TRAUMA Flashcards
1
Q
Why is epidural analgesia more effective pain-control than intercostal nerve block re: flail chest?
A
Latter is short-lived
2
Q
Which nerve is first involved in LE compartment syndrome? Which compartment?
A
deep peroneal nerve
anterior compartment
3
Q
Can you r/o muscle necrosis if concerned for compartment syndrome, if CPK normal? Why?
A
NO.
CPK elevates 4-6hrs after onset necrosis
4
Q
Mgmt femoral shaft fx
A
internal fixation w/ intramedullary rods, OR external fixation if complex bone injury or soft tissue injuries that preclude internal fixation
5
Q
When need femoral angiography post-trauma?
A
- supracondylar femur fx
- post dislocation of knee
6
Q
In trauma resuscitation, gastric mucosal pH reflective of…
A
adequacy of splanchnic perfusion during resus
7
Q
AAST Renal CT Injury Scale
A
- contusion, or subcap hematoma only
- lac <1cm
- lac >1cm
- injury to collecting system or large lac
- main renal artery/vein lac, avulsions, shattered
8
Q
AAST Liver CT Injury Scale
A
- <1cm
- ~2cm
- > 3cm
- > 10cm, or unilobe maceration
- bilobe maceration, venous injury
- avulsion
9
Q
AAST Splenic CT Injury Scale
A
- <1cm
- ~2cm
- > 3cm
- > 10cm
- total devasc or maceration
10
Q
Concern for renal trauma in adults if… (4)
A
- penetrating trauma to flank or abd regardless of hematuria
- blunt trauma with gross/microscopic hematuria + shock
- deceleration injuries
- major associated intraabd injuries + microhematuria
11
Q
When does CK peak following onset of muscle injury?
A
24-72 hours
12
Q
Compartment syndrome pt, +Hgb on dipstick, by neg on microscopy… concern for?
A
Rhabdomyolysis
13
Q
Workup cardiac trauma, no hemothorax vs. none
A
if hemothorax -> subxiphoid exploration
if none -> echo
14
Q
Triangle of safety for CT placement
A
Superior: base of axilla Lateral: edge of lat dorsi Medial: edge of pec major Inferior: 5th intercostal Anterior of mid-axillary
15
Q
Why want CT placed anterior to mid-axillary line?
A
Avoid long thoracic nerve
16
Q
Biggest complicative risk to what organ s/p femur injury?
A
pulmonary (ARDS, embolism)
17
Q
What incisions for compartment syndrome?
A
superficial anterolateral + superficial and deep posterior compartments
18
Q
Grading of blunt carotid injury (BCVI) + mgmt
A
1 = <25% narrow -> ASA325 vs. heparin + fu CT angio 7d 2 = >25% narrow -> same as grade 1 3 = PSA -> open repair (or endo if not accessible) 4 = occlusion -> repair, or AC if not accessible 5 = transection -> repair, or ligate if not accessible
19
Q
C/I placement of trach via perQ dilational technique
A
- elevated respiratory requirements (Fi02 >70%, PEEP >12mmHg)
- peds pt (collapsable and mobile trachea)
- active coagulopathy
- midline neck mass
- BMI >30
- cervical trauma preventing neck extension
20
Q
Which vaccines need booster or to be repeated s/p splenectomy?
A
Pneumococcal: PCV13, then PPSV23 8-wks later, then second 23-valent 5-yr later
Meningococcus: 2-dose series with 8-12wks in between if >2yo; booster q5y
21
Q
What is considered “distal” pancreas anatomically?
A
left of SMA
22
Q
Equation for TEE
A
TEE = BEE * activity factor * stress factor
23
Q
Activity Factor components
A
- vent -> 1.1
- bed rest -> 1.15
- normal -> 1.25
- manual worker -> 1.5-2
24
Q
Stress Factor components
A
- postop, no infxn -> 1.1
- major trauma -> 1.25
- trauma + infxn -> 1.5
- burns -> 2.0
25
Association of decel injuries and GU injury?
Likely @ prox ureter or ureteropelvic junction obstruction
26
Mgmt proximal ureteral leak
retrograde pyelogram at time of surgery w/ open reconstruction
27
Are H2 blockers effective for burn pts?
