trauma Flashcards
(127 cards)
1
Q
4 phases of initial assessment
A
primary survey, resuscitation, secondary surgery, and definitive care
2
Q
ABCDE of primary survery
A
airway,breathing, circulation, disability (neuro: GCS), exposure (head to toe exam)
3
Q
ways to open airway
A
chin lift, jaw thrust, oral airway, nasal airway, endotracheal tube, cricothyroidotomy
4
Q
tx tension pneumothorax
A
vent the high intrapleural pressure w a catheter place in the 2nd rib space at midclavicular line or w a chest tube placed through an incision between the ribs
5
Q
mc cause shock in trauma pt
A
hypovolemia from hemorrhage
6
Q
survey to quickly determine the degree of neurologic disability
A
glasgow coma scale
7
Q
glasgow coma scale
A
Eye opening: spontaneous (4), speech (3), pain (2), none (1)
motor response: obeys commands (6), localizes pain (5), withdraws to pain (4), decorticate posture/abdn flexion (3), decerebrate posture/abn extension (2), none/flaccid (1)
verbal response: oriented (5), confused (4), inappropriate words (3), incomp sounds (2), none (1)
best=15, worst=3
8
Q
secondary survey
A
identify and tx additional injuries not uncovered during primary; PE, med hx, allergies, last meal, tetanus immunization status, meds; ng tube, urine cath, ekg, pulse ox
9
Q
what is indicated if pt has gastric distension
A
can be from injury or from bag mask ventilation; need to decompress so place NG tube; orogastric route if pt is intubated, basilar skull fracture, extensive facial fractures
10
Q
mc cause of trauma related mortality and leading cause of long term disability
A
head injury
11
Q
cushing reflex
A
inc in systemic bp asoc w bradycardia and a slowed respiratory rate; caused by inc intracranial pressure
12
Q
htn, bradycardia and a slow respiratory rate after severe traumatic brain injury indicates
A
cushing reflex
13
Q
best initial eval of head injury
A
non contrast head ct
14
Q
epidural hematoma
A
middle meningeal artery is lacerated, often by a fracture of the overlying bone. Blood collects between the bone and the dura mater. The dura is normally tightly adhered to the skull and as a result the collecting hematoma progressively separates the dura from the skull creating a lens-shaped or convex hematoma that can be seen on CT scan
15
Q
s/sx epidural hematoma
A
brief loss of consciousness at time of injury followed by normal mental status that progressively deteriorates over time as hematoma expands
16
Q
subdural hematoma
A
blood collects between the dura mater and the brain. In this injury, the hematoma follows the contour of the inner cranium and requires surgical drainage if of sufficient size. Typically, subdural hematomas appear concave or crescent shaped on CT scan
17
Q
what osmotic diuretic effectively reduces brain swelling and lowers ICP
A
mannitol
18
Q
mc site for cervical fracture or subluxation
A
c5 level
19
Q
s/sx of tension pneumo
A
affected side if hyper resonant w diminished or absent breath sounds; trachea shifted to opposite side; hypotension; jugular venous distension
20
Q
open pneumo
A
occurs w penetrating thoracic trauma when chest wall wound remains patent; allows lung to collapse completely and creates a sucking chest wound
21
Q
tx open pneumo
A
place dressing over chest wound and secure it to the skin; creates a one way valve that allows egress of accumulated pleural gas during exhalation but prevents inflow from the atmosphere during inhalation; then a chest tube thoracostomy
22
Q
cardiac tamponade
A
compression of the heart from accumulation of fluid or blood within the pericardial sac; ventricular filling is restricted; the increased pressure within the pericardial sac is transmitted to each cardiac chamber; results in equalization of the right atrial, right ventricular diastolic, pulmonary artery diastolic, pulmonary capillary wedge, left atrial, left ventricular diastolic, and intra-pericardial pressures.
