in the right place, assists in ET tube placement

Question 16

eval for circulation in emergency situation

Answer 16

pale cold diaphoretic

SBP v90 MAP v65 not absolutely scary but should get antenna going

U output v.5cc/kg/hr

Question 17

manage airway in trauma

Answer 17

jaw thrust
finger sweep
O2 nc, face tent, non-rebreather
bag valve mask
intubate
cric (done in ed)
trach (done in or in more controlled circumstances for longer placement)

Question 18

MAP =

Answer 18

MAP = CO x SVR
MAP = HRxSV x SVR
MAP = HR x PreloadxContractility x SVR

Question 19

General concepts that can contribute to shock

Answer 19

HR too fast or slow

Preload down… via volume (hemorrhage) or obstruction (tension pneumo, pericardial tamponade, PE)

contractility down (MI, CHF, contusion)

SVR down (sepsis anaphylaxis, anesthesia, spinal trauma)

Question 20

tf

hemorrhage picked up by Hb being low

Answer 20

careful

Hb is a concentration, don’t pick it up until fluid shift eg after giving fluids that anemia becomes evident on lab

Question 21

abdominal bleed in trauma bay, how to dx, manage

Answer 21

FAST US to dx
apply pressure
take to OR - put in IVs, type and cross, IVF, Blood as necessary on the way over

Question 22

pericardial tamponade in trauma bay, how to dx, manage

Answer 22

FAST - ECHO

pericardiocentesis

Question 23

Warm vs cold hypotension ddx

Answer 23

Warm svr problem
-sepsis anaphylaxis anesthesia spinal trauma

Cold a cardiac output (hr sv contractility) problem, svr contracts in reponse
-hemorrhage tension pneumo tamponade chf mi contusion

Question 24

Normal tidal volume

Answer 24

500cc

Question 25

High tidal volume, ventilator, hypotension, think...

Answer 25

Pneumothorax In general, keep tidal volumes lower (500cc is normal) and respiratory higher if necessary to prevent pneumothorax

Question 26

Pulsus paradoxus

Answer 26

Deeper drop in sbp w inspiration than normal (more than 10mmhg, so radial pulses may disappear during inspiration) From pressure around hear preventing expansion for more venous return, r heart expands into left heart, increasing afterload and dec stroke volume so sbp lower Eg in tamponade pericarditis copd osa (Normally sbp drops a little from pooling in pulm vasculture)

Question 27

Define massive PE

Answer 27

Causes hypotension

Question 28

S1Q3T3

Answer 28

deep s wave in lead 1 Deep q wave lead 3 Inverted t wave lead 3 Sign of acute r heart strain Eg PE (only 10% pe's will have s1q3t3) Similar to pattern in left posterior fascicular block