NO - no reduction of stress ulcers; actually increases rate of infection
28
Most important digits of hand
```
#1 Thumb (>50% function of hand)
#2 Pinky (gripping finger)
```
29
Flexor Zones
Zone 1 = flexor digitorum profundus
Zone 2 = flexor digitorum superficialis
Zone 3 = lumbricals
30
Which digit amputations do you not fix? Why?
Zone 2; bc high risk tendon adhesions -> impaired motion at PIP -> digit that is more in the way than useful
31
Need to avoid what two important aspects in pts with head injury?
Hypoxia (PaO2 <60 independent predictor of poor outcome)
| Hypotension (single episode SBP <90 doubles mortality)
32
Mgmt distal ureteral injury
ureteroneocystostomy w/ psoas hitch (bring bladder up)
33
3 components of mini neuro exam
GCS
pupillary function
lateralized extremity weakness
34
If GCS, pupillary fxn, laterality all abnormal... then?
Focal mass lesion (subdural, epidural, intracerebral hematoma); subdural mos t common
35
Abnormal GCS, but normal pupillary fxn and laterality... then?
Diffuse brain injury (diffuse axonal injury, concussion, hypoxemia)
36
Sxs subarachnoid hemorrhage
depressed LOC, severe HA, photophobia
37
mild, moderate , vs. severe brain injury (defined by GCS)
```
mild = 13-14
mod = 9-12
severe = <8
```
38
Mgmt penetrating injury to colon vs. to rectum
Colon -> primary repair (lower cx rate compared to diversion)
Rectum -> drainage + diversion of fecal stream
39
Most common EARLY post-splenectomy complication
Hemorrhage (2/2 bleed from short gastrics or splenic artery)
40
Time frame of OPSI (overwhelming post-splenectomy infection) after splenectomy
weeks to years (40% occur after 5 years)
41
Mgmt radial artery injury (no pulse), but no hand ischemia
wound care + obs; may ligate if signif arterial bleeding
42
Mgmt ulnar artery injury
Revascularize
43
Mgmt options for traumatic diaphragmatic injury
1. primary repair w/ non-absorb suture
2. if large -> synthetic mesh
3. if large + peritoneal contamination -> biologic mesh, placed on pleural side to prevent adhesions
44
Le Fort Fractures + mgmt
I (horizontal maxillary fx) -> reduction, stabilize, intramaxillary fixation
II (maxillary fx that involves nasal bone) -> same as Le Fort I
III (craniofacial separation with entire face moving in relation to skull base) -> suspension wiring to stable frontal bone, may need external fixation
45
Factors used to predict survival in initial 24hrs after severe head trauma
- age (strong)
- best motor score
- pupillary activity
- EOM (significant at 24hrs, but not at initial admission eval)
46
Mgmt isolated bladder injury
Foley 2 weeks -> cysto -> remove foley if no leak (only 25% will require intervention)
47
AAST Duodenal Injury Grade
1. partial thickness
2. <50% lac
3. 50-75% lac
4. >75% lac, involves ampulla or distal CBD
5. involves duo-panc complex, or devascularized
48
Mgmt grade 4 vs. grade 5 duodenal injury
4 -> antrectomy, gastroJ, tube duodenostomy
| 5 -> pancreaticoduodenectomy
49
Mgmt grade 2 vs. grade 3 duodenal injury
2 -> primary repair + feeding access distal to repair
| 3 -> resection w/ primary anastamosis
50
If known intracranial hemorrhage (ie. asymm pupils) + hypotensive... think?
another etiology for hypotension; intracran hem rarely causes hypotension
51
Next step... intra-op see bladder injury that extents to ureteral orifice
IV indigo carmine or methylene blue to access ureteral patency
52
Mgmt stable RIGHT thoracoabdominal penetrating wound vs. LEFT
right -> CT (liver can tolerate)
| left -> CT, then ex-laparoscopy to r/o diaphragmatic injury (do not see on imaging)
53
Signs/sxs esophageal injury
hoarseness, neck hematoma, spitting up blood or NGT, subQ air, anterior tracheal deviation
54
RF for developing tracheoinnominate fistula
- hx neck radiation
- low trach placement
- persistent neck extension
- malnutrition
- steroid use
55
Mgmt tracheoinnominate fistula (4 steps)
- ET tube via trach
- Finger pressure (caudal and anterior)
- Partial sternotomy + resection of involved segment of innominate artery
- Cover region of fistula w/ muscle or adjacent tissue flap
56
2 dx studies that relate to clinically significant myocardial contusion
EKG (most specific) and CPK-MB
57
Concern for what in kids w/ lap belt injury
small bowel and lumbar spine injury (in adults thoracolumbar)
58
Normal Urine Na level
15-250 mEq/L
59
How does alcohol -> increased urinary output?
