Trauma, C38 P226-246 Flashcards Preview

Section II General Surgery P203Surgical Recall Sixth > Trauma, C38 P226-246 > Flashcards

Flashcards in Trauma, C38 P226-246 Deck (163):
1

What widely accepted
protocol does trauma care
in the United States follow?
P226

Advanced Trauma Life Support (ATLS)
precepts of the American College of
Surgeons

2

What are the three main
elements of the ATLS
protocol?
P226

1. Primary survey/resuscitation
2. Secondary survey
3. Definitive care

3

How and when should the
patient history be obtained?
P227

It should be obtained while completing
the primary survey; often the rescue
squad, witnesses, and family members
must be relied upon

4

PRIMARY SURVE
What are the five steps of
the primary survey?
P227

Think: “ABCDEs”:
Airway (and C-spine stabilization)
Breathing
Circulation
Disability
Exposure and Environment

5

PRIMARY SURVE
What principles are followed
in completing the primary
survey?
P227

Life-threatening problems discovered
during the primary survey are always
addressed before proceeding to the
next step

6

AIRWAY
What are the goals during
assessment of the airway?
P227

Securing the airway and protecting the
spinal cord

7

AIRWAY
In addition to the airway,
what MUST be considered
during the airway step?
P227

Spinal immobilization

8

AIRWAY
What comprises spinal
immobilization?
P227

Use of a full backboard and rigid cervical
collar

9

AIRWAY
In an alert patient, what is
the quickest test for an
adequate airway?
P227

Ask a question: If the patient can speak,
the airway is intact

10

AIRWAY
What is the first maneuver
used to establish an airway?
P227

Chin lift, jaw thrust, or both; if successful,
often an oral or nasal airway can be
used to temporarily maintain the airway

11

AIRWAY
If these methods are
unsuccessful, what is the
next maneuver used to
establish an airway?
P227

Endotracheal intubation

12

AIRWAY
If all other methods are
unsuccessful, what is the
definitive airway?
P228 (picture)

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

AIRWAY
What must always be kept
in mind during difficult
attempts to establish an
airway?
P228

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

BREATHING
What are the goals in
assessing breathing?
P228

Securing oxygenation and ventilation
Treating life-threatening thoracic injuries

15

BREATHING
What comprises adequate
assessment of breathing?
P228

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

BREATHING
What are the life-threatening
conditions that MUST be
diagnosed and treated
during the breathing step?
P228

Tension pneumothorax, open
pneumothorax, massive hemothorax

17

BREATHING
What is it?
P229

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

18

BREATHING
How is it diagnosed?
P229

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

BREATHING
What is the treatment of a
tension pneumothorax?
P229

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

BREATHING
What is the medical term for
a “sucking chest wound”?
P229

Open pneumothorax

21

BREATHING
What is a tube thoracostomy?
P229

“Chest tube”

22

BREATHING
How is an open
pneumothorax diagnosed
and treated?
P229

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

BREATHING
What does a pneumothorax
look like on chest X-ray?
P229 (picture

Loss of lung markings (Figure shows a
right-sided pneumothorax; arrows point
out edge of lung-air interface)

24

Flail Chest
What is it?
P230 (picture)

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