Trauma Flashcards
1
Q
What are the different types of shock?
A
Cardiogenic, hypovolemic, septic, neurogenic.
2
Q
Mechanism of hypovolemic shock, and what happens to: HR, SVR, CO, PCWP, CVP
A
Decreased blood and plasma volume. Can be caused by trauma or burns. HR goes way up, SVR goes way up, CO is down, PCWP is down, CVP is down.
3
Q
Mechanism of cardiogenic shock, and what happens to: HR, SVR, CO, PCWP, CVP
A
Failure of myocardial pump (blunt cardiac injury), decreased preload (cardiac tamponade, tension pneumothorax). HR goes up, SVR goes up, CO is down, PCWP goes up, CVP goes up.
4
Q
Mechanism of neurogenic shock, and what happens to: HR, SVR, CO, PCWP, CVP
A
Autonomic dysfunction (loss of sympathetic tone) with peripheral vasodilation. Can be caused by cervical spine injury. HR can be normal or slightly bradycardic, SVR goes down, CO goes down, PCWP goes down, CVP goes down.
5
Q
Mechanism of septic shock, and what happens to: HR, SVR, CO, PCWP, CVP
A
Systemic infection. HR goes way up, SVR goes down, CO goes up, PCWP goes down, CVP is dynamic (up and down).
6
Q
Clinical manifestations of hypovolemic shock
A
Tachycardia (initial sign), hypotension, pale/cool extremities, weak peripheral pulses, prolonged capillary refill, low urine output, altered mental status.
7
Q
Significance of blood at the urethral meatus in a trauma setting
A
Highly suggestive of a urethral injury secondary to a pelvic fracture. Other signs of urethral injury include perineal ecchymosis, scrotal hematoma, and a high-riding (non-palpable) prostate on digital rectal examination (DRE).
8
Q
What is the significance of gross hematuria after blunt trauma?
A
Injury to kidney or bladder
9
Q
How Much Blood Loss Is Necessary to cause Hypotension in the Supine Position?
A
Hypotension in the supine position implies the patient has lost 30–40 % of his blood volume, which represents 1,500–2,000 ml of blood.
10
Q
How much blood loss is Shock class 1-4?
A
Class 1: up to 750 ml
Class 2: 750 - 1500 ml
Class 3: 1500 ml - 2000 ml
Class 4: >2000 ml
11
Q
5 Main sources of Major blood loss in trauma
A
Chest, abdomen, pelvis/retroperitoneum, long bones, and “street” or external.
12
Q
Where can the descending aorta often become transected following blunt trauma?
A
Distal to the ligamentum arteriosum
13
Q
ABCDE of trauma patient management
A
Airway, Breathing, Circulation, Disability (neurologic workup), Exposure and environmental control
14
Q
Types of airway (3 total, 2 surgical) considered in a trauma setting
A
Orotracheal (best, first line) and Cricothyroidotomy.
Sidenote, Tracheostomy is not considered in a trauma setting because it requires more time and more expertise.
15
Q
Why is nasotracheal intubation not indicated in a trauma setting?
A
Trauma patients may have facial and basilar skull fractures. Attempts at nasotracheal intubation may lead to inadvertent intracranial passage of the nasotracheal tube.
16
Q
Secondary survey of trauma patients
A
AMPLE: Allergies, Medications, Past medical history, Last meal, Events preceding the trauma
17
Q
Two types of surgical airways
A
Cricothyrotomy and tracheostomy. Cricothyrotomy is more indicated in a trauma setting.
18
Q
How do you confirm proper intubation placement?
A
End-tidal CO2 determination (capnography), and subsequent chest X-ray
19
Q
FAST scan
A
Focused assessment with sonography for trauma (FAST scan) looks for fluid in the peritoneal cavity. For unstable trauma pts.
20
Q
DPL
A
Diagnostic peritoneal lavage. Abdominal incision –> catheter inserted into the peritoneal cavity. Positive if more than 20 cc of gross blood is aspirated –> pt is transported directly to the OR. If no blood, may perform a lavage of the peritoneal cavity with one liter of normal saline. DPL is positive if there are more than 100,000 RBCs/mm3.