alcohol activates osmoreceptors that signal low osmotic pressure in blood -> triggers inhibition of ADH
60
If penetrating gluteal wound, need to eval for?
Injury to pelvic organs (ie. sigmoidoscopy, bladder cath, urethrocystography)
61
Scapulothoracic dissection associated with... (life-threatening)
massive ARTERIAL bleed
62
Mgmt scapulothoracic dissection
reduce and immobilize chest/arm (prevent hematoma expansion), then IR embolization
63
Mgmt avulsion of Flexor Zone 1
prompt repair
64
Mgmt small distal esophageal perf? What if too friable?
debridement of devitalized tissue + primary repair (if too friable -> T-tube to create large fistula)
65
Absolute indications for renal exploration (3)
Hemodynamic instability 2/2
- renal hemorrhage
- expanding or pulsatile RP bleed at laparotomy
- pedicle avulsion
66
If renal exploration due to trauma contemplated, need to demonstrate what?
c/l renal function (in event need to do ipsilateral nephrectomy)
67
Why blunt cardiac trauma -> cardiac rupture and contusion? (acute vs. delayed)
acute: increased intrathoracic pressure to chambers of heart -> rupture
delayed: contusion -> necrosis -> rupture.
68
Mgmt transection of right renal vein
nephrectomy (bc R-renal vein does not have collaterals)
69
Collaterals of R vs. L renal vein
```
Right = none
Left = gonadal, adrenal
```
70
What is Cattell-Braasch maneuver?
right medial visceral rotation; right colon is mobilized medially/superiorly and duodenum is kocherized
71
What does Cattell-Braasch maneuver expose?
- right kidney
- right kidney vasculature
- IVC
72
What is Mattox maneuver?
left medial visceral rotation
73
What does Mattox maneuver expose?
- left kidney
| - aorta (from hiatus -> iliac)
74
Mgmt child/adolescent with stable duodenal hematoma. what if fail?
- bowel rest, gastric decompression, TPN
| - operative mgmt if obstruction does not resolve in 10-14 days
75
Penetrating anterior chest medial to nipple line OR posterior chest medial to scapula... alert for what injuries?
- great vessels
- hilar structures
- heart
76
If suspect bleeding of common iliacs and IVC... what do you need to do to get better visualization?
divide R-CIA and mobilize aortic bifurcation to left -> expose common iliac veins
77
Antivenin if snakes are what color...?
Coral snakes: "red touch black, venom lack. red touch yellow, kill a fellow"
78
If injury to proximal R-hepatic artery... then?
ligate + cholecystectomy
79
Mgmt rattlesnake bite
immobilization + splint of affected part at level of heart or slight dependence
80
What is Morison's pouch?
hepatorenal recess (seen on FAST)
81
Mgmt cervical perf of esophageal muscularis
debride + expose viable tissue and extent of mucosal injury (often > than that of muscularis injury)
82
Complication of black recluse spiders (south central US)
coagulopathy (if severe, DIC)
83
Mgmt pt 50% TBSA burn + evidence inhalation injury
permissive hypercapnia -> respiratory acidosis w/ low tidal volume
84
If unable to tolerate supine bc severe difficulty breathing following MVA... suspect? Mgmt?
severe laryngeal trauma (particularly in unbelted MVA) -> immediate airway via tracheostomy (no cric)
85
Eval of posterior knee location
ABI, duplex US, CT arteriogram, catheter-based arteriography... ABI <0.90 predictive of arterial injury
86
Second most commonly missed compartment in fasciotomy
deep posterior
87
Incision for exposure of left subclavian artery injury
for PROXIMAL - anterior 3rd intercostal space thoracotomy
for middle/distal - supraclavicular approach
88
Incision for exposure of right subclavian artery injury
medial sternotomy or anterior SCM-type neck extension
89
Thoracic duct empties to where?
confluence of jugular and subclavian veins of left neck
90
Mgmt thoracic duct injury
wide drainage + ligation of thoracic duct in either neck or chest
91
Thoracic duct most susceptible to injury in what surgery?
