Trauma Flashcards
1
Q
The first step in the eval. of trauma is ___ and ___
A
The first step in the evaluation of a trauma patient is airway and protection
2
Q
A airway is considered protected if the patient is ____ and _____ in a normal voice
A
An away is protected if the patient is conscious and speaking in a normal voice
3
Q
An airway is considered unprotected if there is an expanding ____ or subcutaneous ___ in the neck, noisy or gurgly breathing or a Glasgow coma scale of ___
A
An airway is considered unprotected if there is an expanding hematoma or subcutaneous emphysema in the neck, noisy or gurgly breathing or GGC of <8.
4
Q
An airway should be secured before the situation becomes critical. In the field, the airway can be secured by ___ or ___
A
Can be secured by intubation or cricothyroidectomy. This is called the definitive airway.
5
Q
In the ED, airway securing can be done by rapid sequence induction and __ __, with monitoring of pulse oximetry.
A
In the ED, airway securing can be done by rapid sequence induction and orotracheal intubation, with monitoring of pulse oximetry.
6
Q
In the presence of cervical spinal injury, orotracheal intubation can still be done, as long as the ____ is secured and in-line stabilization is maintained during the procedure.
A
In the presence of cervical spinal injury, orotracheal intubation can still be done, as long as the head is secured and in-line stabilization is maintained during the procedure.
7
Q
Another option in that setting is nasotracheal intubation over a ___ bronchoscope.
A
Another option in that setting is nasotracheal intubation over a fiberoptic bronchoscope.
8
Q
If maxillofacial injuries preclude the use of intubation or intubation is unsuccessful, ____ may become necessary.
A
If maxillofacial injuries preclude the use of intubation or intubation is unsuccessful, cricothyroidectomy may become necessary.
9
Q
In pediatric patients, under age ____, tracheostomy is preferred over cricothyoidotomy, due to the high risk of airway stenosis, as the cricoid is much smaller than in the adult.
A
In pediatric patients, under age 12, tracheostomy is preferred over cricothyoidotomy, due to the high risk of airway stenosis, as the cricoid is much smaller than in the adult.
10
Q
Breath sounds indicate satisfactory ventilation; an absence or decrease of breath sounds may indicate ____ and/or hemothorax and necessitate chest tube placement.
A
Breath sounds indicate satisfactory ventilation; an absence or decrease of breath sounds may indicate pneumothorax and/or hemothorax and necessitate chest tube placement.
11
Q
What are the three clinical signs of shock?
A
- Low BP (<90)
- Tachy (>100)
- Low urinary output (<0.5 mL/kg/hr
12
Q
Patients in ___ will be pale, cold, shivering and apprehensive.
A
Patients in shock will be pale, cold, shivering and apprehensive
13
Q
In the trauma setting, shock is either ____, secondary to ___, or ___, secondary to ____
A
In the trauma setting, shock is either hypovolemic (secondary to hemorrhage and the most common scenario), or cardiogenic (secondary to pericardial tamponade or tension pneumothorax due to chest trauma).
14
Q
Hemorrhagic shock tends to cause _____ neck veins due to ___ central venous pressure.
Cardiogenic shock tends to cause ___ CVP with ___ venous distension. Both processes may occur simultaenously.
A
Hemorrhagic shock tends to cause collapsed neck veins due to low central venous pressure.
Cardiogenic shock tends to cause elvated CVP with jugular venous distension. Both processes may occur simultaenously.
15
Q
In ___ ____, there is typically no respiratory distress, while in ___ pneumothorax there is significant dyspnea, loss of unilateral breath sounds and tracheal deviation.
A
In pericardial tamponade, there is typically no respiratory distress, while in tension pneumothorax, there is significant dyspnea, loss of unilateral breath sounds and tracheal deviation.
16
Q
Treatment of hemorrhagic shock includes:
- Volume resuscitation with what?
- Control of bleeding
A
Volume resus with 2L of Lactated Ringer’s solution, unless blood products are immediately available.
17
Q
In the setting of trauma, transfusion of blood products should be in an ___ ratio, between: ____, ____ and ___.
A
In the setting of trauma, transfusion of blood products should be in an 1:1:1 ratio, between packed RBCs, FFP, platelets.
18
Q
Resuscitation should be continued until BP is normalized, and HR normalized and urine output reaches ____
A
Urine output has to reach 0.5-1 mL/kg/hr
19
Q
In the setting of uncontrolled hemorrhage, permissive hypotnesion is recommended to prevent further blood loss while awaiting definitive surgical repair, but a mean arterial pressure (>__ mmHg) should be maintained to ensure adequate ____.
A
In the setting of uncontrolled hemorrhage, permissive hypotension is recommended to prevent further blood loss while awaiting definitive surgical repair, but a mean arterial pressure (>60 mmHg) should be maintained to ensure adequate cerebral perfusion.
20
Q
The preferred route for fluid resuscitation in the trauma setting up ___ IV lines, __-guage or greater. If this cannot be contained, what can you do? What if you cannot do this second alternative?
What do you do in kids under age 6?
A
The preferred route for fluid resuscitation in trauma is setting up 2 large bore peripheral IV lines, 16-guage or greater.
If this cannot be obtained, percutaneous subclavian or femoral vein catheters should be insrted. An acceptable alternative is a saphenous vein-cut-down. In children age <6, intraosseous cannulation of the proximal tibia or femur is the alternate route.
21
Q
Pericardial tamponade is generally a clinical diagnosis and can be confirmed with ___.
Management requires evacuation of the pericardial space by pericardiocentesis, subxiphoid pericardial window or thoracotomy. Fluid and blood administration while evacuation is being set up is helpful to maintain an adequate cardiac output.
A
Pericardial tamponade is generally a clinical diagnosis and can be confirmed with U/S. Management requires evacuation of the pericardial space by pericardiocentesis, subxiphoid pericardial window or thoracotomy. Fluid and blood administration while evacuation is being set up is helpful to maintain an adequate cardiac output.
