Trauma Flashcards
(34 cards)
1
Q
Chest injuries - indications for thoracotomy:
A
- Penetrating thoracic injury w/:
- Prev. witnessed cardiac activity (pre- or in-hospital)
- Unresponsive hypotension (SBP1500ml)
- Unresponsive hypotension (SBP
2
Q
Etiology of traumatic injuries
A
- High energy trauma in stable pt
- Imparied consciousness after trauma
- Thoracic wall injuries
- Rupture of large vessels-thoracic aorta
- Rupture of the heart or cardiac wounds
- Pulm injuries or injuries to hilum w/ massive bleeding
- Lung parenchyma hemorrhages
- Traumatic cardiac arrest, internal cardiac massage should be started ASAP following relief of cardiac tamponade or control of cardiac hemorrhage
- Aortic cross-clamping: redistribute flow to heart, lung and brain in case of lower thoracic/abdominal/lower extrem bleeding.
- Rupture of diaphragm
3
Q
Clinical problems requiring intervention in abdominal trauma victim
A
- Abdominal wound if peritoneum has been breached
- Penetrating injuries in hemodynamic unstable patient
- GSW
- Perforation of GIT
- Intraabdominal bleeding in hemodynamically instable pt w/ life-threatening hypotension (shock):
- Liver injuries (85%)
- Biliary tree injuries
- Spleen injuries
- Injuries of large vessels
- Injuries to pancreas
- Kidney injuries (55%)
- Peritonitis (pain, N&V, inability to pass flatus/stool, muscle guarding, rebound tenderness) after injury to:
- Stomach
- Small bowel
- Large bowel
- Duodenum
- Pancreas.
- Lower urinary tract injuries:
- Intraperitoneal rupture of the bladder is treated by laparotomy and suturing of the bladder.
- Extraperitoneal rupture is treated conservatively.
- Urethral tears req. specialist urological management.
4
Q
Evaluation of the patient with blunt abdominal trauma:
A
- Hx - timing, mechanism, pain characteristics, N&V, inability to pass flatus and stool, concomitant injuries and diseases, allergies, medications, alcohol and drugs
- PE - Puls in all major areas, HR, BP, RR and effor, GCS, other injuries and abnormalities
- Site specific PE - Ext injuries, sings of bleeding, abdominal wall symmetry and mobility, pain and muscle guarding, peristalsis, percussion (free intraperitoneal air - R side), DRE and GU, pulses over femoral AA.
- Blood tests: Type&Screen, Plasma amylase (suspect trauma to pancreas), LFT, Others depending on time and other injuries and diseases
- X-ray: Chest and pelvis (supine and erect): look for free intraperitoneal air, rib Fx, pelvic Fx. Also contrast studies: cystography, urography, angiography
- Imaging: CT=check solid organs, w/IV contrast useful for large vessels. US: FAST, organ injury assessment, monitoring of Tx and complications
- Diagnostic peritoneal lavage: (simple, safe, reliable, time saving, replicable): Dx intraperitoneal bleeding.
- Laparoscopy/endoscopy
- General:
- All pts w/ closed abdominal trauma should be admitted to hospital.
- Compared w/ penetrating trauma there is time for FAST US or CT scanning to diagnose the nature and extent of injury.
- Urgent laparotomy is usually required for hemodynamically unstable patients and those with obvious peritonitis.
- Less urgent laparotomy may be required if investigations reveal injuries surgery or if clinical deterioration occurs (e.g., free air or splenic rupture.)
5
Q
Initial management of the patient with abdominal trauma:
A
- IV fluids and ABC
- Hx & PE
- Type&Screen
- If hemodynamically stable
- Full diagnostic workup (CT, USG, X-ray)
- If hemodynamically UNstable
- Minimal diagnostic workup (AMPLE)
- Immediate surgery
- General
- Shock management (fluids, inotropic drugs, catheter, AB?)
