Trauma, C38 P226-246 Flashcards
(163 cards)
1
Q
What widely accepted
protocol does trauma care
in the United States follow?
P226
A
Advanced Trauma Life Support (ATLS)
precepts of the American College of
Surgeons
2
Q
What are the three main
elements of the ATLS
protocol?
P226
A
- Primary survey/resuscitation
- Secondary survey
- Definitive care
3
Q
How and when should the
patient history be obtained?
P227
A
It should be obtained while completing
the primary survey; often the rescue
squad, witnesses, and family members
must be relied upon
4
Q
PRIMARY SURVE
What are the five steps of
the primary survey?
P227
A
Think: “ABCDEs”: Airway (and C-spine stabilization) Breathing Circulation Disability Exposure and Environment
5
Q
PRIMARY SURVE What principles are followed in completing the primary survey? P227
A
Life-threatening problems discovered
during the primary survey are always
addressed before proceeding to the
next step
6
Q
AIRWAY
What are the goals during
assessment of the airway?
P227
A
Securing the airway and protecting the
spinal cord
7
Q
AIRWAY In addition to the airway, what MUST be considered during the airway step? P227
A
Spinal immobilization
8
Q
AIRWAY
What comprises spinal
immobilization?
P227
A
Use of a full backboard and rigid cervical
collar
9
Q
AIRWAY In an alert patient, what is the quickest test for an adequate airway? P227
A
Ask a question: If the patient can speak,
the airway is intact
10
Q
AIRWAY
What is the first maneuver
used to establish an airway?
P227
A
Chin lift, jaw thrust, or both; if successful,
often an oral or nasal airway can be
used to temporarily maintain the airway
11
Q
AIRWAY If these methods are unsuccessful, what is the next maneuver used to establish an airway? P227
A
Endotracheal intubation
12
Q
AIRWAY If all other methods are unsuccessful, what is the definitive airway? P228 (picture)
A
Cricothyroidotomy, a.k.a. “surgical airway”: Incise the cricothyroid membrane between the cricoid cartilage inferiorly and the thyroid cartilage superiorly and place an endotracheal or tracheostomy tube into the trachea
13
Q
AIRWAY What must always be kept in mind during difficult attempts to establish an airway? P228
A
Spinal immobilization and adequate oxygenation; if at all possible, patients must be adequately ventilated with 100% oxygen using a bag and mask before any attempt to establish an airway
14
Q
BREATHING
What are the goals in
assessing breathing?
P228
A
Securing oxygenation and ventilation
Treating life-threatening thoracic injuries
15
Q
BREATHING
What comprises adequate
assessment of breathing?
P228
A
Inspection—for air movement, respiratory
rate, cyanosis, tracheal shift, jugular
venous distention, asymmetric chest
expansion, use of accessory muscles
of respiration, open chest wounds
Auscultation—for breath sounds
Percussion—for hyperresonance or
dullness over either lung field
Palpation—for presence of subcutaneous
emphysema, flail segments
16
Q
BREATHING What are the life-threatening conditions that MUST be diagnosed and treated during the breathing step? P228
A
Tension pneumothorax, open
pneumothorax, massive hemothorax
17
Q
BREATHING
What is it?
P229
A
Injury to the lung, resulting in release of air
into the pleural space between the normally
apposed parietal and visceral pleura
18
Q
BREATHING
How is it diagnosed?
P229
A
Tension pneumothorax is a clinical
diagnosis: dyspnea, jugular venous
distention, tachypnea, anxiety, pleuritic
chest pain, unilateral decreased or absent
breath sounds, tracheal shift away from
the affected side, hyperresonance on the
affected side
19
Q
BREATHING
What is the treatment of a
tension pneumothorax?
P229
A
Rapid thoracostomy incision or immediate decompression by needle thoracostomy in the second intercostal space midclavicular line, followed by tube thoracostomy placed in the anterior/ midaxillary line in the fourth intercostal space (level of the nipple in men)
20
Q
BREATHING
What is the medical term for
a “sucking chest wound”?
P229
A
Open pneumothorax
21
Q
BREATHING
What is a tube thoracostomy?
