Trauma

Question 1

ABCs

Answer 1

Airway (with C spine precautions - assume C spine injury until proven otherwise)

Breathing and vent

Circulation/Control of hemorrhage

Disability (neuro status)

Exposure/Environment control

Foley

Question 2

Airway and C-spine

Answer 2

Assess patency

use jaw thrust or chin lift initially to open it up

Clear foreign bodies

Insert oral or nasal airway when needed

Intubate obtunded/unconscious patients

Surg airway = cricothyroidotomy - when unable to intubate

Question 3

Patent airway

Answer 3

speaks in full sentences
B/l breath sounds

Just give O2

Question 4

Urgent airway

Answer 4

Has patent airway now but maybe not forever. Will need intervention soon

Expanding hematoma

Cutaneous emphysema (rice crispies in skin)

Give BVM

Question 5

Emergent airway

Answer 5

GCS

Question 6

Breathing and ventilation

Answer 6

Do they need ventilations or a ventilator?

Monitor SpO2 and End tidal CO2 (for intubated patients should be about 40)

What might alter ventilation?
Hemothorax, pneumothorax, flail chest, pulm contusion

Normal RR 12-20

Question 7

Control of hemorrhage

Answer 7

2 large bore IVs (14 or 16 gauge)

Draw blood samples at time of IV catheter placement

Assess cap refill, pulse, skin color

Control life-threatening bleeds using direct pressure

Are they in shock?
- sys BP

Question 8

Disability

Answer 8

Rapid neuro exam

Establish pupillary size and reactivity and level of consciousness using AVPU or GCS

Question 9

AVPU

Answer 9

Alert
Verbal
Pain
Unresponsive

Question 10

Exposure/Environment/Extra

Answer 10

Undress the patient

Question 11

Foley

Answer 11

Contraindicated when transection of urethra is suspected like in pelvic fracture. If suspected get retrograde urethrogram first

Examine prostate and genitals before foley insertion

Question 12

Gastric intubation

Answer 12

NGT or OGT may reduce aspiration risk. If cribiform is fractured used OGT

Question 13

IV fluid

Answer 13

Start with up to 2L of isotonic crystalloid (NS or LR)

Peds should get IV bolus 20cc/kg

3:1 rule. Total amount of crystalloid volume needed acutely to replace blood loss.

Use warm fluids whenever possible

Question 14

Shock in the trauma setting

Answer 14

Hemorrhage
Tension Pneumo
Pericardial Tamponade
Contractility issues
Vasomotor

Question 15

Hemorrhage signs

Answer 15

Bleeding patient with flat neck veins. Low Hgb/Hct. High HR (compensation)

Dx: May beed to do FAST

Tx: 2 large bore IV
Dump fluid and blood into them (T/C, IVF, Blood). Fix the hole. All on the way to the OR

Question 16

Tension pneumo signs

Answer 16

1 - needle decompression in 2nd IC space (goal is to relieve IVC not re-inflate lung). This is NOT a chest tube.

Hole in pleura creates a flap. When pt breathes in, air gets into pleural space. When they exhale it gets trapped

Affected lung collapses. Replaced inside the space with air.

Air compresses IVC

Engorged neck veins
Absent lung sounds on affected side
Hyperresonant
Induces tracheal deviation away from affected side

F/u with chest tube (thoracostomy)

Question 17

Pericardial tamponade signs

Answer 17

RV is looser/floppier than LV so it collapses. We cannot fill. Basically a diastolic HF.

Engorged neck veins
Clear lung sounds

Beck’s triad = distant heart sounds, JVD, hypotension

Dx: FAST

Tx: Pericardialcentesis

Question 18

Contractility issues signs

Answer 18

Pt will have engorged neck veins

Also with pulm edema

Dx = Echo or FAST

Tx = medically manage

Question 19

Vasomotor shock signs

Answer 19

Normal response to shock is to increase SVR therefore preload, HR, contracility issues generally cause cold extremities

HERE, we get vasodilation leading to warm extremities despite low BP.