- Diagnostic - eFAST
6
Q
Pt w/ abdominal wound - evaluation and Tx:
A
- Fluids and ABC
- Hx - eval mechanism of trauma
- PE of the abdomen
- Remove knife, do not check wound before at hospital.
- Do not reduce intestines into the peritoneal cavity
- Apply sterile dressings
- PE of abdomen in ER
- Type&Screen
- Imaging
- OR if indicated!
- Monitoring and re-evaluation
- If hemodynamic unstable, penetrating injury or positive finding on laparoscopy –> LAPAROTOMY
7
Q
Evaluation of the trauma victim in shock:
A
- Shock = Hypovolemia decompensated.
- Loss of >1/3 of blood volume (1,5 L) can cause shock
- Hypovolemic shock = most common type in trauma
- Hypovolemic shock = preload insufficiency
- Preload insuff => decreased dia filling and low CO
- Main causes of fluid loss leading to hypovolemic shock:
1) Revealed hemorrhage
2) Concealed hemorrhage
3) Extensive burns
4) Severe vomiting and diarrhea
5) Sequestration of fluid in bowel (bowel obstruction)
6) 3rd space losses (massive loss into interstitial tissue) - The essential features in shock is fall in BP
- Increase in HR attempt to compensate CO
- Centralization of blood flow
- Sweating
- Hypoxic tissue revert to anaerobic metabolism –> Acidosis
- Oliguria
- Clinical picture: cold, pale, clammy, hypotensive, tachycardia, tachypnea
8
Q
Management of the trauma victim in shock:
A
- Identify cause of fluid loss
- FLUIDS
- Immediate surgery and/or:
1) vasopressors
2) Pulmonary support
3) Analgesics
4) Steroids (anaphylactic shock)
5) Positioning - Laparotomy
1) Wide, good access
2) Control bleeding
3) Check all intraabdominal organs
4) Check for presence of blood, intestinal content, bile in peritoneum
5) Dye test of the GI tract
6) Intraoperative X-rays/US
7) Evaluate retroperitoneal space
9
Q
Open abdomen v. planned relaparotomy - indications
A
- Severe secondary peritonitis
- Edematous bowel or abdominal tissue
- Necrotic pancreatitis
- Abdominal compartment syndrome
- After a damage control procedure
- Tissue loss - inability to close the wound
10
Q
Pre and intraoperative symptoms suggesting duodenal injuries:
A
Pre-op S&Sx:
- Peritonitis (perforation)
1) Unspecific clinical presentation
2) Pain and abdominal distention - Vomiting
- Poor general status not correlating with other injuries
- Jaundice
- Intraperitoneal fluid on US
- Air around the iliopsoas on plain abdominal X-ray
Intraop findings:
- Hematomas
- Biloma
- Seroma/edema
- Crepitations
- Fat necrosis
- Dye leakage
11
Q
Complications of pelvic Fx:
A
- Retroperitoneal hematoma
- Hematuria
- Partial/complete tear of membranous urethra
- Intra-/extraperitoneal rupture of the bladder
- Injury of large vessels
12
Q
COMPLICATIONS OF PELVIC Fx:
Retroperitoneal hematoma: Dx and Tx
A
Dx: exclusion of other sources of bleeding (DPL, US, laparoscopy
Tx: Conservative, external fixation, rarely embolization of the bleeding vessel
13
Q
COMPLICATIONS OF PELVIC Fx:
Hematuria: Eval. and management
A
- PE of abdomen
- IV fluids
- Check for Fx of pelvis
- Type&Screen
- Urinary Catheter
- USG
- Imaging
14
Q
COMPLICATIONS OF PELVIC Fx:
Tear of membranous urethra and puboprostatic ligament:
Complete and partial.