P229
A
“Chest tube”
22
Q
BREATHING How is an open pneumothorax diagnosed and treated? P229
A
Diagnosis: usually obvious, with air
movement through a chest wall defect
and pneumothorax on CXR
Treatment in the ER: tube thoracostomy
(chest tube), occlusive dressing over
chest wall defect
23
Q
BREATHING
What does a pneumothorax
look like on chest X-ray?
P229 (picture
A
Loss of lung markings (Figure shows a
right-sided pneumothorax; arrows point
out edge of lung-air interface)
24
Q
Flail Chest
What is it?
P230 (picture)
A
Two separate fractures in three or more
consecutive ribs
25
Flail Chest
How is it diagnosed?
P230
Flail segment of chest wall that moves
paradoxically (sucks in with inspiration
and pushes out with expiration opposite
the rest of the chest wall)
26
```
Flail Chest
What is the major cause of
respiratory compromise with
flail chest?
P230
```
Underlying pulmonary contusion!
27
Flail Chest
What is the treatment?
P230
Intubation with positive pressure
ventilation and PEEP PRN (let ribs heal
on their own)
28
Cardiac Tamponade
What is it?
P230
Bleeding into the pericardial sac, resulting
in constriction of heart, decreasing inflow
and resulting in decreased cardiac output
(the pericardium does not stretch!)
29
Cardiac Tamponade
What are the signs and
symptoms?
P230
Tachycardia/shock with Beck’s triad,
| pulsus paradoxus, Kussmaul’s sign
30
Cardiac Tamponade
Define the following:
Beck’s triad
P231
1. Hypotension
2. Muffled heart sounds
3. JVD
31
Cardiac Tamponade
Define the following:
Kussmaul’s sign
P231
JVD with inspiration
32
Cardiac Tamponade
How is cardiac tamponade
diagnosed?
P231
Ultrasound (echocardiogram)
33
Cardiac Tamponade
What is the treatment?
P231
Pericardial window—if blood returns
then median sternotomy to rule out and
treat cardiac injury
34
Massive Hemothorax
How is it diagnosed?
P231
Unilaterally decreased or absent breath
sounds; dullness to percussion; CXR, CT
scan, chest tube output
35
Massive Hemothorax
What is the treatment?
P231
Volume replacement
Tube thoracostomy (chest tube)
Removal of the blood (which will allow
apposition of the parietal and visceral
pleura, sealing the defect and slowing
the bleeding)
36
```
Massive Hemothorax
What are indications for
emergent thoracotomy for
hemothorax?
P231
```
```
Massive hemothorax
1. >1500 cc of blood on initial
placement of chest tube
2. Persistent >200 cc of bleeding via
chest tube per hour x 4 hours
```
37
CIRCULATION
What are the goals in
assessing circulation?
P231
Securing adequate tissue perfusion;
| treatment of external bleeding
38
CIRCULATION
What is the initial test for
adequate circulation?
P231
Palpation of pulses: As a rough guide,
if a radial pulse is palpable, then systolic
pressure is at least 80 mm Hg; if a
femoral or carotid pulse is palpable, then
systolic pressure is at least 60 mm Hg
39
CIRCULATION
What comprises adequate
assessment of circulation?
P231
Heart rate, blood pressure, peripheral
perfusion, urinary output, mental status,
capillary refill (normal <2 seconds), exam
of skin: cold, clammy = hypovolemia
40
CIRCULATION
Who can be hypovolemic
with normal blood pressure?
P232
Young patients; autonomic tone can
maintain blood pressure until
cardiovascular collapse is imminent
41
```
CIRCULATION
Which patients may not
mount a tachycardic
response to hypovolemic
shock?
P232
```
Those with concomitant spinal cord
injuries
Those on -blockers
Well-conditioned athletes
42
CIRCULATION
How are sites of external
bleeding treated?
P232
By direct pressure; / tourniquets
43
```
CIRCULATION
What is the best and
preferred intravenous (IV)
access in the trauma
patient?
P232
```
“Two large-bore IVs” (14–16 gauge),
IV catheters in the upper extremities
(peripheral IV access)
44
CIRCULATION
What are alternate sites of
IV access?
P232
Percutaneous and cutdown catheters in
the lower leg saphenous; central access
into femoral, jugular, subclavian veins
45
```
CIRCULATION
For a femoral vein catheter,
how can the anatomy of the
right groin be remembered?
