Trauma

Question 1

Level one trauma

Answer 1

• Penetrating injury of the head, neck, torso, or extremities proximal to and including the elbow/knee
• Paralysis (spinal cord)
• Fracture of 2 or more long bones
• Amputation proximal to the wrist or ankle
• Burns>= 90%
• Age 14 and under
• GCS 9 and under
• Systolic bp<90 at anytime
• RR <10, >30
• Intubated prior to arrival
• Pt’s with respiratory compromise

Question 2

Primary survey

Answer 2

Airway (phonation, edema, blood in OP): intubate

Breathing: effort, rate, excursion, crepitus, O2 sat: O2, needle thoracotomy, chest tube, pain control

Circulation: Pulses, BP, wounds, perfusion: (IO, IV, IV access, Central cordis, Fast exam)

Disability (neuro): GCS, pupils, motor, rectal tone

Exposure: cut off clothes, log roll, palpate spine, check, axilla, and perineum in perineum: cover with warm blankets

(ABCDE)

+/- FAST exam

Question 3

Secondary survey

Answer 3

Head to toe assessment, inspect for visible trauma, palpate for pain/tenderness; determine what needs imaging
CXR and +/-PXR

Question 4

What is FAST exam?

Answer 4

Focus Assessement with sonography in Trauma: dx hemoperitoneum
xyphoid for pericardial window, RUQ (hepatorenal-morison pouch), LUQ (perisplenic view), Suprapubic window

Question 5

What’s limitation of FAST?

Answer 5

low sensitivity (false negative). CT is the gold standard
not for stable pts
provider skills dependent

Question 6

What test should be done on all trauma pts

Answer 6

CXR
do it before going to scanner
R/o pneumothorax, look for free air (pneumoperitoneum), widened mediastinum, hemothorax

Question 7

When should pelvis xray be done in trauma bay?

Answer 7

when pts are unstable, concern for pelvic injury.

apply pelvic binder

Question 8

When can pt go to CT scan?

Answer 8

When they are hemodynamically stable
Concern for internal injury
Pan CT is recommended as the standard dx study in early trauma resuscitation (basic: CTH, CTS, CT CAP,

Question 9

When does a pt go to Or?

Answer 9

hemodynamically unstable, +FAST exam, operative injury in CT imaging, unable to stabilize with blood/chest tubes, etc.

Question 10

When can a pt go to IR?

Answer 10

there’s a bleed identified on CT amenable to IR therapy

Question 11

What is tertiary trauma survey?

Answer 11

within 24hrs, another head to toe (pt should be in calm environment an pain controlled), look for missed injuries.

Question 12

When should a pt be intubated

Answer 12

Maxillofacial trauma, neck trauma, GCS<8, soot in airway, hemodynamically unstable pt

Question 13

4 types of shock

Answer 13

cardiogenic, obstructive, distributive, hypovolemic

Question 14

What leads to neurogenic shock?

Answer 14

spinal injury; not intracranial injuries

Question 15

what are signs of neurogenic shock?

Answer 15

hypotension and bradycardia

Question 16

How to manage neurogenic shock?

Answer 16

fluid, pressors

Question 17

Classes of hemorrhagic shock : I

Answer 17

15% of blood loss, 750 ml, no changes in vs.

Question 18

hemorrhagic shock: II

Answer 18

15-30% blood loss, 750-1500, slight tachy 100-120, RR20-30, mild decrease in UOP

Question 19

Hemorrhagic shock: III

Answer 19

30-40% blood loss, 1500-2000ml, HR120-140, decreased UOP,

Question 20

Hemorrhagic shock: IV

Answer 20

> 40% blood loss, >2000ml, HR>140

Question 21

How does trauma bleeding lead to death

Answer 21

Hypothermia–> coagulopathy–> lactic acidosis–> hypothemia

Question 22

What makes coagulopathy worse?

Answer 22

cold temperature and acidosis

Question 23

What makes acidosis worse?

Answer 23

poor perfusion, NS bolus (LR is better)

Question 24

What are consequences of acidosis?

Answer 24

decreased CO and BP, decrease response to catecholamines, reduced threshold for developing vfib, hyperventilation, decrease strength and fatigue, decreased mental status, decreased coag function,

Question 25

What are consequences of hypothermia?