Dx: depends on mechanism

TX: give back what they’re lacking (ANS tone) with vasopressors

Question 20

Secondary survey

Answer 20

Stage in trauma eval after all the ABC business

Get trauma history (AMPLE history)

Allergies
Meds/Mechanism of injury
PMH/Pregnant?
Last meal
Events surrounding mechanism of injury

Head to toe eval

Question 21

How is body water distributed?

Answer 21

2/3 intracellular
1/3 extracellular
- 1/4 intravascular
- 3/4 extravascular

Question 22

Basilar skull fracture

Answer 22

Look for Battle sign - bruising around eyes and behind ears

Runny nose - that’s CSF actually coming out!

Get CT

Question 23

Epidural hematoma

Answer 23

MMA breaks and starts to bleed. Space btw skull and dura fills with blood. Will get big enough and push on brain.

Initial LOC
Lucid period
Death

“Walk, talk, and die syndrome”

Dx: Get CT (lens-shaped)
Tx: Craniotomy

“Epi was a horrible class that I thought would be easy. I’m glad I can look at it through the lens of time now.”

Question 24

Acute subdural

Answer 24

Young patient. May be sign of abuse in baby.

Usually need a HUGE trauma like MVAs.

Blood fills btw brain and dura

Course = trauma then coma then death

Dx: CT (crescent shaped).
Tx: Keep ICP low (hypervent, raise bed head, mannitol). Pray.

Question 25

Chronic subdural

Answer 25

Older patients or alcoholics Shrunken brain = stretched veins. Tearing of bridging veins from minor trauma or an old trauma maybe weeks ago. HA then progressive dementia. Dx: CT (crescent shaped) Tx: Craniotomy This is why all patients with dementia should get a CT

Question 26

Why should all patients with dementia get a CT?

Answer 26

Could just be chronic subdural hematoma

Question 27

Ways to reduce ICP

Answer 27

Hyperventilation Raise head of bed Mannitol

Question 28

Concussion

Answer 28

Sports injury LOC Amnesia (retrograde) CT is normal Tx: Go home but only if patient has family to keep them up. Keep them awake for 24 hrs

Question 29

Diffuse Axonal Injury

Answer 29

Patient who had angular trauma like a car accident where car spun a lot Presents with coma CT shows blurring of grey-white junction Tx = pray

Question 30

Neck zones

Answer 30

Zone 1 = lowest. Below cricoid and above clavicle (most conservative) Zone 2 = middle (lots of surgery here) Zone 3 = above angle of mandible (some surgery)

Question 31

When does penetrating trauma to the neck always lead to surgical exploration?

Answer 31

All cases where there is: Expanding hematoma Deteriorating vitals Clear signs of esophageal or tracheal injury (coughing or spitting blood) GSW to middle neck

Question 32

GSW to middle neck (zone 2)

Answer 32

surgery always

Question 33

GSW to lower neck (zone 1)

Answer 33

Arteriography, esophagogram (water soluble then barium if negative), esophogoscopy, and bronchoscopy before surgery to decide approach

Question 34

GSW to upper neck (zone 3)

Answer 34

Arteriogram. If abnormal then surgery

Question 35

Stab wounds to all zones

Answer 35

Arteriogram and U/S Looking for expanding hematoma or active bleeding

Question 36

Why is surgery uncommon for zones 1 and 3?

Answer 36

Blood supply is hard to control in these regions.

Question 37

ALS (tract)

Answer 37

Pain and temperature. lateral spinal cord, anterior Crosses over before ascending

Question 38

DCML

Answer 38

Vibration/Position Dorsal, medial Crosses over in brainstem

Question 39

Motor tracts

Answer 39

Upper extremity more medial than lower extremity. Lateral spinal cord.

Question 40

Cord Syndrome

Answer 40

Patient with FND - ED, urine/fecal incont, erection that doesn't stop Dx = MRI Initial trauma doesn't do the damage. It's the edema around it. Therefore, you can really skip the MRI and just give them dexamethasone (decadron)

Question 41

Complete transection of spinal cord

Answer 41

At the site of the lesion you lose LMNs - paralysis Below the site you lose UMNs - upgoing Babinsky and hyperreflexia All sensory is lost and all pain/temp is lost. Basically nothing works below the lesion

Question 42

Hemisection

Answer 42

Ipsilateral loss of motor and sensory (vib/position) Contralateral loss of pain/temp Sharp knife trauma

Question 43

Anterior Cord lesion

Answer 43

Burst fractures of the vertebral bodies. Loss of motor function and loss of pain/temp on both sides distal to injury Preserved vibration/position sense

Question 44

Central Cord Syndrome

Answer 44

Patient is elderly with forced hyperextension of the neck (rear-end collision). There is paralysis and burning pain in upper extremities with preserved functions in lower extremities Sort of like syrinx - cape-like distribution. May expand to include ALS.