21
Q
Most common cause of intra-abdominal bleeding following blunt trauma
A
Splenic injury (the most commonly injured organ is the liver)
22
Q
Kehr’s sign
A
Acute referred pain in the left shoulder due to splenic injury
23
Q
Most common injured organ in blunt trauma
A
Liver
24
Q
Pringle maneuver
A
Clamping the portal triad. Used to stop hepatic artery or portal vein bleeding. If pringle maneuver fails, implies bleeding is coming from hepatic veins.
25
Management of pelvic fracture bleeding other than fluid resuscitation
Pelvic volume reduction by wrapping a pelvic binder or sheet around the greater trochanters of the femurs.
26
MIVT Prehospital report
Mechanism, Injury, Vitals, Treatment
27
Two most common types of penetrating injury
Stab wounds and gunshot wounds
28
Pathology of tension pneumothorax
Air entering the pleural space crushes the IVC, inhibiting venous return to the heart, leading to cardiogenic (obstructive) shock
29
Three physical exam findings that independently mandate immediate operative intervention in a trauma patient
Hypotension, peritonitis, evisceration
30
Borders of the anterior abdomen
Xiphoid and costal margins superiorly, the anterior axillary lines laterally, and the inguinal ligaments and pubic symphysis
inferiorly
31
Borders of the flank
Between anterior and posterior axillary lines from the level of the sixth intercostal space to the iliac crest
32
Borders of the back
Tips of the scapular superiorly, posterior axillary lines laterally, and the iliac crests inferiorly
33
Two most common injuries following penetrating abdominal injury
Small bowel followed by liver
34
Are FAST exam and DPL exam better for blunt or penetrating abdominal trauma?
They are both better for blunt trauma. They also miss things in the retroperitoneum.
35
Massive Transfusion Protocol
Blood component therapy (RBC, plasma, platelets) in pts who are hemorrhaging or exsanguinating.
36
Permissive hypotension
Limiting fluid resuscitation in a trauma patient, permitting mild hypotension to avoid exacerbating bleeding and dilutional coagulopathy. ONLY APPLICABLE TO PENETRATING INJURY PATIENTS, NOT BLUNT.
37
Prophylactic antibiotics and analgesics for patients with penetrating trauma
Trick question, don't give these. Routine antibiotics and analgesics can mask important signs and symptoms in trauma patients. The exception to this rule
is if the patient has clear indications for surgical intervention on initial exam (e.g., peritonitis, hemodynamic instability).
These patients should receive preoperative antibiotics to cover bowel flora.
38
Mainstay of surgical treatment for penetrating abdominal trauma patients
Exploratory laparotamy
39
Damage control surgery
Limiting surgery to controlling life-threatening hemorrhage and temporarily controlling gastrointestinal contamination, followed by temporary closure of the abdomen and transfer to the intensive care unit for ongoing resuscitation. Once patients are adequately resuscitated,
they are brought back to the operating room to undergo definitive repair of the injuries.
40
Criteria for non-op management of penetrating abdominal trauma (list 4)
Hemodynamically stable patient, no peritonitis, evaluable (normal mental status), CT-scan showing no intra-abdominal injury.
41
How long should prophylactic antibiotics be administered following ex lap for trauma?
24 hours
42
Abdominal compartment syndrome - who is at risk, signs/symptoms, and treatment
Who: Pts w/ multiple traumatic injuries, esp. intra- abdominal or retroperitoneal, who received large volumes of fluids/blood products.
Signs: Decreased urine output, increasing peak pressures on the ventilator, and increasing vasopressor support, in the absence of another identifiable cause. Bladder pressure should be measured as it reflects intra-abdominal pressure. Treatment: Decompressive laparotomy (reopening the abdominal fascia and leaving the wound open)
43
Signs a good airway is present in a trauma patient
Conscious and speaking in full sentences, normal tone of voice
44
Signs breathing is okay in a trauma patient
Breath sounds bilaterally, satisfactory pulse oximetry
45
Clinical manifestations of shock in general
Low BP (under 90 mm Hg systolic), fast feeble pulse, and low urinary output (under 0.5 mL/kg/h) in a patient who is pale, cold, shivering, sweating, thirsty, and apprehensive
46
Management of pericardial tamponade
pericardiocentesis (main answer), but also pericardial window or open thoracotomy
47
Management of neurogenic shock
Pharmacologic treatment (e.g. vasopressors) to restore peripheral resistance
48
Linear skull fracture treatment
If closed, leave it alone. If open, close wound. If comminuted or depressed, operate in OR.