22
Q
Tension pneumothorax is a clinical diagnosis, based on ____
Management requires immediate ____ of the pleural space, initially with a large bore needle which converts the ___ to a ____ pneumothorax and followed by ____
A
Tension pneumothorax is a clinical diagnosis, based on physical exam.
Management requires immediate decompression of the pleural space, initially with a large bore needle which converts the tension to a simple pneumothorax and followed by chest tube placement.
23
Q
In the non-trauma setting, shock can also be ____ because of massive fluid loss such as bleeding, burns, peritonitis, pancreatitis, or massive diarrhea. The clinical picture is similar to trauma, with hypotension, tachycardia, and oliguria ith a low CVP. Stop the bleeding and replace the blood volume.
A
In the non-trauma setting, shock can also be hypovolemic because of massive fluid loss such as bleeding, burns, peritonitis, pancreaitis, or massive diarrhea. The clinical picture is similar to trauma, with hypotension, tachycardia, and oliguria ith a low CVP. Stop the bleeding and replace the blood volume.
24
Q
Intrinsic cardiogenic shock is caused by ____ damage. The clinical picture is hotn, tachy, oliguria with ___ CVP (presenting as ___ neck veins). DDx is essential, because additional fluid and blood administration in this setting could be lethal, as the failing heart becomes easily overlooked.
A
Intrinsic cardiogenic shock is caused by myocardial damage. The clinical picture is hotn, tachy, oliguria with high CVP (presenting as distended neck veins). DD is essential, because additional fluid and blood administration in this setting could be lethal, as the failing heart becomes easily overlooked.
25
\_\_\_\_ shock from anaphylaxis, high spinal anesthesia, or spinal cord transection, causes circulatory collapse. Patients are flushed, "pink and warm" with a ___ CVP. Tx is with ____ and fluids is aimed at filling dilated veins and restoring peripheral resistance.
**Vasomotor** shock from anaphylaxis, high spinal anesthesia, or spinal cord transection, causes circulatory collapse. Patients are flushed, "pink and warm" with a **low** CVP. Tx is with **phenylephrine** and fluids is aimed at filling dilated veins and restoring peripheral resistance.
26
After the ABC's have been evaluated, and any immediate life-threatening emergencies addressed, the trauma eval. continues with the secondary survey which is composed of a complete physical exam to evaluate for occult injuries followed by __ and __ xray. The secondary survey may be augmented with further imaging studies, depending on the mechanism of injury and findings on exam. Ay change that occurs requires complete re-eval.
After the ABC's have been evaluated, and any immediate life-threatening emergencies addressed, the trauma eval. continues with the secondary survey which is composed of a complete physical exam to evaluate for occult injuries followed by chest and pelvic xray. The secondary survey may be augmented with further imaging studies, depending on the mechanism of injury and findings on exam. Ay change that occurs requires complete re-eval.
27
Head trauma, as a rule, requires surgical intervention and repair of the damage.
Linear skull fractures are ____ \_\_\_\_\_ if they are closed (no overlying wound).
Open fractures require ____ closure. If comminuted or depressed, treat in the \_\_\_
Anyone with head trauma who has become unconscious gets a ___ to look for ___ \_\_\_. If negative and neurologically intact, they can go home if the family will ____ them frequently during the next 24 hours to make sure they are not going into coma.
Head trauma, as a rule, requires surgical intervention and repair of the damage.
Linear skull fractures are left alone if they are closed (no overlying wound).
Open fractures require wound closure. If comminuted or depressed, treat in the OR.
Anyone with head trauma who has become unconscious gets a CT scan to look for intracranial bleeding. If negative and neurologically intact, they can go home if the family will awaken them frequently during the next 24 hours to make sure they are not going into coma.
28
\_\_\_\_ of the skull fracture:
1. Raccoon eyes, rhinorrhea, otorrhea, or ecchymosis behind the ear (Battle's sign).
CT scan of the head is required to rule out ___ \_\_ and should be extended to include the neck to evaluate the ___ \_\_\_\_ injury. Expectant management is the rule and ____ are not usually indicated.
Base of the skull fracture:
1. Raccoon eyes, rhinorrhea, otorrhea, or ecchymosis behind the ear (Battle's sign).
CT scan of the head is required to rule out intracranial bleeding and should be extended to include the neck to evaluate the cervical spinal injury. Expectant management is the rule and antibiotics are not usually indicated.
29
Neurological damage from trauma can be caused by 3 components:
1. Initial blow
2. Subsequent development of a ____ that ___ the midline
3. Later development of increased intracranial pressure (ICP) due to cerebral edema.
Neurological damage from trauma can be caused by 3 components:
1. Initial blow
2. Subsequent development of a hematoma that displaces the midline
3. Later development of increased intracranial pressure (ICP) due to cerebral edema.
30
\_\_\_\_\_\_\_\_
- occurs with modest trauma to the side of the head, and has a classic sequence of trauma, unconsciousness, a lucid interval (a completely asymptomatic patient who returns to his previous activity), gradual lapsing into coma again, fixed dilated pupil (90% of the time on the side of the hematoma), and contralateral hemiparesis with decerebrate posturing. CT shows bioconvex, lens-shaped hematoma.
Emergency ___ produced a dramatic cure. Because every patient who has been unconscious gets a CT scan, the full-blown picture with the ___ pupil and ___ hemiparesis is seldom seen.
**Acute epidural hematoma**
- occurs with modest trauma to the side of the head, and has a classic sequence of trauma, unconsciousness, a lucid interval (a completely asymptomatic patient who returns to his previous activity), gradual lapsing into coma again, fixed dilated pupil (90% of the time on the side of the hematoma), and contralateral hemiparesis with decerebrate posturing. CT shows **bioconvex, lens-shaped hematoma.**
Emergency **craniotomy** produced a dramatic cure. Because every patient who has been unconscious gets a CT scan, the full-blown picture with the **fixed pupil** and **contralateral** hemiparesis is seldom seen.