23
Q
mc cause of cardiac tamponade
A
stab wound to sternal region
24
Q
s/sx cardiac tamponade
A
muffled heart sounds, jugular venous dissension, hypotension (Beck’s triad); Kussmaul’s sign (jug ben distension w inspiration) and pulsus paradoxes (drop SBP >10 during inspiration)
25
dx cardiac tamponade
bedside focused assessment w sonography in traume (FAST) which reveals pericardial effusion
26
tx cardiac tamponade
volume resuscitation, immediate surgical decompression to release tamponade, rapid underlying cardiac injury
may need to do pericardiocentesis
27
massive hemothorax
rapid loss of more than 1500 mL of blood into the pleural cavity; class III or greater hemorrhage into the pleural cavity; ongoing thoracic blood loss of >200/hr over 4-6hr
28
s/sx massive hemothorax
diminished breath sounds and dullness to percussion
29
tx massive hemothorax
tube thoracotomy for control of hemorrhage; may need blood transfusion
30
simple pneumothorax
gas enters the pleural space causing collapse of the ipsilater lung; gas from atmosphere in penetrating injury or from injury to lung parenchyma or tracheobronchial tree
31
s/sx simple pneumo
diminished breath sounds on affected side; hyper resonance to percusion
32
dx/tx of simple pneumo
cxr and tx by chest tube placement for reexpansion of the lung
33
hemothorax
blood or clots accumulate within pleural space; from pulmonary parenchyma, great vessels, mediastinal structures, or chest wall
34
s/sx hemothorax
dec breath sounds and dullness to percussion
35
dx/tx hemothorax
cxr; placement of large bore (36 french) chest tube to drain the pleural space; post procedure X-ray to confirm evacuation
36
diagnostic peritoneal lavage
surgical procedure used to identify an intraperitoneal injury; under local anesthesia, a peritoneal catheter is inserted into the peritoneal cavity through a small midline incision; a syringe is attached to the catheter and aspirated; if 10 mL blood is aspirated, the test result is positive; if
37
FAST
evaluates for free fluid in the abdomen or pericardium using US views of the right and left upper quadrants, heart, and pelvis
38
mc injuries of blunt trauma
spleen or liver
39
tx hypotensive victim of blunt abd trauma
vol resusc but doesn't respond than rapid transfer to operative room for surgical correction of the cause of bleeding
40
tx penetrating trauma
if clear evidence of peritoneal traverse or hypotension then prompt exploratory lap since incidence of visceral injury is extremely high; if hemodyn stable then CT for more info lowering the risk of non therapeutic operative exploration
41
dx penetrating trauma to flank or back
triple contrast CT helps screen stable pts who may not need operative intervention
42
grades of blunt liver injuries (1 represented by small capsular hematomes or parenchymal lacerations to 6 hepatic avulsion)
1.Hematoma:Subcapsular, nonexpanding, 50% surface area or expanding; ruptured subcapsular hematoma with active bleeding; intraparenchymal hematoma >10 cm or expanding
Laceration:>3 cm parenchymal depth
4.Hematoma:Ruptured intraparenchymal hematoma with active bleeding
Laceration:Parenchymal disruption involving 25%–75% of hepatic lobe or 1–3 segments within a single lobe
5. Laceration:Parenchymal disruption involving >75% of hepatic lobe or >3 segments within a single lobe.
Vascular:Juxtahepatic venous injuries (i.e., retrohepatic vena cava/central major hepatic veins
6. vascular: hepatic avulsion
43
dx of blunt liver injuries
ct
44
tx of ongoing bleeding liver injuries seen on ct
interventional radiology suite w selective angioembolization of bleeding hepatic arterial branches
45
tx higher grade liver injuries involving hepatic veins or retrohepatic vena cava
urgent or intervention and damage control because they can result in massive hemorrhage
46
frequently injured in blunt abd trauma esp deceleration injuries in adults or direct impact inkids
spleen
47
grading of splenic injury 1-5
1.Hematoma:Subcapsular, nonexpanding, 50% surface area or expanding; ruptured subcapsular hematoma with active bleeding; intraparenchymal hematoma >5 cm or expanding
Laceration:>3 cm parenchymal depth or involving trabecular vessels
4.Hematoma:Ruptured intraparenchymal hematoma with active bleeding
Laceration:Laceration Involving segmental or hilar vessels producing major devascularization (>25% of spleen)
5.Laceration:Completely shattered spleen
Vascular: Hilar vascular injury which devascularizes spleen
48
dx spleen injury
ct
49
tx spleen injury
low grade= observation and serial monitoring of hemoglobin and hematocrit
recurrent hemorrhage/peritonitis=lap
active bleeding/hypotension upon presentation=or
either total splenectomy or splenorrhaphy
50
mc cause of postsplenectomy bleeding
unligated short gastric vessel or surgical knot that slips after resuscitation and normalization of blood volume (minimized by greater curvature of stomach systolic pressure of 100)
51
tx hemodyn stable pt w IV contrast extravasation noted on CT
angioembolization of the bleeding splenic after branches
52
splenectomy pt should receive what vaccines
pneumococcus and meningococcus
53
injury of the pancreas from trauma