49
Signs of fracture of base of skull
Raccoon eyes, rhinorrhea, otorrhea/ecchymosis behind the ear
50
3 Components that contribute to neurological damage from trauma
The initial blow, the subsequent development of a hematoma that displaces the midline structures, and the later development of increased intracranial pressure (ICP). There is no treatment for the first, surgery can relieve the second, and medical measures can prevent or minimize the third.
51
CT finding in Acute epidural hematoma
biconvex (lens shaped) hematoma
52
CT finding in acute subdural hematoma
Semilunar, crescent shaped hematoma
53
Purpose of hyperventilation for head trauma patients
Hyperventilation decreases intracranial pressure
54
CT finding of diffuse axonal injury
diffuse blurring of gray/white matter interface, and multiple small punctate hemorrhages
55
Typical subdural hematoma patients
In very old or in severe alcoholics. A shrunken brain is rattled around the head by minor trauma, tearing venous sinuses. Over several days or weeks, mental function deteriorates as hematoma forms
56
Zones of the neck
Zone 1: xyphoid process to sternal notch.
Zone 2: Cricoid cartilage to angle of mandible.
Zone 3: Angle of mandible to mastoid process
57
Spinal Cord injury: Nothing works below point of injury
Complete transection of spinal cord
58
Spinal cord injury: paralysis distal to the injury on the injury side and loss of pain perception distal to the injury on the other side
Hemisection (Brown-Sequard)
59
Spinal cord injury: loss of motor function and loss of pain and temperature sensation on both sides distal to the injury, with preservation of vibratory and positional sense
Anterior cord syndrome
60
Spinal cord injury: paralysis and burning pain in the upper extremities, with preservation of most functions in the lower extremities.
Central cord syndrome
61
PE findings of Pneumothorax
Moderate shortness of breath, and one side of the thorax has no breath sounds and is hyperresonant to percussion
62
PE findings of Hemothorax
Moderate shortness of breath, affected side will be dull to percussion.
63
PE findings of tension pneumothorax
hypotension, dyspnea, tachypnea, jugular venous distention, unilaterally absent breath sounds, and a deviated
trachea to the unaffected side
64
Flail chest
Multiple rib fractures that allow a segment of the chest wall to cave in during inspiration and bulge out during expiration
(paradoxic breathing).
65
X-ray findings of pulmonary contusion
"White out" of the lungs (patchy, irregular alveolar infiltrates)
66
Specific lab to order when sternal fractures present to test for myocardial contusion
Troponins
67
What may happen after traumatic rupture of the diaphragm
Bowel in the chest via PE/X-ray
68
Suggested by developing subcutaneous emphysema in the upper chest and lower neck, or by a large “air leak” from a chest tube.
Traumatic rupture of major bronchi or trachea
69
Subcutaneous emphysema differential diagnosis (list 3)
Traumatic rupture of trachea or major bronchus, rupture of esophagus, tension pneumothorax
70
Suspect this in a pt with multiple trauma, including several long bone fractures, who develops petechial rashes in the axillae and neck; fever, tachycardia, and low platelet count; and who at some point shows a full-blown picture of respiratory distress, with hypoxemia and bilateral patchy infiltrates on chest x-ray.
Fat embolism
71
Suspect this when a sudden death occurs in a chest trauma patient who is intubated and on a respirator
Air embolism
72
If spleen must be removed in a trauma patient, immunization against what is mandatory
Encapsulated bacteria (Pneumococcus, Haemophilus influenza B, and meningococcus)
73
What do you do for a pelvic hematoma that is not expanding
leave it alone, dummy
74
When dealing with a pelvic fracture, what associated injuries must be ruled out?
Injury to rectum (do rectal exam and proctoscopy) and bladder in both sexes; the vagina in women (do pelvic exam); or
urethra in men (do retrograde urethrogram)
75
Signs of urethral injury (list 4)
Blood at the urethral meatus, perineal ecchymosis, scrotal hematoma, and a high-riding (non-palpable) prostate on digital rectal examination (DRE).