P232
```
```
Lateral to medial “NAVEL”:
Nerve
Artery
Vein
Empty space
Lymphatics
Thus, the vein is medial to the femoral
artery pulse (Or, think: “venous close
to penis”)
```
46
CIRCULATION
What is the trauma
resuscitation fluid of choice?
P232
Lactated Ringer’s (LR) solution
(isotonic, and the lactate helps buffer the
hypovolemia-induced metabolic acidosis)
47
CIRCULATION
What types of decompression
do trauma patients receive?
P232
Gastric decompression with an NG tube
and Foley catheter bladder decompression
after normal rectal exam
48
```
CIRCULATION
What are the
contraindications to
placement of a Foley?
P232
```
```
Signs of urethral injury:
Severe pelvic fracture in men
Blood at the urethral meatus (penile
opening)
“High-riding” “ballotable” prostate
(loss of urethral tethering)
Scrotal/perineal injury/ecchymosis
```
49
```
CIRCULATION
What test should be
obtained prior to placing a
Foley catheter if urethral
injury is suspected?
P233
```
Retrograde UrethroGram (RUG): dye in
penis retrograde to the bladder and x-ray
looking for extravasation of dye
50
```
CIRCULATION
How is gastric
decompression achieved
with a maxillofacial
fracture?
P233
```
Not with an NG tube because the tube
may perforate through the cribriform
plate into the brain; place an oral-gastric
tube (OGT), not an NG tube
51
DISABILITY
What are the goals in
assessing disability?
P233
Determination of neurologic injury
| Think: neurologic disability
52
DISABILITY
What comprises adequate
assessment of disability?
P233
```
Mental status—Glasgow Coma Scale
(GCS)
Pupils—a blown pupil suggests ipsilateral
brain mass (blood) as herniation of the
brain compresses CN III
Motor/sensory—screening exam for
lateralizing extremity movement,
sensory deficits
```
53
DISABILITY
Describe the GCS scoring
system.
P233
```
Eye opening (E)
4—Opens spontaneously
3—Opens to voice (command)
2—Opens to painful stimulus
1—Does not open eyes
(Think: Eyes = “four eyes”)
Motor response (M)
6—Obeys commands
5—Localizes painful stimulus
4—Withdraws from pain
3—Decorticate posture
2—Decerebrate posture
1—No movement
(Think: Motor = “6-cylinder motor”)
Verbal response (V)
5—Appropriate and oriented
4—Confused
3—Inappropriate words
2—Incomprehensible sounds
1—No sounds
(Think: Verbal = “Jackson 5”)
```
54
DISABILITY
What is a normal human GCS?
P234
GCS 15
55
DISABILITY
What is the GCS score for a
dead man?
P234
GCS 3
56
DISABILITY
What is the GCS score for a
patient in a “coma”?
P234
GCS ⩽8
57
DISABILITY
How does scoring differ if
the patient is intubated?
P234
Verbal evaluation is omitted and replaced
with a “T”; thus, the highest score for an
intubated patient is 11 T
58
EXPOSURE AND ENVIRONMENT
What are the goals in
obtaining adequate exposure?
P234
Complete disrobing to allow a thorough
visual inspection and digital palpation of
the patient during the secondary survey
59
EXPOSURE AND ENVIRONMENT
What is the “environment”
of the E in ABCDEs?
P234
Keep a warm Environment (i.e., keep the
patient warm; a hypothermic patient can
become coagulopathic)
60
```
SECONDARY SURVEY
What principle is followed
in completing the secondary
survey?
P234
```
Complete physical exam, including all
orifices: ears, nose, mouth, vagina,
rectum
61
SECONDARY SURVEY
Why look in the ears?
P234
Hemotympanum is a sign of basilar skull
fracture; otorrhea is a sign of basilar skull
fracture
62
```
SECONDARY SURVEY
Examination of what part of
the trauma patient’s body is
often forgotten?
P234
```
Patient’s back (logroll the patient and
| examine!)
63
SECONDARY SURVEY
What are typical signs of
basilar skull fracture?
P234
Raccoon eyes, Battle’s sign, clear otorrhea
| or rhinorrhea, hemotympanum
64
```
SECONDARY SURVEY
What diagnosis in the
anterior chamber must
not be missed on the eye exam?
