Flashcards in Trauma Deck (160):
What widely accepted protocol does trauma care in the US follow?
Advanced Trauma Life Support (ATLS)
What are the 3 main elements of the ATLS protocol?
1. Primary survey/resuscitation
2. Secondary survey
3. Definitive care
According to ATLS protocol, how and when should the patient history be obtained?
It should be obtained while completing the primary survey, often the rescue squad, witnesses, and family members must be relied upon
What are the 5 steps of the primary survey?
Airway, Breathing, Circulation, Disability, Exposure and Environment
What principles are followed in completing the primary survey?
Life-threatening problems discovered during the primary survey are always addressed before proceeding to the next step
What are the goals during assessment of the airway?
Securing the airway and protecting the spinal cord
In addition to the airway, what must be considered during the airway step?
What comprises spinal immobilization?
Use of a full backboard and rigid cervical collar
In an alert patient, what is the quickest test for an adequate airway?
Ask a question: If the patient can speak, the airway is intact
What is the first maneuver used to establish an airway?
Chin lift, jaw thrust, or both.
If successful, often an oral or nasal airway can be used to temporarily maintain the airway.
If oral and nasal airways are unsuccessful, what is the next maneuver used to establish an airway?
If endotracheal intubation is unsuccessful, what is the definitive airway?
Incise the the cricothyroid membrane between the cricoid cartilage inferiorly and the thyroid cartilage superiorly and place an endotracheal or tracheostomy tube into the trachea.
What must always be kept in mind during difficult attempts to establish an airway?
Spinal immobilization and adequate oxygenation.
If at all possible, patients must be adequately ventilated with 100% oxygen using a bag and mask before any attempt to establish an airway.
What are the goals in assessing breathing?
1. Securing oxygenation and ventilation
2. Treating life-threatening thoracic injuries
What comprises adequate assessment of breathing?
Inspection (air movement, RR, cyanosis, tracheal shift, JVD, asymmetric chest expansion, use of accessory muscles of respiration, open chest wounds).
Auscultation (breath sounds).
Percussion (hyperresonance or dullness over either lung field)
Palpation (presence of subcutaneous emphysema, flail segments)
What are the life-threatening conditions that must be diagnosed and treated during the breathing step?
Tension PTX, open PTX, massive hemothorax
What is a pneumothorax?
Injury to the lung, resulting in release of air into the pleural space between the normally apposed parietal and visceral pleura
How is a pneumothorax diagnosed?
Tension PTX is a clinical diagnosis: dyspnea, JVD, tachypnea, anxiety, pleuritic chest pain, unilateral decreased or absent breath sounds, tracheal shift away from affected side, hyperresonance on the affected side
What is the treatment of a tension PTX?
Rapid thoracostomy incision or immediate decompression by needle thoracostomy in the 2nd intercostal space midclavicular line, followed by tube thoracostomy place in the anterior/midaxillary line in the 4th intercostal space
What is the medical term for a sucking chest wound?
What is a tube thoracostomy?
How is an open PTX diagnosed?
Usually obvious, with air movement through a chest wall defect and PTX on CXR
How is an open PTX treated?
Tube thoracostomy, occlusive dressing over chest wall defect
What does a PTX look like on CXR?
Loss of lung markings
What is a flail chest?
Two separate fractures in 3+ consecutive ribs
How is a flail chest diagnosed?
Flail segment of chest wall that moves paradoxically (sucks in with inspiration and pushes out with expiration opposite the rest of the chest wall)
What is the major cause of respiratory compromise with flail chest?
Underlying pulmonary contusion
What is the treatment for flail chest?
Intubation with positive pressure ventilation and PEEP PRN
What is cardiac tamponade?
Bleeding into the pericardial sac, resulting in constriction of the heart, decreasing inflow and resulting in decreased cardiac output
What are the signs and symptoms of cardiac tamponade?
Tachycardia and shock with Beck's triad, pulsus paradoxus, Kussmaul's sign
What is Beck's triad?
2. Muffled heart sounds
What is Kussmaul's sign?
JVD with inspiration
How is cardiac tamponade diagnosed?
What is the treatment for cardiac tamponade?
Pericardial window (if blood returns, then median sternotomy to rule out and treat cardiac injury)
How is a massive hemothorax diagnosed?
Unilaterally decreased or absent breath sounds; dullness to percussion; CXR; CT; chest tube output
What is the treatment for a massive hemothorax?
Volume replacement; tube thoracostomy; removal of the blood
What are the indications for emergent thoracotomy for hemothorax?
1. > 1500 cc of blood on initial placement of chest tube
2. Persistent > 200 cc/hr blood loss for 4 hours
What are the goals in assessing circulation?
1. Securing adequate tissue perfusion
2. Treatment of external bleeding
What is the initial test for adequate circulation?