31
\_\_\_\_\_\_\_
- force of trauma is typically much larger then acute epidural hematoma and the patient is usually much sicker (not fully awake and asymptomatic at any point), due to more severe neurologic damage. CT scan will show semi-lunar, crescent-shaped hematoma. If midline structures are deviated, craniotomy will help. Prognosis is \_\_\_\_.
If there is no deviation, therapy is centered on preventing further damage from subsequent \_\_\_\_\_
Acute subdural hematoma
- force of trauma is typically much larger then acute epidural hematoma and the patient is usually much sicker (not fully awake and asymptomatic at any point), due to more severe neurologic damage. CT scan will show semi-lunar, crescent-shaped hematoma. If midline structures are deviated, craniotomy will help. Prognosis is bad.
If there is no deviation, therapy is centered on preventing further damage from subsequent **increased ICP.**
Invasive ICP monitoring, head elevation, modest hyperventilation, avoidance of fluid over-load and diuretics such as mannitol or furosemide can decrease ICP. However, do not over diurese. This can lower systemic arterial pressure, as cerebral perfusion pressure = MAP - ICP. Hyperventilation is recommended when there are signs of herniation, and the goal is PCO2 35 mmHg.
Sedation is used to decrease brain activity and oxygen demand. Moderate hypothermia is currently recommended to further reduce cerebral oxygen demand.
32
Invasive ICP monitoring, head elevation, modest hyperventilation, avoidance of fluid over-load and diuretics such as __ or __ can decrease ICP. However, do not over diurese. This can ___ systemic arterial pressure, as cerebral perfusion pressure = MAP - ICP. Hyperventilation is recommended when there are signs of herniation, and the goal is PCO2 35 mmHg.
\_\_\_\_ is used to decrease brain activity and oxygen demand. Moderate \_\_\_thermia is currently recommended to further reduce cerebral oxygen demand.
Invasive ICP monitoring, head elevation, modest hyperventilation, avoidance of fluid over-load and diuretics such as mannitol or furosemide can decrease ICP. However, do not over diurese. This can lower systemic arterial pressure, as cerebral perfusion pressure = MAP - ICP. Hyperventilation is recommended when there are signs of herniation, and the goal is PCO2 35 mmHg.
**Sedation** is used to decrease brain activity and oxygen demand. Moderate **hypothermia** is currently recommended to further reduce cerebral oxygen demand.
33
Diffuse axonal injury occurs in more severe trauma.
CT scan will show diffuse ___ of the gray-white matter interface and multiple small ____ hemorrhages. Without hematoma, there is no role surgery. Therapy is directed at preventing further damage from ____ ICP.
Diffuse axonal injury occurs in more severe trauma.
CT scan will show diffuse **blurring** of the gray-white matter interface and multiple small **punctate** hemorrhages. Without hematoma, there is no role surgery. Therapy is directed at preventing further damage from **increased** ICP.
34
\_\_\_ ____ hematomas occur in the very old or severe alcoholics. A shrunken brain is __ around the head by minor trauma, tearing __ \_\_. Over several days or weeks, mental function ____ as __ forms. CT scan is diagnostic, and surgical evacuation provides a dramatic cure.
**Chronic subdural** hematomas occur in the very old or 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. CT scan is diagnostic, and surgical evacuation provides a dramatic cure.
35
T or F?
Hypovolemic shock cannot happen from intracranial bleeding.
Why?
True. There is not enough space inside the head for the amount of blood loss needed to produced shock. Look for another cause.
36
Neck trauma
- For the purpose of evaluating penetrating neck trauma, the neck has been divided into three zones:
What are they?
Zone 1: Clavicles to cricoid cartilage
Zone 2: Cricoid cartilage to the angle of the mandible
Zone 3: Angle of mandible to the base of the skull.
37
Penetrating neck trauma mandates surgical exploration in all cases where there is an expanding \_\_\_, deteriorating vital signs, or signs of esophageal or tracheal injury.
The use of ___ or ___ will help decide if surgical exploration is indicated and to determine the ideal surgical approach.
Penetrating neck trauma mandates surgical exploration in all cases where there is an expanding **hematoma,** deteriorating vital signs, or signs of esophageal or tracheal injury.
The use of **esophagoscopy or bronchoschopy** will help decide if surgical exploration is indicated and to determine the ideal surgical approach.
38
For injuries to zone 1:
- Evaluate with angiography, esophagram (water-soluble, followed by barium if negative), esophagoscopy, bronchoscopy to help decide if surgical exploration is indicated and to determine the ideal surgical approach.
Injuries to Zone 2:
- All penetrating traumas to zone 2 require ____ \_\_\_\_, which a recent trend toward selective exploration based on physical exam.
Inuries to Zone 3:
- evaluate with ___ for vascular injury.
For injuries to zone 1:
- Evaluate with angiography, esophagram (water-soluble, followed by barium if negative), esophagoscopy, bronchoscopy to help decide if surgical exploration is indicated and to determine the ideal surgical approach.
Injuries to Zone 2:
- All penetrating traumas to zone 2 require surgical exploration, which a recent trend toward selective exploration based on physical exam.
Inuries to Zone 3:
- evaluate with angiography for vascular injury.
39
In all patients with severe blunt trauma to the neck, the integrity of the ___ \_\_\_ has to be ascertained.
Unconscious patients and conscious patients with ___ tenderness to palpation should be evaluated initially with ___ and potentially followed with \_\_, depending on findings.
Conscious patients with no symptoms (are not intoxicated, have not used drugs, or have no distracting injuries) can be ____ evaluated for a cervical spinal injury; however, if CT scan of the head is being obtained, it is generally acceptable to extend the study to include the ___ \_\_\_.