Question 45

management of spinal cord injuries

Answer 45

MRI: CT is easier to do if we only need to see bones. Some think high dose steroids right after the injury may help

Question 46

Pericardial tamponade - more detail

Answer 46

Usually seen with penetrating thoracic trauma, but blunt can cause it too. Tachycardia, muffled heart sounds, JVD, hypotension and electrical alternans on ECG (alternating heights of R in QRS complexes) Dx with cardiac U/S as part of FAST Requires immediate decompression via needle pericardiocentesis, pericardial window or thoracotomy with manual decompression Clinically apparent tamponade may result from 60-100ml of blood

Question 47

Blunt cardiac trauma

Answer 47

Usually secondary to MVAs, fall from heights, crush injury, blast injury, direct violent trauma Get a screening ECG

Question 48

How should pericardium be opened?

Answer 48

anterior and parallel to phrenic nerve (longitudinally)

Question 49

Pneumothorax

Answer 49

Can be from penetrating trauma or blunt trauma that caused a rib fracture Air in pleural space Usually asymptomatic. Maybe Chest pain. Dyspnea Hyperresonance of affected side Decreased breath sounds of affected side Dx: upright CXR - absence of lung markings where the lung has collapsed. Vertical lung shadow. Tx: Tube thoracostomy in upper lung. Confirm placement with CXR

Question 50

Tension pneumothorax

Answer 50

Air enters pleural space and cannot escape. Causes total ipsilateral lung collapse and mediastinal shift, impairing venous return and thus decreasing cardiac output resulting in shock Same signs as pneumothorax PLUS tracheal deviation away from affected side Dx should be clinical - don't wait on the CXR to start treatment Tx: immediate needle decompression followed by tube thoracostomy

Question 51

Hemothorax

Answer 51

Dyspnea Dullness to percussion Reduced breath sounds Lung compressed upward so there is an air-fluid level. Dx: CXR shows horizontal air-fluid level Tx: Thoracostomy in lower lung. We need to figure out if bleed is from peripheral or pulmonary artery. Pulm vasculature is lower pressure and stops on its own. Look at chest tube output - If 1500cc initial drainage OR 600cc in 6hrs go to surgery (thoracotomy) 25% of hemothorax cases have associated pneumothorax 75% of hemothorax cases are associated with extrathoracic injuries

Question 52

Indications for thoracotomy

Answer 52

1500cc initial drainage from chest tube 200cc/hr for 4hrs continued drainage - Thoracic great vessel injury - Esophageal injury - Patients who decompensate after initial stabilization

Question 53

Sucking chest wound

Answer 53

ONLY from penetrating trauma from the outside (not ribs) Breathe in: air enters Exhale: flap closes. Air gets stuck May get a tension pneumo Pt = trauma, dyspnea, tension pneumo Dx: Visual inspection Tx: Occlusive dressing taped on 3 sides to create our own valve. THEN chest tube to drain whatever air is left.

Question 54

Rib fracture

Answer 54

Blunt trauma usually Can induce ANY of the penetrating traumas CP that makes them splint - won't breathe much. Reduced breathing leads to higher risk for atelectasis and pneumonia ``` Dx = CXR Tx = pain control (avoid tons of opiates) balanced with breathing ```

Question 55

Flail chest

Answer 55

Flail chest is an indication for looking for problems inside the chest HUGE blunt trauma - requires 2+ ribs broken in 2+ places Paradoxical movement ``` Dx = visual inspection and CXR Tx = weights/binders to align it. Maybe surgical placement of a plate ```

Question 56

What are the indications for investigating for problems WITHIN the chest?