76
Study to find bladder injury
Retrograde cystogram: detailed x-ray of the bladder. Contrast dye is placed into the bladder through the urethra.
77
Two possible sequela of kidney injury secondary to blunt trauma
The development of an arteriovenous
fistula leading to congestive heart failure.
Should renal artery stenosis develop
after trauma, renovascular hypertension is another potential sequela.
78
Scrotal hematoma secondary to blunt trauma: what do you do?
leave it alone, dummy, unless the testicle is ruptured.
79
Fracture of the penis
Fracture of the corpora cavernosa or tunica albuginea. Occurs to an erect penis, typically as an accident during vigorous intercourse (with woman on top). There is sudden pain and development of a large penile shaft hematoma, with a normal appearing glans. Do retrograde urethrogram if you suspect urethral damage. Emergency surgical repair.
80
In the setting of a penetrating injury to an extremity, what do you do if: There are no major vessels in vicinity of injury? If injury is near major vessels but pt is asymptomatic? If there is an obvious vascular injury?
If no major vessels in vicinity: tetanus prophylaxis and cleaning of wound.
If near major vessels but asymptomatic: Doppler studies or CT angio.
If obvious vascular injury: surgical exploration and repair
81
Crushing injury of extremities can produce what hematologic complications?
Hyperkalemia, myoglobinemia, myoglobinuria, and renal failure, as well as potential development of compartment syndrome.
82
What do you do for a chemical burn
Irrigate ASAP to remove offending agent. Do not play chemist and try to neutralize burn.
83
Concerns when dealing with high-voltage electrical burns (list 3)
myoglobinemia-myoglobinuria-renal failure (give plenty of fluids and osmotic diuretics like mannitol, and alkalinize the urine), orthopedic injuries secondary to massive muscle contractions (posterior dislocation of the shoulder, compression fractures of vertebral bodies), and late development of cataracts and demyelinization syndromes
84
What do you order to determine if someone with smoke inhalation injury needs respiratory support?
Blood gasses
85
What do you administer if carboxyhemoglobin is elevated in a pt w/ smoke inhalation
100% oxygen, which shortens its half life
86
What are you worried about in circumferential burns, and what do you do about it?
Compartment syndrome. Tx with escharotomy.
87
What might you be suspicious of in cases of scalding burns of children
Child abuse
88
Typical fluid needs in extensive burn victims
1 liter an hour in the adult with extensive burns (>20%), and then adjust the fluid administration on the basis of urinary output
89
Rule of nines in adult burn victims
Head and each arm get 9%, legs get two units of 9%, and trunk gets four units of 9%
90
Desired urinary output for a burn victim
1 or 2 mL/Kg/hr
91
Desired CVP for a burn victim
Less than 15 mmHg
92
Rule of nines in baby burn victims
Head gets 2 units of 9%, both legs share three units of 9% total. Otherwise same as adult.
93
Starting fluid needs in a baby burn victim
20 mL/kg/hr
94
Standard topical agent for burns (list 3)
silver sulfadiazine, sulfamylon (or mafenide acetate), silver nitrate
95
Two alternate choices for topical burn agents instead of silver sulfadiazine
Mafenide acetate (to get deeper) or triple antibiotic ointment (to not irritate eyes)
96
Condition a burn victim should meet to consider early excision and grafting
Burn should be limited (<20%)
97
Is tetanus prophylaxis required for all bites or just some (and what is the deciding factor?)
Yes all bites
98
Is rabies prophylaxis required for all bites or just some (and what is the deciding factor?)
Provoked dog bites do not require rabies prophylaxis, just observe the dog for signs of rabies. If bite is near brain, start rabies treatment and discontinue if observation of dog is reassuring. Unprovoked dog bites or bites from wild animals, treat for rabies.
99
Signs of envenomation in snake bite victims
Severe local pain, swelling, and discoloration developing within 30 minutes of the bite
100
First aid measures for snake bites
The only valid first aid is to splint the
extremity during transportation. All the first aid measures that you learned at boy scouts are wrong. Do not make cruciate cuts, suck out venom, wrap with ice, or apply a tourniquet.
