Trauma and emergency Flashcards by David Felipe Ortiz Paredes

Signs og basical skull fracture

Raccoon eyes
Battle sign (hematoma behind the ear)
Clear otorrhea
Clear rhinorrhea

Next step: CT scan of head and neck

How well did you know this?

Not at all

Perfectly

Patient with righ head trauma who then presents LOC, followed by a lucid interval and then coma. On exam presents right fixed dilated pupil and left hemiparesis.

Dx, Next step, tx?

Epidural hematoma + herniation syndrome

Next step: CT scan will show a lens shaped hematoma

Tx: craniotomy

How well did you know this?

Not at all

Perfectly

Adolescent who had a massive head trauma and then LOC with no licid period.

Dx, Next step, tx?

Acute subdural hematoma

Next step: CT scan showing a crescent shaped hematoma

Tx: ↓ intracranial pressure (ICP)

Hyperventilate once intubated
Elevate head of bed
Manitol

How well did you know this?

Not at all

Perfectly

Old patient who 6 months ago fell from his bed. His daughter says that his is having more headaches ever since and she has notice a decreased cognitive function.

Dx, next step, tx?

Chronic subdural hematoma

Dx: CT scan showing a crescent shaped hematoma

Tx:

Craniotomy
Anticoagulation adjustment if needed

How well did you know this?

Not at all

Perfectly

Patient who was playing football and had head trauma, followed by LOC. He is now lucid bud doesn’t remember the event.

CT is normal

Dx?

Concussion

Close observation at home with alarm signs

How well did you know this?

Not at all

Perfectly

Patient who in a car accident had angular trauma (the car spun). Since the accident is is in coma.

CT scan showing grey/white blurring

Diffuse axonal injury

Tx: Really poor prognosis, basically manage the ICP

How well did you know this?

Not at all

Perfectly

ABCs, patient presentation when airway is patent

o Speaks full sentences
o No use of accessory muscles
o Bilateral breath sounds

How well did you know this?

Not at all

Perfectly

ABCs, patient presentation when airway is urgent or emergent

Urgent airway (may need to be intubated):
o Expanding hematoma
o Cutaneous emphysema

Emergent airway:
o Apnea
o GCS < 8
o Gurgling/gasping

How well did you know this?

Not at all

Perfectly

Parameters that manage problems with ventilation

Ventilation (CO2)
• Assessed with ABG = pCO2
• Managed with Minute ventilation = Tidal volume x RR

How well did you know this?

Not at all

Perfectly

ABCs (breathing)

Parameters that manage problems with oxygenation

Oxygenation (O2)
• Assessed with SatO2 / pO2
• Managed with PEEP, FiO2

How well did you know this?

Not at all

Perfectly

Patient presentation of someone with shock

Syst BP < 90 / (MAP < 65)
Urinary output < 0.5 cc/kg/hr
Pale, cool, diaphoretic, sense of impending doom

How well did you know this?

Not at all

Perfectly

Patient in shock (hypotension) and warm extremities. Differentials?

Problems in systemic vascular resistance, e.g.,

Sepsis
Anaphylaxis
Anesthesia
Spinal trauma

How well did you know this?

Not at all

Perfectly

Patient with Flat neck veins, Normal lungs, ↑HR, Hypotension, Cold extremities.

Dx, next step, tx?

Hemorrhage

Next step: FAST (U/S)

Tx: pressure, surgery
- Large bore IV, type and cross, IVF, transfusion on their way to the OR

How well did you know this?

Not at all

Perfectly

JVD, ↓ breath sounds, hyperresonance, Traqueal deviation, Hypotension, Cold extremities.

Dx, next steps?

Tension pneumo

Next steps:

Needle decompression, i.e., thoracostomy (not a chest tube) with a 14G needel in the 2nd costal space
Then, get the CxR and put the chest tube

How well did you know this?

Not at all

Perfectly

Patient with: 
•	JVD
•	Distant heart sound
•	Hypotension
•	Paradoxal pulse (↓Systolic BP during inspiration > 10 mmHg)
•	Cold extremities
•	Normal lung sounds

Dx, next steps, tx?

Pericardial tamponade

Next step: Pericardiocentesis guided by U/S (FAST)

How well did you know this?

Not at all

Perfectly

Beck’s triad?

JVD
Distant heart sound
Hypotension

How well did you know this?

Not at all

Perfectly

Definition of paradoxal pulse

↓ pulse amplitud and ↓Systolic BP of > 10 mmHg during inspiration

How well did you know this?

Not at all

Perfectly

Patient who was bitten by a raccoon.

Tx?