P234
```
Traumatic hyphema = blood in the
| anterior chamber of the eye
65
```
SECONDARY SURVEY
What potentially destructive
lesion must not be missed on
the nasal exam?
P235
```
Nasal septal hematoma: Hematoma must
be evacuated; if not, it can result in
pressure necrosis of the septum!
66
SECONDARY SURVEY
What is the best indication
of a mandibular fracture?
P235
Dental malocclusion: Tell the patient to
“bite down” and ask, “Does that feel
normal to you?”
67
```
SECONDARY SURVEY
What signs of thoracic
trauma are often found on
the neck exam?
P235
```
Crepitus or subcutaneous emphysema from
tracheobronchial disruption/PTX; tracheal
deviation from tension pneumothorax;
jugular venous distention from cardiac
tamponade; carotid bruit heard with
seatbelt neck injury resulting in carotid
artery injury
68
SECONDARY SURVEY
What is the best physical exam
for broken ribs or sternum?
P235
Lateral and anterior-posterior compression
| of the thorax to elicit pain/instability
69
```
SECONDARY SURVEY
What physical signs are
diagnostic for thoracic great
vessel injury?
P235
```
```
None: Diagnosis of great vessel injury
requires a high index of suspicion based
on the mechanism of injury, associated
injuries, and CXR/radiographic findings
(e.g., widened mediastinum)
```
70
```
SECONDARY SURVEY
What is the best way to
diagnose or rule out aortic
injury?
P235
```
CT angiogram
71
```
SECONDARY SURVEY
What must be considered in
every penetrating injury of
the thorax at or below the
level of the nipple?
P235
```
Concomitant injury to the abdomen:
Remember, the diaphragm extends to the
level of the nipples in the male on full
expiration
72
SECONDARY SURVEY
What is the significance of
subcutaneous air?
P235
Indicates PTX, until proven otherwise
73
```
SECONDARY SURVEY
What is the physical exam
technique for examining the
thoracic and lumbar spine?
P235
```
Logrolling the patient to allow complete
visualization of the back and palpation
of the spine to elicit pain over fractures,
step off (spine deformity)
74
```
SECONDARY SURVEY
What conditions must exist
to pronounce an abdominal
physical exam negative?
P235
```
Alert patient without any evidence of
head/spinal cord injury or drug/EtOH
intoxication (even then, the abdominal
exam is not 100% accurate)
75
```
SECONDARY SURVEY
What physical signs may
indicate intra-abdominal
injury?
P236
```
Tenderness; guarding; peritoneal signs;
progressive distention (always use a
gastric tube for decompression of air);
seatbelt sign
76
SECONDARY SURVEY
What is the seatbelt sign?
P236
Ecchymosis on lower abdomen from
wearing a seatbelt (10% of patients with
this sign have a small bowel perforation!)
77
SECONDARY SURVEY
What must be documented
from the rectal exam?
P236
Sphincter tone (as an indication of spinal
cord function); presence of blood (as an
indication of colon or rectal injury); prostate
position (as an indication of urethral injury)
78
```
SECONDARY SURVEY
What is the best physical
exam technique to test for
pelvic fractures?
P236
```
Lateral compression of the iliac crests
and greater trochanters and anteriorposterior
compression of the symphysis
pubis to elicit pain/instability
79
SECONDARY SURVEY
What is the “halo” sign?
P236
Cerebrospinal fluid from nose/ear will form
| a clear “halo” around the blood on a cloth
80
```
SECONDARY SURVEY
What physical signs indicate
possible urethral injury, thus
contraindicating placement
of a Foley catheter?
P236
```
High-riding ballotable prostate on
rectal exam; presence of blood at the
meatus; scrotal or perineal ecchymosis
81
SECONDARY SURVEY
What must be documented
from the extremity exam?
P236
Any fractures or joint injuries; any open
wounds; motor and sensory exam,
particularly distal to any fractures; distal
pulses; peripheral perfusion
82
```
SECONDARY SURVEY
What complication after
prolonged ischemia to the
lower extremity must be
treated immediately?
P236
```
Compartment syndrome
83
SECONDARY SURVEY
What is the treatment for
this condition?