Evaluation and management:
A
Partial:
- S&Sx: Hematuria
- Eval: USG, DRE, CT
Complete:
- High riding prostate on DRE
15
Q
COMPLICATIONS OF PELVIC Fx:
Rupture of the bladder - Intra vs extraperitoneal:
Eval and Tx
A
Intraperitoneal
- Due to direct blow to a full bladder
- Tx: Laparotomy and suturing
Extraperitoneal: Conservative Tx, with prolonged urethral catheterization or suprapubic catheterization
16
Q
COMPLICATIONS OF PELVIC Fx:
Injury of large vessels
A
- Rapidly enlarging hematoma
- US, DSA (angiography)
- Management: Conservative, surgical reconstruction, endovascular procedures
17
Q
S&Sx of pelvic Fx:
A
- Pain on bimanual compression of iliac wings
- Bone instability
- Hematuria
- High riding prostate on DRE
- Scrotal hematoma
- Blood at urethral meatus
- Rectal bleeding, large hematomas or palpable Fx on DRE
- Hematomas of prox. thigh, above the inguinal ligament, over the perineum or in the flak (rupture of vessels)
- Neurovascular deficits of the lower extremities
18
Q
Evaluation of pelvic Fx:
A
- Plain AP pelvic X-ray (if unstable)
- CT (if Fx is suspected and the pt is stable) (better pelvic anatomy, and shows bleeding in pelvic, retroperitoneal and intraperitoneal location)
- USG eFAST (fluid)
- Arteriography - detect ongoing bleedings
- Diagnostic peritoneal lavage
19
Q
Management of pelvic Fx:
also the Q: Management of the hemodynamically unstable pt with pelvic Fx
A
- External fixation is the Golden standard in the initial management (takes some time to organize)
- Rarely, embolization of bleeding vessels
If unstable:
- In those with no substantial intraperitoneal bleeding, nad an unstable Fx –> Simple wraparound pelvic splint to help control bleeding; then external fixation
20
Q
Causes and types of Acid-Base disturbances in chest trauma victim:
A
- Main risk in chest trauma –> ASPHYXIA
- -> Respiratory acidosis
Etiology of resp acidosis in chest trauma:
- Decreased coughing –> retention of sputum –> decreased ventilation
- Cardiac contusion –> Decreased CO
- Pneumothorax –> Decreased gas exchange (V/Q-mismatch)
- Injury of chest wall –> Decreased chest movements
- Lung contusion –> Decreased gas exchange
- Airway obstruction
21
Q
Eval and Tx of pt w/ rib Fx, flailed chest:
A
EVALUATION
- Hx - timing
- PE - Symmetry and movements of chest, also feel for Fx, paradoxical movements?
- RR increased?
- Auscultate - pneumothorax?
- Hemodynamically stable?
- ABG
- X-ray
MANAGEMENT
- Oxygen
- IV fluids
- Analgesics!!! (Intercostal NN block > opioids(resp depre.)
- Transport on semisupine position of the injured side!
- Intubation and ventilation support
- PPV if necessary
- Chest drainage if necessary (even if no pneumothorax)
22
Q
Causes of resp fail in trauma victims
A
1) Airway obstruction
2) Flail chest
3) Pneumothorax - closed, open, tension
23
Q
Immediately life-threatening conditions in chest trauma victims - evaluation and initial Tx
A
Resp fail:
- *Eval
- Increased RR
- Increased Resp effort
- Increased HR
- Normal or elevated BP
- Pale, wet skin
- Neck veins filled properly?
- *Tx Obstruction:
- Remove foreign object from mouth
- intubation
- O2
- Cricopharyngotomy
- Avoid any movement of the neck
- *Tx flail chest:
- O2
- IV fluids
- Analgesics (intercostal NN block)
- Transport in semisupine position on injured side
- Intubation and ventilation support
Closed pneumothorax
- *Eval:
- Etiology: trauma, COPD, Asthma, Abscesses, neoplasm, inadvertent puncture (iatrogenic)
- Increased RR
- Increased resp effort
- Decreased or absent breath sounds on one side
- Tympany on the affected side
- exam chest (symmetry, movements, paradoxical?, wound)
- ABG
- Check for tension pneumothorax (neck veins, lower BP, etc.)