Capture the animal, kill it and Bx the brain to see if there is rabies. If rabies, give immunoglobulin and vaccine

How well did you know this?

Not at all

Perfectly

Patient who was stung by a wasp and now is hypotensive and has bronchospasm.

Tx?

IM epinephrine 1:1,000

* H1 + steroids (alternative)

How well did you know this?

Not at all

Perfectly

Patient who was bitten by a snake.

How to know if he need the anti-venom?

Snake Likely poisonous if

Slit-like eyes
Cobra cowl
Rattler

Patient risk fx:

Skin changes
Erythema
Pain out of proportion

How well did you know this?

Not at all

Perfectly

Patient who was bitten by a spider with hourglass on the belly. The patient refers abdominal pain.

Dx? What do you have to keep an eye on?

Black widow bite

Calcium levels. Give IV calcium

How well did you know this?

Not at all

Perfectly

Patient who was in florida and was bitten by spider in a attic. He had initially a bite, but now it is a necrotic ulcer.

What type of spider and tx?

Brown recluse

Tx: debride–> grafting

How well did you know this?

Not at all

Perfectly

Patient who was bitten by his domestic dog.

Microorganism? Tx?

Pasteurella

Tx:

Irrigation
Leave the wound open (heal by secondary intention)
Amoxicillin/clavulanate
Tetanus Ig + toxoid if > 5 years since immunization

How well did you know this?

Not at all

Perfectly

Management of human bites?

Tx (same as dog/cat bite):

Irrigation
Leave the wound open (heal by secondary intention)
Amoxicillin/clavulanate
Tetanus Ig + toxoid if > 5 years since immunization

How well did you know this?

Not at all

Perfectly

Patient with penetrating neck trauma and unstable (Gurgling, Stridor, Loss of airway, Vascular, Expanding hematoma, Pulsatile bleeding, Stroke, Shock). Next step?

Surgery

Patient with penetrating neck trauma, but stable and otherwise ASx. Next step?

Observe, if worsens perform a CT angio

Patient with penetrating neck trauma and stable. However, presents soft signs (Dysphonia, Dysphagia, Subcutaneous emphysema, hematoma). Next step?

CT angio, if (+)--> surgery. If (-) observe If proximal third involved, it could be replaced with a arteriogram. If distal third involved, it could be replaced with esophagram, bronchogram, and arteriogram

Patient with trauma of neck. He has Ipsi lateral proprioception/vibration loss, Ipsi lateral motor loss (Flaccid paralysis and Hyporeflexia at the level with Spastic paralysis and Hyperreflexia bellow the level), and contra lateral pain/temp loss. Dx?

Hemi section

Patient with trauma of neck. No sensory, no motor, no pain/temp on both sides. Flaccid paralysis and Hyporeflexia at the level with Spastic paralysis and Hyperreflexia bellow the level. Dx?

Complete transection

Patient with trauma of neck. Bilateral motor loss, Bilateral pain/temp loss, Proprioception/vibration normal. Dx?

Anterior cord lesion

Patient with Loss of pain/temp in a cape-like distribution during the last months. Dx?

Chronic Central cord lesions (syringomyelia)

Patient with trauma of neck for hyperextension. • Loss of pain/temp and motor in a cape-like distribution Dx?

Central cord lesions

Patient with trauma of neck. Bilateral Proprioception/vibration loss, Normal motor, Normal pain/temp. Dx?

Posterior cord lesion

Patient who tried to kill himself by taking 30 pills of acetaminophen. AST and ALT are > 1,000 Next step, tx?

Acetaminophen levels at 4 and 16 hours from ingestion Tx: - N-acetyl cysteine if above lab limits - Observe if below

Patient who tried to kill himself by taking 60 pills of aspirin. Tinnitus, N/V, Vertigo, Primary respiratory alkalosis, anion gap acidosis, Hyperpyrexia. Next step, tx?

Next step: Salicylate levels Tx: - Alkalization urine (to trap the acids of salicylates), then - Forced diuresis

Patient who was on a fire and has headache, N/V. SpO2 100% Dx, next step, tx?

Carbon monoxide intoxication Next step: - ABG - Carboxy hemoglobin Tx: Increase wear off of CO - 100% FiO2 - Hyperbaric

Patient who was on a fire, in a poor state with chery-red skin. Dx, tx?

Cyanide intoxication Tx: Thiosulfate

Farmer who has Salivation, Lacrimation, Urination, Defecation, GI upset, Emesis, Bronchoconstriction. Dx, tx?

Organophosphate toxicity Tx: Atropine and pralidoxime

Patient who is drunk with either alcoholic beverage or robbing alcohol. Tx?