In all patients with severe blunt trauma to the neck, the integrity of the **cervical spine** has to be ascertained.
Unconscious patients and conscious patients with **midline** tenderness to palpation should be evaluated initially with **CT scan** and potentially followed with **MRI** depending on findings.
Conscious patients with no symptoms (are not intoxicated, have not used drugs, or have no distracting injuries) can be **clinicaly** evaluated for a cervical spinal injury; however, if CT scan of the head is being obtained, it is generally accpeted to extend the study to include the **cervical spine.**
40
Brown-Sequard syndrome
- typically caused by clean cut injury such as knife blade, and results in ____ paralysis and loss of proprioception and\_\_\_\_ loss of pain perception caudal to the level of the injury.
Brown-Sequard syndrome
- typically caused by clean cut injury such as knife blade, and results in **ipsilateral** paralysis and loss of proprioception and **contralateral** loss of pain perception caudal to the level of the injury.
41
\_\_\_ ___ syndrome
- typically seen in burst fractures of the vertebral bodies. There is loss of motor function and loss of pain and temp sensation on both sides caudal to the injury, with preservation of vibratory and positional sense.
**Anterior cord syndrome**
- typically seen in burst fractures of the vertebral bodies. There is loss of motor function and loss of pain and temp sensation on both sides caudal to the injury, with preservation of vibratory and positional sense.
42
\_\_ __ syndrome.
- occurs in the elderly with forced hyperextention of the neck, such as a rear-end collision. There is paralysis and burning pain in the upper extremities, with preservation of most functions in the lower extremities.
**Central cord** syndrome.
- occurs in the elderly with forced hyperextention of the neck, such as a rear-end collision. There is paralysis and burning pain in the upper extremities, with preservation of most functions in the lower extremities.
43
Management of spinal cord injuries necessitate precise diagnosis of a cord injury, best done with \_\_\_. There is some evidence that high dose ___ immediately after injury may help, but that concept is still contraversial.
Management of spinal cord injuries necessitate precise diagnosis of a cord injury, best done with **MRI**. There is some evidence that high dose **corticosteroids** immediately after injury may help, but that concept is still contraversial.
44
Rib fractures can be deadly in the elderly, because pain impairs respiratory effort, which leads to hypoventilation, atelectasis, and ultimately, pneumonia.
To avoid this cycle, how can be treat the pt?
Treat the patient's pain from rib fractures with a **local nerve block, or epidural catheter, in addition to oral and IV analgesics.**
45
Simple pneumothorax results from penetrating trauma such as a weapon, or the jagged edge of a fractured rib. There is typically moderate shortness of breath, with absence of unilateral ____ and \_\_\_\_\_resonance to percussion. Diagnosis is confirmed with \_\_\_\_, and management consists of \_\_\_\_\_\_.
Simple pneumothorax results from penetrating trauma such as a weapon, or the jagged edge of a fractured rib. There is typically moderate shortness of breath, with **absence of unilateral breath sounds and hyperresonance** to percussion. Diagnosis is confirmed with **chest Xray**, and management consists of **chest tube placement.**
46
Hemothorax happens the same way as a simple pneumothorax (penetrating trauma such as a weapon or the jagged edge of a fractured rib), but the affected side will be ___ to percussion due to ___ accumulation in the pleural space.
The blood can originate directly from the lung ____ or from the chest wall, such as an ____ artery.
Diagnosis is confirmed with \_\_\_.
\_\_\_\_\_ placement is necessary to enable evacuation of the accumulated blood to prevent late development of ____ or \_\_\_\_, but surgery to stop the bleeding is sometimes required. If the ____ is the source of bleeding, it usually stops spontaneously as it is a ___ pressure system.
In some cases where a systemic vessel such as an ____ artery is the source of bleeding, _____ is needed to stop the hemorrhage. Indications for thoracotomy include:
1. Evacuation of \>\_\_\_mL when the chest tube is inserted
2. Collecting drainage of **\>\_\_\_ L** of blood over ___ **hours** (i.e. ____ mL/hr)
Hemothorax happens the same way as a simple pneumothorax (penetrating trauma such as a weapon or the jagged edge of a fractured rib), but the affected side will be **dull** to percussion due to **blood** accumulation in the pleural space.
The blood can originate directly from the lung parenchyma or from the chest wall, such as an **intercostal** artery.
Diagnosis is confirmed with **CXR.**
**Chest tube** placement is necessary to enable evacuation of the accumulated blood to prevent late development of **fibrothorax or empyema,** but surgery to stop the bleeding is sometimes required. If the **lung parenchyma** is the source of bleeding, it usually stops spontaneously as it is a **low** pressure system.
In some cases where a systemic vessel such as an **intercostal** artery is the source of bleeding, **thoracotomy** is needed to stop the hemorrhage. Indications for thoracotomy include:
1. Evacuation of **\>1500 mL** when the chest tube is inserted
2. Collecting drainage of **\>1 L** of blood over **4 hours** (i.e. **250** mL/hr)
47
Sucking chest wounds
- obvious from physical exam, as there is a ____ that sucks in air with inspiration and closes during expiration. Untreated, it will lead to a deadly ___ pneumothorax.
Initial management is with a partially occlusive dressing secured on 3 sides, with one open side acting as a one-way valve. This allows air to escape but not to enter the pleural cavity (to prevent iatrogenic tension pneumothorax and multiple fractures within each rib).
Sucking chest wounds -
- obvious from physical exam, as there is a **flap** that sucks air with inspiration and closes during expiration. Untreated, it will lead to a deadly **tension** pneumothorax.
Initial management is with a partially occlusive dressing secured on 3 sides, with one open side acting as a one-way valve. This allows air to escape but not to enter the pleural cavity (to prevent iatrogenic tension pneumothorax and multiple fractures within each rib).