P236
Fasciotomy (four compartments below
| the knee)
84
```
SECONDARY SURVEY
What injuries must be
suspected in a trauma
patient with a progressive
decline in mental status?
P236
```
```
Epidural hematoma, subdural hematoma,
brain swelling with rising intracranial
pressure
But hypoxia/hypotension must be
ruled out!
```
85
TRAUMA STUDIES
What are the classic blunt
trauma ER x-rays?
P237
1. AP (anterior-to-posterior) chest film
| 2. AP pelvis film
86
TRAUMA STUDIES
What are the common
trauma labs?
P237
Blood for complete blood count,
chemistries, amylase, liver function tests,
lactic acid, coagulation studies, and type
and crossmatch; urine for urinalysis
87
```
TRAUMA STUDIES
Will the hematocrit be
low after an acute massive
hemorrhage?
P237
```
No (no time to equilibrate)
88
TRAUMA STUDIES
How can a C-spine be
evaluated?
P237
1. Clinically by physical exam
| 2. Radiographically
89
```
TRAUMA STUDIES
What patients can have
their C-spines cleared by a
physical exam?
P237
```
No neck pain on palpation with full range
of motion (FROM) with no neurologic
injury (GCS 15), no EtOH/drugs, no
distracting injury, no pain meds
90
TRAUMA STUDIES
How do you rule out a
C-spine bony fracture?
P237
With a CT scan of the C-spine
91
```
TRAUMA STUDIES
What do you do if no bony
C-spine fracture is apparent
on CT scan and you cannot
obtain an MRI in a
COMATOSE patient?
P237
```
This is controversial; the easiest answer is
| to leave the patient in a cervical collar
92
```
TRAUMA STUDIES
Which x-rays are used for
evaluation of cervical spine
LIGAMENTOUS injury?
P237
```
MRI, lateral flexion and extension
| C-spine films
93
```
TRAUMA STUDIES
What findings on chest film
are suggestive of thoracic
aortic injury?
P237
```
```
Widened mediastinum (most common
finding), apical pleural capping, loss
of aortic contour/KNOB/AP window,
depression of left main stem bronchus,
nasogastric tube/tracheal deviation,
pleural fluid, elevation of right mainstem
bronchus, clinical suspicion, high-speed
mechanism
```
94
TRAUMA STUDIES
What study is used to rule
out thoracic aortic injury?
P238
Spiral CT scan of mediastinum looking
for mediastinal hematoma with CTA
Thoracic arch aortogram (gold standard)
95
```
TRAUMA STUDIES
What is the most common
site of thoracic aortic
traumatic tear?
P238
```
Just distal to the take-off of the left
| subclavian artery
96
```
TRAUMA STUDIES
What studies are available to
evaluate for intra-abdominal
injury?
P238
```
FAST, CT scan, DPL
97
TRAUMA STUDIES
What is a FAST exam?
P238
Ultrasound: Focused Assessment with
| Sonography for Trauma = FAST
98
TRAUMA STUDIES
What does the FAST exam
look for?
P238
Blood in the peritoneal cavity looking at
Morison’s pouch, bladder, spleen, and
pericardial sac
99
TRAUMA STUDIES
What does DPL stand for?
P238
Diagnostic Peritoneal Lavage
100
```
TRAUMA STUDIES
What diagnostic test is the
test of choice for evaluation
of the unstable patient with
blunt abdominal trauma?
P238
```
FAST
101
```
TRAUMA STUDIES
What is the indication for
abdominal CT scan in blunt
trauma?
P238
```
Normal vital signs with abdominal
| pain/tenderness/mechanism
102
```
TRAUMA STUDIES
What is the indication for
DPL or FAST in blunt
trauma?
P238
```
Unstable vital signs (hypotension)
103
TRAUMA STUDIES
How is a DPL performed?
P238
Place a catheter below the umbilicus (in
patients without a pelvic fracture) into
the peritoneal cavity
Aspirate for blood and if <10 cc are
aspirated, infuse 1 L of saline or LR
Drain the fluid (by gravity) and analyze
104
TRAUMA STUDIES
What is a “grossly positive” DPL?
P238
⩾10 cc blood aspirated
105
```
TRAUMA STUDIES
Where should the DPL
catheter be placed in a
patient with a pelvic
fracture?