uncommon because of its location but can become transectioned from being compressed against the vertebral column
54
tx transection pancreas
operative distal pancreatectomy
55
dx pancreas injuries
ct and endoscopic retrograde cholangiopancreatography (ERCP)
56
what does gastric injury frequently coexist with
diaphragmatic injury
57
tx rupture of the diaphragm
interrupted or running permanent suture to minimize risk of recurrence or further tearing; make sure to avoid phrenic nerve
58
why are left sided diaphragmatic injuries concerning
risk of dev of diaphragmatic hernia and visceral incarceration; commonly assoc w injuries of the stomach, colon, spleen, and small intestine
59
tx blunt injury to kidney
rarely require operative intervention unless there is ureteral injury or calyces leak of urine
60
tx of massive destruction or complex hilar injury of the kidney
nephrectomy
61
tx penetrating injuries of kidney
self limiting unless renal artery or vein is involved
62
who long should foley catheter drainage be maintained about kidney injury
7-10d or until hematuria resolves
63
what should be suspected when ct shows hemoperitoneum but no liver or spleen injury
mesenteric tears w hemorrhage from arcade vessels can occur in deceleration injury
64
tx small bowel and mesentery injury from penetrating trauma from knife or gunshot wound
one layer closure w absorbable or nonabsorbalbe suture; staple repair or resection w anastomosis
65
tx of injury to colon that caused devascularization
resection w primary reanastomosis
66
tx injuires to rectum below the peritoneal reflection
fecal diversion to avoid perineal sepsis and allow injury to heal
67
pt w colonic trauma and other injuries or profound shock may be considered candidates for
temporary diverting colostomy due to inc risk for anastomotic breakdown
68
lethal triad assoc w trying to repair all abd wounds during initial operation w shock and hypotension
hypothermia, acidosis, and coagulopathy; worsened by prolonged operation
69
fundamental tenets of damage control surgery for abdomen
control of massive hemorrhage and control of enteric contamination of peritoneal cavity while attempting to minimize hypothermia, acidosis, and coagulopathy
70
how long is the initial control surgery for abd injuries and when is the second surgery
first one takes 60-90min and the next one occurs in 12-36hr after
71
aggressive crystalloid volume resuscitation and severe hemorrhagic shock sometimes result in
retroperitoneal and intra abdominal swelling and intra abdominal pressures above 30mmHg
72
effects of rise of abd pressure from aggressive crystalloid volume resuscitation nd severe hemorrhagic shock
con compromise blood flow to abd viscera, producing ischemia and eventual necrosis if left uncorrected
73
untx abd compartment syndrome results in
multiple organ dysfunction syndrome (MODS) and is commonly fatal
74
abdominal compartment syndrome triad
inc airway pressures, dec urine output, and elev abd pressure
75
tx abd compartment syndrome
opening the abd cavity via lapartomy incision; allows prompt decompression and relieves cephalic pressure on the diaphragm and thoracic cavity; renal perfusion is restored and urinary output inc
76
mc and most stable mechanism of pelvic fracture
lateral compression mechanism; less likely to lead to ligamentous disruption at the sacroiliac joint
77
known as the open book pelvic fracture
anterior posterior compression- symphysis pubis is disrupted and iliac wings open leading to variable ant of sacroiliac ligamentous disruption
78
most unstable pelvic fracture
vertical shear injury; least common; caused by severe upward force that may disrupt the hemipelvis from the spine or create a fracture of the iliac wing; assoc w serious abd, pelvic, or vascular injuries
79
dx pelvic fractures
xray; ct
80
signs of urethral injury in men
scrotal hematoma, blood at urethral meatus, and high riding or non palpable prostate gland on rectal exam
81
3 zones of the neck
1. sternal notch to inferior border of cricoid cartilage
2. cricoid cartilage to angle of mandible
3. distal neck (mandible) to base of skull
82
tx injury to internal jugular vein
lateral venorrhaphy or patch venoplasty
83
compartment syndrome
elevation of the pressure within a fascial compartment of the upper or lower extremity; interstitial tissue pressure becomes higher than capillary perfusion pressure, resulting in ischemia to the muscles and nerves within the fascial compartment.
84
s/sx compartment syndrome
early include pain, paresthesias, and diminished sensation; swollen and tense; late include diminished pulses or capillary refill assoc w irrev ischemia
85
tx compartment syndrome
prompt operative fasciotomy
86
A 22-year-old man is in the emergency department after a high-speed motor vehicle collision. He complains of back pain. He is alert and oriented and is breathing normally. His oxygen saturation is normal and hemodynamically stable. There are ecchymoses on the left chest. Chest x-ray shows fractures of the left first and second ribs. The aortic knob is not clearly visible, and the mediastinum measures 10 cm. Further evaluation should include which of the following?