Palpation of pulses
What comprises adequate assessment of circulation?
HR, BP, peripheral perfusion, UO, mental status, capillary refill, skin (cold, clammy means hypovolemia)
Who can be hypovolemic with normal BP?
Young patients (autonomic tone can maintain BP until cardiovascular collapse is imminent)
Which patients may not mount a tachycardic response to hypovolemic shock?
Those with concomitant spinal cord injuries; beta-blockers; well-conditioned athletes
How are sites of external bleeding treated?
By direct pressure +/- tourniquets
What is the best and preferred IV access in the trauma patient?
Two large-bore IVs (14-16 gauge), IV catheters in the upper extremities
What are alternative sites of IV access?
Percutaneous and cutdown catheters in the saphenous vein; central access (femoral, jugular, subclavian veins)
What is the trauma resuscitation fluid of choice?
LR (lactate helps buffer the hypovolemia-induced metabolic acidosis)
What types of decompression do trauma patients receive?
Gastric decompression with an NG tube and Foley catheter bladder decompression after normal rectal exam
What are the contraindications to placement of a Foley?
1. Signs of urethral injury
2. Severe pelvic fracture in men
3. Blood at the urethral meatus
4. High-riding ballotable prostate
5. Scrotal/perineal injury or ecchymosis
What test should be obtained prior to placing a Foley catheter if urethral injury is suspected?
RUG (retrograde urethrogram): dye in penis retrograde to the bladder and XR looking for extravasation of dye
How is gastric decompression achieved with a maxillofacial fracture?
OG tube (NG tube may perforate through the cribriform plate)
What are the goals in assessing disability?
Determination of neurologic injury
What comprises adequate assessment of disability?
1. Mental status (Glasgow Coma Scale)
2. Pupils (blown pupil suggest ipsilateral brain mass as herniation of the brain compresses CN III)
3. Motor/sensory (lateralizing extremity movement, sensory deficits)
What are the 3 parts of the GCS scoring system?
1. Eye opening
2. Motor response
3. Verbal response
How is eye opening scored in the GCS system?
4. Opens spontaneously
3. Opens to voice
2. Opens to painful stimulus
1. Does not open eyes
How is motor response scored in the GCS system?
6. Obeys commands
5. Localizes painful stimulus
4. Withdraws from pain
3. Decorticate posture
2. Decerebrate posture
1. No movement
How is the verbal response scored in the GCS system?
5. Appropriate and oriented
3. Inappropriate words
2. Incomprehensible sounds
1. No sounds
What is a normal human GCS?
What is the GCS score of a dead man?
What is the GCS score for a patient in a coma
GCS 8 or lower
How does GCS scoring differ if the patient is intubated?
Verbal evaluation is omitted and replaced with a T (hence the highest score for an intubated patient is 11 T)
What are the goals in obtaining adequate exposure?
Complete disrobing to allow a thorough visual inspection and digital palpation of the patient during the secondary survey
What is the "environment" in ABCDEs?
Keep a warm environment (hypothermic patient can become coagulopathic)
What principle is followed in completing the secondary survey?
Complete physical, including all orifices (ears, nose, mouth, vagina, rectum)
Why look in the ears during the secondary survey?
Hemotympanum and otorrhea are both signs of basilar skull fracture
What are the typical signs of basilar skull fracture?
Raccoon eyes, Battle's sign, clear ororrhea or rhinorrhea, hemotympanum
What diagnosis in the anterior chamber must not be missed on the eye exam?
Traumatic hyphema (blood in the anterior chamber of the eye)
What potentially destructive lesion must not be missed on the nasal exam?
Nasal septal hematoma (can result in pressure necrosis of septum if not evacuated)
What is the best indication of a mandibular fracture?
What signs of thoracic trauma are often found on the neck exam?
1. Crepitus or subcutaneous emphysema from tracheobronchial disruption or PTX.
2. Tracheal deviation from tension PTX.
3. JVD from cardiac tamponade.
4. Carotid bruit heard with seatbelt neck injury resulting in carotid artery injury.
What is the best physical exam for broken ribs or sternum?
Lateral and AP compression of the thorax to elicit pain or instability
What physical signs are diagnostic for thoracic great vessel 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 level of the nipple?
Concomitant injury to the abdomen
What is the significance of subcutaneous air?
Indicates PTX, until proven otherwise
What is the physical exam technique for examining the thoracic or lumbar spine?
Logrolling the patient to allow complete visualization of the back and palpation of the spine to elicit pain over fractures, step off (spine deformity)
What conditions must exist to pronounce an abdominal physical exam negative?
Alert patient without any evidence of head/spinal cord injury or drug/alcohol intoxication
What physical signs may indicate intra-abdominal injury?