- X-ray
- *Management
- O2
- Fluids
- Transport in semisupone position on the injured side
- If not immediate decompression, then usually not needed
- Consider chest drain
Open pneumothorax:
- *Eval
- Exam chest
- Check for signs of heart injury (auscultate, look at wound, etc)
- ABG
- X-ray
- Auscultation, percussion, neck veins, paradoxical movements, etc.
- *Tx:
- Air tight wound dressing
- O2
- Fluids
- Analgesics (intercostal nerve block)
- Transport in a semi-supine position on the injured side
- Remove knife
- Hemostasis, closure of wound
- Chest drain
24
Q
Indications for chest drain in trauma pts:
A
1) pneumothorax
2) pleural effusion
- chylothorax
- Empyema (early)
- Hemothorax
- Hydrothorax
25
Tension pneumothorax - etiology, pathomechanism, Tx:
Etiology:
- Often spontaneous, esp in young, tall, thin and smoking men, due to rupture of subpleural bullae
- Other causes: Asthma, COPD, TB, pneumonia, lung abscess, carcinoma, CF, sarcoidosis, CT disorder, trauma, or iatrogenic
Pathomechanism
- Pneumothorax w/hyperpressure
- Air can get into the pleural space, but not escape. With each breath, increasing air in pleural space. The expanding space compresses the lung and mediastinum. (compress IVC, heart and major vessels, and lead to decreased CO --> Cardiogenic shock)
Evaluation:
- Rapidly progressive dyspnea (increased RR)
- Decreased or absent chest wall movements
- Chest in constant inspiration
- Decreased or absent breath sounds
- Tracheal and mediastinal shift
- Distended neck veins
- ABG
- X-ray
- Auscultation and percussion, and exam of symmetry etc.
Tx:
- O2
- IV fluids
- Analgesics (intercostal NN block)
- Decompression 2nd intercostalspace just above 3rd rib; large bore IV-needle
- Chest drain
- Transport in semisupine position on the affected side
26
Shock in trauma - types, causes, Tx
Types:
- Cardiogenic (cardiac tamponade)
- Hemorrhagic (bleed into 1: chest cavity, 2: mediastinum (thoracic aorta) 3: External bleeding)
Cardiac tamponade - Eval and management:
* *Eval:
- Increased HR
- Increased RR
- decreased BP --> Low amplitude pressure
- Dyspnea
- Wet/pale skin
- Weak heart sounds
- Fluid in pericardium USG/X-ray
- Distended neck veins!
* *Management
- ABC,
- fluids,
- O2,
- Pericardiocentesis (if >100ml blood = not in pericadium)
- If Dx confirmed --> leave needle.
- Transfer to OR
Hemorrhagic shock:
* *Evaluation:
- Type&Screen
- Check for symp of cardiac tamponade
- Neck veins collapsed --> Delayed capillary return
* *Management
- ABC
- MASSIVE fluids
- O2
- Analgesics
- Transfer to OR
Ruptured thoracic aorta:
* *Eval:
- Chest or back pain, Dyspnea, Decreased BP, Increased pressure in upper extremities and decreased in lower, high output of blood from the chest tube
- CXR: Widening of the mediastinum above 8 cm
- Distorted shape of thoracic aorta
- Displacement of trachea and nasogastric tube
- Aortography
- CT
- Transesophageal US
* *Tx:
- Thoracotomy
27
Multiple trauma - definition, epidemiology, & mortality/morbidity:
Multiple trauma = Injuries of at least 2 different sites that each req hospital Tx
Multiple traumas are NOT a simple summation of single injuries, it is:
- Immediately life threatening conditions: Shock, resp fail, brain injuries
- Diagnostic dilemma: Intertwining symptoms, alcohol/drugs, hurry
- Complex management: immediate, concomitant, different specialists
Multiple traumas are NOT:
- Injury of different organs of the same localization (e.g., liver and spleen)
- Injury of 2 different parts of one organ (e.g., thigh and lower leg)
- Complex injury caused by 2 or more different factors or in a different mechanism (e.g., burn + fracture)
Epidem:
- Head 80%, chest 50%, lower extrem 50%, Pelvis 30%, Upper extrem 30%, Abdomen 20%, Neck 15%
Mortality and morbidity:
- High mortality at every level of management
- High rate of short and long term complications
- High rate of disability in survivors
28
Initial evaluation and management of the multiple trauma victim:
ABC --> Primary survey, then secondary survey when all ABCs stable, then repeat ABC frequently, or go back to ABC if unstable.