IVF, protect airway

Patient who drank antifreeze. Type of alcohol and tx?

Ethylene glycol Tx: Fomepizole (inhibit conversion of toxic metabolites) or EtOH

Patient who drank moonshine and went blind. Type of alcohol and tx?

Methanol Tx: Fomepizole (inhibit conversion of toxic metabolites) or EtOH

Patient with blunt chest trauma, who has chest pain, and decrease res movements. CxR shows one rb fractured. Tx?

Pain control

Patient who had penetrating chest trauma. Dyspnea, Hyperresonance, ↓ breath sounds, ↓ fremitus. CxR: vertical shadow Dx, tx?

Pneumothorax Tx: Thoracostomy

Patient who had penetrating chest trauma. Dyspnea, Dullness on percussion, ↓ breath sounds, ↓ fremitus. CxR showing horizontal shadow; air-fluid level Dx, tx?

Hemothorax Tx: Thoracostomy

When to operate an hemothorax?

> 20 cc/kg upon tube placement or > 3 cc/kg/h drainage

Patient who had chest trauma, and has a sucking chest wound. Tx?

Occlusive dressing (taped on 3 sides) + chest tube

Definition of flail chest and tx?

2 or more ribs fracture in 2 or more places Tx: Blinders and weights If binders fail--> surgery F/U: consider also pulmonary contusion, myocardial contusion, traumatic dissection of aorta

Patient who had blunt chest trauma. Nomal CxR on day 1 but lung is white out lung on CxR on 2nd day. Dx and tx?

Pulmonary contusion Tx: - Avoid crystalloids - Use calloids (coloides) - PEEP - Diuresis

Patient who had blunt chest trauma who has high troponins and changes on the EKG. Dx, tx?

Myocardial contusion Tx: MONABASH + Diuretics for CHF +/- antiarrhythmic F/U: FAST to look for pericardial tamponade

Patient who had blunt chest trauma who has discordant BP between right and left sides and a wide mediastinum on the CxR. Dx, next step, tx?

Traumatic dissection of the aorta Next step: CT angiogram or TEE or MRI Tx: emergent surgery - ↓ BP with betablockers

Patient who was shot under T4 level. Tx?

Exploratory laparoscopy

Patient who had a penetrating abdominal trauma with a knife. He has peritoneal signs and evisceration. Tx?

Exploratory laparoscopy

Patient who had a penetrating abdominal trauma with a knife. He has no peritoneal signs or evisceration. Tx?

Probe the lesion to see if it's penetrating.

Patient with blunt abdominal trauma. Negative FAST, negative CT scan, but you still have a high suspicion of internal hemorrhage. Next step?

diagnostic peritoneal lavage

Tx of rupured live?

Exploratory laparoscopy - Pringle maneuver during sx (compress the hepatoduodenal ligament, hepatic artery and porta) - Sx repair vs lobectomy

Patient with blunt abdominal trauma which cause a ruptured spleen. The patient underwent splenectomy. Next step?

Vaccinate against encapsulated organism (e.g., strep and Neisseria)

Patient with blunt abdominal trauma whose CT scan shows diaphragmatic hernia. Dx, tx?

Diaphragm rupture Exploratory laparoscopy

Patient with blunt abdominal trauma whose CT scan shows free air at the top of the scan. The KUB shows air under diaphragm. Dx, tx?

Ruptured hollow viscus Exploratory laparoscopy

Patient who was in a car accident. He has pain during the hip-rock maneuver. Dx, next step, tx?

Pelvic fracture Next step: CT scan and retrograde urethrogram Tx: external fixation might be sufficient - If blood goes into the peritoneum then surgery, otherwise generally not needed F/U: urethral trauma, rectal injury

Patient who was in a car accident, who has a pelvic fracture. On digital rectal exam you identify a High-riding prostate. You also see Blood at the meatus. Dx, next step, tx?

Urethral trauma Next step: retrograde urethrogram Tx: suprapubic cath

Patient who was in a car accident in whom you suspect rectal injury and ureter injury. Next steps?

Proctoscope and intravenous pyelogram

Patient with a chemical burn. Tx?

* Irrigate and irrigate and irrigate and irrigate | * NEVER buffer (because it created heat and burns more)

Patient who ingested and acid or alkali Tx?

* Observation, series of CxR and call IG for an EGD * NEVER induce emesis * NEVER NG tube * NEVER buffer

Patient who was on a fire and has  Soot/singed nares and stridor. Next steps?

