Trauma

Question 1

what is a pneumothorax?

Answer 1

injury to the lung, resulting in release of air into the pleural space between the normally apposed parietal and visceral pleura

Question 2

how is a pneumothorax diagnosed?

Answer 2

tension pneumothorax is a clinical diagnosis
- dyspnea, JVD, tachypnea, anxiety, pleuritic chest pain, unilateral decreased or absent breath sounds, tracheal deviation away from affected side, hyper resonance on affected side

Question 3

what is treatment of a tension pneumothorax?

Answer 3

rapid thoracotomy incision or immediate needle decompression in the 2nd ICS, midclavicular line

Question 4

what is the medical term for a ‘sucking chest wound’?

Answer 4

open pneumothorax

Question 5

what does a pneumothorax look like on cxr?

Answer 5

loss of lung markings

Question 6

what is flail chest?

Answer 6

two separate fractures on three or more consecutive ribs

Question 7

how is flail chest diagnosed?

Answer 7

flail segment of chest wall that moves paradoxically

- sucks in with inspiration and pushes out with expiration opposite the rest of the chest wall

Question 8

what is the major cause of respiratory compromise with flail chesT?

Answer 8

underlying pulmonary contusion

Question 9

what is the treatment of flail chest?

Answer 9

intubation with positive pressure ventilation and PEEP PRN

Question 10

what is cardiac tamponade?

Answer 10

bleeding into the pericardial sac, resulting in constriction of heart, decreasing inflow and resulting in decreased cardiac output (the pericardium does not stretch)

Question 11

what are the signs/symptoms of cardiac tamponade?

Answer 11

tachycardia/shock with Beck’s triad, pulsus paradoxes, Kussmaul’s sign

Question 12

define Beck’s triad

Answer 12

hypotension
muffled heart sounds
JVD

Question 13

define Kussmaul’s sign

Answer 13

JVD with inspiration

Question 14

how is cardiac tamponade diagnosed?

Answer 14

ultrasound (echocardiogram)

Question 15

what is the treatment of cardiac tamponade?

Answer 15

pericardial window - if blood returns then median sternotomy to rule out and treat cardiac injury

Question 16

how is a massive hemothorax diagnosed?

Answer 16

unilaterally decreased or absent breath sounds
dullness to percussion
cxr, CT scan, chest tube output

Question 17

what is the treatment for massive hemothorax?

Answer 17

volume replacement
tube thoracostomy
removal of the blood

Question 18

what are the indications for emergent thoracotomy for hemothorax?

Answer 18

massive hemothorax =

• > 1500cc blood on initial placement of chest tube
• persistent >200cc bleeding via chest tube per hour for 4hrs

Question 19

what is the trauma resuscitation fluid of choice?

Answer 19

lactated ringer’s solution

• isotonic
• lactate helps buffer the hypovolemia-induced metabolic acidosis

Question 20

what are the contraindications to placement of a Foley?

Answer 20

signs of urethral injury:

• severe pelvic fracture in men
• blood at the urethral meatus (penile opening)
• ‘high-riding’, ‘ballot able’ prostate (loss of urethral tethering)
• scrotal/perineal injury/ecchymosis

Question 21

what test should be obtained prior to placing a Foley catheter if urethral injury is suspected?

Answer 21

retrograde urethrogram

Question 22

how is gastric decompression achieved with a maxillofacial fracture?

Answer 22

oral gastric tube (OGT)

- not with NGT because the tube may perforate through the cribriform plate into the brain

Question 23

why look in the ears?

Answer 23

hemotympanum is a sign of basilar skull fracture

otorrhea is a sign of basilar skull fracture

Question 24

examination of what part of the trauma patient’s body is often forgotten?

Answer 24

patient’s back

Question 25

what are the typical signs of basilar skull fracture?

Answer 25

raccoon eyes, battle's sign, clear otorrhea or rhinorrhea, hemotympanum

Question 26

what diagnosis in the anterior chamber must not be missed on the eye exam?

Answer 26

traumatic hyphema | - blood in the anterior chamber of the eye

Question 27

what potentially destructive lesion must not be missed on the nasal exam?