A. Contrast-enhanced chest CT
Β. Repeat chest x-ray
C. Diagnostic thoracoscopy
D. Pericardial window
E. Diagnostic mediastinoscopy
Answer: A
The high-speed deceleration mechanism and chest x-ray findings are highly concerning for blunt aortic injury (BAI), which is most efficiently diagnosed by contrast-enhanced chest CT. Repeat chest x-ray would likely reveal the same findings but would not establish the diagnosis. Thoracoscopy is useful for evaluating the pleural space, lungs, and diaphragm, but not the aorta and great vessels. Pericardial window may be utilized to diagnose hemopericardium in suspected penetrating cardiac trauma, but not aortic injury. Mediastinoscopy is used for evaluating lymph node status in lung cancer staging but has no role in trauma
87
A 30-year-old man is brought to the emergency department after crashing his motorcycle at high speed into a concrete divider. He sustains severe trauma to the mid face and mandible and is lethargic upon arrival. He has copious amounts of bloody airway secretions and pulse oximetry reveals oxygen saturation levels of 82% to 85%. Two unsuccessful attempts have been made to place an orotracheal tube. The next step should be
A. bag-valve mask ventilation.
B. nasotracheal intubation.
C. resuscitative thoracotomy.
D. surgical cricothyroidotomy.
E. bronchoscopy.
Answer: D
In the primary survey, obtaining a patent airway is of paramount importance The patient in this scenario has an unstable airway and poor systemic oxygenation, making the establishment of a definitive airway an urgent matter. Since orotracheal intubation attempts have failed, the next step is to perform a cricothyroidotomy. Bag-valve mask ventilation is unlikely to be successful in this circumstance and does not provide a definitive airway. Nasotracheal intubation is contraindicated in severe facial trauma as false passage into the cranium may occur. Resuscitative thoracotomy may restore circulation but does not provide an airway. Bronchoscopy may be utilized after establishment of an airway to clear blood or secretions.
88
A 53-year-old man sustains a severe traumatic brain injury after an assault. His GCS score is 6, and an intracranial pressure monitor is inserted. Vital signs are heart rate—92 beats/minute, blood pressure (BP)—152/88 mm Hg, mean arterial pressure—109 mm Hg, and respiratory rate—16/minute. His intracranial pressure is 32 mm Hg. The patient’s cerebral perfusion pressure is
A. 120 mm Hg.
B. 77 mm Hg.
C. 60 mm Hg.
D. 56 mm Hg.
E. 32 mm Hg.
Answer: B
Cerebral perfusion pressure (CPP) is calculated by subtracting the intracranial pressure (ICP) from the mean arterial pressure (MAP).
89
A 25-year-old woman is brought to the emergency department after involvement in a low-speed motor vehicle collision. She complains of feeling light-headed and states that she is 33 weeks pregnant. Vital signs are heart rate—90 beats/minute and BP—82/44 mm Hg. Abdominal examination reveals a gravid uterus but no tenderness. Chest x-ray is unremarkable, and FAST reveals no intraperitoneal fluid. A viable intrauterine pregnancy is noted, and fetal heart tones are observed The next step in management should be
A. cesarean section.
B. induction of labor with vaginal delivery.
C. left lateral tilt positioning.
D. diagnostic peritoneal lavage.
E. MRI of the abdomen and pelvis.
Answer: C
In the supine position, the gravid uterus compresses the inferior vena cava (IVC), resulting in decreased venous return to the heart and hypotension. Visibly pregnant trauma patients should be placed in the left lateral tilt position (while maintaining spinal precautions) to displace the gravid uterus from the IVC. Induction of labor and cesarean section would not be indicated in the absence of fetal distress. Diagnostic peritoneal lavage (DPL) is relatively contraindicated in pregnancy, as uterine or fetal injury may occur. MRI is not utilized in the acute evaluation of abdominal trauma.
90
A 22-year-old man is brought to the emergency department after falling from a 10-foot ladder, landing on his left side He has multiple left-sided rib fractures and a pneumothorax requiring a chest tube. Physical examination of the abdomen is unremarkable He remains hemodynamically stable throughout the primary and secondary surveys and undergoes contrast-enhanced CT scanning of the abdomen and pelvis. CT scan reveals a grade II laceration of the spleen, with no evidence of active contrast extravasation. The next appropriate step in management is
A. exploratory laparotomy with splenectomy.
B. exploratory laparotomy with splenorrhaphy.
C. splenic angioembolization.
D. video-assisted thoracoscopy with evacuation of hemothorax.
E. observation with serial abdominal examinations.
Answer: E
Most low-grade splenic injuries can be managed nonoperatively. The key factor is hemodynamic stability of the patient. In this patient, splenectomy and splenorrhaphy would represent unnecessary surgical options, and interventional techniques such as angioembolization should be reserved for cases of high-grade splenic injury with active extravasation of intravenous contrast. Thoracoscopy is indicated for evacuation of residual hemothorax or diagnosis of penetrating diaphragmatic injury.