Left neck exploration
92
Mgmt frostbite
RAPID rewarming 40C water bath
93
1-week following lung lac, noted to have lucency on CXR... think?
pneumocele
94
Mgmt Zone 2 neck injury but asyptomatic
CT angiogram of neck
95
Mgmt lac of proximal left main coronary artery
cardiopulm bypass + GSV from prox aorta to coronary artery distal to lac
96
Mgmt lac distal coronary arteries
ligate
97
Mgmt lac ventricles
repair w/ horizontal mattress full-thickness sutures w/ pleget
98
Mgmt lac atria
repair w/ prolene sutures w/ or wo pledgets
99
Pontine hemorrhage -> what eye exam?
bilateral pinpoint pupils
100
High speed MVC with GCS 7, likely to have what kind of brain injury?
intraparenchymal contusion
101
Equation for CPP
CPP = MAP - ICP
102
Reversal agent for dabigatran
idarucizumab (Praxbind)
103
RP zones
```
Zone 1 = aorta, IVA
Zone 2 = kidney, colon, renal artery/vein
Zone 3 (pelvis) = common, external, internal iliacs
```
104
Mgmt penetrating trauma in RP zones?
OR always
105
Mgmt blunt trauma in RP zones
1 -> OR
2 -> OR if expanding or pulsatile; if stable hematoma likely kidney lac (leave)
3 -> OR if expanding or pulsatile; if stable hematoma may be pelvic fx (leave)
106
Lethal triad
- hypothermia
- coagulopathy
- acidosis
107
Neurogenic shock
hypotensive but warm periphery (bc vasodilation)
108
MOA TXA and when to give
within first 3hrs - plasminogen activator inhibitor (stops fibrinolysis)
109
Bolus amount for peds trauma? Blood product amount?
bolus 20cc/kg; blood 10cc/kg
110
Hematemesis 2wks after MVC with grade 4 liver lac... think?
biliary fistula to hepatic artery - mgmt: EGD to confirm, then angioembolization
111
TEG interpretation: time, angle, amplitude, ly
```
time = time takes it take to clot (tx: FFP)
angle = how fast to form clot; fibrin fxn (tx: cryo)
amp = clot strength (tx: platelets)
ly = lysis (tx: txa)
```
112
What does 4-factor PCC contain?
2, 7*, 9, 10, and protein C and S
113
Effects of black widow spider bite
neurotoxic - typically lethal, rarely lethal
114
Effects of brown recluse spider bite
skin necrosis and hemolysis
115
Gustilo classification of open fractures
Type 1 = clean lacerations <1cm
Type 2 = <1cm, but not associated with extensive damage
Type 3 = >10cm, exposed bone, or missing soft tissue
3A: has adequate soft tissue coverage
3B: exposed bone, needs soft tissue transfer
3C: associated w/ vascular injury
116
Abx Tx for each Gustilo classfication
Type 1/2: GP coverage x24hrs
Type 3: GP and GN coverage x72hrs
If farm rollover (exposure to poop) -> add penicillin for anaerobic coverage
117
Classification for blunt aortic injury (BAI)
Grade 1 = intimal tear <10mm
Grade 2 = >10mm
Grade 3 = PSA
Grade 4 = rupture
118
Mgmt blunt aortic injury
Grade 1 = BB, ASA, repeat imaging
Grade 2 = same as Grade 1, but repeat imaging within 7d to assess for progression
Grade 3/4 = operate
119
PTT goal for systemic hep gtt after BCVI
40-50sec (not full therapeutic) bc prevents stroke, but reduces bleeding cx in post-injury pt
120
Factors that reduce hypermetabolism/catabolism in burn pts?
- early excision of burn wound and grafting
- high-carb diet stims protein syn + insulin production
- propranolol reduces resting energy expenditure
121
Blunt injury and HDS, but microscopic hematuria... imaging?
none needed - isolated microscopic hematuria unlikely renal injury.