Answer 27

nasal septal hematoma - hematoma must be evacuated - if not, it can result in pressure necrosis of the septum

Question 28

what is the best indication of a mandibular fracture?

Answer 28

dental malocclusion

Question 29

what is the best way to diagnose or rule out aortic injury?

Answer 29

CT angiogram

Question 30

what must be considered in every penetrating injury of the thorax at or below the level of the nipple?

Answer 30

concomitant injury to the abdomen

Question 31

what is the significance of subcutaneous air?

Answer 31

indicates PTX until proven otherwise

Question 32

what is the seatbelt sign?

Answer 32

ecchymosis on lower abdomen from wearing a seatbelt

Question 33

what must be documented from the rectal exam?

Answer 33

sphincter tone (indication of spinal cord function), presence of blood (indication of colon or rectal injury), prostate position (indication of urethral injury)

Question 34

what is the 'halo' sign?

Answer 34

CSF from nose/ear will form clear 'halo' around the blood on a cloth

Question 35

what complication after prolonged ischemia to the lower extremity must be treated immediately?

Answer 35

compartment syndrome

Question 36

what is the treatment for compartment syndrome?

Answer 36

fasciotomy

Question 37

what injuries must be suspected in a trauma patient with a progressive decline in mental status?

Answer 37

epidural hematoma, subdural hematoma, brain swelling with rising ICP - hypoxia/hypotension must be ruled out

Question 38

what depth of neck injury must be further evaluateD?

Answer 38

penetrating injury through the platysma

Question 39

what is the neck trauma zone III?

Answer 39

angel of mandible and up

Question 40

what is the neck trauma zone II?

Answer 40

angle of the mandible to the cricoid cartilage

Question 41

what is the neck trauma zone I?

Answer 41

below the cricoid cartilage

Question 42

how do most surgeons treat neck trauma zone III?

Answer 42

selective exploration

Question 43

how do most surgeons treat neck trauma zone II?

Answer 43

surgical exploration vs. selective exploration

Question 44

how do most surgeons treat neck trauma zone I?

Answer 44

selective exploration

Question 45

what is selective exploration?

Answer 45

based on diagnostic studies that include A-gram or CT A-gram, bronchoscopy, esophagoscopy

Question 46

what are the signs of a laryngeal fracture?

Answer 46

subcutaneous emphysema in neck altered voice palpable laryngeal fracture

Question 47

what is the treatment of rectal penetrating injury?

Answer 47

diverting proximal colostomy closure of perforation presacral drainage

Question 48

what is the treatment of exztraperitoneal minor bladder rupture?

Answer 48

'bladder catheter' drainage and observation | intraperitoneal or large bladder rupture requires operative closure

Question 49

what intra-abdominal injury is associated with seatbelt use?

Answer 49

small bowel injuries

Question 50

what is the treatment of extensive irreparable biliary, duodenal, and pancreatic head injury?

Answer 50

trauma whipple

Question 51

what is the most common intra-abdominal organ injured with penetrating trauma?

Answer 51

small bowel

Question 52

what is the treatment of penetrating injury to the colon?

Answer 52

if in shock, resection and colostomy | if stable, primary anastomosis/repair

Question 53

what is the treatment of small bowel injury?

Answer 53

primary closure or resection and primary anastamosis

Question 54

what is the treatment of minor pancreatic injury?

Answer 54

drainage

Question 55

what is the most commonly injured abdominal organ with blunt trauma?

Answer 55

liver

Question 56

what is the treatment for significant duodenal injury?

Answer 56

pyloric exclusion - close duodenal injury - staple off pylorus - gastrojejunostomy

Question 57

what is the treatment for massive tail of pancreas injury?

Answer 57

distal pancreatectomy

Question 58

what is the 'lethal triad'?

Answer 58

ACH - acidosis - coagulopathy - hypothermia

Question 59

which lab tests are used to look for intra-abdominal injury in children?

Answer 59

LFTs = elevated AST/ALT

Question 60

what is the treatment of human and dog bites?

Answer 60

leave wound open, irrigation, antibiotics

Question 61

what is sympathetic ophthalmia

Answer 61

blindness in one eye that results in subsequent blindness in the contralateral eye (autoimmune)

Question 62

what is the usual presentation of an anterior hip dislocation?