P239
```
```
Above the umbilicus
Common error: If you go below the
umbilicus, you may get into a pelvic
hematoma tracking between the fascia
layers and thus obtain a false-positive
DPL
```
106
TRAUMA STUDIES
What constitutes a positive
peritoneal tap?
P239
Prior to starting a peritoneal lavage, the DPL catheter should be aspirated; if >10 mL of blood or any enteric contents are aspirated, then this constitutes a positive tap and requires laparotomy
107
```
TRAUMA STUDIES
What are the indicators of a
positive peritoneal lavage in
blunt trauma?
P239
```
```
Classic:
Inability to read newsprint through
lavaged fluid
RBC ⩾ 100,000/mm
WBC ⩾ 500/mm (Note: mm, not
mm)
Lavage fluid (LR/NS) drained from
chest tube, Foley, NG tube
```
```
Less common:
Bile present
Bacteria present
Feces present
Vegetable matter present
Elevated amylase level
```
108
TRAUMA STUDIES
What must be in place
before a DPL is performed?
P239
NG tube and Foley catheter (to remove
the stomach and bladder from the line
of fire!)
109
TRAUMA STUDIES
What injuries does CT scan miss?
P239
Small bowel injuries and diaphragm
| injuries
110
TRAUMA STUDIES
What injuries does DPL
miss?
P239
Retroperitoneal injuries
111
```
TRAUMA STUDIES
What study is used to
evaluate the urethra in cases
of possible disruption due to
blunt trauma?
P239
```
Retrograde urethrogram (RUG)
112
TRAUMA STUDIES
What are the most emergent
orthopaedic injuries?
P240
1. Hip dislocation—must be reduced
immediately
2. Exsanguinating pelvic fracture (binder
or external fixator)
113
TRAUMA STUDIES
What findings would require
a celiotomy in a blunt trauma victim?
P240
Peritoneal signs, free air on CXR/CT
scan, unstable patient with positive FAST
exam or positive DPL results
114
TRAUMA STUDIES
What is the treatment of a
gunshot wound to the belly?
P240
Exploratory laparotomy
115
TRAUMA STUDIES
What is the evaluation of a
stab wound to the belly?
P240
```
If there are peritoneal signs, heavy
bleeding, shock, perform exploratory
laparotomy; otherwise, many surgeons
either observe the asymptomatic stab
wound patient closely, use local wound
exploration to rule out fascial
penetration, or use DPL
```
116
PENETRATING NECK INJURIES
What depth of neck injury
must be further evaluated?
P240
Penetrating injury through the platysma
117
PENETRATING NECK INJURIES
Define the anatomy of the neck by trauma zones:
Zone III
P240
Angle of the mandible and up
118
PENETRATING NECK INJURIES
Define the anatomy of the neck by trauma zones:
Zone II
P240
Angle of the mandible to the cricoid
| cartilage
119
PENETRATING NECK INJURIES
Define the anatomy of the neck by trauma zones:
Zone I
P240 (picture)
Below the cricoid cartilage
120
```
PENETRATING NECK INJURIES
How do most surgeons treat
penetrating neck injuries
(those that penetrate the
platysma) by neck zone:
Zone III
P241
```
Selective exploration
121
```
PENETRATING NECK INJURIES
How do most surgeons treat
penetrating neck injuries
(those that penetrate the
platysma) by neck zone:
Zone II
P241
```
Surgical exploration vs. selective
| exploration
122
```
PENETRATING NECK INJURIES
How do most surgeons treat
penetrating neck injuries
(those that penetrate the
platysma) by neck zone:
Zone I
P241
```
Selective exploration
123
PENETRATING NECK INJURIES
What is selective
exploration?
P241
Selective exploration is based on diagnostic
studies that include A-gram or CT A-gram,
bronchoscopy, esophagoscopy
124
```
PENETRATING NECK INJURIES
What are the indications for
surgical exploration in all
penetrating neck wounds
(Zones I, II, III)?
P241
```
```
“Hard signs” of significant neck damage:
shock, exsanguinating hemorrhage,
expanding hematoma, pulsatile
hematoma, neurologic injury, subQ
emphysema
```
125
```
PENETRATING NECK INJURIES
How can you remember the
order of the neck trauma
zones and Le Forte fractures?