48
Flail chest
- occurs with multiple rib fractures that allow a segment of the chest wall to _____ during inspiration and ____ during expiration (\_\_\_\_ breathing). The real problem is the underlying __ \_\_. A ___ lung is very sensitive to fluid overload, thus treatment includes __ \_\_ and pain management. Pulmonary dysfunction may develop, thus serial CXRs and arterial blood gases have to be monitored.
Flail chest
- occurs with multiple rib fractures that allow a segment of the chest wall to **cave in** during inspiration and **bulge out** during expiration (**paradoxical** breathing). The real problem is the underlying **pulmonary contusion**.
A **contused** lung is very sensitive to fluid overload, thus treatment includes **fluid restriction** and pain management. Pulmonary dysfunction may develop, thus serial CXRs and arterial blood gases have to be monitored.
49
Pulmonary contusion can show up right away after chest trauma with "\_\_\_\_" of the affected lungs or can be delayed up to __ hours.
If a respirator is needed, ____ should be considered to prevent a ___ pneumothorax from developing as the multiple broken ribs may have punctured the lung. Significant force is necessary to result in a flail chest, so traumatic dissection or transection of the ___ should be evaluated for using a \_\_\_\_. Finally, \_\_\_s may develop in this scenario.
Pulmonary contusion can show up right away after chest trauma with "**white out**" of the affected lungs or can be delayed up to **48** hours.
If a respirator is needed, **bilateral chest tubes** should be considered to prevent a **tension** pneumothorax from developing as the multiple broken ribs may have punctured the lung. Significant force is necessary to result in a flail chest, so traumatic dissection or **transection** of the aorta should be evaluated for using a **CT angiogram**. Finally, **ARD**s may develop in this scenario.
50
Blunt cardiac injury should be suspected with the presence of _____ fractures. ___ monitoring will detect any abnormalities. Although serum troponin level was historically obtained, elevations do not generally change management and are therefore not indicated, as treatment is focused on the complications of the injury such as arrhythmias.
Blunt cardiac injury should be suspected with the presence of **sternal** fractures. **ECG** monitoring will detect any abnormalities. Although serum troponin level was historically obtained, elevations do not generally change management and are therefore not indicated, as treatment is focused on the complications of the injury such as arrhythmias.
51
Traumatic rupture of the diaphragm shows up with the ___ in the chest (by physical exam and X rays), almost always on the ___ side (the liver protects the right hemidiaphragm).
All suspicious cases should be evaluated with \_\_\_\_. Surgical repair is typically done from the abdomen.
Traumatic rupture of the diaphragm shows up with the **bowel** in the chest (by physical exam and X rays), almost always on the **left** side (the liver protects the right hemidiaphragm).
All suspicious cases should be evaluated with **laparoscopy**. Surgical repair is typically done from the abdomen.
52
Traumatic rupture of the aorta is the ultimate "\_\_\_ \_\_\_".
It most commonly occurs at the __ and __ where the relatively mobile aorta is tethered by the ligamentum arteriosum.
Such an injury requires significant ___ injury and is totally _____ until the hematoma contained by the ___ ruptures resulting in rapid death. Suspicion should be triggered by one of the following:
1. Mechanism of injury
2. ____ mediastium
3. Presence of atypical fractures such as the ___ rib, \_\_\_, or \_\_\_, which requires great force to fracture.
Dx is made by \_\_\_\_. Surgical repair is indicated once the patient has been stabilized and more immediate life-threatening injuries have been managed. This can be done in an open or endovascular fashion.
Traumatic rupture of the aorta is the ultimate "**hidden injury**."
It most commonly occurs at the **junction of the arch and the descending aorta**, where the relatively mobile aorta is tethered by the **ligamentum arteriosum.**
Such an injury requires significant **deceleration** injury and is totally **asymptomatic** until the hematoma contained by the **adventitia** ruptures resulting in rapid death. Suspicion should be triggered by one of the following:
1. Mechanism of injury
2. **Widened** mediastium
3. Presence of atypical fractures suuch as the **first** rib, **scapula,** or **sternum,** which requires great force to fracture.
Dx is made by **CT angiogram**. Surgical repair is indicated once the patient has been stabilized and more immediate life-threatening injuries have been managed. This can be done in an open or endovascular fashion.
53
Traumatic rupture of the trachea or major bronchus is suggested by developing ___ \_\_\_ in the upper chest and lower neck, or by a large "\_\_\_ \_\_\_" from a chest tube.
CXR and CT scan confirm the presence of air outside the bronchopulmonary tree, and ___ bronchoscopy is necessary to identify the injury and allow intubation past the injury to secure an airway. Surgical repair is indicated.
Traumatic rupture of the trachea or major bronchus is suggested by developing **subcutaneous emphysema** in the upper chest and lower neck, or by a large "**air leak**" from a chest tube.
CXR and CT scan confirm the presence of air outside the bronchopulmonary tree, and **fiberoptic** bronchoscopy is necessary to identify the injury and allow intubation past the injury to secure an airway. Surgical repair is indicated.
54
Differential diagnosis of subcutaneous emphysema also include rupture of the ___ and ___ pneumothorax.
Differential diagnosis of subcutaneous emphysema also include rupture of the **esophagus and tension** pneumothorax.
55
Air embolism should be suspected when __ \_\_\_occurs in a chest trauma patient who is intubated and on a respiratory.
It also can occur when the ___ vein is opened to the air (supraclavicular node biopsies, central venous line placement, or lines that become disconnected), also leading to sudden cardiovascular collapse and cardiac arrest.
Immediate management includes __ \_\_, with the patient in Trendelenburg with the left side down. Prevention includes the Trendelenburg position when the great veins at the base of the neck are to be accessed.
Air embolism should be suspected when sudden death occurs in a chest trauma patient who is intubated and on a respiratory.
It also can occur when the **subclavian vein** is opened to the air (supraclavicular node biopsies, central venous line placement, or lines that become disconnected), also leading to sudden cardiovascular collapse and cardiac arrest.