Answer 62

externally rotated with anterior hip fullness

Question 63

what drug is used to treat a brown recluse spider bite?

Answer 63

dapsone

Question 64

what is the correct diagnosis for: coiled NGT int he left pleural cavity after blunt trauma?

Answer 64

diaphragm rupture

Question 65

what is the correct diagnosis for: blunt trauma patient with GCS <8 and otorrhea?

Answer 65

basilar fracture

Question 66

what is the correct diagnosis for: 20yo male s/p baseball bat to the head, arrives in a coma; CT scan reveals a lens shaped (lenticular) hematoma next to inner table of skull?

Answer 66

epidural hematoma

Question 67

what is the correct diagnosis for: 44yo male s/p fall from a ladder presents with GCS of 5; CT scan reveals a crescent-shaped hematoma next to inner table of skull?

Answer 67

subdural hematoma

Question 68

what is the correct diagnosis for: trauma patient with increasing JVD with inspiration?

Answer 68

cardiac tamponade (Kussmaul's sign)

Question 69

what is the correct diagnosis for: trauma patient with hypertension and bradycardia?

Answer 69

Cushing's response to increased ICP

Question 70

what is the correct diagnosis for: trauma patient with hypotension and bradycardia?

Answer 70

spinal cord injury

Question 71

what is the correct diagnosis for: 28yo woman involved in high-speed, side-impact MVC; stable vital signs; cxr reveals widened mediastinum?

Answer 71

thoracic aortic injury

Question 72

what is the correct diagnosis for: 21yo man involve din high-speed MVC with obvious unstable pelvis, gross blood from the urethral meatus, high-riding prostate on rectal exam?

Answer 72

urethral injury

Question 73

what is the correct diagnosis for: 45yo woman involved in high-speed MVC complains of abdominal pain and shortness of breath; decreased breath sounds on the left; cxr reveals the NGT coiled up in the left chest?

Answer 73

ruptured left diaphragm

Question 74

what is the correct diagnosis for: 56yo involved in high speed MVC complains of severe shortness of breath; on exam, left chest wall moves inwards not outwards on inhalation?

Answer 74

flail chest - paradoxic respirations

Question 75

what is the correct diagnosis for: 67yo involve din a high-speed MVC presents with a GCS of 5, bilateral periorbital ecchymosis, left mastoid ecchymosis, and clear fluid draining from the left ear?

Answer 75

basilar skull fracture - Battle's and raccoon sign

Question 76

what is the correct diagnosis for: 50yo female s/p high speed MVC with rib fractures and flail chest develops hypoxia 12hrs later in the ICU; cxr shows no pneumo- or hemothorax but reveals pulmonary infiltrates/congestion?

Answer 76

pulmonary contusion

Question 77

what is the correct diagnosis for: 29yo s/p MVC arrives with hypotension, sats of 83%, JVD, decreased breath sounds on L?

Answer 77

tension pneumothorax

Question 78

what is the correct diagnosis for: 55yo male s/p 3-story fall reveals the NGT coiled up on chest on cxr?

Answer 78

diaphragm injury

Question 79

what is the correct diagnosis for: 22yo man s/p MVC with transection of right optic nerve; progresses to blindness in the contralateral left eye 3wks later?

Answer 79

sympathetic ophthalmia

Question 80

what is the correct diagnosis for: 8yo male s/p bicycle accident with handle bar to abdomen with duodenal hematoma?

Answer 80

NGT, TPN and observe | may take weeks to open up

Question 81

what is the correct diagnosis for: 30yo male involved in a skiing collision with a tree, arrives in the ER awake (GCS of 15) but then gets confused and next goes unresponsive (GCS of 3)?

Answer 81

'lucid interval' of an epidural hematoma

Question 82

name the diagnostic modality for: 47yo female s/p MVC with a seatbelt sign (ecchymosis) on the left neck?

Answer 82

CT angiogram

Question 83

name the diagnostic modality for: 22yo male s/p gunshot sound to the umbilicus; bullet is int he spine on X-rays?

Answer 83

exploratory laparotomy