Tenderness; guarding; peritoneal signs; progressive distention
What is the seatbelt sign?
Ecchymosis on lower abdomen from wearing a seatbelt
What must be documented from the rectal exam?
Sphincter tone (as an indication of spinal cord function).
Presence of blood.
Prostate position (as an indication of urethral injury).
What is the best physical exam technique to test for pelvic fractures?
Lateral compression of the iliac crests and greater trochanters and AP compression of the pubic symphasis to elicit pain or instability
What is the halo sign?
Cerebrospinal fluid from nose/ear will form a clear halo around the blood on a cloth
What physical signs indicate possible urethral injury, thus contraindicating placement of Foley?
High-riding ballotable prostate on rectal exam; presence of blood at the meatus; scrotal or perineal ecchymosis
What must be documented from the extremity exam?
Any fractures or joint injuries; any open wounds; motor and sensory exam, particularly distal to any fractures; distal pulses; peripheral perfusion
What complication after prolonged ischemia to the lower extremity must be treated immediately?
What is the treatment for compartment syndrome?
What injuries must be suspected in a trauma patient with a progressive decline in mental status?
Epidural hematoma, subdural hematoma, brain swelling with rising intracranial pressure.
Hypoxia and/or hypotension must be ruled out.
What are the classic blunt trauma ER XRs?
1. AP CXR
2. AP pelvic XR
What are the common trauma labs?
CBC, BMP, amylase, LFTs, lactate, coags, T&C, U/A
Will the hematocrit be low after an acute massive hemorrhage?
How can a C-spine be evaluated?
1. Clinically by physical
What patients can have their C-spines cleared by a physical exam?
No neck pain on palpation with FROM with no neurologic injury (GCS 15), no alcohol/drugs, no distracting injury, no pain meds
How do you rule out a C-spine bony fracture?
With a CT of the C-spine
What do you do if no bony C-spine fracture is apparent on CT and you cannot obtain an MRI in a comatose patient?
Leave the patient in a cervical collar (controversial)
Which XRs are used for evaluation of cervical spine ligamentous injury?
MRI (lateral flexion and extension), C-spine films
What findings on CXR are suggestive of thoracic aortic injury?
Widened mediastinum, apical pleural capping, loss of aortic contour/KNOB/AP window, depression of left main stem bronchus, NG tube or tracheal deviation, pleural fluid, elevation of right mainstem bronchus, clinical suspicion, high-speed mechanism
What study is used to rule out thoracic aortic injury?
Spiral CT of mediastinum looking for mediastinal hematoma with CTA; thoracic arch aortogram
What is the most common site of thoracic aortic traumatic tear?
Just distal to the take-off of the left subclavian artery
What studies are available to evaluate for intra-abdominal injury?
FAST, CT, DPL
What is a FAST exam?
Focused Assessment with Sonography for Trauma
What does the FAST exam look for?
Blood in the peritoneal cavity looking at Morison's pouch, bladder, spleen and pericardial sac
What is a DPL?
Diagnostic Peritoneal Lavage
What diagnostic test is the test of choice for evaluation of the unstable patient with blunt abdominal trauma?
What is the indication for abdominal CT in blunt trauma?
Normal vital signs with abdominal pain, tenderness, or mechanism
What is the indication for DPL or FAST in blunt trauma?
Unstable vital signs
How is a DPL performed?
1. Place a catheter below the umbilicus (in patients without a pelvic fracture) into the peritoneal cavity.
2. Aspirate for blood and if < 10 cc are aspirated, infuse 1 L of saline or LR.
3. Drain the fluid (by gravity) and analyze.
What is a grossly positive DPL?
> 10 cc blood aspirated
Where should the DPL catheter be placed in a patient with a pelvic fracture?
Above the umbilicus
What constitutes a positive peritoneal tap?
Prior to starting a peritoneal lavage, the DPL catheter should be aspirated.
If > 10 cc of blood or any enteric contents are aspirated, then this constitutes a positive tap and requires laparotomy.
What are the indicators of a positive peritoneal lavage in blunt trauma?
1. Inability to read newsprint through lavaged fluid.
2. RBC > 100,000/mm3
3. WBC > 500/mm3
4. Lavage fluid drained from chest tube, Foley, NG tube
(Also, bile, bacteria, feces, or vegetable matter present, elevated amylase level.)
What must be in place before a DPL is performed?
NG tube and Foley catheter
What injuries does CT miss?
Small bowel injuries and diaphragm injuries
What injuries does DPL miss?
What study is used to evaluate the urethra in cases of possible disruption due to blunt trauma?
What are the most emergent orthopedic injuries?
1. Hip dislocation (must be reduced immediately)
2. Exsanguinating pelvic fracture (binder or external fixator)
What findings would require a celiotomy in a blunt trauma victim?