Immediate management includes **cardiac massage**, with the patient in Trendelenburg with the left side down. Prevention includes the Trendelenburg position when the great veins at the base of the necka re to be accessed.
56
Fat embolism may also produce respiratory distress in a trauma patient who may not have necessarily suffered from chest trauma.
The typical setting is the following:
1. Pt with multiple traumatic injuries (including severeal __ \_\_\_ fractures) develops __ \_\_\_ in the axillae and neck; fever, tachycardia and low platelet counts.
At some point, patient shows full-blown picture of respiratory distress, with hypoxemia, and ___ \_\_\_ on CXR.
Mainstay of therapy:
- ___ \_\_\_, and therefore precise diagnosis is not needed and rarely confirmed.
Fat embolism may also produce respiratory distress in a trauma patient who may not have necessarily suffered from chest trauma.
The typical setting is the following:
1. Pt with multiple traumatic injuries (including severeal **long bone** fractures) develops **petechial rashes** in the axillae and neck; fever, tachycardia and low platelet counts.
At some point, patient shows full-blown picture of respiratory distress, with hypoxemia, and **bilateral patchy infiltrates** on CXR.
Mainstay of therapy for fat embolism:
- **respiratory support,** and therefore precise diagnosis is not needed and rarely confirmed.
57
Gunshot wounds require __ \_\_\_ for evaluation and possible repair of intra-abdominal injuries, not to "remove the bullet."
Any entrance or exit wound below the level of the ___ line is considered to involve the abdomen.
Stab wounds allow a more individualized approach. If it is clear that penetration has occurred, e.g. protruding viscera, exploratory laparotomy is mandatory.
Gunshot wounds require **exploratory lapartomy** for evaluation and possible repair of intra-abdominal injuries, not to "remove the bullet."
Any entrance or exit wound below the level of the **nipple** line is considered to involve the abdomen.
Stab wounds allow a more individualized approach. If it is clear that penetration has occurred, e.g. protruding viscera, exploratory laparotomy is mandatory.
58
Blunt trauma to the abdomen with obvious signs of internal injury requires emergent ____ evaluation via __ \_\_\_. Signs of internal injury include __ \_\_ and significant abdominal pain with guarding or rigidity on physical exam consistent with \_\_\_\_.
The occurrence of blunt trauma even without obvious signs of internal injury requires further evaluation because internal hemorrhage or bowel injury can be slow and therefore present in a delayed fashion.
Blunt trauma to the abdomen with obvious signs of internal injury requires emergent surgical evaluation via exploratory laparatomy. Signs of internal injury include **abdominal distension** and significant abdominal pain with guarding or rigidity on physical exam consistent with **peritonitis**.
The occurrence of blunt trauma even without obvious signs of internal injury requires further evaluation because internal hemorrhage or bowel injury can be slow and therefore present in a delayed fashion.
59
Signs of internal bleeding include:
1. Drop in \_\_
2. ___ pulse
3. Low **\_\_\_**
4. Low \_\_\_
Patients tend to be cold, pale, anxious, shivering and thirsty and perspiring profusely. These signs of shock occur when \_\_-\_\_\_% of blood volume is acutely lost, ~\_\_\_ mL in the average size adult.
There are few places in the body that this volume of blood can be lost without being obvious on physical or radiographic exam.
Signs of internal bleeding include:
1. Drop in **BP**
2. **Fast/thready pulse**
3. **Low CVP**
4. Low **urinary output**
Patients tend to be cold, pale, anxious, shivering and thirsty and perspiring profusely. These signs of shock occur when **25-30**% of blood volume is acutely lost, **~1500** mL in the average size adult.
There are few places in the body that this volume of blood can be lost without being obvious on physical or radiographic exam.
60
The only place where a volume of blood can cause significant "shock" is in the \_\_\_, ___ or \_\_.
Abdomen, pelvis or thighes
61
Diagnosis can quicklly be done using FAST.
Bedside US evaluates the peri\_\_\_ space, peri\_\_\_\_space, pelvis, and pericardium for free fluid.
Fluid is not typically present in these locations, so if there is a clinical suspician such as hypotension following blunt trauma, consider an internal injury.
Diagnosis can quiclly be done using FAST.
Bedside US evaluates the **perihepatic** space, **perisplenic** space, pelvis, and pericardium for free fluid.
Fluid is not typically present in these locations, so if there is a clinical suspician such as hypotension following blunt trauma, consider an internal injury.
62
Prolonged surgical time and ongoing bleeding can lead to the triad of death:
1.
2.
3.
Accordingly, "damage control" approach has been adopted: immediate life-threatening injuries are addressed, less urgent injuries are temporized. Obviously, repair of a ___ with ongoing bleeding takes precedence.
Next comes control of contamination from injury to GI tract. If a bowel resection is necessary, reconstruction can be ___ as only the contamination is life-threatening, not the inability to digest foods.
If hypothermia, coagulopathy or acidosis is setting in and injuries have been controlled, the operation is terminated and the abdomen is \_\_\_\_\_\_. The patient is resuscitated in the ICU, and returns to the OR at a later date when warm, not coagulopathic, and not acidotic for definitive reconstruction and abdominal closure.
Prolonged surgical time and ongoing bleeding can lead to the triad of death:
**1. Hypotension**
**2. Coagulopathy**
**3. Acidosis**
Accordingly, "damage control" approach has been adopted: immediate life-threatening injuries are addressed, less urgent injuries are temporized. Obviously, repair of a **major vascular structure** with ongoing bleeding takes precedence.
Next comes control of contamination from injury to GI tract. If a bowel resection is necessary, reconstruction can be **delayed** as only the contamination is life-threatening, not the inability to digest foods.