- ABG, SPO2, peak-flow - Bronchoscopy - Close monitor - If deterioration --> prophylactic intubation

Patient who was stricken by a lightning. Next steps, tx?

CK, creatinine to rule out radbomiolisis And monitor for arrhythmias Tx: IVF, mannitol to treat rabdo

Patient with circumferential burn. | Tx?

Cut the eschar and refer

Rule of 9s to determine % of body surface?

``` Head= 9% Front chest= 9% Back of chest= 9% Front abdomen= 9% Back of adbomen= 9% Entire arm= 9% Front of leg= 9% Back of leg= 9% Genitalia= 1% ```

Parkland formuka

(%BSA burned with 2nd and 3rd degree x kg x 4cc) of LR Give 50 % in 8 hrs Give 50% in the next 16 hrs

Tx of burns

``` o IVF o Early movement o Early graft o Pain control o Infection prophylaxis: Topical mupirocin or silver sulfadiazine ```

When to refer a burned patient

``` o Face o Hands o Genitals o Circumferential o More than 10% ```

Class of drugs that may cause syndrome of muscle rigidity, hyperthermia, autonomic instability, and extrapyramidal symptoms.

Antipsychotics (neuroleptic malignant syndrome).

Side effects of corticosteroids.

Acute mania, immunosuppression, thin skin, osteoporosis, easy bruising, myopathies.

Treatment for DTs.

Benzodiazepines.

Treatment for acetaminophen overdose.

N-acetylcysteine.

Treatment for opioid overdose.

Naloxone.

Treatment for benzodiazepine overdose. .

Flumazenil

Treatment for neuroleptic malignant syndrome and malignant hyperthermia.

Dantrolene.

Treatment for malignant hypertension.

Nitroprusside.

Treatment of atrial fibrillation.

Rate control, rhythm conversion, and anticoagulation.

Treatment of supraventricular tachycardia.

If stable, rate control with carotid massage or other vagal stimulation; if unsuccessful, consider adenosine.

Causes of drug-induced SLE.

INH, penicillamine, hydralazine, procainamide, | chlorpromazine, methyldopa, quinidine.

Macrocytic, megaloblastic anemia with neurologic | symptoms.

B12 defi ciency.

Macrocytic, megaloblastic anemia without neurologic symptoms.

Folate deficiency.

A burn patient presents with cherry-red fl ushed skin and coma. SaO2 is normal, but carboxyhemoglobin is elevated. Treatment?

Treat CO poisoning with 100% O2 or with hyperbaric O2 if poisoning is severe or the patient is pregnant.

Blood in the urethral meatus or high-riding prostate.

Bladder rupture or urethral injury.

Test to rule out urethral injury.

Retrograde cystourethrogram.

Radiographic evidence of aortic disruption or dissection.

Widened mediastinum (> 8 cm), loss of aortic knob, pleural cap, tracheal deviation to the right, depression of left main stem bronchus.

Radiographic indications for surgery in patients with acute abdomen.

Free air under the diaphragm, extravasation of contrast, severe bowel distention, space-occupying lesion (CT), mesenteric occlusion (angiography).

The most common organism in burn-related infections.

Pseudomonas.

Method of calculating fluid repletion in burn patients.

Parkland formula.

Acceptable urine output in a trauma patient.

50 cc/hr.

Acceptable urine output in a stable patient.

30 cc/hr.

Cannon “a” waves.

Third-degree heart block.

Signs of neurogenic shock.

Hypotension and bradycardia.

Signs of ↑ ICP (Cushing’s triad).

Hypertension, bradycardia, and abnormal respirations

↓ Cardiac output (CO), ↓ pulmonary capillary wedge pressure (PCWP), ↑ peripheral vascular resistance (PVR).

Hypovolemic shock.

↓ Cardiac output (CO), ↑ pulmonary capillary wedge pressure (PCWP), ↑ peripheral vascular resistance (PVR).

Cardiogenic (or obstructive) shock.

↑ Cardiac output (CO), ↓ Pulmonary capillary wedge pressure (PCWP), ↓ peripheral vascular resistance (PVR).

Septic or anaphylactic shock.

Treatment of septic shock.

Fluids and antibiotics.

Treatment of cardiogenic shock.

Identify cause; pressors (e.g., dopamine).

Treatment of hypovolemic shock.

Identify cause; fl uid and blood repletion.

Treatment of anaphylactic shock.

Diphenhydramine or epinephrine 1:1000.

Supportive treatment for ARDS.

Continuous positive airway pressure.

Signs of air embolism.

A patient with chest trauma who was previously stable suddenly dies.

Trauma series.

AP chest, AP/lateral C-spine, AP pelvis.