Answer 56

Flail chest Sternal fracture Scapular fracture Investigate for: Aortic dissection, pulmonary contusion and myocardial contusion

Question 57

Pulmonary contusion

Answer 57

Get CXR - normal initially. All of a sudden the pt gets dyspnea and pulm edema Takes 48h from trauma for CXR to show b/l whiteout This is a non-cardiogenic pulmonary edema - a lot like ARDS Tx = avoid crystalloids. Give colloids BUT really we treat with PEEP (push fluid back into leaky capillaries)

Question 58

Myocardial contusion

Answer 58

Dx: prophylactic EKG and troponin Tx: Control HF and arrythmias with MONA BASH

Question 59

Aortic dissection

Answer 59

High speed MVAs. Torn at ligamentum arteriosum due to inertia Patient is either DOA (total tear) or if tear is incomplete there is an adventitial hematoma Dx: CXR - This determines index of suspicion - If widened mediastinum, tearing CP radiating to back or dif BPs on exam then index is very high. THEN do CT. If index is high and CT is negative do angiogram. If index is low and CT negative stop. Tx = surgical repair. Get systolic BP as low as you can first.

Question 60

Seat-belt sign

Answer 60

ecchymotic area found in distribution of lower anterior abdominal wall and can be associated with perforation of bladder or bowel as well as lumbar distraction fracture (Chance Fracture)

Question 61

Cullen's sign

Answer 61

Periumbilical ecchymosis is indicative of intraperitoneal hemorrhage

Question 62

Grey-Turner sign

Answer 62

Flank ecchymosis indicative of retroperitoneal hemorrhage

Question 63

Kehr's sign

Answer 63

L shoulder or neck pain secondary to splenic rupture Increases in trandelenburg position or with LUQ palpation Caused by irritation of diaphragm

Question 64

GSW to abdomen

Answer 64

All go to ex-lap

Question 65

Knife to abdomen treatment

Answer 65

If you see: Evisceration Peritoneal signs Shock GO TO EX-LAP If you probe the wound and cannot enter peritoneum then watch/wait. If you can enter then GO TO EX-LAP

Question 66

How much blood can each compartment hold?