101
Anti-venin dosages in children vs. adults
They're the same, dosage is based on size of envenomation not on the size of the patient
102
Treatment for anaphylactic shock secondary to bee sting
Epinephrine
103
Type of shock caused by bee stings
Vasomotor (neurogenic) shock
104
Symptoms of black widow bite
Nausea, vomiting, and severe generalized muscle cramps
105
Treatment for black widow bite
IV calcium gluconate, and muscle relaxants help
106
Symptoms of recluse spider bite
Next day skin ulcer, with necrotic center and a surrounding halo of erythema
107
Treatment for recluse spider bite
Dapsone. Surgical excision or grafting may be needed, but observe first to see full extent of damage.
108
Dirtiest bites one can get in terms of bacteria
Humans
109
Treatment for human bite
Extensive irrigation and debridement in the OR. Then special orthopedic care.
110
6 P's of limb ischemia
pain, pallor, paresthesias, paralysis, pulselessness, and poikilothermia
111
What Is the Implication of an Audible Bruit/Palpable Thrill Near an Artery in Association with Trauma
It is highly suggestive of a traumatic arteriovenous fistula.
112
If a Conduit Is Needed to Replace an Injured Artery, Where Is It Taken from?
Great saphenous vein from uninjured leg
113
What Is a Pseudoaneurysm?
A pseudoaneurysm develops when an artery sustains a focal full-thickness injury that is temporarily tamponaded by the surrounding soft tissue (it is not surrounded by the media or adventitia). Blood continues to be pumped into the pseudoaneurysm cavity, creating a pulsatile quality that can be felt on exam as a pulsatile mass on palpation of the overlying skin.
114
differential diagnosis of a pulsating mass (3)
AV fistula, aneurysm, and pseudoaneurysm
115
What Nerve Would Be Injured if a Patient with a GSW to the neck Presented with Vocal Cord Paralysis
The recurrent laryngeal nerves, which supply the vocal cords, are both branches of the vagus nerve on their respective sides.
116
Hard signs of vascular injury (4)
arterial bleeding, shock, pulsatile or expanding hematoma, and thrill/bruit
117
How Is the Diagnosis of Traumatic Cardiac Tamponade Established?
Beck’s triad (hypotension, distended neck veins, and muffled heart sounds) should be suspected of having tamponade. The diagnosis can be supported with a FAST scan which demonstrates fluid in the pericardial sac. Patients may also exhibit pulsus paradoxus (decrease in systolic pressure ≥10 mmHg with inspiration).
118
What Is the Most Dangerous Complication Following Pericardiocentesis?
Laceration of a coronary vessel is the most dangerous complication of pericardiocentesis and can lead to worsening of cardiac tamponade
119
What Nerve Is at Risk When Opening the Pericardium?
Left phrenic nerve. It passes longitudinally over the posterior aspect of the pericardium of the left ventricle.
120
3 components of inhalational injury
upper airway edema, acute respiratory failure (secondary to a chemical pneumonitis from the products of combustion), and carbon monoxide poisoning
121
What Is the Significance of Cherry-Red Skin in a Patient Rescued from a House Fire
Carbon monoxide (CO) poisoning. Patients initially present with headaches and other nonspecific constitutional symptoms such as nausea and dizziness. If severe or left untreated, CO poisoning may progress to seizures, coma, and multiorgan failure, and death.
122
Curling's ulcer
An ulcer of the duodenum in patients with severe burns
123
What Organisms Are Classically Involved in Burn Wound Infections?
Pseudomonas aeruginosa (gram-negative bacillus) is the most common cause of infections in burn patients, followed by Staphylococcus aureus and Streptococcus pyogenes . Fungal: Candida albicans . Viral: herpes simplex virus.
124
How do you diagnose inhalational injury?
Fiberoptic bronchoscopy is definitive. Clinically, facial burns, singed nasal hairs, and history of injury in an enclosed space.
125
Best Way to Evaluate for Carbon Monoxide (CO) Poisoning
Carbon monoxide pulse oximetry is best, but not always available. Standard pulse oximetry is not always reliable. Arterial blood gases will demonstrate a normal PaO2 and decreased SaO2.
126
Management of inhalational injury
Early intubation to prevent sudden loss of the airway due to the thermal injury and upper airway edema
127
Carbon monoxide poisoning management
100 % oxygen via non-rebreather face mask.