If hypothermia, coagulopathy or acidosis is setting in and injuries have been controlled, the operation is terminated and the abdomen is **packed with gauze pads and close with a temporary closure**. The patient is resuscitated in the ICU, and returns to the OR at a later date when warm, not coagulopathic, and not acidotic for definitive reconstruction and abdominal closure.
63
If coagulopathy does not develop during surgical exploration, it is objectively treated with transfusion of \_\_\_, ___ and \_\_\_. This most realistically mimics the replacement of whole blood and enables not only adequate quantities of hemoglobin, but also adequate clotting factors to reverse the developing coagulopathy and enable control of hemorrhage.
If coagulopathy does not develop during surgical exploration, it is objectively treated with transfusion of **RBCs, FFP and platelets in a 1:1:1 ratio.** This most realistically mimics the replacement of whole blood and enables not only adequate quantities of hemoglobin, but also adequate clotting factors to reverse the developing coagulopathy and enable control of hemorrhage.
64
What is abdominal compartment syndrome?
How do you manage it?
It occurs when pressure in the peritoneal cavity is elevated and leads to end organ injury. This occurs when a significant amount of fluid is administered in an effort to resuscitate a patient in hypovolemic shock. Bowel edema develops, increasing intra-abdominal pressure, which is detrimental for several reasons:
1. Elevated pressure of viscera on the diaphragm leads to acute kidney injury and possibly bowel and hepatic ischemia.
2. Upward pressure of viscera on the diaphragm prevents adequate expansion of the lungs and ventilation, contributing to respiratory failure
3. If a patient is not surgically explored but undergoes a significant volume resuscitation and abdominal compartment syndrome develops, a decompressive lapratomy may be indicated.
65
Ruptured spleen
- most common source of significant intra-abdominal bleeding in blunt abdominal trauma. Often, there are additional diagnostic hints, such as fractures of __ ribs on the right side. Given the limited function of the spleen in the adult, a splenic injury resulting in hemodyanmic instability or requiring significant blood product transfusion is an indication for \_\_\_
Post op treatment includes what?
Ruptured spleen
- most common source of significant intra-abdominal bleeding in blunt abdominal trauma. Often, there are additional diagnostic hints, such as fractures of lower ribs on the right side. Given the limited function of the spleen in the adult, a splenic injury resulting in hemodyanmic instability or requiring significant blood product transfusion i an indication for **splenectomy.**
**Post op immnization against encapsulated bacteria is mandatory.**
66
Pelvic fracture
- complex ring, much like a pretzel in that it cannot be fractured in only one location. Multiple fractures typically present.
How do you manage a pelvic fracture with ongoing bleeding?
1. Angriography to see injury - **NOT SURGICAL EXPLORATION!**
This is because it is incredibly difficult to identify the source of bleeding in the pelvis where a deep cavity contains significant organs and vessels including the complex sacral venous plexus.
However, interventional radiologists can angiographically identify an arterial source of bleeding and potentially embolize the branch vessels and control hemorrhage.
If no arterial bleeding is identified, the ongoing blood loss is presumed to be venous in origin, and the **internal iliac arteries are prophylactically embolized** to prevent the inflow to these bleeding veins.
67
Why do you do angiography instead of surgical exploration in pelvic bleeding?
his is because it is incredibly difficult to identify the source of bleeding in the pelvis where a deep cavity contains significant organs and vessels including the complex sacral venous plexus.
However, interventional radiologists can angiographically identify an arterial source of bleeding and potentially embolize the branch vessels and control hemorrhage.
If no arterial bleeding is identified, the ongoing blood loss is presumed to be venous in origin, and the internal iliac arteries are prophylactically embolizedto prevent the inflow to these bleeding veins.
68
In any pelvic injury, other associated injuries must be ruled out such as:
1. rectal injury (do a __ and \_\_\_)
2. vaginal injury (do a ___ \_\_\_\_)
3. urethra (do a __ \_\_\_)
4. bladder (do a ___ or \_\_\_\_)
In any pelvic injury, other associated injuries must be ruled out such as:
1. rectal injury **(rectal exam and rigid proctoscopy)**
2. vaginal injury (**pelvic exam**)
3. urethra (do a **retrograde urethrogram**)
4. bladder (do a retrograde cystogram or CT cystography)
69
Hallmark of urological injuries is what?
blood in urine of someone who has sustained penetrating or blunt abdominal trauma. gross hematuria in that setting must be investigated with appropriate studies.
70
Blunt urologic injuries may affect the kidney, in which case the associated injuries tend to be ___ rib fractures. If they affect the bladder or urethra, the usual associated injury is ___ fracture.
Urethral injuries occur almost exclusively in \_\_\_. They are typically assciated with a ___ fractures and may be present with blood at the \_\_\_.
Other clinical findings include a ___ hematoma, the sensation of wanting to \_\_\_\_, but \_\_\_to do so, and a \_\_-\_\_\_ prostate on rectal exam (i.e. it is not palpable on rectal exam).
Blunt urologic injuries may affect the kidney, in which case the associated injuries tend to be **lower** rib fractures. If they affect the bladder or urethra, the usual associated injury is **pelvic** fracture.
Urethral injuries occur almost exclusively in **men**. They are typically assciated with a **pelvic** fracture and may be present with blood at the **meatus.**
Other clinical findings include a **scrotal** hematoma, the sensation of wanting to **void, but inability to do so**, and a **high riding** prostate on rectal exam (i.e. it is not palpable on rectal exam).
71
In urological injuries, DO NOT INSERT A __ \_\_\_, as it might compound an existing injury; a retrograde urethrogram should be performed instead.
Do not insert a foley.
The procedure involves the insertion of a Foley catheter into the distal urethra and minimally inflating it. This is followed by instillation of 30mL of water-soluble contrast and a plain radiograph is obtained; leakage of the contrast suggests urethral injury (usually secondary to pelvic trauma) and is an indication for surgical intervention.
72
A rare but fascinating potential sequelae of injuries affecting the renal pedicle is the development of what?