Answer 66

``` Head = 50cc Chest = 500cc Abdomen = 1500cc Pelvis = 2000cc Thighs = 1000cc each Ankles = 200cc each Arms = 100cc each Forearms = 50cc each ``` Anything below nipple and above knee then can kill you

Question 67

Blunt trauma to abdomen

Answer 67

We need to know if patient is bleeding or not Get FAST or CT If bleeding then Ex-Lap

Question 68

FAST

Answer 68

Positive if free fluid is demonstrated in abdomen 4 views used to search for free fluid (presumed to be blood in trauma patient) that collects in dependent areas and appears as hypoechoic on US 1) Morrison's pouch (RUQ) - btw liver and kidney 2) Splenorenal recess (LUQ) - btw spleen and kidney 3) Pouch of Douglas - above rectum "bladder view" 4) Subxiphoid and parasternal views - looks for hemopericardium

Question 69

Pros/Cons to FAST

Answer 69

Pros: Fast, noninvasive, 80-95% sensitive for intra-abdominal blood Cons: user dependent, low specificity for individual organ injury

Question 70

What are some potential iatrogenic causes of great vessel injuries?

Answer 70

CVP line or CP placement Intra-aortic balloon pump placement Overinflation of Swan-Ganz

Question 71

What is the mortality associated with traumatic aortic rupture?

Answer 71

90% die at scene another 50% die within 24h

Question 72

How can you detect an injury to innominate or subclavian arteries?

Answer 72

Absent/low upper extremity pulses and BP Increased lower extremity pulses

Question 73

What are some possible sources of bleeding detected by FAST?

Answer 73

#1 = ruptured liver - ligamentum teres tears from inertia - Tx = repair or lobectomy. Can do pringle (grab hepatoduodenal ligament and cut off hepatic artery/portal vein) Ruptured spleen - massive bleed - has a capsule so repair is pretty easy - if you can fix it save it - if not sacrifice it - remember to vaccinate against encapsulated organisms Ruptured diaphragm - BS in thorax - Kehr's sign - Get CXR - Tx = surg

Question 74

Pelvic trauma

Answer 74

Major MVA/Fall to break a pelvis Use hip-rocking maneuver - will always be broken in 2 places. Can move it in 2 directions at once with extreme pain Look for urethral injuries - high riding prostate, blood at meatus. Get an IV pyelogram and avoid foley. May require prophylactic protoscopy to rule out rectal injury Dx = CT (the same one we got during FAST) Tx = give them blood and track H/H Do NOT operate. Let the hip heal first.

Question 75

25 yo F presents after high speed MVA with dyspnea and tachycardia. Local bruising over right side of chest. CXR shows a right upper lobe consolidation.

Answer 75

Pulmonary contusion.

Question 76

First degree burn

Answer 76

Like a sunburn Erythema, warm, tender No blisters

Question 77

Second degree burn

Answer 77

Erythema, warm, tender Blisters

Question 78

Third degree burn

Answer 78

Deeper than dermis (into fascia or muscle) Painless Surrounded by 2nd degree burns White/charred lesions

Question 79

Chemical burn

Answer 79

Alkali or acidic Alkali are worse Either on the skin - never buffer. just irrigate a ton OR swallowed - never vomit. CAN buffer here bc it's in stomach

Question 80

Respiratory burns

Answer 80

Closed fire/explosion Chemicals/smoke inhaled and may burn larynx. Eventual edema can block the airway Look for soot on nostrils/mouth Dx = bronchoscopy Tx = intubation

Question 81

Electrical burns

Answer 81

Lightning strikes or touching high voltage wires Entrance and exit wounds Can cause arrhythmias Can burn muscle in contact with bone (bones conduct electricity well). This can cause rhabdo. Can act on nerves as well and generate muscle contractions that can cause posterior dislocation of shoulder Dx = check CK. If positive get creatinine Tx = IVF and mannitol

Question 82

Circumferential burns

Answer 82

No matter the source Initially blood vessel is patent. THEN cut off by eschar Watch for signs of vascular compromise. ``` Dx = clinical Tx = cut the eschar at bedside (it's 3rd degree so it won't hurt) ```

Question 83

Parkland formula

Answer 83

Tells us how much fluid we need to give burn patients (%BSA involved)(kg body weight)(4cc) = fluids lost Add that number of cc's of LR to 2000cc of D5W Replace the total as: 50% in first 8hrs. 50% in next 16hrs.

Question 84

Rule of 9s

Answer 84

ONLY count 2nd/3rd degree burns ``` Whole head = 9% Chest front = 9% Upper back = 9% Abdomen front = 9% Lower back = 9% Leg front = 9% x 2 Leg back = 9% x 2 Arm = 9% x 2 ``` Total = 99% Genitalia = 1%

Question 85

Rabies algorithm

Answer 85

Animal bite... was it a wild animal? Wild: Capture it and kill it. Look at its brain. If you see signs of rabies or you couldnt catch the animal then vaccinate (vaccine + IgG) Domestic: Observe the animal. If you see signs of rabies then vaccine + IgG If never see signs of rabies then nothing needs to be done

Question 86

bee sting

Answer 86

Anaphylaxis? Yes: SubQ Epi 1:1000 + H1/H2 blockers No: remove stinger

Question 87

Snake bite

Answer 87

Signs it's venomous: slit-like eyes, cobra cowl, rattlers Patient will have skin changes, erythema and lots of PAINNN if it's venomous. ``` Dx = clinical Tx = anti-venom ```

Question 88

Black widow bite

Answer 88

Pt has bite and abdominal pain OR enzymatic evidence of pancreatitis** ``` Dx = it's pretty much too late Tx = IVF and IV Calcium to treat the pancreatitis ```

Question 89

Brown recluse bite

Answer 89

Attic. Old boxes. Southern USA. Starts off with small dot of erythema Progresses to necrotic ulcer with ring of erythema ``` Dx = clinical Tx = debridement over and over. Skin grafting when toxin has resolved ```

Question 90

Human bite

Answer 90

WORST ONE Sex act or fist fight Shady story Dx = clinical and shady story Tx = Debride, explore wound and irrigate a ton THEN give Abx (amoxicillin or augmentin)