Question 29

``` Lung and heart sounds Pneumothorax Pericardial tamponade PE MI ```

Answer 29

Pneumo reduced lung normal heart Tamponade normal lung distant heart PE normal both MI normal both if R sided Pulm edema normal heart if L sided

Question 30

In emergency, order of attempts at venous access

Answer 30

Peripheral venous line x3 attempts (or at least Say you tried 3 times per some veteran medics) IO intraosseous line (good for 24 hours if need right now, can get fluid up and get more definitive peripheral line later) .... Central line (jugular, subclavian, femoral)

Question 31

Is jugular venous access considered central or peripheral?

Answer 31

Internal jugular is central External jugular is peripheral

Question 32

When is ng tube with enteral hydration typically called for

Answer 32

For ICU pt getting meds and fluids but not drinking, develops hypernatremia - enteral ng tube hydration for gradual restoration of fluid balance

Question 33

Sites for central venous access

Answer 33

Internal jugular Subclavian Femoral

Question 34

When is a PICC line typically placed

Answer 34

In non-emergent situation for Pt who needs long term abx, chemo, or becomes difficult to stick (sickle cell pt in 30's or 40's)

Question 35

What is a saphenous vein cutdown and when will it be used

Answer 35

Peripheral venous access via dissecting out saphenous ant to medial malleolus and ligating it, using proximal end to insert a catheter Not used in too many emergency situations

Question 36

TF | In tachycardic hypotensive pt w story consistent w hemorrhage, wait for low hb before transfusing

Answer 36

F Hb will be normal in acute blood loss because it is a concentration. Give fluids, give blood "Don't transfuse above 7 or 8 because worse outcomes" does not apply to acutely hemorrhaging pt

Question 37

Typical situations to expect hemoconcentration (high hb)

Answer 37

Dehydration Insensible water loss (severe sepsis) Insensible water loss = evaporated from skin or airway

Question 38

What is insensible water loss

Answer 38

Eveporated from skin or airway

Question 39

3 key signs and sx of aortic dissection

Answer 39

Chest pain radiating to back Widened mediastinum Pressures different between arms

Question 40

Mechanism of traumatic aortic dissection

Answer 40

Ligamentum arteriosum tacks aorts down, but free to move on either side, shear

Question 41

What does blood pressure over palp mean

Answer 41

Measured via cuff and palpation, not auscultation, eg in emergency situation

Question 42

Reflex treatment of hemodynamically unstable chf

Answer 42

Furosemide and dobutamine

Question 43

TF | Peritoneum does not like blood and blood there presents as acute abdomen

Answer 43

T

Question 44

Vasomotor shock Define Signs and symptoms

Answer 44

Vasodilation from neurogenic origin

Question 45

Why check rectal tone in pt hypotensive after fall from height

Answer 45

May be neurogenic shock, looking for neurologic deficits to support

Question 46

When is 1-2 L blood loss in OB cool vs not cool

Answer 46

can be cool in childbirth as plasma and rbc volumes have expanded Not cool in elective procedure, 1-2 L is 20-40% of circulating blood volume

Question 47

When to consider vasopressors in pt in shock

Answer 47

When due to SVR | -sepsis anaphylaxis anesthesia vasomotor/neurogenic

Question 48

What does flushing a foley attempt to do

Answer 48

Unobstruct, unkink

Question 49

Gunshot wound through and through lower third of neck, pt stable, how to proceed?

Answer 49

Need to go to surgery to make sure structures intact (airway, esophagus, vasculature), but difficult to explore structures near thoracic inlet so get diagnostic studies first as pt is stable -angiogram esophogram bronchoscopy vs ct angiogram

Question 50

Knife vs through-and-through bullet to lower neck, pt stable, how to proceed

Answer 50

Bullet gets surgical exploration, arteriogram esophogram bronchoscopy vs ct angio first ad pt stable and near thoracic inlet complicated surgery can do more harm than good Knife wound if superficial Can be observed in Stable pt

Question 51

When to intubate bullet neck wound guy holding it shouting

Answer 51

If airway compromised (difficulty speaking, breathing( Expanding hematoma Coughing up blood

Question 52

Spinal trauma with FND's | What is Always the next step

Answer 52