128
What type of fluid do you use on a burn victim?
Lactated Ringer's. Colloid solutions can increase pulmonary/respiratory complications within the first 24 hours of a burn injury. Use of normal saline will lead to hyperchloremic metabolic acidosis as high volumes will be required in burn victims.
129
What Electrolyte Abnormality Must Be Closely Monitored in Burn Patients?
Serum sodium and potassium. Hyponatremia can increase the risk of developing seizures in burn patients. Hyperkalemia can develop from the destruction of cells and tissues and can lead to cardiac conduction abnormalities
130
What Medication Should All Burn Patients Be Started on to Prevent Curling’s Ulcers
Proton pump inhibitors or H2 blockers
131
What Are the Principles of Management for Chemical Burns?
Protection of others from exposure and removal of patients from area of exposure. Remove all clothing, brush dry chemicals off the patient, COPIOUS IRRIGATION. The longer the acid/alkali material stays in contact with the patient’s body, the worse the prognosis.
132
What Is the Key Management Principle for Patients with Electrical Burns
Cardiac monitoring for 12–24 hours to look for arrhythmias, particularly when a high-voltage injury (>1,000 V) is suspected.
133
6 P's of Compartment Syndrome
pain, paresthesia, pallor, paralysis, pulselessness, and poikilothermia (loss of temperature regulation ability)
134
How does compartment syndrome differ from acute limb ischemia
In compartment syndrome, pulselessness is a LATE finding. In acute limb ischemia, pulselessness is an EARLY finding.
135
What are the two earliest signs of compartment syndrome
Pain (especially on passive extension) and paresthesias
136
Compartment syndrome can lead to these electrolyte / serum abnormalities which can result in end organ damage
Hyperkalemia, acidosis, myoglobinuria
137
What Is the Significance of the First Web Space Numbness in a patient with leg compartment syndrome?
For lower leg injuries, the anterior compartment is most susceptible to compartment syndrome. The deep peroneal nerve courses within this compartment and supplies motor fibers to the extensor digitorum brevis and extensor hallucis brevis, w/ afferent cutaneous sensation for the first web space. Nerve ischemia within the anterior compartment thus produces characteristic numbness
between the first and second toes.
138
Volkmann’s Ischemic Contracture
A sequela of untreated compartment syndrome. Classically seen in children after a supracondylar fracture --> marked swelling of forearm muscles, brachial artery injury --> ischemia. Untreated, the compartment syndrome leads to ischemic muscle that becomes fibrosed and contracted --> clawlike hand with flexion of the hand at the wrist as well as damaged and insensate nerves.
139
Treatment of extremity compartment syndrome
Fasciotomy (all compartments of the affected limb)
140
Appropriate next step if a hemodynamically stable pt after blunt trauma to the abdomen has signs of splenic injury, but FAST scan was negative for intraperitoneal fluid
CT scan.
141
Suspect this in a patient who has blunt trauma and gets chest wall bruising and decreased breath sounds on the same side, develops <24 hours after the trauma.
Pulmonary contusion. Chest X-ray with patchy, irregular alveolar infiltrate without anatomical borders confirms
142
In a patient with severe hemoptysis, how can you manage the bleeding?
Place patient with bleeding lung in dependent position, and do a bronchoscopy. This allows you to visualize where the bleeding is from, suction, and possibly intervene.
143
Suspect this in a child who had some trauma a few days ago, and presents with epigastric pain / bilious vomiting. X-ray shows dilated stomach.
Duodenal hematoma
144
What do you give someone who has ingested methanol or ethylene glycol, to stop them from being digested into their toxic metabolites?
Fomepizole
145
What to give for Acetominophen toxicity
N-Acetylcysteine IV
146
Suspect this in a poisoned patient who develops tinnitus, vertigo, hyperventilation. Then an anion-gap metabolic acidosis.
Salicylates (aspirin)
147
What to do for Salicylate toxicity?
Alkalinize the urine, force diuresis
148
Treatment for cyanide poisoning
Thiosulfate
149
Symptoms of organophosphate poisoning
```
SLUDGE:
Salivation
Lacrimation
Urination
Defacation
GI upset
Emesis
```
150
Treatment for organophosphate poisoning
Atropine and pralidoxime