122
Symptom representing highest mortality after radiation exposure?
vomiting within 1-hr exposure (>50% mortality) - acute radiation sickness (ARS) indicates high dose radiation in short amount of time (min)
123
Do you need systemic AC for temporary vascular shunts?
NO.
124
Resus thoracotomy is futile after how long prehospital CPR for blunt traumas?
10 min
125
Resus thoracotomy is futile after how long prehospital CPR for penetrating trauma to neck?
5 min
126
Which pts have best chance survival after resus thoracotomy? What %?
penetrating cardiac wound, esp when associated with pericardial tamponade
~14%
127
Who should be screened for BCVI?
- neuro abnormalities not explained, suspect arterial source
- petrous bone fx
- diffuse axonal injury
- cervical spine fx C1-C3
- LeFort II/III fx
128
Define occult pnuemothorax
not seen on CXR, seen on CT
129
What timeframe is TXA beneficial?
best within 1-hr of injury, but still some benefits within 3-hrs
130
Mgmt blunt or penetrating renal injury (based on AAST grade)
Tx based on HDS - if asymptomatic, obs.
| If symp: angioembolization for bleeding; nephrostomy tube for collecting system leaks - if need, total nephrectomy
131
Mgmt severe frostbite limb injuries (after rewarming) if present <24-hrs vs. >24-hrs
<24hrs: tPA thrombolysis, prostacyclin, or both
| >24hrs: may need amputation bc irreversible tissue necrosis -> at risk sepsis
132
What type of fx associated with significant maternal and even greater fetal mortality?
pelvic and acetabular fx
133
How long Abx in setting of hollow viscus injury to decrease rate SSI in post-op period?
x1 day
134
Penetrating trauma and HDS, but microscopic hematuria... imaging?
CT contrast (unlike blunt + hematuria)
135
Penetrating trauma to flank/back and HDS... no microscopic hematuria... imaging?
YES - still bc need to assess RP injuries (colon, duo, urinary tract)
136
Reversal for Factor Xa inhibitors (ie. rivaroxaban)
PCC (factors 2, 7, 9, 10, C/S) - metabolized by liver
137
Reversal for direct thrombin inhibitors (dabigatran)
Idarucizumab (Praxbind) or HD - bc metabolized by kidney
138
Pregnancy in unrestrained MVC, need how long fetal monitoring?
24hrs indicated if >24wks pregnancy (time which fetus may be able to survive if need urgent C-section)
139
All pts after blunt cardiac injury should have what evaluation?
EKG + troponin (if BOTH neg -> okay discharge)
140
If after blunt cardiac injury + EKG abnormality or unexplained hypotension, then what evaluation?
Echo
141
What pharm Tx can be used to promote drainage of residual loculated pleural effusion, not effectively drained by pigtail?
tPA + DNase combination
142
Threshold intra-abdominal pressure before define intra-abdominal HTN? Threshold before define abdominal compartment syndrome?
IAH: >12 mmHg
ACS: >30 mmHg (but also if >20 AND organ dysfxn)
143
First step if envenomation + sxs of compartment syndrome?
antivenom first - bc envenomation mimics compartment syndrome
144
How long can IO cannulas stay in place?
72-96 hrs
145
If neurogenic shock, next steps to maintain BP?
volume resuscitation
| if shock persists, dopamine or phenylephrine (vasoconstrictors) to correct.
146
Damage control resus with goal SBP of...? what if has head-injury?
80-90 mmHg
if head-injury: 110 mmHg
to achieve adequate perfusion wo worsening bleeding from recently clotted vessels
147
Mgmt: HDS pt with pelvic blush seen on CT
obs - bleeding often self-limited.
148
Mgmt: stable, asymptomatic pt w/ stab wound to anterior neck
serial examination (NO local wound exploration)
149
MC reason of death for blast lung injury
hypoxia 2/2 intrapulmonary hemorrhage and edema - typically die at scene
150
Good prognosis predictors for resolution of biliary injury after hepatic trauma s/p drain
low-volume leak (<500cc/day) AND time since injury is <14d - most resolve wo intervention
151
MC presenting sxs of spontaneous pneumothorax
chest pain
152
Morel-Lavalle lesion
closed, internal degloving injury when skin and subQ tissue are separated from underlying fascia -> collection
153
Mgmt Morel-Lavalle lesion
Tx based on size of collection + state of overlying skin
- <50cc, then compression dressing okay
- >50cc or reaccumulates, wound closed over drains
- if skin not viable, needs to be debrided -> vac -> STSG
154
Pelvic fracture + gross hematuria is an absolute indications for...?
retrograde urethrogram to eval for possible urethral injury
155
Fat embolism typically presents when after injury?
