Trauma

Question 1

What component of GCS has most prognostic ability?

Answer 1

motor score

Question 2

GCS at which intubation is warranted

Answer 2

GCS < 8 = intubate

Question 3

What information does a unilateral fixed and dilated pupil give you?

Answer 3

ipsilateral space occupying lesion with compression on optic nerve

Question 4

What information does bilateral pinpoint pupils give you?

Answer 4

Pontine hemorrhage, or narcotic overdose

Question 5

what patient’s need ICP monitor?

Answer 5

GCS < 8 with intracranial abnormality on CT

Question 6

what is the difference between a bolt and a ventriculostomy?

Answer 6

ventriculostomy - in ventricle and can drain CSF

bolt - in parenchyma

Question 7

what is cushing’s reflex? and what does it indicate?

Answer 7

hypertension, bradycardia and altered respirations

indicates impending herniation

Question 8

initial management of patient with cushing’s reflex

Answer 8

sedate, elevate HOB, PaCO2 <35, mannitol or 3%, paralytic

Question 9

classic presentation of epidural hematoma

Answer 9

head injury with lucid interval with rapid GCS decline

Question 10

describe the CTH of epidural hematoma

Answer 10

lenticular lucency contained by suture lines

Question 11

describe CTH of SDH

Answer 11

crescent shaped lucency that crosses suture lines

Question 12

CPP = ?

goal CPP and ICP

Answer 12

CPP = MAP - ICP

CPP >60 and ICP < 20

Question 13

interventions to reduce ICP? (5 examples)

Answer 13

1. elevate HOB
2. hyperventilate
3. remove C collar
4. 3% or mannitol
5. sedate or paralyze

Question 14

reversal agent for coumadin in the trauma setting

Answer 14

PCC for rapid reversal
FFP is okay
Vitamin K

Question 15

reversal agent for pradaxa (dabigatran)

Answer 15

dialysis or praxbind (idarucizumab)

Question 16

reversal agent for apixaban/rivaroxaban

Answer 16

PCC gives partial reversal, dialysis

andexanet alpha

Question 17

clinical clearance for spine trauma (3 criteria)

Answer 17

1. no distracting injuries
2. no intoxication and GCS 15
3. no midline tenderness or neuro deficits

Question 18

injury pattern for central cord syndrome?

Answer 18

upper extremity weakness and burning - ‘cape and gloves’

ex. elderly with spinal stenosis

Question 19

injury pattern for brown sequard?

Answer 19

ipsilateral motor deficit and contralateral pain/temp deficit below injury
ex. stab wound

Question 20

injury pattern for anterior cord syndrome?

Answer 20

motor deficit below the level of injury

ex. vascular injury to anterior spinal artery

Question 21

difference between neurogenic shock and spinal shock

Answer 21

neurogenic shock - hemodynamics affected

spinal shock - sensory/motor affected. no bulbocavernosus or cremasteric reflex. some functions may return.

Question 22

what constitutes an ‘unstable’ spinal cord injury

Answer 22

when 2/3 ligamentous columns are disrupted - need operative fixation

Question 23

borders of zones of the neck ?

Answer 23

Zone 1 - clavicles to cricoid
Zone 2 - cricoid to angle of mandible
Zone 3 - mandible to skull base

Question 24

next best step in management: penetrating neck injury with unstable hemodynamics

Answer 24

OR

Question 25

next best step in management: penetrating neck injury with hard sign of vascular injury

Answer 25

OR

Question 26

What are hard signs of vascular injury? (4 examples)

Answer 26

1. Observed pulsatile bleeding. 2. Arterial thrill (ie, vibration) by manual palpation. 3. Bruit over or near the artery by auscultation. 4. Visible expanding hematoma.

Question 27

NBS penetrating neck injury without hard sign of vasc injury?

Answer 27

CT neck with angiogram | -if concerned for esophageal injury - esophagram or EGD

Question 28

how to repair esophageal injury?

Answer 28

extend myotomy to see mucosal injury extend, repair in 2 layers, buttress, drain

Question 29

Who to consider for CTA for BCVI?