```
Blood loss related to Fx:
- Pelvic - 4000 ml
- Femur - 1500 ml
- Arm or crus - 750 ml
- Forearm - 400 ml
- Each rib - 200 ml
- Each vertebra - 100 ml
+ blood loss into soft tissue, even w/o Fx
```
- Assess vital functions
(chest wall motion, airway patency, ventilation adequate, circulation present and adequate, neurological condition)
- Tx aimed at regaining and supporting vital func.
- Assessment, Tx and prevention of life-threatening conditions
- Prevention of injuries during transportation
Management
- Warm IV fluids!
- Pain relief
- Sedation
- Monitor
29
Causes of blood loss in multiple trauma - evaluation and management:
Ext bleeding:
- Body surface hematomas
- Non-penetrating wounds
- Penetrating wounds with rupture of organs or major blood vessels
Int bleeding
- Abdominal
(liver, spleen, kidneys, mesentery, abdominal aorta, other large vessels)
- Thoracic
(thoracic aorta, rupture of other large vessles, lung injury)
- Pelvic:
(Fx, venous bleeding, rupture of large vessels)
- Extremities
(Fx)
Eval:
- PE, ABC, Assess vital func
- Imaging - US &/or DPL
Tx:
- Laparotomy
30
Eval and management of internal chest hemorrhage:
- Puncture, if positive then drainage, still bleeding after drainage --> THORACOTOMY
- X-ray, if positive perform drainage, still bleeding after drainage --> THORACOTOMY
- Aortography, if positive, do thoracotomy
31
Eval and management of internal pelvic hemorrhage:
- Fixation of the Fx
| - X-ray or US, if positive, do urography and/or angiography, if still positive, send for urology or vascular surgery.
32
Evaluation and management of increased ICP:
- Unconscious pt. --> intracranial hyperpressure --> CT caput, if positive, the pt will need craniotomy
- Signs of intracranial hyperpressure:
1) Lateralization?
2) GCS less than 8
3) Fracture on X-ray
4) ICP more than 20 cm H2O
33
Tx priorities in multiple trauma victim - problems that should be solved within first hour:
1: decompression of pneumothorax
2: Laparotomy for internal bleeding or craniotomy for hematoma
3: Other operations (vascular, urological etc.)
4: Stabilization of fractures
34
Treatment of multiple trauma victim - operations that should be performed within first 6 and 24 hrs:
First 6 hrs:
- Life saving operations
(Laparotomy, urological procedures, craniotomy, wound closure of open CNS injuries, thoracotomy)
- Disability preventive operations:
* Spinal decompression, stabilization
* Arterial reconstruction, suture;
* Face and neck surgery, wound closure, reconstruction, stabilization
* Ophthalmic surgery, wound closure, reconstruction, stabilization
* Joint displacement, wound closure, stabile osteosynthesis;
* Open fractures, wound closure, stabile osteosynthesis.
First 24 hrs:
- Patient hemodynamically stable, hydrated, without hypothermia
- Planned relaparotomy
- Stabilization of fractures not treated previously (Fx of long bones, spine, pelvis --> Stable osteosynthesis)
- Monitoring and Tx of compliations
- Prevention of complications (decubitus, pulm embolism sepsis, metabolic and neurologic disorders, and ARDS)
- Decrease time of supported ventilation
- Decrease pain
- Easier and sager nursin, rehan and transportation
- Optimal immune status
