Trauma II

Question 1

Multiple gunshot wounds to the abdomen. Diaphoretic, pale, cold, shivering, anxious, asking for water and a blanket. BP 60/40. HR 150, barely perceptible.

Answer 1

Likely blood loss causing hypovolemic shock

Question 2

Hypovolemic shock from gunshot wounds. Next step?

Answer 2

Two large bore IV’s. Foley catheter. IV Abx

Question 3

For hypovolemic shock from internal bleeding, what comes first? Lap for control of bleeding or fluids?

Answer 3

Emergency Lap

Question 4

Multiple gunshot wounds to chest/abd. Diaphoretic, pale, cold, shivering, thirsty. What are three options knowing just this?

Answer 4

Hypovolemic shock
Tension pneumothorax
Pericardial tamponade

Question 5

Multiple gunshot wounds to chest/abd. Distended neck veins (or high measured CVP.)

Answer 5

Tension pneumo or pericardial tamponade

Question 6

Multiple gunshot wounds to chest/abd. Distended neck veins (or high measured CVP.) Breathing okay, no tracheal deviation

Answer 6

Pericardial tamponade

Question 7

Pericardial tamponade. Next step?

Answer 7

Thoracotomy right away. May or may not need a pericardial window.

Question 8

Tension pneumo. Next step?

Answer 8

Emergency big bore IV cath into right pleural space, followed by chest tube to right side RIGHT AWAY.

Question 9

72 yr old male who lives alone calls 911 with severe chest pain. Cannot give coherent history when picked up by EMT. BP 80/65, diaphoretic, HR feeble and irregular at 130. Distended neck and forehead veins.

Answer 9

Cardiogenic shock from massive MI

Question 10

Next step in cardiogenic shock from massive MI?

Answer 10

EKG, enzymes, coronary care unit, use thrombolytic if offered.

Question 11

Patient undergoing surgery under spinal anesthetic develops a BP of 75/25, HR 150, warm and flush

Answer 11

Vasomotor shock

Question 12

Vasomotor shock. Next step?

Answer 12

Vasoconstrictors. Volume resusc wouldn’t hurt

Question 13

25 yr old stabbed in right chest. Moderately short of breath, stable vitals. No breath sounds on right. Resonant to percussion.

Answer 13

Pneumothorax

Question 14

How is a plain pneumo verified?

Answer 14

Chest XR

Question 15

How do you treat a plain pneumo?

Answer 15

Chest tube to underwater seal and suction high in pleural cavity

Question 16

25 yr old stabbed in right chest. Moderately short of breath, stable vitals. No breath sounds on base on the right. Faint distant breath sounds at the apex. Dull to percussion.

Answer 16

Hemothorax

Question 17

How is a hemothorax dxd?

Answer 17

Chest XR

Question 18

What is the treatment for hemothorax?

Answer 18

Chest tube at the base of the pleural cavity

Question 19

25 yr old stabbed in right chest. Moderately short of breath, bp 95/70, HR 100. No breath sounds on base on the right. Faint distant breath sounds at the apex. Dull to percussion. Chest tube is placed at right pleural base and recovers 1250 cc of blood. Further treatment?

Answer 19

Rare exception who is bleeding from systemic vessel. Will need thoracotomy to ligate vessel.

Question 20

25 yr old stabbed in right chest. Moderately short of breath, stable vitals. No breath sounds on the right. Resonant to percussion at apex, dull at base. CXR shows single large air fluid level.

Answer 20

Hemo pneumothorax. Chest tube, surgery if bleeding a lot

Question 21

33 yr old in high speed automobile collision. Arrives gasping for breath, cyanotic at lips, flaring nostrils. Bruises over both sides of chest, tenderness suggestive of multiple fractured ribs. BP 60/45 HR 160. Distended neck veins, forehead veins, diaphoretic. Left hemithorax has no breath sounds, is tympanitic to percussion.

Answer 21

Tension pneumo, chest tube to left immediately.

Question 22

54 yr old crashes car against telephone pole at high speed. Moderate resp distress. Multiple bruises over chest, multiple areas of point tenderness over ribs. Show multiple rib fractures on both sides. Left side caves in when she inhales and bulges out when she exhales.

Answer 22

Paradoxical breathing, likely flail chest. At high risk for further injury.

Question 23

Flail chest management?

Answer 23

Rule out other injuries (aortic rupture, abd injuries)
Underlying pulmonary contusion, fluid restrict, diuretics, colloid rather than crystalloid fluids, respiratory support. DO NOT mechanically support

Question 24

What do you do if flail chest has to go to OR?

Answer 24

Prophylactic bilateral chest tubes because high risk for tension pneumo under positive pressure breathing of anesthetic

Question 25

Crashes into telephone pole, bruised ribs, points of tenderness over ribs. Xray shows rib fractures but fine otherwise. A few days later lungs “white out” on xray and she is in respiratory distress

Answer 25

pulmonary contusion

Question 26

How do you treat pulmonary contusion?

Answer 26

Fluid restriction (using colloid), diuretics, resp support (intubation, mech ventilation and PEEP)

Question 27

54 yo lady crashes car at high speed. Breathing well in ER. Multiple bruises over chest, tender over sternum at a point where there is a crunching feeling of crepitation elicited by palpation

Answer 27

Sternal fracture.

Question 28

What is a risk from sternal fracture?

Answer 28

Myocardial contusion and traumatic rupture of aorta

Question 29

53 yo male high speed auto collsion. He has moderat respiratory distress. Physical exam shows no breath sounds over left chest. Percussion unremarkable. Chest XR shows air fluid levels in left chest.

Answer 29

Diaphragmatic rupture.

Question 30

What side is the diaphragmatic rupture on?

Answer 30

Always on left

Question 31

How do you treat a diaphragmatic rupture?

Answer 31

surgical repair.

Question 32

Daredevil jumps over 12 fountains in front of Caesar’s palace in Las Vegas. Falls off motorcycle as he hits ramp, rag-doll hits the retaining wall. In ER he is remarkably stable, although with multiple fractures. Chest XR shows fractured left first rib and widened mediastinum.

Answer 32

Aortic rupture

Question 33

How is an aortic rupture diagnosed?

Answer 33

Arteriogram

Question 34

Treatment for aortic rupture?

Answer 34

Emergency surgical repair

Question 35

Blunt trauma in car accident. Multiple injuries to extremities, head trauma, pneumothorax on left. Shortly after initial examination, progressive subcutaneous emphysema all over upper chest and lower neck.

Answer 35

Traumatic rupture of trachea or major bronchus.

Question 36

Management

Answer 36

Fiberoptic bronchoscopy to confirm diagnosis and level of injury and to secure an airway. Surgical repair afterward.