Answer 29

``` hanging mechanism neuro exam not explained by brain imaging DAI skull base fx involving foramen lacerum Horner syndrome LeFort II or III C1-C3 fracture cervical bruit cervical seatbelt sign ```

Question 30

most common site for BCVI

Answer 30

distal internal carotid artery

Question 31

Tx for BCVI

Answer 31

mostly heparin vs antiplatelet therapy endovascular approach for some grade III injuries coil embolization for grade IV and V

Question 32

Chest tube output where going to OR is indicated?

Answer 32

initial output >1500cc or >200 cc/hr for 4 hours

Question 33

definition of flail chest

Answer 33

3 or more consecutive ribs fractured in two locations

Question 34

tx for flail chest

Answer 34

pain control, PPV, rib plating?

Question 35

Initial workup for blunt cardiac injury

Answer 35

EKG - look for Tachycardia or PVCs | troponins are controversial...negative EKG and troponins effectively rule out cardiac injury

Question 36

NBS patient with blunt cardiac injury with hemodynamic instability or persistent new arrhthmia?

Answer 36

Echocardiogram

Question 37

location for most blunt aortic injuries?

Answer 37

proximal descending aorta just distal to ligamentum arteriosum

Question 38

Tx for retained hemothorax despite tube thoracostomy?

Answer 38

Early VATS superior to placing second tube

Question 39

initial Tx for aortic dissection?

Answer 39

anti-hypertensive regimens to maintain <120 mmHg | esmolol +/- nitroprusside

Question 40

is open or endovascular repair of blunt aortic injury preferred?

Answer 40

endovascular

Question 41

Tx for hemodynamically stable patient with solid organ blush on CT?

Answer 41

angioembolization

Question 42

clinical indications to go to the OR for penetrating injuries? (3 of them)

Answer 42

hemodynamic instability, peritonitis, evisceration

Question 43

imaging test of choice to get for flank stab wounds?

Answer 43

triple contrast CT (oral, rectal, IV) - controversial

Question 44

best way to assess thoracoabdominal stab wounds?

Answer 44

diagnostic laparoscopy. this injury is frequently missed on CT

Question 45

how do you repair sm bowel injury if >50% of circumference is damaged?

Answer 45

resect and anastomosis

Question 46

how do you repair sm bowel injury if segment is devascularized?

Answer 46

resection and anastomosis

Question 47

Tx of <50% sm bowel injury without devascularization

Answer 47

primary repair

Question 48

how do you repair large bowel injury if >50% of circumference is damaged?

Answer 48

primary repair

Question 49

how do you repair large bowel injury if segment is devascularized or >50% circumferential injury ?

Answer 49

resection and anastomosis

Question 50

what is a bucket handle injury?

Answer 50

mesentery of bowel torn from bowel. bowel intact

Question 51

Tx for bucket handle injury?

Answer 51

resect

Question 52

Tx distal pancreatic injury without duct disruption?

Answer 52

leave drains

Question 53

Tx distal pancreatic injury with duct disruption?

Answer 53

distal pancreatectomy with splenectomy

Question 54

Tx injury to head of pancreas with duct disruption

Answer 54

drainage only

Question 55

Tx injury to head of pancreas withOUT duct disruption

Answer 55

drainage only

Question 56

where is zone 1 of the retroperitoneum

Answer 56

centrally located - aorta and vena cave

Question 57

where is zone 2 of the retroperitoneum

Answer 57

kidneys

Question 58

where is zone 3 of the retroperitoneum

Answer 58

pelvis (iliac)

Question 59

penetrating injury to what retroperitoneal zones mandates exploration

Answer 59

ALL 3 zones need to be explored in penetrating injury

Question 60

Tx blunt zone 1 injury?

Answer 60

explore

Question 61

Tx blunt zone 2 injury?

Answer 61

explore only if pulsatile or expanding hematoma

Question 62

Tx blunt zone 3 injury?

Answer 62

do not explore. pack and angiography

Question 63

Next step in open book pelvic fx with hypotension?

Answer 63

place abdominal binder

Question 64

definitive Tx in stable patient with pelvic fx and hemorrhage?

Answer 64

angioembolization

Question 65

Next step, open book pelvic fx, with binder, unstable?

Answer 65

OR for preperitoneal packing

Question 66

Blood loss needed for Class I hemorrhage?

Answer 66

0-15% | no physiologic changes

Question 67

Blood loss needed for Class II hemorrhage?

Answer 67

15-30% | tachycardia, narrowed pulse pressure

Question 68

Blood loss needed for Class III hemorrhage?

Answer 68

30-40% | hypotension

Question 69

Blood loss needed for Class IV hemorrhage?

Answer 69

>40%

Question 70

what is the earliest sign of shock ?

Answer 70

tachycardia and narrow pulse pressure

Question 71

what is the triad of death?

Answer 71

coagulopathy, hypothermia, acidosis

Question 72

principal of damage control surgery?

Answer 72

control sepsis/spillage and hemorrhage temporary abdominal closure resuscitation return to OR when more physiologically stable

Question 73

First signs of abdominal compartment syndrome? (2)

Answer 73

decreased UOP | increased peak pressures on vent

Question 74

how to diagnose abdominal compartment syndrome?

Answer 74

bladder pressure >20

Question 75

Tx abdominal compartment syndrome?

Answer 75

decompressive laparotomy | except in burn patients - place drains to drain ascites

Question 76

Adjunct to give bleeding trauma patient requiring MTP?

Answer 76

TXA 1g within 3 hours of injury then 1g over the next 8hr

Question 77

ROTEM/TEG | What product to give if clot formation time (CFT) prolonged?

Answer 77

FFP

Question 78

ROTEM/TEG | What product to give if alpha angle low?

Answer 78

cryoprecipitate

Question 79

ROTEM/TEG | What product to give if amplitude of clot is low?

Answer 79

platelets

Question 80

ROTEM/TEG | What product to give if LY30 (lysis) is high?

Answer 80

TXA

Question 81

tx intraperitoneal bladder injury?

Answer 81

operative repair

Question 82

Tx extraperitoneal bladder injury?

Answer 82

foley drainage

Question 83

tx mid ureteral injury?

Answer 83

primary anastomosis over double J stent with absorbable suture

Question 84

tx distal ureteral injury?

Answer 84

reimplant into bladder

Question 85

tx distal ureteral injury if not enough length to reach bladder?

Answer 85

psoas hitch

Question 86

Dx for urethra injury?

Answer 86

retrograde urethrogram

Question 87

hard signs of vascular injury?

Answer 87

pulsatile bleeding, expanding hematoma, absent pulses, bruit/thrill

Question 88

soft signs of vascular injury

Answer 88

non expanding hematoma, decreased ABI <0.9

Question 89

Dx for soft signs of vascular injury?

Answer 89

CT angiogram

Question 90

Tx extremity arterial trauma ?

Answer 90

typically reverse saphenous vein graft

Question 91

Tx extremity venous injury?

Answer 91

primary repair if possible or ligate

Question 92

What do you need to do after popliteal artery and vein repair?

Answer 92

fasciotomy

Question 93

crystalloid bolus amount for pediatric?

Answer 93

20cc/kg

Question 94

blood bolus for pediatrics?

Answer 94

10cc/kg