Answer 25

impaired platelet function, inhibition of coag factors, impaired tissue O2 delivery, inappropriate activation of clot breakdown

Question 26

How to resuscitate during hemorrhagic shock in trauma pt?

Answer 26

Balanced resuscitation: improves outcome and coagulation 1. permissive hypotension, limit crystalloid 2. Transfuse 1:1:1 ratio (1 PRBC, 1FFP, 1 platelet for every 6 of PRBC/FFP)

Question 27

When to trigger MT protocol?

Answer 27

Persistent hemodynamic instability, active bleeding requiring OR or angioembolization, blood transfusion in the trauma bay, ABC score 2 or more

Question 28

What is ABC score?

Answer 28

``` Assessment for need of MT. HR>120 SBP<90 Positive FAST exam Penetrating injury to torso ```

Question 29

What are immediate life threatening injuries?

Answer 29

Tension pneumo Flail chest and pulm. contusion Massive hemothorax Cardiac tamponade

Question 30

What is a sign of massive hemothorax?

Answer 30

rapid accumulation of 1500ml in chest cavity | 200ml/hr for 2-4hr on chest tube

Question 31

Tx for massive hemothorax:

Answer 31

Chest tube, blood transfusion, thoracotomy,

Question 32

How to assess for cardiac tamponade?

Answer 32

muffled heart sounds, hypotension, distended neck veins, FAST

Question 33

How to treat cardiac tamponade?

Answer 33

thoracotomy, pericardiocentesis to temporize,

Question 34

How to assess for flail chest:

Answer 34

paradoxical movement, associated with major pulm. contusion

Question 35

Pulm contusion: most common potential lethal thoracic injury

Answer 35

associated with multiple rib fractures....they are insidious. comorbidities: COPD, renal failure

Question 36

How to manage pulm contusion:

Answer 36

aggressive pain control (prevents pna, splinting, intubation) Promote ventilation, transfer to higher level of care b/c they'll get worse before getting better.

Question 37

Abd injuries in trauma

Answer 37

``` Solid organ injury: can lead to blood loss. mostly treated non-operatively -serial H/H -abd exam -bedrest -can control bleeding with IR -OR for liver packing, splenectomy, nephrectomy - ```

Question 38

Holoviscous injury sign

Answer 38

Blunt- seatbelt sign, sudden deceleration mechanism, | Penetration- look at bullet tract on CT, consider blast injury

Question 39

How to manage holoviscous injury?

Answer 39

must be repaired in OR declares itself within 24hr serial abd exam, regular diet

Question 40

When to do laparotomy?

Answer 40

- penetrating abd wound with hypotension, GSW thru abd cavity. - blunt abd trauma with hypotension and +FAST or clinical evidence of bleeding - peritonitis or evisceration - free air or diaphragm rupture - CT scan showing ruptured GI tract, or other solid organ injury

Question 41

What is the most common source of significant bleeding in pelvic trauma?

Answer 41

venous

Question 42

What is the management for pelvic trauma

Answer 42

Place external compression Resus with fluid/blood IR for angioembolism OR for packing

Question 43

TBI

Answer 43

mild to severe concussion : post concussive symptoms common: headache, nausea, Diffuse axonal injury: CT is not sensitive, Do MRI mild: GCS 13-15 mod: GCS 9-12 severe: GCS 8

Question 44

Focal brain injuries

Answer 44

epidural hematoma (art. bleed) subdural hematoma (venous), crosses midline SAH Contusions: (mostly frontal and temporal)- typically evolve and grow

Question 45

normal ICP

Answer 45

<10. ICP>20 associated with poor outcomes | CPP nl:>60

Question 46

How to manage head trauma?

Answer 46

``` Avoid bleeding SBP 100-140 Avoid edema: Na>140 Anticonvulsants: Q1hr neurochecks Repeat head CT if GCS drops 2+points ``` Avoid secondary injury: hypotension, hypoxia, hyperthermia, hypercarbia, hypocarbia, hyponatremia, hypo/hyperglycemia, HTN

Question 47

Life threatening musculoskeletal trauma

Answer 47

major art. bleeding: Use a tourniquet, transfuse, OR ``` crushing injury: Rhabdomyolysis CK> 10,000 -aggressive IVF -goal UO> 10,000 -serial CK values ```