IV methylprednisolone

Question 53

Spinal trauma w FND's, give steroids, get ct, or get mri?

Answer 53

All of the above, in that order

Question 54

When can you uncollar a major trauma pr

Answer 54

When on physical exam: No FNDs No tenderness to palpation No spinal pain with movement

Question 55

Major trauma pt w neck pain, xr negative, get ct?

Answer 55

Yes If history concerning enough for fracture, or tenderness, especially pinpoint spinal tenderness, persists Get ct so don't miss unstable fracture or edema that may soon cause FND's

Question 56

TF | IV methylprednisolone for spine trauma w FND's will decrease usefulness of subsequent diagnostic MRI

Answer 56

F | Give the IV steroids to reduce edema and further spinal injury, MRI will still be diagnostic

Question 57

Mild trauma, no loss of consciousness, progressive decline in cognitive function without fnd's Diagnosis Who is at risk

Answer 57

Subacute or Chronic Subdural Hematoma Alcoholics Elderly Anticoagulated

Question 58

Intraparenchymal hematoma is caused by

Answer 58

Hypertension

Question 59

Grade and treat a concussion

Answer 59

Grade I, ouchie, no loc or amnesia - sit out the Game. rest, analgesics, observation at Home Grade II, Bam, loc no amnesia - sit out the Week. rest, analgesics, observation at home or in hospital depending on family reliability to make sure doesn't slip into coma Grade III, POW, loc and amnesi - sit out the Season. CT to rule out a deadly bleed like an elidural hematoma. rest, analgesics, observation more likely in Hospital

Question 60

MVA trauma patient with GCS 3 intubated unresponsive but vitals otherwise normal and CT showing blurring of gray/white junction consistent with diffuse axonal injury Manage Prognosis

Answer 60

Elevate head of bed Hyperventilate IV mannitol If that doesn't help then craniotomy (Decrease ICP, try conservative measures first) this pt not likely to recover

Question 61

Choose imaging for trauma pt with LOC, Racoon eyes (periorbital ecchymoses) and/or Battle sign (retro auricular hematomas) consistent with basilar skull fracture

Answer 61

CT Head AND C-Spine | chance of neck trauma is high

Question 62

2 causes of acute hypotensio from blunt chest trauma

Answer 62

Tension pneumothorax Aortic transection

Question 63

TF | Tracheal deviation, hypotension, and subcutaneous air in the neck and chest in trauma pt think esophageal rupture

Answer 63

F Esophageal rupture usually in setting of wretching Think pneumothorax or aortic dissection in acute hypotension in trauma pt Think pneumothorax when you add tracheal deviation and subcutaneous emphysema, also look for decreased breath sounds

Question 64

TF | Both arterial and venous pulmonary vasculature is considered low pressure

Answer 64

T

Question 65

Indications for thoracotomy to resolve hemothorax What to do if these criteria not met

Answer 65

^1500cc 1.5L drained from chest tube or More than 100cc/hr over 6 hours (Probably from a systemic arterial bleed, pulmonary arteries and veins are all low pressure) Observe chest tube for resolution of bleed if below these amounts

Question 66

In penetrating trauma, consider the start of the abdomen to be at ______, so do an ex lap if penetrating trauma below this

Answer 66

In penetrating trauma, consider the start of the abdomen to be at T4 NIPPLE LEVEL, so do an ex lap if penetrating trauma below this

Question 67

TF | It is necessary to retrieve bullet fragments in the body

Answer 67

False You leave them in

Question 68

When does a pneumothorax require thoracostomy vs needle decompression

Answer 68

Thoracostomy (chest tube) for pneumothorax Emergent needle decompression if tension pneumo with HYPOTENSION

Question 69

Pneumothorax Get cxr or just place chest tube?

Answer 69

Hust place chest tube (on test) | ED may get cxr in real life

Question 70

In chest trauma pt especially with rib, sternal, scapular fractures, be on lookout for aortic _____, and ____ and ____ contusions _____ hours after trauma

Answer 70

In chest trauma pt especially with rib, sternal, scapular fractures, be on lookout for aortic DISSECTION, and PULMONARY and CARDIAC contusions 48-72 hours after trauma

Question 71

Why avoid agressive fluid resuscitation with sternal, rib, scapular fractures in chest trauma patient

Answer 71