91
trauma deaths first peak
immediate at time of injury; lacerations to brain, brain stem, spinal cord, heart, major arteries
92
trauma deaths second peak
golden hr where intervention can make a difference; subdural, epidural, hemopneumothorax, rupture of spleen, laceration of liver, multi injuries w sig blood loss
93
trauma deaths third peak
days to weeks later; sepsis and organ failure
94
algorithmic approach of advance trauma life support
primary survery, resuscitation phase, secondary survery, definitive tx
95
jane resuscitation
supplemental oxygen (often intubated); 2 lg bore IVs (18gauge), crystalloid fluid; urinary cath; ng tube; ekg monitor; constantly reassess abc's, monitor urine output
96
when is AMPLE done
during definitive care
allergies, meds, past illness, last meal, events preceding injury
97
blood work that should be ordered
cbc, chem 12, pt/ptt/inr, type and screen
98
imaging right away
cxr, lateral c spine xr, pelvis xr
99
when should a ct be ordered on a pt w a head hematoma
lg, sig mechanism of injury, alt LOC
100
tx head hematoma
rice, nsaids
don't attempt any aspiration or evacuation
101
dx closed skull fracture
ct scan
102
tx closed skull fracture
admit for observation
103
tx open skull fracture
admit, neurosurgery consult, seizure prophylaxis, +/- abx
104
dx and tx depressed skull fracture
pe and ct; admit, neurosurgery consult to OR for debridement, abx
105
s/sx basilar skull fracture
(fracture of temporal bone along base of skull)
battle sign (ecchymosis along mastoids), raccoon eyes (b/l periorbital ecchymosis); can have csf leak from ears or nose (accucheck/halo test)
106
tx basilar skull fracture
admit, neurosurgery consult
107
epidural hematoma
bleeding between dura and skull that is arterial; oval shaped (biconvex); lucid interval (brief period of normalcy after head injury)
108
subdural hematoma
bleeding between dura and brain venous source; crescent shaped, elderly pt
109
tx subdural hematoma
neurosurgery for eval, aggressive conservation, seizure prophylaxis
110
tx epidural hematoma
neurosurgery for immediate evacuation; seizure prophylaxis
111
canadian head ct rules
pts w minor head trauma:
gcs 13-15
witnesed LOC
amnesia or confusion
if on blood thinners getting scanned
scan if any are met:
gcs
112
who should get seizure prophylaxis
head injury:
| gcs
113
ex of seizure prophylaxis
phenytoin (dilantin): inc na efflux/dec na influx; 15-20mg/kg once
fosphenytoin (cerebyx): water soluble prodrug of phenytoin; 10-20mg/kg once; loaded within 30m
114
tx elevated ICP
mannitol: osmotic agent limiting renal resorption and causes diuresis; 0.25-1g/kg IV Q6 prn; can lead to renal dysfunction
115
which neck zones are surgical and which are not
2 surgical w ct angio, esophogoscopy and tracheoscopy
1/3 are non surgical
116
pain in jaw, mal occlusion, step off/malallignment of teeth, truisms, mucosal lacerations
mandible fx
117
dx mandible fx
pe and ct
118
tx mandible fx
update tetanus; abx (penicillin or clinda); barton bandage to splint
119
when should mandible fx get immediate OMFS consult
open fx, complex fx w dislocation, grossly dislocated, airway complication
120
maxillofacial trauma w tripod fx
zygomaticomaxillary complex;
fx through infraorbital rim, zygomatic/frontal suture, and zygomatic/temporal suture
121
mc orbital fx
maxilary bone (the floor)
122
s/sx of orbital fx
pain along orbital rim, +/- periorbital ecchymosis; diplopia w upward gaze (inferior rectus entrapment); enophthalmosis (sign of sig inferior displacement)
123
imaging orbital fx
non contrast ct
124
tx orbital fx
update tetanus, pain control, abx (augmenting), don't blow nose, OMFS f/u 7-10d
125
tx nasal fx
ice packs, pain control, orc decongestants, OMFS f/u 3-5d for early correction
126
auricular hematoma
cauliflower ear; blunt trauma to eat; bleeding between perichondrium and auricular cartilage
127
tx auricular hematoma
i/d or aspiration; pack w petroleum gauze and stitch in place; pack behind ear and wrap w ace around head; abx (cephalexin), pain, OMFS in 1 d