Arteriovenous fistula leading to CHF.
Should RAS develop after trauma, renovascular HTN is another problem.
73
Scrotal hematomas. How do you manage them?
Scrotal hematomas can attain alarming size, but typically do not need intervention unless the testicle is ruptured. The latter can be assessed with US.
74
Fracture of the penis (fracture of the ___ \_\_\_), fracture of the tunica albuginea) occurs to an erect penis, typically as an accident during __ \_\_. There is sudden pain and development of a large penile shaft hematoma, with a normal appearing glans.
Emergency surgical repair is needed. If not done, impotence will ensue as either AV shunts or painful erections.
Fracture of the penis (fracture of the **corpora cavernosa**), fracture of the tunica albuginea) occurs to an erect penus, typically as an accident during **vigorous intercourse**. There is sudden pain and development of a large penile shaft hematoma, with a normal appearing glans.
Emergency surgical repair is needed. If not done, impotence will ensue as either AV shunts or painful erections.
75
If penetrating injuries to extremities occurs, the main issue is whether a ____ injury has occured or not. Anatomic location provides the first clue.
When there are no major vessels in the vicinity of the injury, only ____ PPx and ___ of the wound is required.
If the penetration is near a major vessel, and the patient is asymptomatic, ___ or __ angiogram is performed and will guide the need for surgical intervention.
If there is an obvious vascular injury, (absent distal pulses or expanding hematoma) __ \_\_ and repair are required.
If penetrating injuries to extremities occurs, the main issue is whether a **vascular** injury has occured or not. Anatomic location provides the first clue.
When there are no major vessels in the vicinity of the injury, only **tetanus** PPx andi **irrigation** of the wound is required.
If the penetration is near a major vessel, and the patient is asymptomatic, **dopper or CT** angiogram is performed and will guide the need for surgical intervention.
If there is an obvious vascular injury, (absent distal pulses or expanding hematoma) surgical exploration and repair are required.
76
What do you do if there is a simultaneous injury to the bone and vasculature?
What is a good solution?
Stabalize bone first, then do the delicate vascular repair which could otherwise be disrupted by the bony reduction and fixation.
However, during the orthopedic repair, ongoing ischemia is occuring as the arterial flow is disrupted.
A good solution is to place a **VASCULAR SHUNT** which allows temporary revasculatization during the bony repair, which definitive vascular repair completed subsequently. A fasciotomy should usually be added because the prolonged ischemia could lead to compartment syndrome.
77
High velocity gun shot wounds. What do you do?
You have to do extensive debridement and potential amputation
78
Crushing injuries.
What things can happen? (3)
What do you do?
Results in extensive myonecrosis and poses a hazard of hyperkalemia and renal failure as well as compartment syndrome.
Aggressive fluid administration, osmotic diuresis and alkalinzation of the urine with NaHCO3 are good preventive measures for acute kidney injury, and a fasciotomy may be required to prevent or treat compartment syndrome
79
Chemical burns require ____ to remove the offending agent. ____ burns (liquid plummer, drano) are worse than ___ burns (battery acid). Irrigation must begin ASAP at the site where injury occured (tap water, shower). Don't attempt to ___ the agent.
Chemical burns require massive **irrigation** to remove the offending agent. **Alkaline** burns (liquid plummer, drano) are worse than **acid** burns (battery acid). Irrigation must begin ASAP at the site where injury occured (tap water, shower). Don't attempt to **neutralize** the agent.
80
\_\_ \_\_\_electrical burns are always deeper and worse than they appear to be. Massive debridements or amputations may be required Additinal concerns include \_\_-induced kidney injury, orthopedic injuries secondary to massive ___ \_\_\_ (posterior dislocation of the shoulder, compression fractures of vertebral bodies), and late development of __ (eye stuff) and ___ syndromes. Of course, cardiac electrical integrity and function must be evaluated.
**High voltage** electrical burns are always deeper and worse than they appear to be. Massive debridements or amputations may be required Additinal concerns include **myonecrosis**-induced kidney injury, orthopedic injuries secondary to massive **muscle contractions** (posterior dislocation of the shoulder, compression fractures of vertebral bodies), and late development of c**ateracts and demyelinzation syndromes**. Of course, cardiac electrical integrity and function must be evaluated.
81
Respiratory burns (inhalation injuries) occur with flames in an enclosed space. They are ___ injuries caused by smoke inhalation. Burns around the mouth or soot inside th throat are suggestive clues. Dx is confirmed with __ \_\_.
Respiratory burns (inhalation injuries) occur with flames in an enclosed space. They are chemical injuries caused by smoke inhalation. Burns around the mouth or soot inside th throat are suggestive clues. Dx is confirmed with **fiberoptic bronchoscopy.**
82
Circumferential burns of the extremities can lead to tissue ___ and restriction of arterial flow, resulting in ischemia and ____ syndrome secondary to eschar.
This can also occur in circumferential burns to the chest, with resultant limitations in ventilation.
\_\_\_ done at the bedside with no need for anesthesia will provide immediate relief.
Circumferential burns of the extremities can lead to tissue **edema** and restriction of arterial flow, resulting in ischemia and **compartment** syndrome secondary to eschar.
This can also occur in circumferential burns to the chest, with resultant limitations in ventilation.
**Escharotomies** done at the bedside with no need for anesthesia will provide immediate relief.
83
Parkland formula?
Why do we use it?
BW (kg) x % of burn (up to 50%) x 4 cc RL.
This number tells us how much LR is required in the first 24 hours.
Give first 1/2 in the first 8 hours. Give second 1/2 in the next 16 hours.
84
Estimation for burns in babies. How is it different from adults?
Babies get three 9s for the head. Three 9's for the legs, and one 9 for the arms, 2 for the body
In adults, they get 2 9's for the head, 4 for the legs and 2 for the arms, 2 for the body.