P241 (picture)
```
In the direction of carotid blood flow
126
MISCELLANEOUS TRAUMA FACTS
What is the “3-for-1” rule?
P241
Trauma patient in hypovolemic shock
acutely requires 3 L of crystalloid (LR)
for every 1 L of blood loss
127
MISCELLANEOUS TRAUMA FACTS
What is the minimal urine
output for an adult trauma patient?
P241
50 mL/hr
128
```
MISCELLANEOUS TRAUMA FACTS
How much blood can be lost
into the thigh with a closed
femur fracture?
P242
```
Up to 1.5 L of blood
129
```
MISCELLANEOUS TRAUMA FACTS
Can an adult lose enough
blood in the “closed” skull
from a brain injury to cause
hypovolemic shock?
P242
```
Absolutely not! But infants can lose
enough blood from a brain injury to
cause shock
130
MISCELLANEOUS TRAUMA FACTS
Can a patient behypotensive
after an isolated head injury?
P242
Yes, but rule out hemorrhagic shock!
131
MISCELLANEOUS TRAUMA FACTS
What is the brief ATLS history?
P242
```
“AMPLE” history:
Allergies
Medications
PMH
Last meal (when)
Events (of injury, etc.)
```
132
```
MISCELLANEOUS TRAUMA FACTS
In what population is a
surgical cricothyroidotomy
not recommended?
P242
```
Any patient younger than 12 years; instead
| perform needle cricothyroidotomy
133
MISCELLANEOUS TRAUMA FACTS
What are the signs of a
laryngeal fracture?
P242
Subcutaneous emphysema in neck
Altered voice
Palpable laryngeal fracture
134
MISCELLANEOUS TRAUMA FACTS
What is the treatment of
rectal penetrating injury?
P242
```
Diverting proximal colostomy; closure
of perforation (if easy, and definitely if
intraperitoneal); and presacral drainage
```
135
```
MISCELLANEOUS TRAUMA FACTS
What is the treatment of
EXTRAperitoneal minor
bladder rupture?
P242
```
“Bladder catheter” (Foley) drainage and
observation; intraperitoneal or large
bladder rupture requires operative closure
136
MISCELLANEOUS TRAUMA FACTS
What intra-abdominal injury is
associated with seatbelt use?
P242
Small bowel injuries (L2 fracture,
| pancreatic injury)
137
MISCELLANEOUS TRAUMA FACTS
What is the treatment of a
pelvic fracture?
P242
+/- pelvic binder until the external
fixator is placed; IVF/blood; +/- A-gram
to embolize bleeding pelvic vessels
138
```
MISCELLANEOUS TRAUMA FACTS
Bleeding from pelvic fractures
is most commonly caused by
arterial or venous bleeding?
P242
```
Venous (≈85%)
139
```
MISCELLANEOUS TRAUMA FACTS
If a patient has a laceration
through an eyebrow, should
you shave the eyebrow prior
to suturing it closed?
P242
```
No—20% of the time, the eyebrow will
| not grow back if shaved!
140
```
MISCELLANEOUS TRAUMA FACTS
What is the treatment of
extensive irreparable biliary,
duodenal, and pancreatic
head injury?
P243
```
Trauma Whipple
141
```
MISCELLANEOUS TRAUMA FACTS
What is the most common
intra-abdominal organ
injured with penetrating
trauma?
P243
```
Small bowel
142
MISCELLANEOUS TRAUMA FACTS
How high up do the
diaphragms go?
P243
To the nipples (intercostal space #4);
thus, intra-abdominal injury with
penetrating injury below the nipples
must be ruled out
143
```
MISCELLANEOUS TRAUMA FACTS
Classic trauma question:
“If you have only one vial of
blood from a trauma victim
to send to the lab, what test
should be ordered?”
P243
```
Type and cross (for blood transfusion)
144
MISCELLANEOUS TRAUMA FACTS
What is the treatment of
penetrating injury to the colon?
P243
If the patient is in shock, resection and
colostomy
If the patient is stable, the trend is
primary anastomosis/repair
145
MISCELLANEOUS TRAUMA FACTS
What is the treatment of
small bowel injury?