24-72 hrs post-injury
156
Sxs fat embolism
triad: hypoxemia, neuro abnormality (AMS to seizures), petechial rash
157
Persistent pain and progressing respiratory failure in pt with multiple rib fractures... next step?
rib fx repair via VATS (video-assisted thoracoscopic surgery)
158
If have multiple rib fx + pulmonary contusion, but worsening respiratory distress... next step?
intubation - will need surgical rib fixation AFTER resolution of pulmonary contusion
159
Retinal hemorrhages in child... think?
nonaccidental trauma
160
After blunt cardiac injury, if EKG with sinus tachy, then need admission with...?
Echo and admission to telemetry if no motion abnormalities (no need for serial troponins)
161
Use of NS for trauma resus (as opposed to LR) associated with...?
- hyperCl acidosis
- greater urine output
- dilutional coagulopathy
162
Repair of through-and-through injury to IVC
Extend anterior incision, then repair both posterior and anterior injuries primarily (interposition grafts and bypasses are time-consuming, and not indicated in unstable pts)
163
Seizure -> risk ? dislocation -> ? artery injury
Posterior dislocation of the shoulder -> axillary artery injury
164
Axillary nerve injury associated with ? Dislocations
Anterior should dislocations
165
Brachial artery injury associated with ? Fractures
Mid shaft humerus fractures
166
Median nerve associated with ? Fractures
Supracondylar fracture
167
Which dens fracture is considered “unstable” and will likely need surgical intervention?
2 - fracture at base of dens; may have posterior displacement causing impingement of spinal cord (Type 1 and 3 dens fracture relatively stable, rarely need surgical intervention)
168
Diaphragmatic injuries should be repaired with what kind of suture?
Nonabsorbable
169
Mgmt nasal septal hematomas (“nasal septal bulge that is blue in color”)
Urgent I&D to avoid necrosis of septal cartilage + ppx Abx
170
Esophageal injuries should be repaired with what kind of sutures?
2-layers absorbable sutures
171
Trachea should be repaired with what kind of suture?
Single layer interrupted absorbable suture - buttressed to tissue flap
172
Biliary injury in hepatic trauma most likely at intra or extra-hepatic ducts? What is the MC extrahepatic biliary injury?
Intrahepatic bile ducts (MC extrahepatic biliary injury is gallbladder)
173
What cc/day drain from biloma perQ drain predicts that injury will close spontaneously?
If <300 cc/day, will likely close spontaneously
174
Persistence of biloma perQ drainage >50cc/day beyond 2-weeks indicates ...?
Development of biliary fistula
175
If external sphincter is injured beyond repair, then need what intervention?
APR (+ end colostomy)
176
Indications for damage-control operation
- core temp 35C (95F)
- SBP <80
- pH <7.2
- base deficit >14
- INR or PTT >50% normal
- blood loss >4L
- blood transfusion >10U
- fluid replacement >10L
- persistent non-surgical bleeding
177
Persistence of biloma perQ drainage >50cc/day beyond 2-weeks indicates ...?
Development of biliary fistula
178
What cc/day drain from biloma perQ drain predicts that injury will close spontaneously?
If <300 cc/day, will likely close spontaneously
179
Biliary injury in hepatic trauma most likely at intra or extra-hepatic ducts? What is the MC extrahepatic biliary injury?
Intrahepatic bile ducts (MC extrahepatic biliary injury is gallbladder)
180
Biliary injury in hepatic trauma most likely at intra or extra-hepatic ducts? What is the MC extrahepatic biliary injury?
Intrahepatic bile ducts (MC extrahepatic biliary injury is gallbladder)
181
What cc/day drain from biloma perQ drain predicts that injury will close spontaneously?
If <300 cc/day, will likely close spontaneously
182
Persistence of biloma perQ drainage >50cc/day beyond 2-weeks indicates ...?
Development of biliary fistula
