Trauma Flashcards
What are 5 traumatic injuries missed on CT Abdo/Pelvis?
- Holoviscous/ bowel injury
- Pancreatic injuries
- Bladder injuries (need retrograde urethrogram)
- Diaphramatic injuries (need diagnostic laparoscopy)
- Mesenteric injuries - small vessel may not reveal bleeding
What is considered high velocity vs low velocity GSW?
High velocity: military and hunting weapons (>2000 ft/s)
- direct pathway/predictable
Low velocity: smaller caliber hand guns and airguns. speed ~300 ft/sec for 0.22 caliber pistols.
- erratic pathway can bounce around.
What are the triangles of the neck?
Anterior (high risk neurovascular and GI injuries)
- Midline, Ant. border SCM, angle of mandible superiorly.
Posterior (more favorable prognosis)
- Post edge SCM, Clavicle and Trapezius m.
What are the zones of the neck?
Zone I: sternal notch and clavicles (thoracic outlet) to cricoid cartilage
Zone II: Cricoid cartilage to angle of mandible
Zone III: Angle of mandible to base of skull
What structures lie in Zone I?
Vascular
- Proximal carotid a.
- Vertebral a.
- Subclavian a.
- Major vessels of upper mediastinum (SVC, arch of aorta, pulmonary a.)
Airway
- Lung apicies
- Trachea
- Thoracic duct
GI
- Esophagus
- thyroid
Neurologic
- Spinal cord
What are the structures in zone II?
Vascular
- Common carotid a.
- Vertebral a.
- Jugular vein
Airway
- Larynx
- Trachea
GI
- Pharynx
- Esophagus
Neurologic
- Vagus n.
- Recurrent laryngeal n.
- Spinal cord
What is in zone III?
Vascular
- Distal carotid a.
- Vertebral a.
- Distal jugular vein
GI
- Salivary and parotid glands
Neurologic
- Cranial n. 9-12
- Spinal cord
What are 8 soft signs of penetrating neck trauma?
Pursue investigations
Soft (8): Think complications that deal with blood, air, nerves.
- Hemoptysis, hematemesis
- Oropharyngeal blood
- Non-expanding hematoma
- Dyspnea
- Dysphonia, dysphagia
- SQ or mediastinal air
- Chest tube leak
- focal neurologic deficits
What are 7 Hards signs of penetrating neck trauma?
needs emergent surgical intervention
Hard (7): Think airway, vascular and bleeding. Go from head down to be systematic
- Airway obstruction
- Cerebral ischemia (stroke)
- Thrill or bruit
- Decr. radial pulse
- Pulsatile bleeding
- Expanding hematoma
- Shock refractory to fluids.
With penetrating neck trauma what are a few ways to theoretically avoid an air embolism?
- Cautious BVM - can introduce air into disrupted vessels
- Trandeleburg
- Immediately occlude bubbling wound.
What do you immediately do when suspecting a venous air embolism?
(senerio: patient has profound shock unresponsive to fluids or cardiopulmonary arrest unresponsive to ED thoracotomy)
- Head down - trandelenberg
- Left lateral decubitus
- cause intra-cardiac air to accumulate to apex of right ventricle
If above doesnt work…
- Attempt to aspirate air embolism from apex of right ventricle AFTER the aorta has been cross clamped..
What are contra-indications for Nasotracheal intubation? (3)
- Basilar skull # (risk of penetrating into brain)
- Midface #
- Laryngeal injury
In the neck trauma patient, what is a major concern with respect to: BVM, Endotracheal intubation and a surgical airway?
BVM: can worsen SQ emphysema and cause an air embolism
Intubation: can transform a partial LT tear into a complete one
Surgical
- Anatomy distorted
- Can potentially disrupt a cervical hematoma that has tamponaded and result in exsanguination.
Which area of the esophagus is more prone to injury in neck trauma?
The cervical portion
Esophageal injuries are very difficult to diagnose. Physical exam is unreliable, which 2 Ix are indicated?
- Barium swallow
- Endoscopy
- Not good enough on its own, misses proximal injuries.
CT is not sensitive enough to dx esophageal injuries. But can show trajectory of penetrating object…
What is the most serious laryngeal injury?
Criocoid cartilage fracture because it can result in complete airway obstruction.
- The criocoid is the only complete ring in the larynx.
What are 10 signs of Larygnotracheal injury (LT)?
- Air leaking through a neck wound (bubbling)
- Only hard sign. - Subcutaneous emphysema
- Dyspnea
- Hemoptysis
- Dysphonia, Aphonia
- Stridor
- Cough
- Larygneal Crepitus
- Tender over larynx
- Large Neck wound
Pain with tongue movement suggests injury to what 3 potential areas?
- Largyneal cartilage
- Epiglottis
- Hyoid bone
Patient with neck trauma has horner’s syndrome. What injury do they have?
Carotid a. dissection.
In context of trauma we accept permissive hypotension. Why is 80 mmHg a common target?
Dont want to go over 80 mmHg SBP because arteries with complete transection tend to spasm and stop bleeding with pressures below 80mmHg.
- Also, higher pressures can dislodge a clot from vasculature and result in further exsangunation.
What pressure is indicative of immediate fasciotomy in compartment syndrome?
Pressures >30 mmHg indicates immediate fasciotomy.
- At this pressure, capillary flow is compromised.
- The patient can still have a strong pulse at this point but will have microvascular ischemia.
what are the indications for an EDT (ED thoracotomy)?
- Penetrating trauma + cardiac arrest
- better prognosis if narrow complex PEA - Blunt trauma with vital signs in the field.
- Nontraumatic hypothermic cardiac arrest
What are 4 contraindications for an EDT?
- Blunt trauma arrest patients without vital signs in the field (there is no chance of survival)
- Trauma patients with open cranial wounds
- Initial rhythm of asystole
- CPR ongoing >15 minutes
What is the survival rate of patients undergoing EDT for blunt trauma?
about 2%