P243
Primary closure or resection and primary
| anastomosis
146
MISCELLANEOUS TRAUMA FACTS
What is the treatment of
minor pancreatic injury?
P243
Drainage (e.g., JP drains)
147
```
MISCELLANEOUS TRAUMA FACTS
What is the most commonly
injured abdominal organ
with blunt trauma?
P243
```
Liver (in recent studies)
148
MISCELLANEOUS TRAUMA FACTS
What is the treatment for
significant duodenal injury?
P243
Pyloric exclusion:
1. Close duodenal injury
2. Staple off pylorus
3. Gastrojejunostomy
149
MISCELLANEOUS TRAUMA FACTS
What is the treatment for
massive tail of pancreas injury?
P244
```
Distal pancreatectomy (usually perform
splenectomy also)
```
150
MISCELLANEOUS TRAUMA FACTS
What is “damage control” surgery?
P244
```
Stop major hemorrhage and GI soilage
Pack and get out of the O.R. ASAP to
bring the patient to the ICU to warm,
correct coags, and resuscitate
Return patient to O.R. when stable,
warm, and not acidotic
```
151
MISCELLANEOUS TRAUMA FACTS
What is the “lethal triad”?
P244
```
“ACH”:
1. Acidosis
2. Coagulopathy
3. Hypothermia
(Think: ACHe = Acidosis, Coagulopathy,
Hypothermia)
```
152
```
MISCELLANEOUS TRAUMA FACTS
What comprises the workup/
treatment of a stable
parasternal chest gunshot/
stab wound?
P244
```
1. CXR
2. FAST, chest tube, / O.R. for subxiphoid
window; if blood returns, then
sternotomy to assess for cardiac injury
153
MISCELLANEOUS TRAUMA FACTS
What is the diagnosis with
NGT in chest on CXR?
P244 (picture)
```
Ruptured diaphragm with stomach in
pleural cavity (go to ex lap)
```
154
```
MISCELLANEOUS TRAUMA FACTS
What films are typically
obtained to evaluate
extremity fractures?
P244
```
Complete views of the involved extremity,
including the joints above and below the
fracture
155
MISCELLANEOUS TRAUMA FACTS
Outline basic workup for a victim of severe blunt trauma In ER:
Airway, physical exam. IV X 2, labs, type and cross, OGT/NGT, Foley, chest tube PRN
X-rays: CXR, pelvic, femur
(if femur fracture is suspected)
[Note: AP = anteroposterior; Ext = extremity; OGT = orogastric tube;
FAST = Focused Assessment Sonogram for Trauma; lat = lateral; C = cervical.]
P245 (Table)
(see table
156
```
MISCELLANEOUS TRAUMA FACTS
What finding on ABD/pelvic
CT scan requires ex lap in
the blunt trauma patient
with normal vital signs?
P245
```
Free air; also strongly consider in the
patient with no solid organ injury but lots
of free fluid = both to rule out hollow
viscus injury
157
```
MISCELLANEOUS TRAUMA FACTS
Can you rely on a negative
FAST in the unstable patient
with a pelvic fracture?
P245
```
No—perform DPL (above umbilicus)
158
```
MISCELLANEOUS TRAUMA FACTS
What lab tests are used to
look for intra-abdominal
injury in children?
P246
```
Liver function tests (LFTs) = ↑AST
| and/or ↑ALT
159
MISCELLANEOUS TRAUMA FACTS
What is the only real indication
for MAST trousers?
P246
Prehospitalization, pelvic fracture
160
MISCELLANEOUS TRAUMA FACTS
What is the treatment for
human and dog bites?
P246
Leave wound open, irrigation, antibiotics
161
```
MISCELLANEOUS TRAUMA FACTS
What percentage of pelvic
fracture bleeding is
exclusively venous?
P246
```
85%
162
MISCELLANEOUS TRAUMA FACTS
What is sympathetic
ophthalmia?
P246
Blindness in one eye that results in
subsequent blindness in the contralateral
eye (autoimmune)
163
```
MISCELLANEOUS TRAUMA FACTS
What can present after blunt
trauma with neurological
deficits and a normal brain
CT scan?
P246
```
Diffuse Axonal Injury (DAI), carotid
| artery injury