Peritoneal signs; free air on CXR/CT; unstable patient with positive FAST or DPL
What is the treatment of a gunshot wound to the belly?
What is the evaluation of a stab wound to the belly?
If there are peritoneal signs, heavy bleeding, shock, perform exploratory laparotomy.
Otherwise, many surgeons either observe the asymptomatic stab wound patient closely, use local wound exploration to rule out fascial penetration, or use DPL.
What depth of neck injury must be further evaluated?
Penetrating injury through the platysma
What is trauma zone III of the neck?
Angle of the mandible and up
What is trauma zone II of the neck?
Angle of the mandible to the cricoid cartilage
What is trauma zone I of the neck?
Below the cricoid cartilage
How do most surgeons treat penetrating neck injuries in zone III?
How do most surgeons treat penetrating neck injuries in zone II?
Surgical exploration vs. selective exploration
How do most surgeons treat penetrating neck injuries in zone I?
What is selective exploration of a neck injury?
Based on diagnostic studies that include A-gram or CT A-gram, bronchoscopy, esophagoscopy
What are the indications for surgical exploration in all penetrating neck wounds?
Shock, exsanguinating hemorrhage, expanding hematoma, pulsatile hematoma, neurologic injury, subcutaneous emphysema
What is the 3-for-1 rule of trauma?
Trauma patient in hypovolemic shock acutely requires 3 L of crystalloid for every 1 L of blood loss
What is the minimal urine output for an adult trauma patient?
How much blood can be lost into the thigh with a closed femur fracture?
Up to 1.5 L
Can an adult lose enough blood in the closed skull from a brain injury to cause hypovolemic shock?
Can a patient be hypotensive after an isolated head injury?
Yes (but not due to hypovolemic shock)
What is the brief ATLS history?
Allegies, Medications, PMH, Last meal (when), Events (injury)
In what population is a surgical cricothyroidotomy not recommended?
< 12 years (instead perform needle cricothyroidotomy)
What are the signs of a laryngeal fracture?
Subcutaneous emphysema in neck; altered voice; palpable laryngeal fracture
What is the treatment of rectal penetrating injury?
1. Diverting proximal colostomy
2. Closure of perforation (if easy, and definitely if intraperitoneal)
3. Presacral drainage
What is the treatment of extraperitoneal minor bladder rupture?
Foley drainage and observation
What intra-abdominal injury is associated with seatbelt use?
Small bowel injuries (L2 fracture, pancreatic injury)
What is the treatment of a pelvic fracture?
Possible pelvic binder until the external fixator is placed; IVF or blood; possible A-gram to embolize bleeding pelvic vessels
Bleeding from pelvic fractures is most commonly caused by arterial or venous bleeding?
If a patient has a laceration through an eyebrow, should you shave the eyebrow prior to suturing it closed?
No (20% of the time, the eyebrow does not grow back)
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?
How high up do the diaphragms go?
To the nipples (4th intercostal space)
What is the treatment for penetrating injury to the colon?
If in shock, resection and colostomy.
If stable, primary anastomosis/repair.
What is the treatment for small bowel injury?
Primary closure or resection and primary anastomosis
What is the treatment for minor pancreatic injury?
Drainage (JP drains)
What is the most commonly injured abdominal organ with blunt trauma?
What is the treatment for significant duodenal injury?
1. Close duodenal injury
2. Staple off pylorus
What is the treatment for massive tail of pancreas injury?
Distal pancreatectomy (usually splenectomy as well)
What is "damage control" surgery?
1. Stop hemorrhage and GI soilage.
2. Pack and get out of the OR ASAP to bring the patient to the ICU to warm, correct coags, and resuscitate.
3. Return patients to OR when stable, warm, and not acidotic.
What is the lethal triad?
What comprises the workup/treatment for a stable parasternal chest gunshot or stab wound?
2. FAST, chest tube, +/- OR for subxiphoid window. If blood returns, then sternotomy to assess for cardiac injury.
What is the diagnosis with NG tube in chest on CXR?
Ruptured diaphragm with stomach in pleural cavity
What films are typically obtained to evaluate extremity fractures?
Complete views of the involved extremity, including the joints above and below the fracture
What finding on abdominal or pelvic CT requires ex lap in the blunt trauma patient with normal vital signs?
Free air (also strongly consider in the patient with no solid organ injury but lots of free fluid)
What lab tests are used to look for intra-abdominal injury in children?
What is the only real indication for MAST trousers?
Prehospitalization, pelvic fracture
What is the treatment for human and dog bites?
Leave wound open, irrigation, antibiotics
What is sympathetic ophthalmia?
Blindness in one eye that results in subsequent blindness in the contralateral eye (autoimmune)