High risk of pulmonary contusion which is sensitive to fluid administration and will leak right into alveoli and white out lungs

Question 72

ECG changes and elevated trops and heart failure with pulmonary edema on cxr but clean coronaries on heart cath in trauma pt Dx

Answer 72

Cardiac contusion

Question 73

Pathology of ARDS in an adult

Answer 73

Sepsis with circulating cytokines causing inflammation in lungs and stiffness with low compliance

Question 74

Compliance and PaO2/FiO2 ratio in ARDS

Answer 74

Low compliance | PaO2/FiO2 v200

Question 75

What does ventilator associated pneumonia look like on cxr

Answer 75

Pulmonary consolidation

Question 76

Treat pelvic fracture with hematoma, hemodynamically stable after IVF resuscitation

Answer 76

External fixation and allow hematoma to tamponade itself off (Pelvic bleeds usually venous) (IF hemodynamically unstable options include angiography with embolization, ORIF, last ditch pelvic exploration, but test will not give hemodynamically instable pelvic trauma bleed because course of action not standardized

Question 77

Caustic ingestion with oropharyngeal erythema and drooling | Next steps

Answer 77

Admit for observation for stridor/laryngeal involvement/airway compromise EGD to assess damage Day 1 NPO, day 2 CLD if low severity edema erythema shallow ulcers NPO 72 hours if high severity deep ulcers circumferential burns black necrosis

Question 78

Electrical burn pt with normal EKG started on fluids and morphine, next step? Later sequelae?

Answer 78

Check for thermal burns under the skin (bones heat up, sustained contraction causes rhabdo) with serum CK, urine myoglobin, or blood in urine without RBCs Later sequelae Compartment syndrome, cataracts and demyelination syndromes

Question 79

Parkland formula, how much is an arm or a leg worth

Answer 79

9% for a Whole arm or leg, 4.5% for just the front or the back

Question 80

Anaphylaxis with wheezing, first step IM Epinephrine or intubate? After steps?

Answer 80

First step IM Epinephrine Anaphylaxis -- IM Epinephrine Diphenhydramine, Cimetidine, fluids to support blood pressure, steroids, consider intubation

Question 81

What are the risks of treating rabies

Answer 81

Cost and injection So give IVIG and Vaccine if possibly exposed and don't have animal to observe

Question 82

Treat a human bite

Answer 82

Surgical debridement / irrigation Leave open to close by secondary intention Consider abx vs just monitor for abscess

Question 83

Treat possible rabies exposure when animal not available to monitor

Answer 83

IVIG and Vaccine

Question 84

In acetaminophen toxicity, _____ is depleted

Answer 84

In acetaminophen toxicity, GLUTATHIONE is depleted

Question 85

In acetaminophen toxicity, hepatic toxicity occurs after _____ is depleted

Answer 85

In acetaminophen toxicity, hepatic toxicity occurs after GLUTATHIONE is depleted from toxic metabolite build up

Question 86

Manage acetaminophen toxicity

Answer 86

N-acetyl cysteine Liver transplant if all else fails

Question 87

For all toxic ingestions, give ____ For all recent toxic ingestions within 1 hour, give ____ and ____

Answer 87

For all toxic ingestions, give ACTIVATED CHARCOAL For all recent toxic ingestions within one hour, give ACTIVATED CHARCOAL and GASTRIC LAVAGE

Question 88

Ethylene glycol (antifreeze) is converted to _____ when ingested, which causes _____ and _____ Confirm dx by observing blue _____ under _____ Treat with _____ or _____ and potentially _____

Answer 88

Ethylene glycol (antifreeze) is converted to OXALIC ACID when ingested, which causes RENAL FAILURE and METABOLIC ACIDOSIS Confirm dx by observing blue URINE under WOOD'S LAMP Treat with ALCOHOL or FOMEPIZOLE and potentially HEMODIALYSIS if renal failure occurs

Question 89

Typical setting of methanol toxicity How to diagnose Complications

Answer 89

Kentucky Moonshine home fermented alcohol Fundoscopic exam for hyperemic optic disks metabolic acidosis, blindness and death

Question 90

TF | Consider syrup of ipecac for a toxic ingestion

Answer 90

F NEVER syrup of ipecac, we don't do it anymore -- makes you vomit, risk aspiration, re-burn esophagus if caustic. We now prefer nasogastric lavage

Question 91

Side effects of N-acetyl cysteine Threshold for giving in possible acetaminophen overdose

Answer 91

None. Very well tolerated. Low threshold for administration in possible acetaminophen overdose